Children with Down’s Syndrome can counter the learning problems caused by the condition if the intervention is early and strong enough. Angela Hurd reports on her communication work with Rosie  and how  her cognitive skills were strengthened
 

Researcher Jean  Rondal explored  in 1995 the most commonly cited cognitive problems in people with Down syndrome, all of which to differing degrees, could impact on the cognitive development and learning skills of an individual. She concluded that these primarily included “limited efficiency in information processing, limited attentional capacity, slower reaction time, deficit of auditory-vocal processing, limitation of short term memory, slower retrieval of learned information form long term memory, reduced perceptual discrimination and generalisation capability, deficit of symbolisation capacity and inability with respect to the abstract attitude”.
 

In typical development, speech and language skills play a central role and are seen as pivotal to the development of further thinking, reasoning and memory tasks. Buckley and  Sacks (2001) stated that “Speech and language development is inextricably linked to cognitive development in typically developing children and, when children have speech and language delay, it is important to recognise the impact of this and still try to teach as many concepts as possible.” 
 

Rosie was born, at full term with Down syndrome, type one – what does this mean for the layman? Rosie was the first child in the family. My role was to facilitate the development of her communication skills across all modalities, working in partnership with all the significant people in Rosie’s life. My aim was to ensure, as far as I could, that Rosie had a strong foundation on which to build so that she could achieve her full potential.  
 

Rosie’s parents were keen to do everything they could to facilitate her development and were particularly concerned to develop her cognitive skills. They had a distant cousin who also had Down Syndrome but no expressive language skills and who lived at home with his elderly parents. This had been their only contact with people with Down Syndrome.
 

The introduction of signs to support spoken language has been shown to improve both understanding and use of language and Rosie’s parents used Makaton signing with her from six weeks.
 

In addition, there has been a lot of research that supports the view that all children with Down syndrome will benefit from being taught reading skills from an early age as these activities will improve their spoken language and memory skills. There, is a body of research advocating the early introduction of literacy skills as a means of facilitating cognitive development generally. This is particularly important as language skills are also seen to lag behind cognitive skills generally in people with Down syndrome, creating further disparity with age and reducing the impact of language as a tool for learning and enhancing cognitive development.   
  
 

Children with Down syndrome have also been shown to have much stronger visual processing skills when compared to the auditory – the higher incidence of middle ear problems, may also impact on this. The written word has been used as a “scaffold” for the spoken word – when developing expressive language for example.

Buckley and Bird (2001), go as far as to say  “Teaching reading to teach talking is probably the single most effective intervention for helping children with Down syndrome to overcome their learning difficulties. Reading and writing skills are important for everyday life and for access to the world of literature for all children. They are also powerful tools for teaching speech and language to children with Down syndrome and for mediating their cognitive development.”
 

Thus there was no argument that Rosie should be taught to read – and that she needed to begin early. However, Rosie also needed to increase the range of sounds in her jargon/babble repertoire and phonetic inventory. By the time she was 18 months old, she could sign a range of both nouns and verbs, having been introduced to Makaton signing at six weeks, but her range of vocalisation was slower to develop. Her expressive sign vocabulary was roughly commensurate with the norms for expressive language development but her sound production and speech with sign use was more limited. This is a fairly typical finding according to Rondal (1995). She noted that “in particular phonological contrasts in production, are slow and difficult to develop”.
 

Rosie had been encouraged to engage in a range of early listening and sound discrimination tasks through play. It was evident that Rosie needed a multisensory approach to her learning so that she could use her stronger visual skills for example, to facilitate the development of the more challenging auditory processing tasks. This appears to be typical of development in children with Down syndrome. Buckley and Sacks (2001) note that visual processing and visual memory skills are a strength, and there are studies that show that children with Down syndrome can acquire a sight vocabulary at the same rate as their age matched peers.
 

So it seemed expedient to teach Rosie the skills that she would need to help her along the road to becoming literate.  In addition, Rosie’s phonetic inventory was limited, despite the early introduction of sound cards. I felt that it would be useful expand this and have a shared vocabulary for talking about sounds to make the process of contrasting meaning through minimal pairs for example (phonological contrasts), much more concrete and much broader.

 
Why focus on phonological awareness?

There is much more to literacy than can be taught through the visual route alone. Use of a phonological route is critical in the Simple Model of Reading (Rose Review). Systematic phonic work is widely accepted as being critical in a positive outcome for reading. “Findings show that systematic phonics instruction produced superior performance in reading compared to all types of unsystematic or no phonic work. Phonics instruction is systematic when all the major grapheme-phoneme correspondences are taught in a clearly defined sequence’ (Ehri 2003).
 

In 1998, the DFEE defined phonological awareness as “awareness of sounds within words – demonstrated for example by the ability to generate rhyme, alliteration and in segmenting and blending compound sounds”. Phonological awareness is an awareness of the ways 'in which words and syllables can be divided into smaller units" (Goswami & Bryant, 1990) or an awareness of the sound system of language that allows an individual to make judgements about, or manipulate sounds and syllables in words.
 

A similar term, metaphonological awareness, refers to the individual's ability to talk about and explain his or her use or understanding of the phonological awareness skill. In rhyming for example, a child may produce a rhyme strand in vocal play but not be aware of the fact that he or she is rhyming. The child's skill becomes metaphonological, if when asked how two words (that rhyme) are alike, the child responds with the fact that they rhyme and understands the concept of rhyme/ not rhyme. Being able to talk about the way their thinking is operating, is an exciting way for the teacher to understand how an individual perceives a given task and thus gain insights into the individuals learning style. The door is opened for  dialogue once individuals share key concepts.
 

Historically there has been much debate, as to whether phonological awareness is a prerequisite of literacy or a consequence of literacy. But researchers now believe a reciprocal relationship exists between the two. It appears that phonological awareness skills provide the foundation for literacy development but once children begin to read, their phonological awareness develops even more because of their experience. Phonological awareness is not dependent on literacy skill as evidenced by pre school non readers' ability to segment words into syllables and to identify the initial sounds in words for example. Rather these children seem to use their speech production skills to identify the syllables they hear in words or the first sound they hear in a word.

So as per letters and sound, there is no need to wait for the child to become “ready to read” – a hopefully dead and buried notion.
 

Phonological awareness is not simply phonic knowledge. Ratherit involves the ability to make links, form connections and reflect on the sound system. This is done in a variety of ways and has been shown further to develop before the introduction of written words. There are several different levels at work, all of which need to be taught in a structured way if a child is going to be able to make the necessary links and connections.

Adams (1990) found that four key tasks could predict later reading skill and each was important:

• syllable and phoneme segmentation
• phoneme manipulation, including onset and rime
• sound blending/synthesis
• rhyming tasks in the broadest sense
   

These do not follow one another sequentially but are all part of the repertoire a child needs in order to develop metaphonological awareness. For example, Carroll (2003) et al found that children's rime skills developed earlier than their phoneme skills. The most powerful predictors of literacy success appear to be phoneme segmentation and phoneme manipulation skills according to Adams (1990). Muter (1996) found that phoneme segmentation skills and letter knowledge is a predictor of children's ability to sound out words that are unfamiliar.
 

According to Stackhouse and Wells (1997), children develop this awareness of the sounds and structure of their language by developing the speech processing system. Thus children who are at risk for having difficulties in this area, are also at risk for literacy difficulties. In fact, many children with decoding problems, have been hampered in their learning, because “ they are unable to generalise from one word to another” (Reid 1998). I wanted to do everything possible to avoid this scenario for Rosie.

Phonological awareness and Down syndrome

Bayliss (2000) supported the view that  research has found that children with Down's syndrome are able to learn to read. However she pointed out that “their reading is at an early stage and typically consists of up to 100 common words. They have difficulty in developing phonologically based reading and comprehension skills. As a result, they have difficulties in accessing a mainstream curriculum.” I wanted Rosie to have the skills necessary to access the curriculum.
 

A study by Fletcher and Buckley, (2002) looking at older children with Down syndrome, found that there was “a significant positive correlation between phonological awareness and reading and spelling competence, ability to spell non-words and non-verbal measures”. However a review of the research evidence showed that use of phonological awareness to facilitate reading was not generally in evidence. Cossu carried out two studies with Italian children in 1990 and 1993 respectively. He found that although his first subject could read text and single words, he had no conscious phonological awareness. In his second study of 10 boys, he found that although on average the children could read to an age equivalent of eight years, they performed poorly on the metalinguistic tasks: phoneme segmentation (phoneme counting) phoneme deletion oral spelling: phonemic synthesis (blending).  Snowling, Hulme and Mercer (2002) reported on a matched pairs study for reading ability and found that the Down syndrome children had significantly greater difficulty with rime detection. However, this may be due to the type of teaching that they had received. This research may indicate that this area needs to be explicitly taught, along with other areas of phonological awareness.

Why choose Salley

There are a number of programmes out there for the practitioner to choose from, but most seem geared to older children who have already begun to read. I wanted a means of facilitating phonological awareness from the very beginning. The programme also had to meet certain criteria. It had to:

• Be highly structured
• focus on all the aspects of phonological awareness
• Use pure phonics for help facilitate Rosie’s phonetic inventory
• teach the linguistic concepts necessary for the development of meta phonological awareness explicitly
• Allow for differentiation to match her rate of learning
• Use errorless learning to build success and motivation
• Facilitate the development of auditory and visual sequencing needed for later decoding and blending
• Use a multisensory approach

What happened

  
The Salley programme was introduced to Rosie at 18 months with some adaptations. Rosie was taught “good listening” as a concept using Makaton, and further concepts were taught using Makaton and the visual referents in the programme. Rosie did not appear to have attention control difficulties but as attention is a learned skill, it was noted that the use of “good sitting” through to “good listening” had a number of pay off’s in group based learning activities at nursery, where her attention was more likely to wander. It also gave the staff a strategy for bringing her back on to task.
 

The focus on the input mode enabled her to participate in all the tasks and the programme was followed in the order given, but over a much longer time span, although it probably equated to around 100 days. A greater amount of time was also spent comparatively in the initial stages in presenting the individual sounds for discrimination, alongside learning the sound based lingustic concepts. This also had benefits in facilitating Rosie’s discrimination skills generally. She was able to match, sort and create categories of her own for sorting by the end of the programme and she could tell us why she had done so. 
 

The concept of errorless learning advocated, suited our needs well, allowing Rosie to succeed every time and the use of recurrent themes, meant that Rosie’s individual learning style could be responded to. Due to the delivery constraints of the home teaching service, Rosie was seen once every six weeks and the interim teaching was carried out on a daily basis by her mother and by an early years childcare practitioner at mum’s workplace nursery. This worked well as new work was modelled and practised and then reinforced and revisited. Having three people involved also increased the range of learning opportunities and meant that Salley was being delivered even when it was not Salley time. For example, Rosie was encouraged to participate in more literacy activities within the nursery and her lack of spoken language was not seen as a lack of ability to participate – thus expectations overall were raised, which also has been shown to have a profound influence on outcome.
 

One of the major gains was the increase in speech sound production generally. The focus on the input route and the introduction of individual phonemes seemed to increase Rosie’s awareness that the sounds existed. In fact the time Rosie was three and a half she had a complete phonetic inventory of single sounds ad she was using the sounds contrastively to signal meaning – with the exception of th – which would be considered typical for her age. We felt that Salley had had a direct impact on the quality of articulation well as the quantity. Pure phonics and syllable awareness seemed to play a part in this. Her sentence sequencing skills had also been enhanced, we believe through working on auditory memory and sequencing and teaching her that order/ sequence mattered. All her expressive language was spoken and she was rapidly dropping the signs in favour of spoken language alone. She continued to use the visual modality to support her learning of new concepts.

By the time Rosie was due to enter state nursery school at CA 3:2, she had “graduated” from Salley and could:

• sort words on the basis of their syllable structure
• decode 3 and 4 letter words and “read” them out loud or find a corresponding picture
• make a 3 letter word when given a verbal model or a “silent” picture so she had to generate the representation in her head
• sort words according to whether they rhymed or not and say why she had sorted or grouped words (represented by picture – no visual matching involved)
• alliterate
• find the position of a given sound in a CVC (Consonant vowel consonant word or non word) beginning, middle, end
   

In addition, Rosie’s auditory memory was commensurate with her visual memory. She was able to sequence three items in a posting game and could also sequence three sounds eg find me and post l, b, a  from an array of six letter cards. Given that the results of a study by Brock and Jarrold (2005) “ provide strong evidence that Down syndrome is associated with a selective deficit in verbal short-term memory, and a deficit in verbal serial order memory in particular”, any intervention which may have an impact on these, is noteworthy.
 

Rosie’s language development also benefited. She had the concepts at her disposal, for example to describe rhyme and real words versus non- words, which gave us further insights into how she perceived and tackled a task. This in turn as a strategy, may help us to help Rosie learn. The use of recurrent themes was particularly beneficial – and has facilitated consolidation and longer maintenance of the areas covered. In addition, Salley enabled Rosie to be faced with and to succeed in solving more challenging problems. As Fisher (2006) pointed out “cognitive challenge is important at all stages, but especially in the early years of education.

Clearly all these skills gave her sound underpinning for structured phonic teaching in relation to writing.

Overall, Rosie taught me a lot about the role that high expectations have. Not that many years ago when I started working in a school for children with moderate/ severe learning difficulties, there was still in evidence a move to teach functional vocabulary – e.g. toilet, exit, only. Reading for pleasure and for learning was not considered a priority. Thankfully much has changed and now I know that if a child is to become literate, it is never too early to start and that phonological awareness is absolutely fundamental. In fact as the Rose Review pointed out “the knowledge, skills and understanding that constitute high-quality phonics work should be taught as the prime approach in learning to decode (to read) and encode (to write/spell) print”. Independent Review of the Teaching of Early Reading, paragraph 240, page 70.
For children with Down syndrome, we also have to be mindful that learning has to be a positive and motivating experience, as research has shown that affect can influence the desire of an individual to engage in a task in the future. More dramatically, the  Down Syndrome Research and Treatment Foundation (2008) point out that  “ a 10-20% improvement in cognitive capability can provide a greater number of people with the ability to live independently, to hold a job and to be more integrated into their communities”.

References.

Adams, Marilyn Jager. 1990.Beginning to read: Thinking and learning about print. Urbana-Champaign, IL: University of Illinois,

Bayliss, P (2000) The Reading Skills of Children with Down Syndrome. ISEC.
Brock J, Jarrold C  (2005) Serial order reconstruction in Down syndrome: evidence for a selective deficit in verbal short-term memory
J Child Psychol Psychiatry 46 (3): 304-16 (2005 Mar)

Buckley,S and Bird, G (2001) Speech and Language development for children with Down Syndrome. Down Syndrome Issues and Information

Buckley SJ, Sacks B.  (2001) An overview of the development of infants with Down syndrome (0-5 years). Down Syndrome Issues and Information.

Carroll, Julia M., Snowling, Margaret J., Stevenson, Jim and Hulme, Charles (2003) The development of phonological awareness in preschool children. Developmental Psychology, 39, (5), 913-923.

Cossu G, Marshall JC, (1990) 'Are cognitive skills a prerequisite for learning to read and write?: Cognitive Neuropsychology 7:p21-40

Cossu G, Rossini F,Marshall JC (1993) 'When Reading is acquired but phonemic awareness is not: A study of literacy in Down Syndrome: Cognition 46:p129-138

Ehri, L. C. (2003). Systematic Phonics Instruction: Finding of the National Reading Panel. Paper presented at the seminar of the Standards and Effectiveness Unit, Department of Education and Skills, British Government, London, England.

Fisher R. (2006) ‘Thinking Skills’, in Arthur J, Grainger T & Wray D (eds) Learning to teach in primary school , Routledge Falmer

Fletcher H, Buckley SJ. (2002)  Phonological awareness in children with Down syndrome. Down Syndrome Research and Practice. 2002;8(1);11-18.

GOSWAMI, U., & BRYANT, P.E. (1990). Phonological skills and
learning to read. London: Erlbaum.

Muter, V (1996) - Dyslexia, speech and language: a practitioner's handbook.
Predicting children's reading and spelling difficulties
 Reid, G (1998)  Dyslexia – a practitioners handbook. Wiley
Rondal, J (1999)Exceptional language development in Down Syndrome – implications for cogntive language relationship. Applied linguistics CambridgeUniversity Press.5)

Snowling M.J. Hulme C.; Mercer R.C. (2002) A deficit in rime awareness in children with Down syndrome Reading and Writing, Volume 15, Numbers 5-6, September 2002 , pp. 471-495(25)

Stackhouse, J and  Wells, B (1997) Children's Speech and Literacy Difficulties — a Psycholinguistic Framework  Stackhouse & Bill Wells (London: Whurr Publishers Ltd

Wishart J G, (1996) 'Learning in Young Children with Down's Syndrome: Developmental Trends. In Rondal JA, Perera J, Nadel L Comblain A (eds) 'Down's Syndrome Psychological Psychobiological and Socio-Educational Perspectives 'chapter 6.p81-96.London Whurr

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