International Journal of Speech-Language Pathology, 2018; 20: 75–83

Speech therapy in adolescents with Down syndrome: In pursuit of

communication as a fundamental human right

SUSAN RVACHEW1 & MARLA FOLDEN2

1
School of Communication Sciences and Disorders, McGill University, Montreal, Canada and 2Down Syndrome
Research Foundation, Vancouver, Canada

Abstract
Purpose: The achievement of speech intelligibility by persons with Down syndrome facilitates their participation in society.
Denial of speech therapy services by virtue of low cognitive skills is a violation of their fundamental human rights as
proclaimed in the Universal Declaration of Human Rights in general and in Article 19 in particular. Here, we describe the
differential response of an adolescent with Down syndrome to three speech therapy interventions and demonstrate the use
of a single subject randomisation design to identify effective treatments for children with complex communication disorders.
Method: Over six weeks, 18 speech therapy sessions were provided with treatment conditions randomly assigned to targets
and sessions within weeks, specifically comparing auditory-motor integration prepractice and phonological planning
prepractice to a control condition that included no prepractice. All treatments involved high intensity practice of nonsense
word targets paired with tangible referents.
Result: A measure of generalisation from taught words to untaught real words in phrases revealed superior learning in the
auditory-motor integration condition.
Conclusion: The intervention outcomes may serve to justify the provision of appropriate supports to persons with Down
syndrome so that they may achieve their full potential to receive information and express themselves.

Keywords: Down syndrome; speech sound disorder; speech therapy; single subject randomisation design; Article 19;
Universal Declaration of Human Rights; United Nations; speech-language pathology; intervention

Introduction removing barriers to full participation in society, and

The Universal Declaration of Human Rights
(United Nations, 1948) explicitly avoids placing
rights in a hierarchy – each is inalienable, that is,
must not be denied to any person. At the same time
it is recognised that some rights empower others:
Article 19, guaranteeing freedom of expression and
free access to information, is fundamental to the
realisation of the other rights accorded by the
declaration. La Rue Lewy (2012) describes how
recent interpretations of Article 19 reveal ‘‘freedom
of speech and communication as a human right and
as a way to fight against all forms of discrimination,
be they based on race, religion, ethnic group, gender
or different physical capabilities’’ (pp. 57–58).
Accordingly, the Convention on the Rights of
Persons with Disabilities introduced specific provi-
sions to remedy disadvantages in the exercise of
Article 19 rights (Article 19, 2016). These include
not discriminating against individuals on the basis of
disability so that they may enjoy equal opportunity,
providing reasonable accommodations to ensure
freedom of expression and access to information.
Persons with intellectual disabilities face many
challenges in the exercise of their right to free
expression. More specifically, persons with Down
syndrome experience persistent delays in language
development with expressive abilities being signifi-
cantly more delayed than receptive abilities (Grieco,
Pulsifer, Seligsohn, Skotko, & Schwartz, 2015).
Severe difficulties with morphosyntax and speech
intelligibility can persist into adulthood. In order to
achieve their full communicative potential, persons
with Down syndrome will require interventions to
remediate their specific speech and language dis-
abilities, access to alternative and augmentative
forms of communication when necessary, and rea-
sonable accommodations that permit access to
information and effective communication. With
appropriate supports individuals with Down syn-
drome can achieve full participation in society, but

Correspondence: Susan Rvachew, School of Communication Sciences and Disorders, McGill University, 2001 McGill College Avenue, 8th Floor, Montréal,
H3A 1G1 Québec, Canada. Email: susan.rvachew@mcgill.ca
ISSN 1754-9507 print/ISSN 1754-9515 online ß 2017 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group
This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License (http://
creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original
work is properly cited, and is not altered, transformed, or built upon in any way.
DOI: 10.1080/17549507.2018.1392605
76 S. Rvachew & M. Folden
surveys of their families indicate service provision is
typically inadequate.
A Canadian survey revealed that one-third of
children with disabilities struggled to obtain special
education services and 60% did not obtain speech–
language pathology services (Statistics Canada,
2003), according to parent report. Furthermore,
parents of children with cognitive disabilities were
much less likely to believe that their children were
being challenged to their full potential in school,
compared to parents whose children have physical
disabilities or no disabilities. A survey of Canadian
adults with disabilities revealed barriers to higher
educational attainment, specifically poor access to
supports such as tutors and digital technologies as
well as school exclusion or bullying. The employ-
ment rate for adults with a developmental disability
was the lowest of any disability type at only 22% (for
US data specific to Down syndrome, see Kumin &
Schoenbrodt, 2016).
Families in the UK also reported significant
difficulties obtaining needed supports for their
children with Down syndrome in school, with
access to speech and language therapy being a
particular concern. Only 58% were scheduled to
receive a speech and language service, the frequency
of entitlement to that service was not usually
specified, and the service was provided by a
speech–language pathologist (SLP) in only 14% of
cases (Down’s Syndrome Association, 2004).
Surveys of SLPs further reveal inadequate levels of
service provision (Meyer, Theodoros, & Hickson,
2017), a tendency to treat language over speech
intelligibility and insufficient intensity of service.
In the Down’s Syndrome Association (2004)
report, parents also indicated distress about discrim-
inatory attitudes by school personnel including SLPs
who sometimes discouraged parents from seeking
private speech and language therapy. Young children
with Down syndrome may be deemed ‘‘not ready’’
for speech therapy if they are unable to imitate
speech; however, speech imitation can emerge as an
outcome of vocal play therapy that provides the child
with the prerequisite internal model of the vocal
system (Dethorne, Johnson, Walder, & Mahurin-
Smith, 2009; Rvachew & Brosseau-Lapré, 2018).
Older children may be considered poor candidates
for speech therapy due to cognitive limits on
language learning, but research shows that receptive
vocabulary growth can exceed cognitive growth
given appropriate environmental inputs to children
with Down syndrome (Chapman & Hesketh, 2001).
In adolescence, speech–language services may be
curtailed due to assumptions about a presumed
critical period for language development; however,
Chapman, Hesketh, and Kistler, (2002) demon-
strated that expressive language learning continues
into adolescence and recommend continued services
during this period for young people with Down
syndrome. These forms of ‘‘cognitive referencing’’
have been proscribed by the National Joint
Committee for the Communication Needs of
Persons With Severe Disabilities (2002) which
states that services must be based on ‘‘individual
student needs’’. The type and intensity of services
provided may continue to reflect biases about the
learning potential of individuals with severe disabil-
ities nonetheless. In this paper, we present a unique
research design that permits an objective determin-
ation of individual responses to individual therapy
approaches or intervention targets.
In the current study, we implemented a single
subject randomisation design with a single adoles-
cent with Down syndrome to determine response to
speech therapy. Resources for the remediation of
speech and language disabilities in persons with
Down syndrome are limited in the public and private
sectors and the profiles of strengths and needs
among this population are heterogeneous. SLPs
require tools for deciding how best to target their
interventions, choose treatment approaches and
organise service delivery components. The ability
to conduct short-term experiments with specific
cases could support decision making tailored to the
learning potential of each individual with Down
syndrome.
Speech production accuracy was chosen as the
target of this trial as it is the foundation of speech
intelligibility (Shriberg & Kwiatkowski, 1982), iden-
tified as a major concern by parents of 937 persons
with Down syndrome (Kumin, 2006). Poor speech
production accuracy is sometimes attributed to
structural impairments in Down syndrome but the
severity of the speech problem is more directly
related to difficulties with speech motor control,
complicated by concomitant hypotonia (Kent &
Vorperian, 2013; Rupela, Velleman, &
Andrianopoulos, 2016). Given this profile, one of
the treatment conditions assessed in this study
addressed motor planning, using sensory-motor
procedures designed to improve auditory-motor
integration. Speech errors produced by persons
with Down syndrome have also been described as
atypical and inconsistent (Dodd & Thompson,
2001), suggesting difficulties with phonological
memory and planning (Rvachew & Matthews,
2017a). Difficulties with verbal working memory
are characteristic of Down syndrome (Grieco et al.,
2015) leading to the recommendation that interven-
tions for the treatment of expressive language
disabilities employ visual cues as a specific accom-
modation (Chapman & Hesketh, 2001; Chapman
et al., 2002). Therefore, the second intervention to
be used in this trial involved procedures shown
effective for improving speech impairment second-
ary to phonological memory and planning problems
(Crosbie, Holm, & Dodd, 2005). It was expected
that a statistically significant effect would be
observed over a six-week treatment interval, indicat-
ing superior learning in one or both experimental

conditions relative to a control intervention, and that
learning would be maintained over a three month
follow-up interval.
Method
The method section is organised in accordance with
the SCRIBE statement (Tate et al., 2016) for
describing behavioural intervention trials in a single
participant (i.e. research design, participant, meas-
ures, interventions and treatment fidelity, and
finally, analysis strategy).
Research design
A single subject randomisation design is a form of
single case research in which sessions are randomly
allocated to treatment conditions within subjects
(Edgington & Onghena, 2007; Rvachew &
Matthews, 2017b). Sessions were randomly allo-
cated to the three treatment conditions within
weeks. The participant was scheduled to receive 18
one-hour treatment sessions, each occurring on a
separate day, three sessions per week, over a six-week
period. Research Randomiser software (Urbaniak &
Plous, 2013) was used to randomly assign the
treatment sessions to treatment conditions by gen-
erating six sets of three numbers in different inde-
pendent orders. Furthermore, treatment conditions
were randomly assigned to one of three different
treatment goals, so that ultimately he received six
sessions of treatment for each treatment goal
remediated with a different treatment approach.
The first author allocated the treatments to sessions
and goals while blind to the participant’s assessment
profile and uninvolved in the intervention. One
experiment is described here in abbreviated form.
The reader is strongly encouraged to consult Folden
(2016) for further details about the choice and
implementation of the experiment treatments and
for details regarding two additional replications of
this experiment.
Participant
The male participant identified as TASC-DS35,
aged 15.08 years, was recruited via referrals from
local SLPs, after obtaining approval from the
Institutional Review Board of the Faculty of
Medicine at McGill University and informed con-
sent from his parents. A written case history and
interview with his mother confirmed that he met the
inclusion criteria of Down syndrome, severe speech
sound disorder and behavioural maturity to cooper-
ate with the intense treatment schedule.
Subsequently, TASC-DS35 attended the laboratory
clinic at McGill University for direct assessments
that included: Diagnostic Evaluation of Articulation
and Phonology (DEAP; Dodd, Zhu, Crosbie, Holm,
and Ozanne, 2006); free speech sample; Kaufman
Brief Intelligence Test (KBIT; Kaufman &
Adolescents with Down syndrome 77
Kaufman, 2004); Peabody Picture Vocabulary
Test-III (PPVT; Dunn & Dunn, 1997); Maximum
Performance Tasks (MPTs; Rvachew, Hodge, and
Ohberg, 2005); Syllable Repetition Task (SRT;
Lohmeier & Shriberg, 2011; Shriberg et al., 2009).
The results of these assessments are presented in
Table I and were interpreted in view of the frame-
work presented in Rvachew and Matthew (2017a).
The case history and parent interview revealed a
history of multiple therapies including occupational
therapy, massage therapy, physiotherapy and
speech–language therapy directed at language skills
and use of an augmentative and alternative commu-
nication device. His mother also reported a past
history of pressure equalisation (PE) tubes and
ongoing difficulties with swallowing. The speech
assessment, as revealed by the DEAP and free
speech samples, revealed a severe speech disorder
and poor speech intelligibility as well as stuttering
(common in Down syndrome, Kent & Vorperian,
2013). Error patterns included consonant and syl-
lable harmony and the insertion of extraneous
syllables (e.g., shark /Sa‘k/ ! [ka‘k], zebra /zib\@/ !
[ææææ], umbrella /ˆmb\el@/ ! [ˆb@l@l@did@],
[ˆmb@b@b@æææ@]). Inconsistency within words, oral/
nasal, voicing and vowel confusions were observed,
along with disrupted transitions between segments
and syllables and poor coordination of multiple
articulators (e.g. jump /d¡Zˆmp/ ! [map], [bap]).
Although his phonetic repertoire included
[p,b,t,d,k,m,n,f,v,l,j], none of these sounds were
mastered.
Verbal and nonverbal intelligence were signifi-
cantly delayed with nonverbal skills advanced rela-
tive to verbal skills. Oral motor skills were also
delayed: specifically, he had difficulty producing
combinations of nonspeech movements and was
unable to produce trisyllable sequences; simple
movements and monosyllable repetition were rela-
tively less impaired. The Syllable Repetition Task
yielded scores in the ranges typical of respondents
with apraxia of speech in the areas encoding,
memory and transcoding (Shriberg, Lohmeier,
Strand, & Jakielski, 2012).
Treatment goals and speech production
probes
The intake assessment provided data for the selec-
tion of treatment production goals through a quick
multilinear analysis as described in Rvachew and
Brosseau-Lapré (2018). Three goals were selected
using strengths to supports needs (in other words,
targeting known segments in new word shapes and
new segments or features in familiar word shapes).
This process resulted in three goals: (1) suppress
consonant and vowel harmony in two syllable words;
(2) stabilise major sound classes in syllable onset
(i.e. stop [+consonantal] vs. glide [+sonorant] vs.
liquid [+consonantal][+sonorant]) and (3) establish
78 S. Rvachew & M. Folden

Table I. Pretreatment and follow-up formal assessment scores.

Assessment Score Pretreatment Follow-up
DEAP Percent consonants correct 22 38
Percent vowels correct 75 86
Percent phonemes correct 41 56
Oral motor score 30 –
Word inconsistency (%) 52 60
Free speech sample Mean length of utterance 2.0 1.63
Percent consonants correct 42 50
Percent vowels correct 67 78
KBIT Verbal IQ (SS) 40 –
Nonverbal IQ (SS) 58 –
PPVT Standard score 40 –
Age equivalent 3;06 –
MPTs Phonation duration (sec) 6.35 –
Monosyllable repetition/sec 3.85 –
Trisyllable repetition/sec Unable –
SRT Competency score 26.00 –
Encoding score 33.33 –
Memory score 47.68 –
Transcoding score 38.89 –
Items with additions 11 –
Note. DEAP, Diagnostic Evaluation of Articulation and Phonology; KBIT, Kaufman Brief Intelligence Test; PPVT,
Peabody Picture Vocabulary Test; MPT, Maximum Performance Test; SRT, Syllable Repetition Task; SS, standard
score.

consistent production of /f/. For each goal, five target
words were selected to be thematically congruent
with a specific play routine. The play routines
included the names of nonsense words to name
characters, constructed to fit the phonological goal
while not inviting interference from misarticulated
known words in TASC-DS35’s lexicon. Additional
words were selected or created to be congruent with
the phonological target and theme so as to support
phrase level practice. The three sets of five target
words, including nouns, verbs and adjectives, were
as follows: [tæmdAU], [bundeI], [pAgtAg], [dAUnˆp],
[pinˆt] (Goal 1, monster routine, phonological
memory condition); [wit], [lut], [d˘t], [wAQ@],
[jAd] (Goal 2, alien flower routine, auditory-motor
integration condition) and, [pˆf], [fæp], [wUf],
[fuwi], [fud] (Goal 3, dog routine, control
condition).
Learning of the specific targets was tracked by
coding treatment performance from video record-
ings of each treatment session. However, the pri-
mary outcome was generalisation of learning from
the taught words to untaught real words, measured
with probes that consisted of short phrases con-
structed of real words that mirrored the taught
phonological structures (e.g. Goal 1: toy bag, onset
Cs and Vs expected to be correct; Goal 2: you go,
glide and stop manner expected to be matched; Goal
3: two feet, segment /f/ expected to be correct). For
each goal a pool of 30 probe items was constructed;
from each pool 12 sets of 10 were selected to form
six same day probes and six next day probes, each
one containing a unique set of items. Same day
probes were administered at the end of the session
during which the goal was targeted in therapy to
assess immediate generalisation from the taught
target words to the real word probes. Next day
probes were administered at the beginning of the
next treatment session to assess maintenance of
learning over a short interval. All probes were
administered via imitation using a live voice elicit-
ation procedure and recorded using Sony HDR-
XR150 camera mounted on a tripod and a Zoom H2
Recorder, placed 53–71 cm from the participant,
and set to 4-way stereo recording.
Intervention
The structure of every session was identical regard-
less of the randomly assigned treatment condition, as
follows: (1) introduce session activities using a visual
schedule, (2) record 10-item next day probe, (3)
prepractice of target words, (4) high intensity prac-
tice, (5) record 10-item same day probe, (6) family
debrief. Prepractice and practice activities were each
scheduled to last 20 min. The remaining activities
required an additional 20 min altogether. The
accompanying family member observed the sessions
through a two-way mirror. Under typical circum-
stances, home practice and functional words would
be chosen as targets and we would advise this for
most clinical applications of these procedures.
However, in this experiment, home practice was
discouraged and the target words and play routines
themselves were designed so that spontaneous prac-
tice of specific target words was unlikely to occur.
This exceptional restriction allowed us to be sure
that improvements in speech accuracy and differ-
ences across conditions could be attributed to the
experimental procedures.
Prepractice procedures
Prepractice is implemented to ensure that the
learner is capable of producing the target words
and has strategies to maintain a high level of correct
production during the practice portion of the treat-
ment session. Prepractice occurs at a relatively slow

pace and knowledge of performance feedback is
provided as needed (specifically in the form of verbal
descriptions of the participant’s articulatory ges-
tures). During auditory-motor integration sessions,
the procedures were designed to ensure that TASC-
DS35 had a strong auditory-phonetic representation
of the target words that was linked to the semantic
and articulatory representations of the words. These
procedures were also designed to ensure that he
could effectively use information provided in audio-
visual models to improve production and that he
could integrate and use somatosensory and auditory
feedback of his own productions in relation to this
knowledge of the target to monitor and correct his
own productions, specifically auditory bombard-
ment, error detection and focussed stimulation (as
described in detail in Chapters 9 and 10 of Rvachew
& Brosseau-Lapré, 2018). During phonological
memory and planning sessions, the procedures
were designed to support the independent construc-
tion of phonological plans for the production of each
target word. Specifically he was taught to associate
visual cues with the articulatory gestures for each
phoneme in the target word. Using segmentation
and chaining techniques, he was taught to produce
the target words without the provision of an audi-
tory-visual model, using the visual cues when
necessary (as described in more detail in Chapter
11 of Rvachew & Brosseau-Lapré with respect to the
procedures for implementing the Core Vocabulary
Approach). During control sessions, no prepractice
procedures were employed; rather activities that did
not involve speech practice were conducted during
this segment of the session.
Practice procedures
Regardless of the assigned prepractice condition, the
goal of the practice session was to encourage high
intensity practice – aiming for at least 100 practice
trials – at the highest level of complexity possible
while maintaining accuracy ‘‘at the challenge point’’.
In keeping with the challenge point framework
(Guadagnoli & Lee, 2004; Rvachew & Brosseau-
Lapré, 2018) practice performance must be neither
too high nor too low for optimum learning.
Specifically, if responding fell below 4/5 correct
responses, practice components were adjusted to
make the task easier; when responding rose above
this level, practice components were adjusted to
make the task more difficult. Adjustable practice
components included target complexity (e.g. single
word vs. phrase), pre-trial support (e.g. imitative
model vs. question prompt), stimulus variability
(blocked vs. random presentation) or feedback
schedule (e.g., after every trial vs. after a block of
five trials). Some aspects of the practice components
were unique to the randomised treatment condition
as follows: in the auditory-motor integration condi-
tion, auditory-visual models were provided fre-
quently and feedback was delayed as much as
Adolescents with Down syndrome 79
possible to encourage self-monitoring; in the phono-
logical memory condition, the use of visual cues was
encouraged to support spontaneous generation of
phonological plans; in the control condition, the
feedback schedule was fixed at 60% of trials,
congruent with the principles of motor learning
(Maas et al., 2008; Maas, Butalla, & Farinella,
2012).
Treatment fidelity
Treatment sessions were conducted by a student
clinician with supervision from the trial coordinator,
an ASHA certified speech–language pathologist,
both of whom received three days of training in
trial procedures prior to implementation. Lesson
plans were reviewed by the trial coordinator prior to
each session to ensure congruence with the trial
protocol. All session videos were coded for compli-
ance by the second author for inclusion of mandated
procedures, by randomly allocated condition, using
a checklist. Treatment fidelity was 100% for the
phonological planning prepractice sessions (meaning
that all expected procedures were used during all six
sessions) but only 73% during the auditory-motor
integration prepractice sessions because activities
targeting self-monitoring were often omitted due to
the difficulties TASC-DS35 was having detecting
errors in the clinician’s speech. During the practice
portion of each session, the expectation of at least
100 practice trials was generally achieved on average
but not during every session as shown in Table II.
The cumulative treatment intensity varied among
treatment conditions with total practice trials being
588 in the auditory motor integration condition, 678
in the control condition and 726 in the phonological
memory condition. The clinician did not succeed in
maintaining practice performance at the challenge
point, as shown in Table II, where it can be seen that
TASC-DS35 performed below 80% correct during
all sessions.
Analysis strategy
Same day and next day probe scores were tran-
scribed and scored out of 10 points. The probes
were transcribed by two independent transcribers
with graduate level training in phonetic transcrip-
tion, using PHON (Rose & McWhinney, 2016) to
ensure blind transcriptions by multiple coders. Inter-
rater agreement for the narrow transcription of
probes was 86% for vowels, and 85% for conson-
ants. The inter-scorer agreement for probe item
correctness was 97.7%. Probe scores were submitted
to a nonparametric randomisation test of the null
hypothesis which is that the probe scores are
independent of the treatment that was allocated for
any given session. This kind of statistical test is
performed using only the data obtained in the
randomised single case experiment – the obtained
data points are permuted repeatedly to represent all
80 S. Rvachew & M. Folden

Table II. Total practice trials, percent correct trials, same day (SD) probe scores and next day (ND) probe scores by
session and treatment condition.
Session Practice trials Probe scores
Number Condition Total % Correct SD ND
1 Control 106 46.23% 0 0
2 PMP 95 23.16% 1 3
3 AMI 61 21.31% 3 3
4 AMI 90 50.00% 5 5
5 Control 90 52.22% 1 0
6 PMP 106 49.06% 2 4
7 PMP 108 44.44% 2 2
8 Control 95 68.42% 2 2
9 AMI 88 43.18% 7 5
10 AMI 113 40.71% 5 4
11 PMP 129 50.39% 1 1
12 Control 137 47.45% 2 3
13 AMI 119 75.63% 3 5
14 PMP 128 57.03% 0 4
15 Control 123 60.16% 5 5
16 Control 126 73.81% 2 3
17 PMP 162 34.57% 4 1
18 AMI 117 50.43% 4 4
Mean Control 113 58.05% 2.00 2.17
Mean PMP 121 43.11% 1.67 2.50
Mean AMI 98 46.88% 4.50 4.33
Note. PMP, phonological memory and planning prepractice; AMI, auditory-motor integration prepractice.

possible allocations of treatment conditions to
obtained probe scores; the test statistic is recalcu-
lated for each possible allocation yielding a test
distribution against which to evaluate the signifi-
cance of the obtained statistic (in this experiment,
the test distribution is (3!)6 ¼ 66 ¼ 46,656, F
statistics).
Results
The results by session are presented in Table II
which shows the number of practice trials, the
number of correctly produced practice trials, the
same day probe score and the next day probe score
for each session as a function of randomly allocated
treatment condition. The next day probe scores are
shown adjacent to the session for the associated
treatment goal, rather than the ‘‘next day’’ session
during which the probe was recorded. TASC-DS35
did not progress beyond the word level with the
target words in any condition, although the com-
plexity of practice was generally more complex in the
auditory-motor integration sessions (three sessions
involving drill-play activities targeting whole words
in a delayed imitation or spontaneous word context)
when compared to the control and phonological
memory and planning sessions during which drill
activities targeted direct imitation of part-words or
whole words. These differences in practice context
explain the variation in number of practice trials by
condition because practice intensity is typically
higher during simple drill than drill-play activities.
Despite these differences in achievement across
conditions, the overall impression is that TASC-
DS35 was struggling to master all three treatment
goals, given that accuracy during practice trials did
not reach the goal of 80% correct in any treatment
condition. Nonetheless, learning occurred as illu-
strated in Figure 1 that shows the mean and
standard error of these probe scores along with the
follow-up probe scores, recorded 84 days following
the end of the treatment trial. A significant treatment
effect was obtained for the same day probes, as
determined by resampling (F ¼ 5.71, p¼ 0.035,
1000 samples). Mean scores on next day probes
show the same pattern of respondings but were not
significantly different due to greater variability
within and across conditions (F ¼ 4.15, p ¼ 0.056,
1000 samples). Effect sizes (dz for matched samples)
were calculated to compare pairs of treatment
conditions (Lakens, 2013). When comparing probe
scores in the auditory motor integration condition to
the control condition, the effect size was large for
both same day probes (dz ¼ 1.03) and next day
probes (dz ¼ 1.18). When comparing probe scores in
the auditory motor integration condition to the
phonological memory and planning condition, the
effect size was large for both same day probes
(dz ¼ 1.65) and next day probes (dz ¼ 1.38). When
comparing probe scores in the phonological memory
and planning condition to the control condition, the
effect size was small for both same day probes
(dz ¼ 0.13) and next day probes (dz ¼ 0.13). The
follow-up assessment showed that gains were main-
tained for major sound class contrasts in the audi-
tory-motor integration condition and that
improvements continued over this interval for the
production of multisyllabic words with reduced
consonant and vowel harmony. Quick multilinear
analysis of the repeat DEAP results also revealed
improvements even where perfect accuracy was not
achieved: the major class contrasts were better

Figure 1. Mean scores (with standard errors) shown for same day (left patterned bars) and next day probes (middle white bars) by
randomly assigned treatment condition and treatment goal. Total score on probes recorded during the follow-up assessment was also shown
(right patterned bars). AMI, auditory-motor integration prepractice condition; CTL, no prepractice control condition; PMP, phonological
memory and planning prepractice condition.
maintained (e.g. elefant /el@f@nt/ ! [eæ@b@l@] at
intake, but [alel@vIt] at follow-up), and consonant
and syllable harmony were reduced (e.g. this /ôIs/ !
[gIk] at intake, [dIs9] at follow-up).
Discussion
One adolescent with Down syndrome received three
interventions, with a schedule of one session per
week for six weeks, provided concurrently with
randomised order of conditions within weeks. The
intention of these interventions was to improve the
participant’s speech sound accuracy to foster greater
speech intelligibility, thereby facilitating increased
success in communication and improved enjoyment
of his right to free expression.
Statistically significant improvements in speech
sound accuracy were achieved, as measured by same
day generalisation probes. The treatment condition
designed to remediate his specific underlying impair-
ments in motor planning yielded the best result.
Although a statistically significant result was not
obtained for next day probes, there is evidence that
the interventions facilitated his participation in
activities of daily living; specifically, many individ-
uals who interacted with him on a daily basis
observed improvements in his ability to communi-
cate verbally with family members, peers and sup-
port staff. Although TASC-DS35 did not master
the goals taught during the six-week intervention,
generalisation from taught to untaught words was
observed with maintenance over a three-month
interval. Furthermore, the effect size was large and
clinically significant, given the discernable impact on
Adolescents with Down syndrome 81
intelligibility as reported by his parents and study
staff. The findings of this experiment support the
claim made by Chapman et al. (2002) that learning
continues through adolescence in DS. For public
service providers, deciding whether to continue
targeting speech intelligibility at this intensity will
require an ongoing value judgment – the decision
cannot be made on the basis of this evidence alone,
without further reflection. However, future decisions
about this young man’s treatment program can be
made with clear information about his learning
potential in the area of speech accuracy.
Customising therapy to the individual’s profile of
strengths and impairments is crucial in a heteroge-
neous population that infrequently receives treat-
ment: in adolescents with Down syndrome there is
no known blanket approach that can effectively
remediate speech impairments.
McDaniel and Yoder (2016) discuss the import-
ance of collaborations among researchers and clin-
icians for developing precision speech–language
services for children with Down syndrome. The
single subject randomisation design we describe in
this report is a useful tool for such collaborations as
it provides high quality research evidence while
supporting clinical decision making for individual
patients. By pursuing the realisation of freedom of
communication and access to information through
speech therapy, clinicians hope to empower their
clients with developmental disabilities so that they
can achieve other fundamental human rights such as
those pertaining to education, employment, dignity
and security (United Nations, 1948). In light of this
perspective, evidence that adolescents with Down
82 S. Rvachew & M. Folden
syndrome can indeed make gains towards effective
communication supports the idea that continued
access and therapy for this population is warranted.
Limitations
The primary limitation of this study is that a single
experiment was conducted with this adolescent,
exploring only the relative effectiveness of different
treatment approaches with respect to short-term
changes in speech accuracy. For example, objective
measures of speech intelligibility were not obtained
and the study does not reveal the intensity of
treatment required to obtain functional improve-
ments in speech communication. The study was not
designed to directly explore the relationship between
improvements in speech accuracy and the functional
outcomes that are ultimately the goal of speech
therapy. The design used in this study permits the
SLP to choose an intervention that will be effective
for improving speech accuracy for a specific client.
Larger questions, such as whether a focus on speech
accuracy or other means of communication will have
a greater impact on participation and inclusion,
would require a different design such as a parallel
groups randomised control design.
Another limitation is that the study provides no
information about optimum intensity or scheduling
of intervention. Improvements were observed in the
goal of establishing the major sound class contrasts
over six one-hour treatment sessions even though he
did not master the goal. It is not clear that the same
result would be obtained if these six sessions were
provided without interleaving of multiple weekly
sessions targeting multiple goals: given that variable
practice of multiple treatment goals is a predictor of
generalisation, it cannot be assumed that sequential
rather than concurrent targeting of the three goals
would lead to the same result. It is also not known if
greater cumulative intervention intensity for each
goal would ultimately lead to mastery of any of the
goals. It is our sense that if he had received annual
six week blocks of intense articulation therapy
throughout his 12 years of schooling, his speech
intelligibility would be considerably enhanced but it
is impossible to be sure. Therefore, without con-
tinued clinical research with this young man and
other persons with Down syndrome, the choice of
speech articulation therapy versus a singular focus
on augmentative communication remains a difficult
decision for therapists and families.
Conclusion
In this study, we demonstrated that an adolescent
with Down syndrome can make changes in speech
accuracy, and according to parent report,
speech intelligibility, given 6 weeks of intensive
speech therapy. Furthermore, we have introduced a
research design that permits the SLP to compare an
individual’s response to different treatment condi-
tions as a support for decision making about
treatment targets, approaches or service delivery
models. If we are to properly commit to the
realisation of Article 19 rights for persons with
Down syndrome much greater efforts must be made
to enhance their communication skills in the verbal
and nonverbal domains.
Acknowledgements
We thank the family that participated in the research
project. We are also grateful for the assistance of
students and research assistants including Lizzie
Carolan, Omar Obregozo Zalava, Melanie Orellana,
Pegah Athari and Alexandre Herbay.
Declaration of interest
No potential conflict of interest was reported by the
authors.
Funding
This project was supported by a McGill Faculty of
Medicine Summer Research Bursary awarded to the
second author and the Ruth Ratner Miller
Foundation and the Centre for Research in Brain,
Language and Music.
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