Speech Sound Disorders and Children with Down syndrome

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Continuing our discussion on speech in children with Down syndrome, today we’re going to explore speech sound disorders.

Speech sound disorders may cause problems making individual sounds or difficulty with groups of sounds. Sounds can be changed, left off, or added. The two speech sound disorders we’ll focus on today are articulation disorder and phonological disorder.

Articulation Disorder: Explanation and Treatment

A child who has only one or a few sound errors may be diagnosed with an articulation disorder. For example, a child may substitute the “w” in the word red  changing theart word to “wed.” Even a few errors may make it hard for people to understand your child – especially if they don’t know the topic! 

The underlying cause for this type of speech disorder is largely unknown but in children with Down syndrome this may be related to structural differences in the mouth, persistent ear infections or fluid-filled ears, or other health problems that interrupt development. This type of speech sound disorder is different from dysarthria (muscle weakness), apraxia (muscle coordination), or phonological disorder which is discussed below.

Traditional speech therapy focuses on individual sounds.  Treatment may involve showing how to produce the sound correctly, teaching the child to recognize correct and incorrect sound productions, and practicing sounds in different words. The goal is for accuracy of each sound in all positions of the word (beginning, middle, and end), in phrases, sentences, and ultimately in conversation.

Phonological Disorder: Explanation & Treatment

© Mommy Speech Therapy www.mommyspeechtherapy.com

© Mommy Speech Therapy www.mommyspeechtherapy.com

Another type of speech sound disorder is called a phonological process disorder. This disorder is related to understanding and using the rules of speech production.  As children grow they learn how to organize the sounds of speech. They listen to the sounds around them storing each in their mind. When they begin speak on their own children depend on the stored sound (s), combined with the rules they learned listening to mature speech, to produce sounds themselves.

Children don’t start off with perfect speech. Instead, they naturally simplify speech as they are learning to talk – this is called using phonological processes. As they grow and learn the rules of adult speech they replace this child-like form of talking. If the child continues to use these processes past the age when it is considered developmentally appropriate they may be diagnosed with a phonological disorder.

Treatment for phonological disorders involves targeting each process or class of sounds. This starts by targeting the group of sounds that mature or are established first. For instance, your child may leave the ending off of words (eat to “ee”) and glide sounds (changing “r” and “l” to “w” and “y” – like love to “yuv”). So the SLP would first establish a goal  to have the child produce final sounds, then later address the process of gliding. Heidi at Mommy Speech Therapy has a very nice post with links to treatment ideas for phonological disorders.

Phonological disorders are not related to difficulty producing sounds because of muscle weakness or poor coordination. Rather, the child exhibits difficulty organizing sounds and understanding the rules that govern their production. Ultimately it’s a language problem. This is why techniques that focus on strength or coordination often prove ineffective when trying to improve speech accuracy. In children with Down syndrome, improving working memory may have a positive effect on speech production as the child uses more complicated words and sentences.

An SLP with experience in speech sound disorders will help differentiate these disorders. It is crucial to have an accurate diagnosis in order to effectively improve your child’s speech. We will continue our series on speech disorders looking at apraxia and stuttering in upcoming posts.

Understanding speech problems in children with Down syndrome

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In honor of Better Hearing and Speech Month I am resurrecting and updating a series of posts on common speech disorders in children with Down syndrome. I said it two years ago and it remains today - the most frequent concern I hear is,

whatchasay

“I can’t understand what Joe says. He gets so frustrated because he knows what he wants to say, but it is so unclear! What can you do?”

Contrary to comments I’ve heard, there is no such thing as “Down syndrome speech.” Unclear speech is a symptom of a larger problem. It is important to mention that before your child undergoes a speech evaluation, make sure they’ve had a recent hearing test (within 12 months to the test date). Even mild hearing loss can affect your child’s ability to hear sounds and produce them accurately.

To understand how to improve speech we first need to determine the kind of speech disorder presenting itself. The most common types of speech disorders in children with Down syndrome are as follows:

  • Speech Sound Disorders  - Two types of disorders in this category include 1.) articulation disorder (problems making individual sounds) and 2.) phonological disorder (problems with groups or patterns of sounds).
  • Dysarthria - One type of motor (muscle movement) speech disorder where the muscles of the mouth, face, and/or respiratory (breathing) system may be weak or move slowly. It is important to remember not all children with low tone have dysarthria.
  • Childhood Apraxia of Speech - Some children with DS have apraxia. Like dysarthria, apraxia is a motor speech disorder. Unlike dysarthria it is not due to weakness. Instead, the brain has difficulty planning the movements of the muscles that create speech. Other signs of apraxia include limited consonant and vowels, an appearance of ‘groping’ movements when trying to say sounds, and inconsistent sound errors that are not the result of immaturity or other speech disorder.
  • Stuttering - A disorder in which the flow of speech is broken by repetitions (li-li-like this), prolongations (lllllike this), or abnormal stoppages (no sound) of sounds and syllables.

In order to determine what kind of speech problem affects your child’s speech a thorough evaluation with a speech pathologist (SLP) is necessary.

An SLP is trained to :

  1. Look at the structures that create speech. This includes watching non-speech (puckering, smiling, sticking the tongue out) movements during an oral mechanism examination.
  2. Listen to speech. An experienced clinician will be able to distinguish patterns (or lack of patterns) to understand the type of errors affecting your child’s speech.
  3. Analyze. The SLP will likely use a standardized assessment such as the Goldman Fristoe Test of Articulation to identify sound errors in spontaneous and imitated words. A speech sample during play may also be used.
  4. Diagnose. Usually a differential diagnosis can be completed in one session. However, depending upon the child’s age, cooperation, or type of speech disorder additional visits may be needed. This is especially true of apraxia, a notoriously difficult disorder to accurately diagnose.

Once a diagnosis is made the speech pathologist can help create a treatment plan that specifically addresses your child’s speech disorder.

“Why does it matter what kind of speech disorder the child has – Can’t you just fix it?”

It matters a great deal! If you take your car in because the check engine light is on and the dealer turns it off without addressing the real problem … the light will come back on. The underlying problem isn’t solved.

There are specific ways to target each type of speech disorder. While they all have similar elements, there are very significant differences. Most importantly if your child isn’t properly diagnosed this may lead to ineffective treatment (not to mention a waste of time and money).

Over the next few posts I will address each type of speech disorder as it relates to children with DS. Treatment techniques, tips, and tools will be discussed.

DS/ASD as I know it: The process of diagnosing autism in children with Down syndrome

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pointAlthough Autism Awareness Month is over, today starts May is Better Hearing & Speech Month! To continue our series on dual-diagnosis is an interview with Jennifer Weiner, MA, CCC-SLP. Jennifer is a speech-language pathologist who has worked in clinical and educational settings treating children with a variety of developmental disabilities, including Autism and Down syndrome, for the last twenty years.  With extensive experience in autism, she joined the diagnostic team at The Kelly O’Leary Center for Autism Spectrum Disorders, in the Division of Developmental and Behavioral Pediatrics at Cincinnati Children’s Hospital Medical Center, in 2011. 

Jennifer, Thank you for sharing your expertise with us. When evaluating a child with Down syndrome (DS) for possible autism spectrum disorder (ASD), what is the assessment like? 

The assessment process at The Kelly O’Leary Center is performed on an interdisciplinary level.  Children are typically seen by a psychologist, speech-language pathologist, and a medical provider.  Occasionally, the referring physician will request occupational therapy and/or special education evaluation as well.  The psychologist will first do a Diagnostic Interview with the child’s caregiver.  This is followed by a psychological evaluation in which various assessments are used.

The speech-language pathologist typically performs an evaluation using appropriate standardized language assessments in addition to the Autism Diagnostic Observation Schedule-2 (ADOS-2).  The ADOS-2 is an instrument that is used for assessing autism.  This instrument consists of structured and semi-structured activities that observe a child’s language and communication skills as well as their social interaction.  The ADOS-2 also notes the presence of restricted and repetitive interests. Observations are then categorized into these three areas and research-determined cut-offs identify the potential diagnosis of autism or an autism spectrum disorder.

Once all assessments are completed, the physician compiles the information and determines the most appropriate diagnosis based on the findings of the multi-disciplinary evaluation team.  An information sharing session is then scheduled for the family where results are reviewed and recommendations are made. 

The ADOS-2 is very different from other tests. What features influence the results on this measure?

As stated, the ADOS-2 looks at language and communication, social interaction, and for any repetitive interests or behaviors.  However, there are various factors and behaviors which can impact the scoring of the ADOS-2, thus elevating the individual’s score. For example, activity level or impulsivity may impact a child’s level of engagement and his or her social overtures but does not necessarily preclude an autism spectrum diagnosis.  For reasons like this, the results of the ADOS-2 in children with Down syndrome, as well as all other developmental disabilities, should be interpreted within the context of other reported information, assessments, and clinical judgment before a medical diagnosis is made.  In no way are the results of the Autism Diagnostic Observation Schedule-2 interpreted in isolation to confirm or rule out a diagnosis of autism. 

Why is the accuracy of diagnosis so important in children with Down syndrome and autism?

Having a clear diagnosis opens the door for appropriate services.  Areas of need should guide treatment.  If there is a dual-diagnosis, it is important to choose treatmentbaby strategies specific to the needs of the child. This means that a child with DS and ASD may benefit more from  treatment strategies that are typically used for children on the autism spectrum. For example, a child with Down syndrome may have the foundational skills, including gestural communication and social interaction skills that will allow him/her to access educational settings, services, and communication aides that may differ from a child with a diagnosis of both autism spectrum and Down syndrome. 

Over the years, I have had the opportunity to provide speech-language services in a variety of school environments, including self-contained settings as well as integrated or mainstreamed classrooms.  In my experience, while having an appropriate diagnosis is helpful for access to resources, I have found that all children typically receive the related services necessary to meet their Individualized Education Plan as determined by their educational team.

 Jennifer, what are the areas focused on in speech-language therapy in children with a dual-diagnosis?

An integral part of treatment for autism includes goals targeting the child’s social-interaction skills. Treatment should address the symptoms that most significantly interfere with the child’s daily life. In a child with a dual-diagnosis this may require direct work targeting foundational communication skills that we often expect children with DS to have. These skills include directed eye-gaze, gestures, pointing, facial expressions, joint attention, and shared enjoyment.

Thank you so much for taking the time to answer my questions. It is so helpful to understand the process a bit more. 

Jenn

Mini-Moment: What to tell a grad student about your child?

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This Monday, April 29th I will once again guest lecture for the speech language pathology graduatestudents students of Miami University. I always have fun teaching SLP’s in training about Down syndrome and would like to add a new twist this year.

What advice do you, as a parent of a child with DS, want to tell a future SLP?

If you’ve started the speech therapy journey, I would love your input. I am looking for ways interest budding clinicians in Down syndrome through words of encouragement from you!

Comments here or on my Facebook wall (Talk Down syndrome) are appreciated! If you have a photo to share, please send my way.

Jennifer

DS/ASD as I know it: An interview with an adoptive parent

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stockphoto.com

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Continuing our series on dual-diagnosis I’ve asked Mary to share her experience as mother and adoptive parent. She shares the story of her son Michael and the decision to adopt their son Brendan. Both boys are diagnosed with Down syndrome and autism.

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Mary, thank you for letting me interview you. First, will you give a little background on your family?

My husband Ken is one of 6 kids; I’m one of 2. He grew up on a farm; I grew up in a suburb of Cleveland. Both previously married, I had 3 kids and he had none. I had no experience with individuals with special needs, but he has a younger sister who had spinal meningitis (misdiagnosed) as a baby, and thus has mental retardation, epilepsy, and a whole host of other things.

And together you had Michael. After his diagnosis of Down syndrome, what was the process for diagnosing ASD?

‪We knew Michael “marched to a different drummer” than the rest of the kids in our DS group, but thought it was because he had been hospitalized so much because of all of his birth defects. A friend whose son is autistic and attended the same preschool suggested that we have Michael tested because his behavior was very similar to her son’s. So I made an appointment with Dr. Bonnie Patterson, who set us up with a behavioral test.

After the very complex start to Michael’s life, what prompted you to adopt?

The decision to adopt had a lot of facets. I had heard Robin Steele speak at a conference about adoption, I had read an article about a family who had a son with DS and adopted another, and being on the MVDSA board, I knew of couples who didn’t want to raise a child with DS.

Both Ken and I felt we had enough room in our hearts for another child, and that we could offer them love and a good home and life. If the child had special needs, OK, but that wasn’t a requirement. But if it did, we already had a wonderful network established and they could fit right in.

Kids with special needs were nothing new to Ken, and I realized before Michael was born, that children are children, no matter their health, quirks, intelligence, or anything else. Everyone wants to have a chance to love and be loved. Everyone deserves a home where they can be accepted for who they are, where all pretenses can be dropped. Unconditionally.

When did you first realize Brendan [Mary’s youngest son] also had autism?

Almost immediately. Although children’s services in Idaho declared that autism was not a factor on his “bio sheet”, if you look at his picture taken when they brought him to Cincinnati, he is doing a major full body stim in the airport lobby.

How do you balance therapy, school, and family?

raft

“We have learned that our life is like white water rafting. Hang on tight, go with the flow, and enjoy the ride!” Mary

Flexibility is the name of the game! When the boys were younger, I would schedule their doctor and therapy appointments back-to-back, and since no one could walk, I would pull a large wagon. As boys got heavier and more able, I started scheduling them separately. So if the boys have therapies every other week, we alternate weeks. I try to schedule appointments so that the non-appointment child is in school.

Surgeries usually mean I call my sister for help. We have learned that no matter how badly we may want to go somewhere, or do something, the guys need to come first. Many plans have been cancelled at the last-minute, and while it may be disappointing, pitching a fit and crabbing will definitely not make things any different, and definitely not better! We have learned that our life is like white water rafting. Hang on tight, go with the flow, and enjoy the ride!

What advice can you give to families with similar situations (DS/ASD diagnosis or considering adoption)?

With both things I think it’s helpful to have a heart-to-heart talk with your partner. Discussion of each of your strengths and weaknesses, what your expectations are, and become a true team, where you complement each other (with regards to both becoming adoptive parents or parents of a child with special needs).

Be gentle with each other and yourselves. Be realistic.

There are some days the dishes and/or laundry won’t make it to the sink or hamper, let alone get done.

There will be good times and tough times.

You’ll make mistakes, but we all do. You’ll learn from them and grow stronger. There will be lots of tears, but also lots of laughter.

Every parent of a child with special needs that I have talked with has said the experience has made them a better person – More compassionate and empathetic. And every night, when you reflect back on your day, you can sleep well because you’ll have given it your best shot. And you’ll have given someone else unconditional love, and their own chance to give life their own best shot.

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Thank you Mary for your insightful, realistic, and encouraging words! Jenn

If you are considering adoption of a child with Down syndrome a helpful resource is the National Down Syndrome Adoption Network.