Speech production in people with Down syndrome
There is a well developed literature on the development of vocabulary and grammar in children with Down syndrome but limited information in the area of speech production. The spoken language of people with Down syndrome often leads to a lack of intelligibility which does not necessarily diminish with age, despite slow but steady development of phonology. This paper explores some of the elements in speech production which may contribute to the listeners’ perception of reduced intelligibility in the speech of people with Down syndrome.
There is a general consensus that speech difficulties are common in individuals
with Down syndrome and that these consist of a complex interweave of phonological
and motor-speech delay and deviance. Phonological immaturities such as final consonant
deletion, use of stops for fricatives, producing voiced for voiceless sounds and
vice versa are common. Many studies
have suggested the pattern of speech delay to be similar to that of young developmentally
typical children. This may be
an over-simplistic view of the situation. Roberts et al. found additional systematic
errors not previously reported, for example palatal fronting, fricative simplification,
deaffrication, and lateralisation of sibilants.
Dodd and Thompson clearly show that children with Down syndrome are inconsistent
in speech production, with over half of all words produced being pronounced differently
on repeated productions. Variability is also
reported in the articulation of fricatives by young people with Down syndrome.
Speech can be analysed in terms of its segmental structure (the precision and appropriateness
of the sequences of sounds produced), or its suprasegmental aspects (intonation,
rhythm, stress, voice). Studies undertaken by Bray and associates indicate that
there may be suprasegmental differences which appear to be associated with problems
of identifying and signalling word and phrase boundaries[6,7,8].
For some of the people with Down syndrome studied, word and phrase endings were
better articulated and carried more stress than the initial syllable or the head
of the tone group. This is contrary to typical speech in English where the first
syllable in a disyllabic word and the initial sentence position carries the higher
stress. Syllable deletion is common in the speech of people with Down syndrome and
Heselwood, Bray and Crookston have suggested that syllable deletion allows for simplification
of the rhythmic structure of the utterance, making the neurophysiological process
of speaking easier. Links between
production and perception need to be considered as Pettinato and Verhoeven show
that perception of weak syllables is problematic in adolescents with Down syndrome.
Dysfluency (stuttering) is the inability to move forward in the utterance because
of repetitions of a sound, syllable or word, prolongations of sounds or of silence
and tense pauses (both filled and unfilled) associated often with obvious struggle
to produce the word. The issue of whether the dysfluencies of people with Down syndrome
can be defined as stuttering is unresolved as the definition includes more than
just overt speech behaviours (levels of awareness, anxiety and avoidance form part
of the stuttering syndrome).
The literature on dysfluency in people with Down syndrome suggest a much higher
incidence than in the general population (47% as against 1%[10,11]).
Dysfluency can add to the lack of intelligibility in speakers and adds another level
of difficulty in the production of speech by children with Down syndrome. Berstein
Ratner suggests that, in typically developing children, dysfluency is related to
language processing. As grammatical
morphemes are rapidly expanding, children find the processing load significantly
higher and a breakdown in fluency can result. Bray, in a study of two young dysfluent
children with Down syndrome, found that the dysfluencies did not show a definite
relationship to word finding problems and that the nature of the speech output consisted
of complex patterns of interjection of sounds, production of non-English sounds
(clicks) and, in addition, changes in prosodic features such as increased durations
of sounds, sudden pitch changes and numerous filled and unfilled pauses.
These speech difficulties were also identified by Heselwood in a young dysfluent
man with Down syndrome who used clicks (found in African languages) seemingly as
a result of involuntary dorso-velar closure while attempting sonorant productions. This suggests a motor-speech difficulty
rather than/ as well as a linguistic programming problem.
What could be applied in intervention?
Making direct connections between theory and practice is complicated by the complexity
of the speech problems. Unintelligibility is a problem often mentioned by those
who live and work with people with Down syndrome.
It is related to both sentence construction and the segmental and suprasegmental
levels of speech as well as to the listeners' perception and expectations. It is
important therefore to (a) find ways of enhancing the message giving by the person
with Down syndrome and (b) improve the 'listening' and awareness of the communication
partner. There is also a growing literature showing that cognitive and affective
factors have a strong influence on the planning and production of speech. This suggests that a relaxed, at ease, dialogue
is far more likely to be understood by both parties than one where one or both partners
in the exchange is anxious. The work of Wishart alerts us to the necessity of understanding
the learning styles of children with Down syndrome and ensuring that the learning
environment is facilitative. In
the stuttering literature, the importance of keeping a balance between the child's
capacities in language and cognition and the performance demands made on that child
is seen as highly significant in maintaining fluency. This is known as The Demands
and Capacities model.
Possible approaches to managing speech output difficulties therefore must include:
- A holistic approach which supports the child in any attempt at communication – thus
reducing the demands on a fragile speech-motor system.
- Training in careful listening should precede any production attempts as speech perception
is important in the laying down of linguistic and motor processes in the brain.
- Training of others in identifying and understanding the speech patterns of children
with Down syndrome in order to enhance the message detection ability of listeners.
- The use of simple rhythms to improve both fluency and sequencing difficulties (clapping
of syllables of multisyllable words or short phrases).
- The use of visual and tactile prompts for the placement of speech articulators in
order to reduce the auditory memory load.
- A focus on teaching speech and fluency in single functional words or simple phrases
through parent support and education.
- Stoel-Gammon C. Down syndrome phonology: Developmental
pattern and intervention strategies. Down Syndrome Research and Practice.
2001;7:93-100. [Open Access Full
- van Borsel, J. Articulation in Down's syndrome adolescents
and adults. European Journal of Disorders of Communication. 1996;31:415-444.
- Roberts J, Long S, Malkin C, Barnes E, Skinner M, Hennon
E, Anderson K. A comparison of phonological skills of boys with Fragile X syndrome
and Down syndrome. Journal of Speech, Language and Hearing Research. 2005;48:980-995
- Dodd B, Thompson L. Speech disorder in children with Down's
syndrome. Journal of Intellectual Disability Research. 2001;45:308-316.
- Timmins C, Hardcastle W, Wood S, McCann J, Wishart J.
Variability in fricative production of young people with Down's syndrome: An EPG
analysis. International Congress of Phonetic Sciences. 2007;XVI:1981-1984.
- Heselwood B. A case of nasal clicks for target sonorants:
a feature geometry account. Clinical Linguistics and Phonetics. 1995;11;42-61.
- Heselwood B, Bray M, Crookston I. Juncture, rhythm
and planning in the speech of an adult with Down's syndrome. Clinical Linguistics
and Phonetics. 1995;9:121-137.
- Jansen W, Bray M. (ongoing) Exploring the speech of a young
child with Down syndrome.
- Pettinato M, Verhoevan J. Production and perception
of word stress in children and adolescents with Down syndrome. Down Syndrome Research
and Practice. Manuscript submitted.
- Preus A. Stuttering in Down's syndrome. In: Lebrun Y, Hoops
R, editors. Neurolinguistic Approaches to Stuttering. The Hague: Mouton;1973.
- Devenny D, Silverman W. Speech dysfluency and manual specialization
in Down's syndrome. Journal of Mental Deficiency Research. 1990;34:253-260.
- Bernstein Ratner N. Stuttering: a psycholinguistic perspective.
In: Curlee RF, Siegel GM, editors. The Nature and Treatment of Stuttering: New Directions.
2nd edition. Boston: Allyn and Bacon. 1997:p.99-126.
- Bray M. Language and dysfluency in two young children with
Down syndrome. Conference paper. International Fluency Association.
- Kumin L. Intelligibility in speech in children with Down
syndrome. Parents' perspective. Perceptual and Motor Skills. 1994;78:307-313.
- Ludlow C, Loucks T. (2003) Stuttering: a dynamic motor
control disorder. Journal of Fluency Disorders. 2003;28:273-295.
- Wishart J. Learning in young children with Down's syndrome:
Developmental trends. In: Rondal J, Perera J, Nadel L, Comblain A, editors. Down's
Syndrome. Psychological, Psychobiological and Socio-educational Perspectives.
London: Whurr;1996. p.81-98.
- Starkweather CW, Gottwald SR. The demands and capacities
model II: Clinical application. Journal of Fluency Disorders. 1990;15,143-157.
- Dodd B, McCormack P, Woodyatt G. Training parents of children
with Down syndrome as agents of therapy. In: Dodd B, editor. Differential Diagnosis
and Treatment of Children with Speech Disorder. London: Whurr;1995. p.249-261.
Monica Bray is at The Department of Speech and Language Therapy, Leeds Metropolitan
Correspondence to Monica Bray • e-mail:
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 5 November 2007; Accepted: 12 November 2007;
Published online: 2 July 2008
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