Jennifer Gray 2/11/26 Jennifer Gray 2/11/26

Verbal Language for Past, Present, Future

Abstract concepts of **time** (past, present, hours, minutes, seconds) & **quantity** (money and math) require language use of grammar, syntax, and verb tenses.

Why is answering questions so difficult for those with Down syndrome? Answering questions such as “What did you have for breakfast?” can be consistently difficult for those of all ages. Those unfamiliar with Down syndrome are tempted to think the person does not know or cannot remember answers to simple questions when, in fact, they do. Knowledge is rarely the issue. It is retrieval and language structure that are difficult. When we don’t use language to talk about the past and future, we don’t learn underlying time concepts. Grammar, syntax, and verb tenses describe time and quantity (e.g., “I ate pancakes for breakfast yesterday, but I really wanted cereal”) and we learn to use them prior to any formal education as toddlers IF we are encouraged to use verbal language organization.

Do you remember learning about time before you were in school? Did your parents give you lessons about time, quantity, or hor how you can talk about yesterday or tomorrow? Were you taught to use terms like past-tense or future tense when talking about what you would eat for dinner? Probably not. So, how did we learn to understand and use parts of speech to indicate we did something yesterday or will do something tomorrow?

We learn about time (past, present, future) by being around those who spoke about the past and future differently than what is happening now. We learned how to speak the same way: by speaking and being corrected. It may have come easily to us.. We spoke alot Children with Down syndrome have difficulty using concepts of time and quantity and how that is tied to difficulties using past and future verb tense, mean length of utterance, omission of grammar and syntax, executive function, and having conversations to build relationships with others. Use supporting evidence to describe how underdeveloped speech clarity and verbal language use are the underlying cause of communication difficulties and not the result of intellectual deficits or organic language disorders.

>>> Understanding the Challenges of Time and Quantity Concepts in Children with Down Syndrome

Children with Down syndrome often face unique challenges in their cognitive and communicative development. Among these challenges, difficulties in grasping concepts of time and quantity emerge prominently. These difficulties can significantly impact their ability to use past and future verb tenses, affect their mean length of utterance (MLU), lead to omissions in grammar and syntax, and complicate their executive function. Understanding these issues requires exploring the intricate relationship between language development and social communication skills, rather than attributing these difficulties solely to intellectual deficits or organic language disorders.

>>> The Link Between Language and Concepts of Time and Quantity

1. Cognitive Development and Abstract Thinking

- Children with Down syndrome may exhibit slower cognitive development, particularly in areas requiring abstract reasoning. Concepts of time (e.g., past, present, future) and quantity (e.g., more vs. less) are inherently abstract and often require a level of cognitive processing that can be challenging.

- A study by Abbeduto et al. (2006) highlights that children with Down syndrome may struggle with tasks that involve sequencing events or understanding temporal relationships.

2. Verb Tense Usage

- The ability to use past and future verb tenses is closely tied to a child's understanding of time. Children with Down syndrome may exhibit difficulties in verb tense usage due to their challenges in understanding sequences of events.

- Research indicates that such grammatical difficulties are not necessarily indicators of cognitive deficits but rather stem from underdeveloped language skills, particularly in expressive language (Fowler, 1990).

3. Mean Length of Utterance (MLU)

- MLU is a crucial measure of linguistic complexity and is often lower in children with Down syndrome. This reduced MLU correlates with their challenges in expressing complex ideas related to time and quantity.

- A study by Chapman (2006) found that the MLU in children with Down syndrome does not reflect their cognitive abilities but rather highlights the need for targeted language interventions to support expressive skills.

4. Omission of Grammar and Syntax

- Children with Down syndrome frequently omit grammatical markers, including tense markers that are essential for conveying temporal information. This omission can hinder their ability to communicate effectively about past and future events.

- Research suggests that these omissions are not simply errors but represent a broader struggle with language processing that differs from organic language disorders (Wetherby & Prizant, 1993).

>>> Executive Function and Social Communication

1. Executive Function

- Executive function encompasses a range of cognitive processes including planning, flexibility, and working memory. Children with Down syndrome often experience executive function challenges, which can impact their ability to organize thoughts related to time and quantity.

- These challenges can lead to difficulties in participating in conversations where sequencing and timing are crucial for relational building (Zelazo et al., 2008).

2. Building Relationships through Conversation

- Effective communication is essential for building relationships. The challenges in using language to express time and quantity can hinder social interactions, making it difficult for children with Down syndrome to engage in meaningful conversations.

- A lack of clarity in speech can lead to misunderstandings and frustration, both for the child and their peers, further isolating them socially.

>>> Underlying Causes of Communication Difficulties

It is essential to recognize that the communication difficulties faced by children with Down syndrome are primarily rooted in underdeveloped speech clarity and verbal language use, rather than being a direct result of their intellectual capabilities.

1. Speech Clarity

Many children with Down syndrome experience speech intelligibility issues, which can affect their ability to articulate thoughts clearly, particularly when discussing abstract concepts like time and quantity.

2. Verbal Language Use

The challenges in using language effectively often stem from limited exposure to rich language environments and opportunities for practice. This limitation can hinder their ability to develop the necessary skills for effective communication.

>>> Conclusion

Understanding the complexities surrounding the difficulties children with Down syndrome face in using concepts of time and quantity reveals a multifaceted issue that extends beyond mere intellectual deficits. By focusing on the underlying language development challenges, caregivers and educators can create more effective intervention strategies that support expressive language skills, enhance executive function, and foster social communication.

Investing in tailored language interventions and encouraging environments rich in communication can significantly improve the ability of children with Down syndrome to express themselves, thereby enhancing their capacity to build meaningful relationships with others.

Recognizing these nuances is not just about addressing language deficits but also about affirming the potential for growth and development in every child, regardless of their challenges.

Jennifer Gray 2/11/26 Jennifer Gray 2/11/26

Velopharyngeal Insufficiency

Exercises

Suggestions

3.Blowing Exercises

Blowing Bubbles: Use a bubble wand and encourage the child to blow bubbles. This helps strengthen oral and respiratory control.
Blowing through Straws: Have the child blow through different sizes of straws into liquids (like water) or to move lightweight objects (like cotton balls) across a table.

2. Nasal Sound Exercises

"M" and "N" Sounds: Practice producing nasal sounds, such as "m" and "n" in isolation, then in simple words (e.g., "man," "no"). Encourage the child to feel the vibrations in their nose to understand the sound production.

3. Lip and Tongue Exercises

Lip Pursing: Have the child practice puckering and relaxing their lips. This can be done by blowing kisses or pretending to sip from a straw.
Tongue Lateralization: Encourage the child to move their tongue side to side and up and down. This can be done by having them lick their lips or pretend to lick ice cream.

4. Vocal Exercises

Sustained Vowel Sounds: Practice holding out vowel sounds (like "ah," "ee," "oxo") for as long as possible. Use visual timers or games to make it fun.
Pitch Variation: Encourage the child to produce sounds at different pitches (high/low) to help with vocal control.

5. Articulation Practice

Practice Words with High Oral Pressure: Work on words that require good oral pressure, such as "pop," "bat," or "cap." Use visual aids or pictures to make it engaging.
Syllable Repetition: Practice repeating syllables like "baobab" or "pa-pa-pa" to strengthen oral muscle control.

6. Facial Muscle Exercises

Cheek Puffing: Have the child puff their cheeks and hold the air for a few seconds to strengthen the muscles around the mouth.
Facial Expressions: Encourage the child to make different facial expressions (happy, sad, surprised) to engage various facial muscles.

7. Play-Based Activities

Animal Sounds: Have the child imitate animal sounds, which often require different types of oral and nasal airflow control.
Sound Games: Create games where the child has to make sounds while completing a fun task, like "Simon Says" with specific sounds.

How to Address Velopharyngeal Insufficiency in Individuals with Down Syndrome

Jennifer Gray 5/28/19 Jennifer Gray 5/28/19

Learning The Hard Way

People with Down syndrome are often denied the assumption of competence. Knowing how those with Down syndrome learn best will allow them to achieve skills with greater success.

How Adaptive Strategies Hinder Future Success for Those with Down Syndrome

Jennifer Gray, MS, CCC-SLP

1. Learning the hard way:

Young children with Down syndrome develop adaptive strategies that hinder current and future success. Easy and difficult tasks are often avoided and past successes do not lead to future consolidation of skills for improved success (https://library.down-syndrome.org/en-gb/research-practice/01/2/learning-hard-way-avoidance-strategies-young-down-syndrome?_ga=2.187327016.1067879216.1658796451-1201909322.1656700315).
“Every child (including children with Down syndrome) adapts to their environment. Where children with Down syndrome struggle to develop key skills in a typical way, they tend to employ alternative adaptive strategies. Although these strategies can yield immediate benefits, they may restrict the child's later experiences, affecting their developmental trajectory.” https://www.psychol.cam.ac.uk/babylab/embodied-attention-learning/summaries-our-research-parents-and-practitioners-embodied
This has vast implications for learning in school and how avoidance and refusal behaviors are interpreted. Without this knowledge about how children with Down syndrome approach learning, teachers and SLPs resort to dealing with undesired behaviors instead of teaching, thereby removing the child from those learning environments that appear not to work. This makes inclusion extremely confusing.
Students with Down syndrome have difficulty with passive learning (listening). They must be an active participant!

Strategies: Anticipating behaviors and using techniques that hinder the child’s ability to avoid and refuse.

Use what they love: visual materials, not worksheets, music, peers, schedules, video modeling, reading, mastering tasks before moving on, memory games (visual and verbal), let them be the teacher, PREPARE them for what comes next.

2. Difficulty answering questions is bigger than you think: this may be the #1 barrier preventing social communication and determination of knowledge in school. Learning is rooted in active listening and executive functioning prior to assessment of language use. This is a perplexing and VERY common occurrence for those with DS. Getting answers wrong or not answering questions has nothing to do with knowing the answers. For many reasons (including those above), children with Down syndrome do not attend to questions in a way that allows them to hold the question in mind while searching for the answer from memory or in the environment, then planning the expressive language and speech fast enough to answer the question. This is a complex sequence of cognitive steps needed to retrieve information and share it. Many children won’t even attempt it for reasons above and a cycle of failure. I try, it is wrong, I try again, still wrong, act out, forget task, get in trouble, get out of work. Multiple secondary gains are a common result to failed attempts are common and many times we don’t recognize the incidents as failures, so we don’t change our methods.

§ Strategies:

§ Demonstrate how to answer before asking questions.

§ Goals and strategies for “wh” questions should be targeted AFTER lower-level questions are answered consistently. The problem isn’t the understanding and use of “who, what, where, why” but of active listening and verbal short-term memory skills needed to answer any question.

§ Praise effort, identify error, try again: Instead of saying “no”, say “almost, good idea but, I heard …, close, good guess but, that was tricky let’s try again, etc.”

§ Identify level of questions the child can get right and build from there: Start with choice questions; use questions that contain the answer “do you want 2 or 3 fish crackers?”

§ Predict the answer you want and switch the order of choices (do you want juice or water? If the child simply repeats the last item, give them what they say, not what you know they want).

§ Ask yes/no questions

§ Answers should be what a typical child might say: the answer to “what is your name?” should be the child’s first name only; not “my name is Jennifer.”

§ Pair with visuals that give the answer.

3. Speech clarity IS possible: Focusing on articulation as the only speech target will not improve speech clarity over time and the use of alternative communication strategies shouldn’t replace speech practice. Research shows the importance of speech at very young ages as indicators of later language abilities. Speech must be practiced in dosages that approximate the speech practice of typical peers regardless of other expressive language targets. How should school SLPs target the above suggestions given very little time with each student?

Strategies:

· Melodic Intonation Therapy (MIT), modify pitch and loudness, reading words and phrases, imitate the speech rhythm of others, attention to voice and resonance, use fluency/stuttering strategies.

· Practice saying functional words and phrases using a technique that eliminates error patterns of rate, loudness, pitch, rhythm, and fluency that can be incorporated into daily routines for a couple of minutes each day.

· Daily Practice: Say name 5 times using a technique that works (above); greet 5 people during the day (pick a specific activity or time (passing periods, lunch, before and after school, the playground, etc.); use peer models to be the aid or facilitator, round robin in group tasks, use a video model on a phone or iPad, assign as homework, ask teacher(s) to practice a word or phrase during direct instruction, etc. Observe the child’s classroom, lunch hour, and others to find gaps where quick practice can be “squeezed in” or when the teacher could incorporate some repetitions.

· Speech clarity should be determined according to the listener. The goal is for listeners to attend to what is said, not how it is said.

Resources:

1. Down Syndrome Education International: Research, articles, materials, in easy to digest formats.

· https://www.down-syndrome.org/en-us

2. @connectedspeech

Jennifer Gray 5/28/19 Jennifer Gray 5/28/19

Impacts of Limited Access to Speech Development Opportunities

It is well published that those living with Down syndrome have categorical disabilities that affect every person with the syndrome (referred to as phenotypes) . Those categories are how we describe areas of need. Unfortunately, what we often forget is how to teach those skills to reduce the impact of the deficit. When we repeat that those with Down syndrome have difficulty with grammar, syntax, vocabulary use, fluency, short-term verbal memory, and short mean lengths of utterance (how many words said at a time), we are stating that these problems are immovable. This leads to developmental milestone guidelines to expect, instead of targeting a needed skill, such as speech use and practice. What would a child without Down syndrome exhibit if they were discouraged from using speech to communicate but allowed to use sign language, pictures, and rudimentary speech-generating devices from toddlerhood? What would that look like next to the same outcomes for those with Down syndrome?

If we believe that those with Down syndrome can’t do certain things well, will we encourage those skills just as we would for a child without Down syndrome? Research has shown that mothers tend to talk to their children with Down syndrome less than those without DS. This begins a spiral that can lead to lifelong speech and language deficits. Even most doctors, teachers, and allied professionals believe speech should be delayed or reduced in favor of non-speech communication strategies.

What happens when speech and language are not encouraged or when other means of communication are taught instead (sign language, picture use, & speech-generating devices)? What would happen to a typically developing child compared to a child with Down syndrome? Current popularity of AAC use for all children with communication delays and disorders has inadvertently left many children without speech proficiency and verbal language skills due to a lack of speech practice (speech therapy is usually offered one time per week or less, making time to learn multiple communication systems impossible). Would we see the same speech and language patterns and deficits in a typical child not encouraged to speak? Let’s compare what we know.

https://www.canva.com/design/DAG-0oPi0kQ/yx86eed2EONa0Yubdn6NCg/view?utm_content=DAG-0oPi0kQ&utm_campaign=designshare&utm_medium=link2&utm_source=uniquelinks&utlId=h6899f5bf2f

https://www.canva.com/design/DAG-0fAuIJA/BsIxjyfUbk8js4xOKjJZSQ/view?utm_content=DAG-0fAuIJA&utm_campaign=designshare&utm_medium=link2&utm_source=uniquelinks&utlId=hdf36f66872

Jennifer Gray 5/28/19 Jennifer Gray 5/28/19

This topic has been on my top 3 bucket-list riddles to solve before the end of my career. Every person with Down syndrome I have met and worked with has difficulties answering questions. Even simple questions. Even questions they know the answer to. It can be as baffling as incorrectly answering “what is your name?” Recently, I have come much closer to realizing why this happens. Answering questions is only one part of a bigger issue related to, you guessed it, the use of speech and verbal language.

>>> Understanding the Challenges of Time and Quantity Concepts in Children with Down Syndrome

>>> The Link Between Language and Concepts of Time and Quantity

1. Cognitive Development and Abstract Thinking

- A study by Abbeduto et al. (2006) highlights that children with Down syndrome may struggle with tasks that involve sequencing events or understanding temporal relationships.

2. Verb Tense Usage

3. Mean Length of Utterance (MLU)

4. Omission of Grammar and Syntax

- Research suggests that these omissions are not simply errors but represent a broader struggle with language processing that differs from organic language disorders (Wetherby & Prizant, 1993).

>>> Executive Function and Social Communication

1. Executive Function

- These challenges can lead to difficulties in participating in conversations where sequencing and timing are crucial for relational building (Zelazo et al., 2008).

2. Building Relationships through Conversation

- A lack of clarity in speech can lead to misunderstandings and frustration, both for the child and their peers, further isolating them socially.

>>> Underlying Causes of Communication Difficulties

1. Speech Clarity

2. Verbal Language Use

>>> Conclusion

Recognizing these nuances is not just about addressing language deficits but also about affirming the potential for growth and development in every child, regardless of their challenges.

Jennifer Gray 5/28/19 Jennifer Gray 5/28/19

Stuttering

Stuttering is a disruption in the forward flow of speech.

Stuttering in Individuals with Down Syndrome: Understanding, Gaps, and Therapy Approaches

Jennifer Gray, MS, CCC-SLP

Introduction

People living with Down syndrome have multiple speech and language disorders simultaneously due to the many systems affected by a third 21st chromosome. These systems include anatomy and physiology, dynamic hearing and vision differences, executive dysfunction, cognitive language delays, gross and fine motor

Down syndrome (DS) is a genetic condition characterized by the presence of an extra copy of chromosome 21, often associated with intellectual disability, distinct physical features, and developmental delays—including speech and language impairments. Among these challenges, fluency disorders such as stuttering are often observed but remain understudied and underrecognized in this population. This article explores the prevalence, contributing factors, and best therapy practices for addressing stuttering in individuals with Down syndrome.

Prevalence and Characteristics of Stuttering in Down Syndrome

I became a Speech-Language Pathologist because I wanted to help people who stutter. To date, stuttering remains a mystery. We do not have a cure nor can we predict it’s occurrence. Treatments are still being developed to address different types of stuttering in various populations. The unknown elements of stuttering still appeals to me today. Like most of us, our career paths take on their own path, and I began working with people with Down syndrome.

Stuttering, a disorder that disrupts the forward flow of speech through repetitions, prolongations, or blocks, occurs at a significantly higher rate in individuals with Down syndrome than in the general population. Research estimates that up to 45–53% of children and adults with Down syndrome exhibit features of stuttering (Abbeduto et al., 2001; Bothe & Richardson, 2011), compared to about 1% in the general population. This astonishing difference, however, has not alerted our attention to the disruptive elements stuttering has on speech clarity.

Because people with Down syndrome have multiple speech and language delays and disorders simultaneously, stuttering is often unrecognized as it’s own speech disorder, but a consequence language complexity has on the motor act of speech. Many parents and therapists don’t recognize the speech characteristics of repeated sounds and blocking of sounds when speaking. When untreated, stuttering can become handicapping.

Key Characteristics of Stuttering in DS:

Late onset: May begin in later childhood or adolescence, contrasting with typical developmental stuttering (which usually emerges between ages 2–5 years). Most adults with Down syndrome have experienced stuttering in their lifetime and many experience worsening symptoms later in life.
Atypical disfluencies: Severe blocks when beginning to speak and more frequent whole-word and phrase repetitions, and rapid syllable repetitions within words, differing from classic stuttering behaviors.
Cognitive and linguistic impact: Slower cognitive processing, auditory memory difficulty, verbal language delays, and reduced self-awareness contribute to increased dysfluency.

Lack of Research and Awareness

Despite the high prevalence, stuttering in the Down syndrome population is poorly understood. Most research on stuttering excludes individuals with intellectual disabilities, leading to:

Limited diagnostic clarity: Many clinicians mislabel stuttering as a natural part of Down syndrome communication rather than as a treatable fluency disorder.
Scarce evidence-based interventions: Therapy approaches for the general population may not be appropriate or effective without adaptation.
Underreported by caregivers: Disfluency is often overshadowed by broader communication or cognitive challenges.

Contributing Factors

Several factors intersect to increase the likelihood of stuttering in this population:

Language formulation difficulties: Delays in expressive syntax can make it harder for individuals to construct grammatically correct sentences, leading to speech disruptions.
Oral-motor issues: Hypotonia (low muscle tone), dysarthria, motor planning, mouth breathing, smaller oral cavity, and hearing loss affects articulation and fluency.
Working memory deficits: Impaired short-term memory can disrupt the ability to plan and sequence speech efficiently.
Lack of speech practice , especially longer utterances attempted at older ages.
Learned Anxiety and self-monitoring challenges: Most have little self-awareness abilities and do not hear or recognize their own speech errors, dysfluencies, or the response others have when they are not understood. Most people with Down syndrome don’t learn to monitor their own speech and rely on others to tell them. incorporate the Increased awareness of speech errors without the cognitive flexibility to adjust can exacerbate disfluencies.

Limited research and Down syndrome-specific treatment innovations have left Speech-Language Pathologists to use the same therapies for those with Down syndrome as those without Down syndrome. This often leads to poor therapy outcomes. While therapy must be highly individualized, it should also be tailored to the phenotypical presentation of stuttering for those with trisomy 21. Making the speaker aware of their stuttered speech may also be a common first step. In the past, many thought drawing attention to stuttered speech would increase anxiety or avoidance of speech, but it actually improves awareness and leads to self-correction and speaking confidence.

Treatments for stuttering are generally grouped into 2 categories: One addresses stuttering at the moment it happens (modification), while the other uses a speaking style that is incompatible with stuttered speech (fluency shaping). Determining which to use can be determined through an evaluation process that trials techniques for the best fit and outcome. Because stuttering may be only one of several speech targets in therapy, techniques chosen should limit the complexity of the technique to match the speaker’s working memory. The unpredictable nature of stuttering in the Down syndrome population makes fluency shaping a preferred first choice due to its use at all times. Such techniques include a manner of speaking for all purposeful speech (louder, quieter, slower, rhythmic, and continuous voicing/melodic intonation. Remembering to speak one way all the time is less complex than applying a technique after stuttered speech is initiated.

Techniques that are incompatible with stuttering (stuttering can’t occur when using the technique) such as using a louder voice or melodic intonation (continuous voicing like singing) automatically slows the rate of speech, emphasizes consonants/syllable accuracy, maintains voicing, and prohibit repetitions and blocks. Remembering one way of speaking that targets multiple disorders (articulation, motor planning, vocal quality, and healthy vocal use) is ideal for those with executive functioning needs. Repetitive and applied practice creates self-awareness (alerting the speaker of own errors) and engages neuroplasticity/habit over time, enhancing carryover and maintenance of fluency and speech clarity.

1. Indirect Therapy (for younger children)

Parent-focused models like the Lidcombe Program, adapted for cognitive level, may help reduce stuttering severity.
Reduce communicative pressure by slowing speaking rate, using pauses, and modeling easy speech.

2. Direct Therapy (for older children and adults)

Fluency shaping techniques: Teach strategies such as slow, smooth speech, easy onsets, and continuous phonation.
Stuttering modification: Focus on reducing struggle and desensitizing negative reactions to stuttering (e.g., voluntary stuttering).
Combine with visual supports and repetition for individuals with intellectual disability.

3. AAC Support

Augmentative and Alternative Communication (AAC) systems may help reduce the pressure to speak fluently and allow for more relaxed communication.

4. Pragmatic and Expressive Language Goals

Target syntax, vocabulary, and social communication to reduce cognitive-linguistic load on speech production.
Use structured scripts and role-play to promote smoother speech in everyday scenarios.

5. Family and Environmental Involvement

Train parents, teachers, and caregivers to support fluency strategies and create low-pressure communication environments.
Emphasize functional outcomes over perfect fluency.

Conclusion

Stuttering is a significant yet underacknowledged issue in individuals with Down syndrome. While more research is urgently needed, clinicians can draw on existing principles of fluency therapy, cognitive-behavioral support, and family involvement to create effective interventions. Recognizing stuttering in this population—and treating it with compassion, expertise, and evidence-based tools—can dramatically improve quality of life and communicative confidence.

References

Abbeduto, L., Warren, S. F., & Conners, F. A. (2007). Language development in Down syndrome: From the prelinguistic period to the acquisition of literacy. Mental Retardation and Developmental Disabilities Research Reviews, 13(3), 247-261.
Bothe, A. K., & Richardson, J. D. (2011). Stuttering in individuals with Down syndrome: A review of the literature. Journal of Fluency Disorders, 36(4), 225–243.
Chapman, R. S. (2006). Language learning in Down syndrome: The speech and language profile compared to adolescents with cognitive impairment of unknown origin. Down Syndrome Research and Practice, 10(2), 61–66.
Summary: https://www.down-syndrome.org/en-gb/library/research-practice/online/2008/speech-production-people-down-syndrome/#:~:text=Speech%20difficulties%20are%20common%20in%20people%20with,compared%20to%201%25%20in%20the%20general%20population