The development of literacy skills in children with Down syndrome: Implications for intervention
Margaret Snowling, Hannah Nash and Lisa Henderson
The cognitive profile observed in Down syndrome is typically uneven with stronger visual than verbal skills, receptive vocabulary stronger than expressive language and grammatical skills, and often strengths in reading abilities. However, there is considerable variation across the population of children with Down syndrome. We begin by outlining some of the methodological issues that surround research on literacy development in Down syndrome before surveying what is known about literacy and literacy-related skills. We proceed to review interventions to promote reading in school-age children with Down syndrome and conclude with directions for future research.
Methodological and contextual issues in Down syndrome research
In order to interpret research findings it is critical to compare performance of
individuals who have Down syndrome to that of a comparison group. There is debate
surrounding the selection of appropriate comparison groups in research with special
populations. The aim of matching groups is to rule out potential explanations of
group differences. Choosing what to match groups on is driven by the particular
research questions being asked and this issue is pertinent to the study of reading
given that it is a componential skill. Many studies have included typically developing
children matched for chronological age, for non-verbal mental age or on a measure
of language or reading ability. Individuals with Down syndrome have also been compared
to individuals with learning difficulties of an unknown origin and to individuals
who have learning difficulties of a different aetiology (e.g., specific language
impairment). The particular measures of language, reading or non-verbal ability
used for matching can affect the conclusion drawn. There are also behavioural aspects
of the Down syndrome phenotype other than non-verbal ability and language ability
(such as motivational style) that may affect their performance on tasks, including
attainment tests, and need to be taken into account.
In terms of education, there is strong evidence to suggest that the relatively recent
policy of educating children with Down syndrome in mainstream schools has had a
positive effect on language skills and academic attainments. This means that the
findings of studies conducted a number of years ago need to be interpreted with
Reading development in Down syndrome
Home and school influences on literacy development in Down syndrome
A wide range of factors both intrinsic and extrinsic to the child are known to influence
literacy development. Children and young people with Down syndrome
attending mainstream schools outperform their peers in special schools in reading
and language, emphasising the role of environmental factors[2,3]. Home
environment is also likely to be a critical factor and there is at least anecdotal
evidence that the introduction of reading in the pre-school years to children with
Down syndrome is beneficial.
A dissertation by Ricci suggests that home literacy environment is a predictor of
the interest children with Down syndrome have in reading. Moreover,
parental beliefs about reading, including their propensity to ask questions during
shared reading, predicted children's receptive vocabulary and comprehension skills.
However, Trenholm and Mirenda who surveyed the carers of 224 Canadian adolescents
and adults with Down syndrome reported that, although there was a wide range of
reading materials in their homes, many parents expressed concerns about the availability
of good literacy programmes. A notable observation was that few parents
reported asking any higher-level questions during reading with their offspring suggesting,
perhaps, that comprehension aspects may be relatively neglected.
It is well-established that phonological awareness, the ability to reflect on the
sound structure of speech, is a strong predictor of individual differences in reading
skills in typically developing children. Phonological awareness has been assessed
in Down syndrome at the level of the syllable, onset and rime and phoneme.
An early study by Cossu and colleagues suggested that children with Down syndrome
learn to read in the absence of phonological awareness. Subsequent
studies have shown that children with Down syndrome have measurable levels of phonological
awareness and that although phonological skills are weak, they are
nevertheless associated with variations in these children's reading skills[8-12].
It has been suggested that compared to typically developing children, the development
of phonological awareness follows a different path in children with Down syndrome.
Gombert found that a group of French children with Down syndrome were poorer on
tasks of rhyme oddity, rime judgement and phoneme synthesis than on tasks tapping
more explicit awareness of phonemes, such as phoneme counting, phoneme spelling
and phoneme deletion, in contrast to the findings from typical development.
Snowling et al. reported that children with Down syndrome could identify initial
sounds in words but found identifying rimes difficult. The observation
of a specific deficit in rhyme processing has been replicated by a number of investigators[13,14,15].
There is also a suggestion from some studies that letter sound knowledge is not
related to reading or phonological awareness skills as strongly in Down syndrome
as in typical development (see ref 11).
Together the findings suggest that phonological awareness in Down syndrome is only
weakly associated with learning to read and is also poorer than expected based on
receptive vocabulary. When non-verbal mental age, rather than receptive vocabulary
knowledge, is used to match groups, findings suggest that children with Down syndrome
perform worse than controls on tests of rhyme and initial phoneme awareness.
Thus, phonological awareness may be out of line with general cognitive ability too.
However, there is a note of caution. In the case of Françoise, the single case study
(with a relatively high IQ) reported by Rondal, performance on rhyme detection and
production tasks was at ceiling and her performance on some phoneme tasks was also
good. Similarly, KS, an 8-year-old child with Down syndrome who had
been taught to read at an early age, showed well developed phoneme level skills
and no sign of a rhyme deficit. She also performed at an age appropriate
level on tests of rapid automatised naming and speech rate, attesting to the integrity
of speech output processes, and unusually, her verbal as well as non-verbal memory
skills were well-developed.
Reading skills are often an area of relative strength for individuals with Down
syndrome. Most children with Down syndrome acquire literacy skills, although a great
deal of variability exists in the level of achievement obtained[9,19-25].
Factors that are associated with reading skills in Down syndrome include cognitive
ability, expressive and receptive language skills[16,23,26,27],
and phonological awareness [12,21]. It needs to be noted, however, that
there is variation in the tasks used and inconsistency across studies, many of which
have included children from a variety of school backgrounds.
A number of studies suggest that word identification skills develop relatively well
in Down syndrome, perhaps suggesting a 'logographic' approach, with
decoding abilities lagging behind. In line with this Kennedy and
Flynn, and Verruci, Menghni and Vicari reported nonword reading deficits in Down
syndrome which were out of keeping with levels of word identification[11,30].
However, Fowler et al. found a significant relationship between nonword reading
and word reading, as did Kay-Raining Bird et al.. Furthermore,
the exceptional reader KS was a competent nonword reader. In fact,
she read nonwords more fluently than age-matched typically developing readers (gaining
a standard score of 122), and she had no difficulty reading those without orthographic
neighbours, suggesting she was relying on grapheme-phoneme correspondences (see
Cross-sectional studies of reading are limited in their ability to elucidate the
process of reading development. Longitudinal studies allow the investigation of
growth in reading and phonological skills over time and have greater potential for
exploring causal relationships. Byrne et al. followed a group of 24 children with
Down syndrome who attended UK mainstream schools over two years and compared their
progress with that of a group of average readers and a group of slow readers from
the same classrooms. The group of typically developing average readers
performed at higher levels on all language, literacy and memory measures and also
progressed significantly more in all areas over the two years than the children
with Down syndrome did. The children with Down syndrome made steady progress in
reading accuracy but their progress on measures of reading comprehension, language,
spelling and memory was more limited.
Kay-Raining Bird, Cleave and McConnell followed the development of reading skills
in a small group of 12 children with Down syndrome over four and a half years.
They found improvements in word identification skills over time and there was an
advantage of word reading over nonword reading. They also monitored the development
of phonological awareness. There was no improvement in segmentation skills over
the years but spontaneous rhyming skills improved steadily.
Similar findings have been reported by Hulme, Goetz, Brigstocke, Nash and Snowling,
who followed 55 children with Down syndrome aged 5 to 16 years (mean age 9;11) over
a period of two years, assessing them at three points in time. Their
progress was compared to that of a comparison group of 61 typically developing children
matched for reading ability but of higher verbal and non-verbal ability. Despite
starting out with similar levels of word recognition, the children with Down syndrome
made significantly less progress in reading accuracy over time than the typically
developing group and in particular, their nonword reading skills lagged behind.
Among typically developing children, the predicted relationship between phonological
awareness and reading development was found. However, among children with Down syndrome
it was a measure of receptive vocabulary that predicted reading rather than phonological
awareness. Similarly, Byrne et al. found that reading in their Down syndrome group
was associated with understanding of grammar and auditory memory.
Correlates of reading in Down syndrome
Laws, Nye, Lombard and Briscoe reported preliminary findings from a study comparing
the reading and language skills of children with Down syndrome with those of children
with specific language impairment and children with specific reading difficulties.
The groups were of similar age (8-9 years) but varied in IQ and language skill.
There was considerable overlap between the reading scores of the children with Down
syndrome and those with specific reading difficulties. However, levels of letter
knowledge and of phonological awareness were significantly lower in the Down syndrome
group than in matched subgroups of children with specific language impairment and
specific reading difficulties, especially in rhyme awareness where few of the children
with Down syndrome scored above chance.
One plausible reason that children with Down syndrome are better at reading than
predicted by their oral language skills is that they have relatively good visual
ref 9). Fidler, Most and Guiberson explored the relationship between
reading skills and visual perception in 29 children and adolescents with Down syndrome
and 20 with learning difficulties of mixed origin. The two groups
were matched for age and non-verbal mental age, and subsequently found to be equated
in reading skill. Participants were administered tests of visual memory, figure-ground
discrimination, spatial relationships, visual closure and visual discrimination.
There was a significant correlation between a composite score on the perceptual
tests and word identification in the group with Down syndrome (r=.66) but not in
the group with mixed aetiologies r=.23). When age was controlled, visual processing
skills accounted for 34% of the variance in word identification in the group with
The high incidence of mild to moderate hearing loss associated with Down syndrome
might in principle affect the development of phonological awareness and reading
skills. However, although one study found that a group of children with Down syndrome
who could read differed in their hearing thresholds from a group of children with
Down syndrome who were not able to read, other studies found no association
with either phonological awareness or reading levels [14,34].
Reading comprehension in Down syndrome has attracted much less research interest
than decoding ability; however it presents a significant area of difficulty for
individuals with Down syndrome[21,30,31,35]. Boudreau showed that reading
comprehension and decoding skills were less well developed in a group of young people
with Down syndrome compared with a younger group matched on non-verbal mental age.
However, both word identification and passage comprehension were predicted by measures
of receptive vocabulary, sentence memory and MLU (Mean length of utterance). Similarly,
Fowler et al., and Laws and Gunn reported relationships between language and reading
comprehension in children with Down syndrome as in typical development[9,21].
In the case of the exceptional reader described by Groen et al., comprehension for
literal facts was within the normal range but she had significant difficulty answering
comprehension questions that required her to make knowledge-based inferences; in
general, her reading comprehension was in line with wider language comprehension
skills. In summary, reading comprehension appears to lag behind accuracy
in Down syndrome because it is limited by language skills.
Literacy interventions for children with Down syndrome
Phonological awareness training
In a small scale study, Kennedy and Flynn evaluated whether phonological awareness
training would improve grapheme-phoneme skill and lead to clearer speech production
in a group of three children with Down syndrome (using an intervention
programme devised by Gillon). Following eight one-hour intervention
sessions the children gained higher scores on alliteration matching and spelling
tasks, though no statistics were reported to ascertain whether these increases were
statistically significant. The spelling data suggested that over the course of the
intervention, participants moved from an awareness of initial sounds to an awareness
of final sounds. The increase in phonological awareness did not generalise to the
phoneme segmentation task, suggesting that children with Down syndrome need to be
specifically taught the phonological awareness skills needed for fluent decoding.
This study found no positive effect of training phonological awareness on speech
Van Bysterveldt, Gillon and Moran evaluated the effects of a six week phonological
awareness training programme on seven 4-year-old children with Down syndrome.
The intervention involved training parents to bring their children's attention to
letters and sounds in words, and to initial phonemes during daily shared reading
activities. There were improvements in phonological awareness and letter knowledge,
and knowledge of phonemes depended upon whether or not the child knew the particular
letter that represented the phoneme. The findings of this study suggest that phonemic
awareness may be a consequence of letter learning in Down syndrome (however, Hulme
et al., did not replicate this item-specific effect).
Like other children with intellectual disability, children with Down syndrome are
often taught to read using a 'sight word' or 'Look and Say' approach, in which they
learn to associate whole printed words with their spoken forms. An obvious limitation
of the sight word approach is that it does not equip the child with strategies that
enable him or her to read untrained words. An alternative approach to reading instruction
is 'word analysis' or 'phonics'. In an earlier review of research on reading instruction
for children with moderate mental retardation, Conners suggested that a word-analysis
approach is feasible and appropriate for this population. In line
with this view, Farrell and Elkins reported findings from a group of children with
Down syndrome who could use 'the alphabetic principle' in reading and writing and
who attended to the forms and sounds of words.
A direct comparison of two instructional techniques for teaching oral reading skills
to children with Down syndrome was undertaken by Cupples and Iacono.
In this study, four children were taught using a whole-word (look and say) approach
and three children were taught with a word-analysis approach in which children were
taught to read monosyllabic words by combining the phonological units of onset and
rime. After 6 weekly sessions lasting approximately 45 minutes, 4 out of the seven
children (2 from each intervention group) showed measurable improvement in reading
the trained words. Only two children from the word-analysis group were able generalise
their skills and showed an improvement in reading a set of untrained words (note
though that these words had the same rime unit as the trained words).
Baylis conducted a small-scale training study using a programme designed to develop
the emergent literacy skills of 10 children with Down syndrome who possessed some
letter sound awareness but did not use this knowledge to decode unfamiliar words
in their reading. The programme was an adaptation of the 'reading
and phonology' approach developed by Hatcher, Hulme and Ellis. Children
were seen individually for two one-hour sessions a week (for 9 weeks) in which they
received training in phonological awareness at the onset-rime level incorporated
into a programme of text reading encouraging letter knowledge, syllable segmentation
skills, comprehension, spelling and writing. The onset-rime level of phonological
awareness was chosen because of the inability of the children to blend at the phoneme
level and because it was considered this would reduce the memory load placed on
the children by presenting 'chunks' of words rather than individual phonemes.
Each of the ten children in the study acted as their own control and performance
on tests of reading and phonological awareness was assessed twice before the intervention
began to provide baseline measures (t1, t2), the week following
the last teaching session (t3) and three months after the end of the teaching
sessions (t4). All ten children made gains in letter recognition and word
recognition and in a measure of book reading performance, though progress was quite
variable across the group. Gains in phonological awareness were much less consistent,
with some children showing gains and others showing deteriorations in performance.
For 6 of the 10 children gains were larger than to be expected when compared with
the progress made by a larger cohort from which the children were drawn.
Along similar lines, Goetz, Hulme, Brigstocke, Carroll, Nasir and Snowling
delivered a modification of the Hatcher et al. approach, training
phonological awareness in the context of learning letters sounds and working with
words in books. In this study, phonological awareness training was
targeted at the phoneme level; the programme also incorporated sight word learning
activities and speech production exercises that focused the child's attention on
articulating sounds in words and perceiving sound contrasts as well as decoding
Eight children with Down syndrome received the intervention for a period of 8 weeks
(Group 1; delivered on a daily basis in a 40-minute one to one session) before intervention
for a further 6 children in a 'waiting list' control group (Group 2) commenced.
Group 1 made significantly more progress in letter and word recognition during the
period when they received intervention compared to the waiting control group; effect
sizes were large for Word Reading (Cohen's d = 0.80) and moderate for nonword
reading (Cohen's d = 0.4). The waiting group started to make progress once
their intervention began and overall, children progressed more in word reading skills
over the duration of the intervention than they did when they did not receive this
intervention programme. Progress in phonological awareness was modest; although
there was significant progress in alliteration matching during the intervention,
the majority of the children remained at chance on tests of explicit phoneme awareness.
This finding contrasts with that from case studies reported by Cologon, Cupples
and Wyver who compared the effects of instruction in phonological awareness (through
oral reading) and reading comprehension (through silent reading) in a sample of
15 children with Down syndrome aged between 2;11 and 10;8 years.
The phonological awareness intervention trained decoding skills at the onset-rime
level and individual phoneme level combined with picture matching and sentence completion
tasks. The reading comprehension or 'silent reading' intervention trained word and
picture matching, sentence and picture matching, action sentence tasks and sentence
completion tasks. Participants were seen individually in a weekly session for 10
weeks. They were assessed pre-intervention, immediately following completion of
the intervention and for maintenance testing six months later.
Although there was considerable variation in progress across children, all demonstrated
significant gains following the intervention. Participants in the phonological awareness
intervention condition showed significant improvement on measures of phonological
awareness, phonic decoding, letter-sound knowledge and reading comprehension. Participants
in the silent reading intervention condition showed significant improvement on measures
of reading comprehension, reading ability, phonological awareness and letter-sound
Finally, a number of other small scale or pilot studies are in progress for children
with Down syndrome. These include an intervention to promote literacy stimulation
during joint book reading which has positive effects and an intervention programme
to promote reading comprehension strategies.
Conclusions and future directions
Research on literacy development in Down syndrome has burgeoned in recent years,
though study remains focused on word level decoding abilities and phonological skills
with a relative neglect of spelling and reading comprehension processes. Both areas
of enquiry could offer important insights into the relationships between speech
and language skills, specific forms of linguistic representation and written language
abilities. In addition, the majority of research remains small in scale, often involving
children and young people widely ranging in age and there is a dearth of longitudinal
studies. Moreover, relatively few comparisons have been made between the literacy
skills of children with Down syndrome and those with learning difficulties of mixed
The picture that emerges is that of considerable variation in the reading attainments
of children with Down syndrome. The extent to which this is the outcome of constitutional
versus environmental factors is uncertain. It appears that verbal rather than non-verbal
mental age is a predictor of individual differences in word recognition in Down
syndrome but nonetheless, word-level reading skills are generally in advance of
what might be predicted given receptive vocabulary knowledge. In terms of component
reading skills, levels of phonological awareness and decoding ability are generally
lower than levels of word identification (but they are related and there are some
exceptions) and the majority of children with Down syndrome have poorer reading
comprehension than reading accuracy, probably due to language limitations. A consistent
finding across studies is of difficulties in rhyme recognition and awareness in
this population suggestive of atypical development of phonological skills.
With these findings as a back-drop, a number of small-scale intervention studies
have evaluated the effects of programmes targeting phonological awareness and reading
skills. Most of these studies report very short-term interventions, few have included
control groups and none have used randomised trials. The picture emerging to date
is that word recognition skills are more amenable to training than phonological
awareness skills or decoding abilities but more research is required to clinch this
Finally it should be emphasised that, just as in the general population, there is
variance in ability in Down syndrome resulting from genetic differences and differences
in the environments through which genes act. Individuals with Down syndrome inherit
a full set of chromosomes from their parents, as typically developing children do,
along with the extra chromosome material. They also experience a wide range of environments
at home and in school that will contribute to their literacy outcomes. There is
an urgent need for longitudinal studies that follow the development of literacy
in Down syndrome from before the start of formal schooling and that map relations
between their general cognitive abilities, language and reading skills. Such studies
should also investigate environmental influences on literacy. Findings from these
studies will inform individual difference in responsiveness to intervention in Down
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Work towards this review was funded by a British Academy Readership to MS, a grant
for the Health Foundation and ESRC studentships to HN and LH. Thanks to Charles
Hulme and Kim Manderson for assistance at various stages.
Margaret J Snowling, Hannah M Nash and Lisa M Henderson are at the University of
Paper prepared from presentations and discussions at the Down Syndrome
Research Directions Symposium 2007, Portsmouth, UK. The symposium was
hosted by Down Syndrome Education International in association with the
Anna and John J Sie Foundation, Denver. Major sponsors also included the
Down Syndrome Foundation of Orange County, California and the National
Down Syndrome Society of the USA. Information about the symposium can be
Received: 17 January 2008; Accepted: 24 January 2008;
Published online: 2 July 2008.
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