Teaching spontaneous responses to a young child with Down syndrome
Kathleen Feeley and Emily Jones
Children with Down syndrome experience significant communication impairments, particularly in expressive language. Although receiving little attention in the literature, deficiencies in expressive language are likely to affect spontaneous communicative responses in children with Down syndrome. In this study, using a multiple baseline design across responses, we demonstrated the effectiveness of discrete trial instruction in establishing spontaneous responses in a preschooler with Down syndrome. Spontaneous responses generalised to a novel setting involving a novel person and novel materials. Implications for the use of behaviourally based interventions to address the social-communicative needs of children with Down syndrome are discussed.
Feeley KM, Jones EA. Teaching spontaneous responses to a young child with Down syndrome. Down Syndrome Research and Practice. 2008;12(2);148-152.
Children with Down syndrome experience significant impairments in communication across a range
of skills including articulation, morphology, syntax, and semantics[1-3]. While both
receptive and expressive language are specifically impaired, the expressive language of children
with Down syndrome lags further behind their receptive capabilities, affecting
interactions with family, peers, and community members.
An area of expressive language in children with Down syndrome receiving little attention in the
literature is spontaneity, defined by Charlop, Schreibman, and Thibodeau
as "a verbal response to a nonverbal discriminative stimulus in the absence
of a verbal discriminative stimulus" (Ref.6, p.156).
For example, a child spontaneously comments, "I see a bird," in response to a bird flying (the
discriminative stimulus [SD]), or says "Thank you" upon receiving a new toy (SD).
In contrast, many children with communication impairments verbalise only in response to an
adult's vocal directions to do so, such as commenting only when asked "What do you
see?" or saying "Thank you" only when told "Say 'Thank you.'" Nonverbal stimuli to which
children emit spontaneous utterances do not include explicit adult vocalisations, rather the
important features may include nonvocal components (e.g., a bird flying) or the action of
another person (e.g., presenting a new toy).
The impaired expressive language affects the communicative competence of young children with
Down syndrome, including the spontaneity of language, further limiting their opportunities to
interact with others. The child may not have acquired the appropriate verbal response to be
emitted within the specific context. Additionally, a variable likely to affect spontaneity is
the decreased saliency of nonverbal stimuli. Specifically, nonverbal stimuli may not be salient
enough to exert control over a child's communicative behaviour.
Researchers have addressed spontaneity in children with autism (for whom spontaneity is often
impaired) using intensive intervention procedures (in which multiple teaching opportunities were
presented in close proximity with unrelated reinforcers delivered for correct responding)
including teaching spontaneous requests (e.g. Ref.6-8), expressions of affection (e.g.
Ref.9), social niceties (e.g. Ref.10), greetings (e.g.
Ref. 11), and comments (e.g. Ref.12). Naturalistic teaching strategies (i.e., intervention
implemented during naturally occurring routines) have also been utilised to teach spontaneous
communication to children with autism.
Two studies addressing spontaneous communication in children with Down syndrome also utilised
naturalistic teaching strategies. Warren, Yoder, Gazdag, Kim and Jones taught a
20 month old boy with Down syndrome to comment on the presentation of a novel item. Hemmeter,
Ault, Collins and Meyer taught spontaneous responses to two children with Down
syndrome (7.2 and 5.9 years). One child, who was taught spontaneous requesting (e.g., saying,
"More"), showed poor maintenance and generalisation. For the second child, who was taught to
comment (e.g., saying, "Big ball"), prompted comments increased during intervention, but there
was little spontaneous commenting with no generalisation.
In a previous study, we addressed spontaneity in two preschoolers with autism using an intensive
behavioural intervention (i.e., discrete trial instruction). In this study, we
examined the same intervention to teach spontaneous responses to a child with Down syndrome.
Max, a 3 year 9 month old boy with Down syndrome, participated in this study. At the time, Max's
expressive and receptive language scores fell between one half and one standard deviation below
the mean on the Preschool Language Scale Third edition. On the Goldman-Fristoe
Test of Articulation, Max performed at the 1st percentile. On the Learning
Accomplishment Profile-Diagnostic Standardized Assessment (LAP-DO) Max performed
at the 21st percentile for language, 85th percentile for cognitive, 13th
percentile for fine motor, and 27th percentile for gross motor domains. Max used one to two word
utterances to signify possession (e.g., "Mine"), desires (e.g., "I want"), greetings (e.g.,
"Hi"), and protests (e.g., "No"). He was able to identify pictures of common objects, animals,
and characters (e.g., ElmoTM), respond to questions (e.g., "Where is it?"), and
followed simple directions. In his preschool, Max rarely interacted spontaneously, depending
instead on teacher questions (e.g., "Max, what would you like?") or directives (e.g., "Max Say,
'I want'.") to verbalise.
Interventionists and setting
Max's educational programme consisted of 2.5 hours of intensive intervention each day in
addition to 4 hours of participation in an integrated preschool class (6 children with
disabilities and 6 typically developing children) in preparation for placement in his community
preschool. Intervention occurred in a partitioned area within the classroom where Max received
intensive intervention. Max's teacher (a certified special educator) and teacher's assistant,
who were trained in applied behaviour analysis, implemented the intervention procedures.
Identification of communicative targets and materials
Based on observations of typically developing preschoolers, the authors generated a list of
potential controlling stimuli that were not vocal in nature (i.e., did not contain explicit
spoken utterances) and corresponding communicative responses. Max's parents selected three
appropriate targets: saying "Bless you" when someone sneezed, "Uh oh" when someone dropped
something, and "Coming" when someone gestured "come here" by curving their index finger. Items
commonly found in the preschool (e.g., crayon or book) were used to teach saying "Uh oh."
Different materials (e.g., toy ) were used for the assessment of generalisation.
A correct response was an unprompted verbal utterance (i.e., saying "Bless you," "Uh oh," or
"Coming") emitted within 5 seconds of the presentation of the discriminative stimulus (SD)
(i.e., someone sneezing, dropping something, or gesturing "come here").
Design and procedure
A multiple baseline design across three communicative responses was utilised. Generalisation
probes were conducted with novel people in novel settings with novel materials.
During baseline, the interventionist presented the SD, waited 5 seconds, and then
terminated the opportunity in the absence of feedback, regardless of a correct, incorrect, or no
response. Baseline opportunities (5 opportunities per session per day) were presented between
other instructional programmes or while Max was engaged in an activity (e.g., blowing bubbles).
Intervention involved discrete trial instruction in which multiple opportunities were presented
in close proximity, with prompts to elicit correct responses, followed by a predetermined
reinforcer paired with natural consequences or the use of an error correction procedure.
One or two intervention sessions, consisting of 10 opportunities per session, were conducted
daily. During the first three intervention sessions, the interventionist immediately prompted
the correct response. That is, she presented the discriminative stimulus (SD) (e.g.,
dropped something), immediately prompted the target response with a verbal model (e.g., "Say
oh'"), and delivered reinforcement (i.e., edible paired with praise and natural consequences,
such as saying, "I'll pick it up"). (Note: During the second intervention session addressing the
response "Bless you," Max immediately performed the correct response [i.e., said "Bless you"]
prior to the delivery of the prompt, therefore correct responses were recorded within the second
session.) After the first two intervention sessions for the response "Bless you" and the first
three sessions for the responses "Thank you" and "Coming," each subsequent session began with a
probe during which the SD was presented followed by a 5 second interval to allow Max
to emit the target response. This determined procedures for the remaining opportunities within
that session. If Max did not emit the correct response (i.e., emitted a different or no
response) during the probe opportunity, corrective feedback (i.e., interventionist said, "No" or
"Uh uh") was delivered and the SD was repeated, followed by a prompt to ensure a
correct response. The interventionist then prompted the correct response for the remainder of
that session. If Max emitted a correct response on the probe opportunity, reinforcement was
delivered and the remaining opportunities for that session involved the delivery of the SD
followed by a 5 second interval with reinforcement for correct responses and error correction
for incorrect responses (consisting of corrective feedback [e.g., the interventionist said "uh
uh"] followed by repetition of the SD and a prompt to ensure a correct response).
Mastery criteria was 80% independent correct responding during two consecutive sessions across
two days and two different interventionists. Following mastery, intervention sessions continued
to ensure the skills maintained.
One generalisation probe opportunity for each response was conducted each week by
interventionists (not involved in this intervention) within Max's integrated classroom or in
other areas in the school (e.g., gym, hallway) with novel materials (when relevant).
Response and procedural reliability were evaluated by the first author and an undergraduate
volunteer research assistant (i.e., reliability coders) who recorded data simultaneously with
the interventionist for 51% of opportunities, distributed across each condition (i.e., baseline,
intervention, and generalisation). Percent agreement for response reliability, cumulated across
all opportunities, was 94%. For procedural reliability, each intervention opportunity was
examined for accurate presentation of each component of intervention; SD, prompting
procedure, and provision of appropriate consequences. Percent agreement for procedural
reliability was 96% for correct presentation of the SD, 90% for use of the correct
prompting procedures, and 94% for delivery of appropriate consequences.
Results and discussion
Figure 1 illustrates Max's performance across the
three responses during baseline, intervention, and generalisation probes. During baseline, Max
did not emit any target responses (0%). Max reached mastery criterion (i.e., performed at or
above 80% across two consecutive sessions, days, and interventionists), indicated by a
vertical line in Figure 1,
across all three responses (3 sessions for "Bless you," 8 for "Uh oh," and 14 for "Coming"). Max
continued to demonstrate all three responses following mastery and generalised across stimuli.
Figure 1 | Percentage of opportunities with a correct
response for Max across three communicative responses and performance during
generalisation probes. Mastery (i.e., performance at or above 80% across two
consecutive sessions, days, and interventionists) is indicated by the blue dotted
Because of significant impairments in expressive language among children with Down syndrome,
identification of effective intervention strategies is imperative. This study supports the use
of intensive intervention to address deficits in spontaneous use of language. We hypothesise
that, in many instances, children with Down syndrome refrain from spontaneously communicating
due to not having been taught specific responses. Although it is not possible to predict all
stimuli to which a child will be exposed, caregivers can identify those highly likely to occur,
as well as those particularly relevant for a child, and implement specific intervention.
The spontaneous utterances taught within this study were acquired relatively quickly which may
be due to numerous teaching opportunities within close temporal proximity, characteristic of
discrete trial instruction. Others have utilised more naturalistic teaching procedures (e.g.
Ref.14), demonstrating advantages
to both contexts of instruction. Discrete trial instruction allows for multiple teaching
opportunities in a relatively short period of time with the use of powerful reinforcers (albeit
not necessarily related to the target response). Naturalistic instruction involves the use of
naturally reinforcing stimuli and increased likelihood of generalisation. However, in research
on spontaneity in children with autism, a greater number of teaching opportunities were required
for acquisition within naturalistic contexts than within intensive intervention
contexts (e.g. Ref.6). In
evaluating the relative effectiveness of intensive versus naturalistic interventions, it is
worth considering not only the skill to be addressed, but the immediacy with which the child
must acquire the skill. Some skills, specifically impaired in children with Down syndrome (e.g.,
expressive language), may be more conducive to intensive intervention. When a child needs to
acquire a skill within a short period of time, a more intensive approach to instruction may be
warranted. The comparative effects of intensive and naturalistic intervention for children with
Down syndrome remain to be demonstrated.
Problems with generalisation have also been noted when skills are acquired within intensive
intervention contexts, however, Max generalised the responses across stimuli. Anecdotally,
following Max's acquisition of the "Bless you" response, his father also reported Max using the
social nicety at home. We hypothesise that generalisation occurred as a result of Max's ability
to recruit natural contingencies of reinforcement across stimuli. As children with Down syndrome
encounter potentially socially reinforcing situations, they may not have acquired relevant
language forms prohibiting them from recruiting natural social reinforcement. As demonstrated in
this study, once acquired, these forms were displayed across environmental stimuli.
Three additional issues warrant future examination. First, in this study responses reflected a
range of communicative functions, including a social nicety ("Bless you"), comment ("Uh oh"),
and confirmation of a directive ("Coming"). It is important to assess the full range of
communicative functions to determine those that are impaired in individual children and then
teach each so that children with Down syndrome can interact effectively. Second, because
articulation is an area of difficulty for children with Down syndrome, increased
opportunities to practice communicative targets may enhance performance. In fact, prior to this
study, two responses (i.e., "Bless you" and "Coming") were taught to Max through verbal
imitation practice. Third, finer discriminations on the part of the child (e.g., when particular
responses should and should not be emitted, that is, conditional use of communicative responses)[21,22]
should be assessed and directly taught if necessary.
In this study, we explored teaching spontaneous communicative responses to a young child with
Down syndrome. Results support the use of an intensive intervention approach to address
expressive communication deficits. Further examination of functional communicative targets and
the use of intensive intervention approaches to ameliorate communicative impairments prevalent
among young children with Down syndrome is warranted.
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We thank Developmental Disabilities Institute for the dedication of resources to this project.
We also thank our participant, his parents, and teachers who devoted their time and effort, as
well as Jillian Bauza, a Stony Brook student, who assisted with data collection.
Received: 21 September 2006; Accepted 14 February 2007; Published online: 6
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