La Trobe University
Children with Down syndrome often acquire expressive vocabularies at a rate that is not only significantly slower compared to typically-developing peers, but also to peers with other kinds of intellectual and developmental delays and disorders (Wright, Kaiser, Reikowsky, & Roberts, 2013). Frequently, children with Down syndrome are also subject to deficits in their ability to store and encode speech sounds into memory, process auditory information, and, in some cases, reliably and accurately hear speech in the first place (Wright et al., 2013).
It is clear, then, that it cannot be assumed that approaches which have been suc- cessful in remediating the communication skills of other populations will necessarily yield the same results in children with Down syndrome. Moreover, even when posi- tive results are obtained, there is good reason to anticipate that these effects will not be maintained outside of the treatment condition (e.g., in the home or preschool, as opposed to the clinic) or beyond the conclusion of the treatment (Kaiser & Roberts, 2013). Interventions aimed at improving the expressive language skills of children with Down syndrome must, therefore, employ teaching strategies that will facilitate the long-term maintenance of these skills in contexts and situations outside of the therapy session (Kaiser & Roberts, 2013; Wright et al., 2013).
Leveraging those areas of communication in which children with Down syndrome tend to possess strengths has been one strategy pursued by researchers and therapists in order to improve language gains for this population. One communicative strength that tends to be prevalent in children with Down syndrome is that they tend to use gestures with greater frequency, and for a longer period of time than do their typically-developing peers (Wright et al., 2013). Consequently, approaches which leverage this strength by teaching gestural signs to children with Down syndrome in addition to speech is an approach that has been investigated by researchers as a means of promoting the development of spoken-language capabilities in children for DS, and for which there exists some tentative evidence (Wright et al., 2013).
Additional strengths that can potentially be leveraged in children with Down
syndrome are their social skills and engagement in social activities. Naturalistic
approaches to teaching language skills aim to incorporate said teaching into everyday
routines and play activities, and involve a high degree of social interaction between the
child and either the therapist, or appropriately-trained caregivers, and are therefore
well suited to build upon the strengths children with Down syndrome possess in
the social domain—and this seems to be supported moderately-well by the available
research evidence (Wright et al., 2013).
One particular naturalistic approach—milieu teaching—is specifically designed to embed the teaching of language skills in a way that reflects the child’s immediate interests in their environment. Rather attempting to direct the child’s attention to teaching content or aids, the content is instead adapted to conform to what the child is interested in exploring at any given point in the interaction (Hemmer & Kaiser, 1994). Enhanced milieu teaching builds upon the milieu teaching model by incorporating specific strategies to increase the responsiveness (the frequency and quality of the ways in which the communication partner, be it a caregiver or educator, responds to the child’s utterances or other attempts at communication) of the adult communication partner to the children in these interactions (Hemmer & Kaiser, 1994).
What are some of the main benefits of milieu and enhanced milieu teaching for children with Down syndrome?
Milieu and enhanced milieu teaching represent potentially advantageous inter- ventions for children with Down syndrome for a number of reasons. Both approaches can be incorporated into everyday routines and play activities, and so can be practised in a wide range of different settings. This means that there are more opportunities for the child with Down syndrome to engage in communication with other people, even when he or she is not in the clinic or participating in a structured therapy session (Wright et al., 2013).
In addition to being able to implement milieu and enhanced milieu teaching in a diverse range of settings, it is also possible to train parents, givers, teachers, and other adults in the life of a child with Down syndrome to deliver the intervention. This often means that the child’s communication partner is highly responsive to their communications, and thus said communications engender social rewards which motivate the child to persist with, or even amplify, their attempts at communication. Persistence with communication has often been found to flag in children with Down syndrome, so this particular feature of milieu teaching makes it particularly well suited to ameliorating levels of motivation and persistence (Wright et al., 2013).
Does training parents in milieu teaching benefit children with Down syn-
Research evidence to date tentatively supports a link between the frequency of prelinguistic communication (for example, gestures or single words) and and later language development in both typically-developing and delayed-development children (Yoder & Warren, 2002; Yoder, Woynaroski, Fey, Warren, & Gardner, 2015). With this in mind, exposing children with Down syndrome to as many opportunities for practising pre-linguistic communication in the context of milieu teaching may mean that later language outcomes are more favourable (Warren, Yoder, Gazdag, Kim, & Jones, 1993; Yoder et al., 2015). One avenue via which increased frequency of communicative interactions can be obtained is by having people in the life of the child with Down syndrome trained to deliver milieu or enhanced milieu teaching. And as it is usually parents and caregivers who spend the most time with their children, they are the ones who would be able to deliver milieu teaching interventions with the greatest frequency (Wright et al., 2013).
Why not teach language skills more directly or explicitly to children with Down syndrome?
Acquiring the rule sets and other components of human languages is only pos- sible when a child has reached a particular stage of maturation. Before this point is reached, a child simply does not meet the developmental requirements for learning language, and every effort to instil language prior to this developmental milestone be- ing reached will result in failure. The same is true of children with Down syndrome, except that the duration of this pre-language or pre-linguistic period is significantly greater than for typically-developing peers (Yoder et al., 2015).
Targeting language acquisition directly is, for the aforementioned reasons, liable to yield few if any benefits until the child receiving therapy has passed through the necessary developmental steps that prepare him or her to learn language. Moreover, attempts in this direction may well frustrate the child, and thus lead them to associate interpersonal communication with negative emotional states. The child with Down syndrome would likely benefit far more, both in the short and long term, from therapy which instead generates positive associations by way of enhancing pre-linguistic skills that the child can use to engage with significant others in successful and rewarding ways. These positive associations can then serve as motivational support during later learning targeted at language acquisition (Yoder & Warren, 2002).
Why might it be important to increase parent responsiveness?
Outcomes for milieu and enhanced milieu teaching are influenced by a number of factors, including the responses of parents who participate in and deliver these therapies to children with Down syndrome. Children whose parents more responsive to their communication attempts tend, when all else is equal, to experience improved language-development outcomes (Yoder & Warren, 2002). When the child with Down syndrome is successful in using pre-linguistic communications to make requests which are then fulfilled by his or her parent, an intrinsic reward mechanism emerges that provides a plausible mechanism for the child developing greater motivation in the area of communication and language learning, thus supporting later progress towards language acquisition (Yoder & Warren, 2002). One of the advantages of enhanced mi- lieu teaching in particular is that it equips parents with specific strategies to provide higher-quality responses to their children, which typically take the form of acknowl- edgements of the child’s communicative attempt, or expansions of the content of the child’s communication into linguistic forms which are appropriately targeted to the child’s developing linguistic skills (Hemmer & Kaiser, 1994; Kaiser & Roberts, 2013).
Hemmer, M. L. & Kaiser, A. P. [Ann P.]. (1994). Enhanced milieu teaching: Effects of parent-implemented language intervention. Journal of Early Intervention, 18(3), 269–289. doi:10.1177/105381519401800303. eprint: https://doi.org/10. 1177/105381519401800303
Kaiser, A. P. [Ann P] & Roberts, M. Y. (2013). Parent-implemented enhanced milieu teaching with preschool children who have intellectual disabilities. Journal of Speech, Language, and Hearing Research, 56 (1), 295–309.
Warren, S. F., Yoder, P. J., Gazdag, G. E., Kim, K., & Jones, H. A. (1993). Facilitating prelinguistic communication skills in young children with developmental delay. Journal of Speech, Language, and Hearing Research, 36 (1), 83–97.
Wright, C. A., Kaiser, A. P., Reikowsky, D. I., & Roberts, M. Y. (2013). Effects of a naturalistic sign intervention on expressive language of toddlers with down syndrome. Journal of Speech, Language, and Hearing Research, 56 (3), 994–1008.
Yoder, P. J. & Warren, S. F. (2002). Effects of prelinguistic milieu teaching and parent responsivity education on dyads involving children with intellectual disabilities. Journal of Speech, Language, and Hearing Research, 45 (6), 1158–1174.
Yoder, P. J., Woynaroski, T., Fey, M. E., Warren, S. F., & Gardner, E. (2015). Why dose frequency affects spoken vocabulary in preschoolers with down syndrome. American journal on intellectual and developmental disabilities, 120(4), 302– 314.