Speech-language therapy stimulation in children with Down’s syndrome

ABSTRACT

Objective:

to analyze the contributions of speech-language therapy to the language development of children with Down syndrome (DS).

Methods:

eleven children with DS participated in the research. The children were between zero and five years of age, of both genders and attending a university extension project involving eight therapy sessions following stimulation guidelines. Children were evaluated before and after speech-language stimulation. The stimulation guidelines were based on the following aspects of language development: coordination of sensorimotor schema, constitution of object permanence, gestural/body imitation, imitation of utterances, deferred imitation and use of symbolic schema, communicative intent, receptive vocabulary and expressive vocabulary: words and phrases. The study was approved by the Research Ethics Committee of the institution. Data were analyzed quantitatively.

Results:

there were significant differences in the pre- and post-speech-language intervention in the following skills parameters: gestural/body imitation, imitation of utterances, deferred imitation and use of symbolic schema, communicative intent and receptive vocabulary.

Conclusion:

early stimulation of linguistic and cognitive aspects is important in the development of children with DS, as evidenced by the immediate development of speech-language skills in children after the intervention.

Keywords:
Speech-language; Down syndrome; Language; Rehabilitation of Speech and Language Disorders

RESUMO

Objetivo:

analisar as contribuições da intervenção fonoaudiológica para o desenvolvimento da linguagem em crianças com síndrome de Down (SD).

Métodos:

os participantes da pesquisa foram 11 crianças com SD, entre zero a cinco anos de idade de ambos os sexos, que foram atendidos em um projeto de extensão universitária, durante oito sessões terapêuticas pautadas em diretrizes de estimulação. Antes e após a estimulação fonoaudiológica foi realizada a avaliação das crianças. As diretrizes de estimulação contemplavam os seguintes aspectos do desenvolvimento da linguagem: coordenação dos esquemas sensório-motores; constituição da permanência do objeto; imitação gestual/corporal; imitação de produções orais; imitação diferida e uso de esquema simbólico; intenção comunicativa; vocabulário receptivo e vocabulário expressivo: palavras e frases. O trabalho foi aprovado pelo comitê de ética em pesquisa da instituição de origem. Os dados foram analisados quantitativamente.

Resultados:

houve diferença estatística nos resultados pré e pós-intervenção fonoaudiológica em habilidades dos parâmetros de: imitação gestual/corporal, imitação de produções orais, imitação diferida e uso de esquema simbólico, intenção comunicativa e vocabulário receptivo.

Conclusão:

a estimulação precoce de aspectos linguísticos e cognitivos é importante no desenvolvimento da criança com SD, como observado na evolução terapêutica imediata da crianças após a intervenção fonoaudiológica.

Descritores:
Fonoaudiologia; Síndrome de Down; Linguagem; Reabilitação dos Transtornos da Fala e da Linguagem

Introduction

Down syndrome (DS) is a genetic alteration of chromosome 21. It is the most common syndrome in the world and can be observed in different regions and races and among different socioeconomic levels. This chromosomal disorder affects the development a person's motor, cognitive, language, self-care and socialization skills¹.

In terms of language in this population, especially when compared with typically developing (TD) children, the expressive area develops later than and out of phase with the receptive area and symbolic function^2,3. Furthermore, the lexical, receptive and expressive performance of children with DS is lower than that of children with TD, even when matched for mental age¹.

The development of oral language involves a complex series of cognitive, perceptual and language skills that start to form in the preverbal period. Symbolic construction is a cognitive ability that is essential to linguistic sign formation and, consequently, to the use of words as a form of expression. Therefore, the development of symbolism is directly related to oral language^4,5.

DS causes a deficit in language development, but even with this difficulty, a person with the syndrome can use language and to develop it if this process is stimulated effectively by family members and by a multidisciplinary team, particularly by a speech-language therapist.

The symbolism and cognition of children with DS serve as a basis for the development of representation skills, which are related to the emergence of oral language. This language modality is of fundamental importance to the subject's development and is the starting point for future language acquisition, such as reading and writing.

To encourage the development of cognition and language, interventions are needed at every life stage of a person with DS and must be developed according to each individual's characteristics.

Speech-language interventions oriented toward language development in DS have a unique importance because earlier intervention results in greater stimulation of the subject’s brain plasticity. This term includes an adaptive skill/ability to modify the structural and functional organization of the central nervous system, which is affected by the quality, duration and form of stimulation that the individual receives so that he/she can develop⁶.

Brain plasticity can help promote language development in children with DS; moreover, the therapeutic process is more promising when these children receive intervention as early as possible. Therefore, studies are needed to examine the language development process in this population of children to provide insights into speech-language therapy in terms of the development and selection of resources and strategies that aid in the complex journey of language acquisition².

Thus, speech-language therapy that is appropriate for language development in children with DS would help reduce further losses, contribute to their overall development and could offer them a better quality of life and increased interaction with the environment as well as stimulate his/her learning, providing greater independence, within their limitations, along with better social performance and the development of reading and writing.

Therefore, the goal of this study is to analyze the contributions of speech-language therapy to language development in children with DS.

Methods

All ethical considerations were preserved during this research, and this study was approved by the Ethics Committee for Research with Human Beings of the home institution under approval number 0386/15 and CAAE No. 46076215.8.0000.5188. The protocol respected all provisions of Resolution #466/2012 of the National Health Council relating to ethics in research involving human subjects.

The research was conducted at the Speech-Language Clinic-School of the home institution under the auspices of the extension project "Literacy at Stake: Speech-language interventions in subjects with Down syndrome." The research was descriptive, experimental and longitudinal in nature.

Forty-nine individuals with DS, aged between zero and 33 years old, were included in the extension project. The eligibility criteria for participation in the study were as follows: child with DS, of either gender, aged between zero and five years old, with no other syndromes or associated hearing loss, regularly attending the extension project and whose guardians had given their consent to participate in all study procedures. Eleven children with DS met the eligibility criteria and participated in the research.

Data collection began after interviewing the children's parents and explaining the research objectives and procedures. After signing the terms of free and informed consent, the subject's initial evaluation was conducted, based on the application of an evaluation plan for the early development of language and cognition in DS. This plan had been developed for use in the extension project by means of an analysis of treatment plans for this population⁷ (^{Appendix A}).

The evaluation plan had eight points of inquiry: 1. Coordination of sensorimotor schemas, 2. Constitution of object permanence, 3. Gestural/body imitation, 4. Imitation of utterances, 5. Deferred imitation and use of symbolic schema, 6. Communicative intent, 7. Receptive vocabulary and 8. Expressive vocabulary: words and phrases. The researchers evaluated the children at each point of the plan and kept a record of the participants’ responses as follows: unsatisfactory (U), the child did not perform the proposed activity; regular (R), the child performed the activity partially or performed the whole activity with the therapist's help; or satisfactory (S), the child performed all activity autonomously, without the therapist's help.

The evaluation plan points then served as clinical guidelines for the speech-language process that was applied to the research participants. The guidelines contained specific evidence for the researched group, and each was applied in one therapy session (Figure 1).

Figure 1:
Speech-language stimulation guidelines in Down syndrome

The guidelines were applied to the children with DS by two therapists who worked on the extension project and who were Speech-Language Therapy undergraduates at the home institution, trained by the study researchers and given a prior schedule of the goals to be achieved in the therapeutic sessions.

Student training occurred over the course of eight meetings as the research was being conducted. In this training, the researchers presented the objectives and procedures for each session, performed simulations and engaged in theoretical and case discussions for each stimulation guideline.

After each child's eight-week intervention, comprising one appointment every week, the evaluation plan was reapplied to verify the effectiveness of the therapeutic interventions in order to investigate the benefits of speech-language therapy for the development of children with DS. It should be emphasized that the parents were not involved in the evaluation sessions, guideline application or reevaluation. The extensions provided information about the procedures performed, and the guardians were given guidelines after the treatments.

Finally, the before and after speech-language therapy responses in each plan were evaluated. The study variables included the items investigated by the evaluation plan and stimulated by the intervention guidelines. These variables were described numerically and systematized for data analysis (Figure 2).

Figure 2:
Study variables for each stimulation guideline

The data were categorized and entered into a digital spreadsheet. Subsequently, the variables were analyzed descriptively and inferentially using the Wilcoxon test for related samples in order to compare the pre- and post-speech-language periods. R Statistical software version 2.11.0 was used, and a significance level of 5% was adopted.

Results

The performance of children with DS on the evaluation plans was compared before and after implementation of the speech-language stimulation guidelines proposed in this study. Statistical differences in variables T5, T7, T9, T11, T12, T13, T15 and T16 were observed between the pre- and post-speech-language stimulation periods (Table 1).

Table 1:
Results of pre- and post-speech-language stimulation

Variable	p-value
T1A x T1B	0.180
T2A x T2B	0.564
T3A x T3B	0.257
T4A x T4B	0.414
T5A x T5B	0.038*
T6A x T6B	0.157
T7A x T7B	0.048*
T8A x T8B	0.119
T9A x T9B	0.048*
T10A x T10B	0.608
T11A x T11B	0.042*
T12A x T12B	0.046*
T13A x T13B	0.008*
T14A x T14B	0.017
T15A x T15B	0.048*
T16A x T16B	0.021*
T17A x T17B	0.317
T18A x T18B	1.000
T19A x T19B	0.257

• Legend: A = Pre-speech-language stimulation; B = Post-speech-language stimulation; T = Test/Study variable (Figure 2)
• Test: Wilcoxon; Significance level p < 0.05*

Based on the data in Table 1, the variables with significant differences were selected, and the results of the initial and final evaluations were determined (Table 2).

Table 2:
Descriptive analysis of variables with significant difference before and after speech-language stimulation

VARIABLES	RESPONSES	SPEECH-LANGUAGE EVALUATION
		PRE-INTERVENTION		POST-INTERVENTION
		N	%	N	%
T5	Unsatisfactory	1	9.1	0	0
	Regular	4	36.4	0	0
	Satisfactory	6	54.5	11	100
T7	Unsatisfactory	3	27.3	2	18.2
	Regular	5	45.5	4	36.4
	Satisfactory	3	27.3	5	45.5
T9	Unsatisfactory	6	54.5	2	18.2
	Regular	2	18.2	4	36.4
	Satisfactory	3	27.3	5	45.5
T11	Unsatisfactory	4	36.4	1	9.1
	Regular	2	18.2	0	0.0
	Satisfactory	5	45.5	10	90.9
T12	Unsatisfactory	4	36.4	1	9.1
	Regular	3	27.3	1	9.1
	Satisfactory	4	36.4	9	81.8
T13	Unsatisfactory	3	27.3	3	27.3
	Regular	4	36.4	0	0.0
	Satisfactory	4	36.4	8	72.7
T15	Unsatisfactory	6	54.5	2	18.2
	Regular	1	9.1	2	18.2
	Satisfactory	4	36.4	7	63.6
T16	Unsatisfactory	6	54.5	2	18.2
	Regular	1	9.1	2	18.2
	Satisfactory	4	36.4	7	63.6

• Legend: T = Test/Study variable (Figure 2)

Discussion

Changes between pre- and post-speech-language stimulation were observed in the tests that analyzed gestural/body imitation (T5), imitation of utterances (T7 and T9), deferred imitation and the use of symbolic schema (T11 and T12), communicative intent (T13) and receptive vocabulary (T15 and T16).

The literature confirms that imitation is very important for the development of socialization, cognition and especially language and affects symbolic play and directed attention in a positive manner⁸. At the end of the sensorimotor period, the imitating action becomes internalized, and the child acquires the ability to mimic events without the presence of the model (deferred imitation). Earlier, imitation is only an extension of action and involves only what the child already has in his repertoire and, in the case of movements, includes those that he/she can see himself/herself doing⁸.

In the imitation of utterances tests (T7 and T9), a reduction in the "unsatisfactory" level and an increase in the "satisfactory" level were observed. In the deferred imitation and use of symbolic schemas tests (T11 and T12), almost all children reached the "satisfactory" level in post-stimulation (Table 2). When the child becomes capable of deferred imitation and representation, the first representative gestures and symbolic schemas are observed and generally combined with the first words⁹. Any type of imitation performed by the child, such as body/gestural imitation, imitation of utterances or deferred imitation, follows a hierarchy preceding future language acquisition.

The DS child first understands facial and language expressions based on the physical context in which communication takes place¹⁰. The use of verbal language can begin in several ways, such as in words and phrases, and emerges from the communicative intentions of the speaker. In this study, it was observed that the children with DS had communicative intent, which was confirmed in the test in which the therapist presented a song and danced with the patient. When stopping the game, it was expected that the child would somehow ask for the music to continue.

It was also noted that in the expressive vocabulary: words and phrases guideline, no significant improvement was observed in the post-intervention responses compared with the initial evaluation. Note that children with DS have a greater developmental delay in this area; thus, the reduced development in the expressive part was because the eight therapeutic sessions were inadequate. Continuation of the stimulation process would be required for improvements to be observed.

Confirming the findings of Lima et al.¹¹ and Seno et al.¹², expressive oral language is typically more changed than receptive language; thus, children with DS use gestural communication in a more persistent and prolonged manner than children with typical development¹³.

Gestures play a predictive role in the lexical development of children with DS, and continuity of preverbal and verbal development can be observed by means of gestural production, which will have no negative influence on the emergence of oral language; in contrast, it can play the role of a "bridge" to the start of these utterances and an increase in lexicon^9,13,14.

Early stimulation aimed at the characteristics of children with DS, associated with the family's adherence to treatment, promotes neural plasticity mechanisms, which is important for the overall development of these children¹⁵. The continuity of speech-language stimulation is crucial to language development in children with DS, as a complex network of skills is involved in this process. Having regular stimulation can aid in the development of all necessary aspects of communication during childhood.

Therefore, some tests may not have registered responses after the eight therapy sessions included in this research; stimulation would need to continue so that these skills can be developed and substantiated, always emphasizing the quality, duration and form by/in which the individual is stimulated. It should be noted that a limitation of this study was that speech-language stimulation was reevaluated immediately after the intervention. Therefore, new studies should be developed in which a later reevaluation of the stimulation is performed, after a longer period of time, to verify the long-term benefits of the speech-language intervention.

Conclusions

Speech-language stimulation contributes to the development of language in children with DS. This study revealed positive and immediate post-stimulation effects on the skills of gestural/body imitation, imitation of utterances, deferred imitation and the use of symbolic schema, communicative intent and receptive vocabulary of the participants.

References

• ¹
  Ferreira-Vasques AT, Abramides DVM, Lamônica DAC. Mental age in the evaluation of the expressive vocabulary of children with Down Syndrome. Rev. CEFAC. 2017;19(2):253-9.
• ²
  Lima ILB. Interações multimodais na clínica de linguagem: a criança com síndrome de Down. [Dissertação] João Pessoa (PB): Universidade Federal da Paraíba; 2016.
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  Flabiano-Almeida FC, Limongi SCO. The role of gestures in oral language development of typically developing children and children with Down syndrome. Rev Soc Bras Fonoaudiol. 2010;15(3):458-64.
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  Santana CCVP, Souza WC, Feitosa MG. Recognition of facial emotional expressions and its correlation with cognitive abilities in children with Down syndrome. Psychol neurosci. 2014;7(2):73-81.
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  Lima ILB, Delgado IC, Cavalcante MCB. Language development in Down syndrome: literature analysis. Distúrb Comun. 2017;29(2):354-64.
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  Seno MP, Giacheti CM, Moretti-Ferreira D. Narrative language and fluency in Down syndrome: a review. Rev. CEFAC. 2014;16(4):1311-7.
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  Zampini L, Salvi A, D'Odorico L. Joint attention behaviours and vocabular development in children with Down syndrome. J Intellect Dis Res. 2015;59(10):891-901.
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  Bello A, Onofrio D, Caselli MC. Nouns and predicates comprehension and production in children with Down syndrome. Res Dev Disabil. 2014;35(4):761-75.
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• Research support source: Scientific Initiation by the National Council for Scientific and Technological Development (CNPq); Master’s Scholarships from the Brazilian Federal Agency for the Support and Evaluation of Graduate Education -(Capes).

APPENDIX A - EVALUATION PLAN FOR THE INITIAL DEVELOPMENT OF LANGUAGE AND COGNITION IN DOWN SYNDROME

(Adapted from Limongi; Fabian-Almeida, Carvalho, 2012 ⁷ )

Publication Dates

• Publication in this collection
  May-Jun 2018

History

• Received
  12 Dec 2017
• Accepted
  27 Mar 2018