Parent-training in Narrative Language Intervention with children with Down syndrome: case study

The purpose of the present study was to introduce parent training as a method to increase narrative language production in their children with Down syndrome. Two children and their mothers participated in this intervention. Children were pre-tested using the Peabody Picture Vocabulary Test-III (PPVT-III) to measure receptive language abilities for a general indication of language abilities. In addition, an elicitation of a narrative language sample (story retell and story generation) was evaluated for mean length of utterance, number of communication units (C-units), as well as the presence or absence or narrative and story grammar elements. Parents participated in a training workshop and then completed the narrative training over a four-week period in their homes. Through two case studies, the effectiveness of this type of intervention in increasing overall language, but particularly narrative language elements, is demonstrated.

Down Syndrome Research and Practice

Review of the literature

Research has shown that the language development of children with Down syndrome differs significantly from children with typical language development in several ways. Chapman and Hesketh, in their review, identified that children with Down syndrome exhibit a strength in receptive vocabulary, but a delay in syntax that affects language production[1]. The authors further stated that this delay is not explained by overall cognitive limitations. There are also conflicting studies in the literature which conclude that there is a critical age at which children with Down syndrome no longer continue to develop in syntactic growth, while other studies showed that growth in mean length of utterance (MLU) continued through adolescence[2].

While children and adolescents with Down syndrome display less developed expressive language and syntax skills, a study by Miles and Chapman showed that this group was able to utilise effective narrative language skills when using a story as a prompt[3]. The researchers used the wordless picture story, Frog, Where are you? as the prompt with 33 children and adolescents with Down syndrome. The stories were analysed for identification of the plot, story theme, and problems by the protagonists. The results showed that the individuals with Down syndrome were able to express each of the above categories more often than the group matched for similar expressive language skills. The results of this study further stated that the findings of higher grammatical comprehension skills in addition to the exposure to stories may have had a significant impact on the higher level narratives that were obtained. Miles further reported that

"this study shows the importance of attending to the content of children's stories, as well as the form and that narrative may be an excellent clinical tool in closing the gap between conceptual skill and expressive language" [4: p2].

There are many reasons why narratives are a good choice of intervention. Narrative language skills are highly associated with other academic skills. In addition, narratives occur naturally within and outside of school settings allowing for the generalisations of the skills that would be learned in a therapeutic setting. Narrative production is also related to many levels and aspects of content (vocabulary), form (grammar), and use (conversational skills). Narratives can also be adjusted to increase or decrease in difficulty therefore revealing the amount of prompting needed. Finally, narratives take in to account the diversity of speakers[5-8]. Narrative language intervention uses literature as the stimulus for all intervention activities. Books are chosen based upon factors such as:

  1. vocabulary targeted in the classroom,
  2. structure in language which may be weak such as prepositions, connector words, conjunctions and grammatical markers, and
  3. overall themes related to home, school, or the community.

Intervention strategies focus on teaching the content of stories, as well as the internal structure or story grammar. While narrative language intervention is frequently used in the classroom or therapy room, it lends itself to be administered in any setting.

As speech language pathologists, aside from providing direct therapy to our school age clients, we also encourage the generalisation of concepts that are taught in therapy to outside environments such as home. This generalisation is often programd in homework assignments or in providing training for parents who will carry over the skill. Narrative language intervention on the whole has been shown to be effective with children and adolescents with Down syndrome. The purpose of the present case studies was to introduce parent training as an additional method to increase narrative language production in children with Down syndrome.

Methodology

Participants

Two children and their mothers were selected to take part in the training, following an initial screening of receptive language skills using the Peabody Picture Vocabulary Test (PPVT-R) and narrative language skills using informal measures for story retelling and story generation. For narrative language functioning, both children were read a story about a Genie and asked to retell the story exactly as they had heard it. They were then asked to tell a story, given five pictures that depicted a sequence of events about a common routine: getting ready for school. Both mothers were interviewed for their abilities to participate in the study given commitments and time constraints. They were also asked not to share information regarding the actual training with teachers and others until the study was completed, so that the initial effectiveness of the training could be measured.

Michael and Nicholas

Michael was an eight-year, four-month old male with Down syndrome enrolled in a general education third grade class in Central Maryland. Nicholas was an eight-year, seven-month old male with Down syndrome enrolled in a general education third grade class in Northern Virginia. Both boys attended public schools and were receiving speech language and special education services in an inclusive environment. Both mothers were interested in participating in the training to augment language and literacy abilities as they were frustrated by the amount of time given in the school dedicated to increasing language skills.

The mothers both attended a training session conducted by the investigators that was held at the Loyola College Columbia Maryland campus. A training module was presented that gave an overview of narrative language and narrative language development. This training was delivered through a PowerPoint presentation and with direct interaction in question and answer format with the parents. The materials for the study were also distributed with explicit directions and a calendar for conducting the training in their homes. Both mothers were instructed to follow the calendar as closely as possible with outlined activities. The activities were designed to take place two times per week, once at the beginning of the week, and once at the end. Parents were asked not to conduct any activities on Wednesdays, but to email the primary investigator with progress and problems (see Appendix A for calendar and examples of materials).

Materials

he book that was chosen for this study for the parent training was Strega Nona by Tomie DePaola. This book was chosen as it is a Caldecott award winner, is appropriate for children in lower elementary school grades, and has a highly repetitive quality, as well as many rhyming words and interesting dialogue between the characters. Each parent received a copy of the book; laminated cut-out pictures of the main characters, Strega Nona and Big Anthony, as well as a scene depicting the setting; vocabulary to be targeted for the story with instructions for pre-testing and post-testing the vocabulary; directions and sample 'Think Alouds' (i.e., questions designed to ask children to think about the content and things that are confusing in the book); ideas and materials for culminating art activities; 'pasta pots' containing important elements of the story for retelling the story (obtained from "The Magic of Stories"); index cards containing transition words, such as "first", "then", "next" and "finally", to be used in retelling the story; and a calendar providing step by step instructions for each of the four weeks of intervention.

Parent training intervention

In the first week, parents were trained to introduce a pre-story activity that utilised a semantic word map. Both Nicholas and Michael were asked to think about the word "pasta" and the types of pasta with which they were familiar. Their mothers were able to make this activity specific to their own household based on their child's particular likes or dislikes or overall experience. This activity was explained to act as the introduction for the story. At the end of the first week, parents were given vocabulary for the book, and asked to give a pre-test that was developed. Following the pre-test, parents introduced the vocabulary and the definitions that were provided to them, and were asked to take a picture walk through the book. A picture walk simply allows the child to view the pictures, and perhaps to comment on what the illustrations may mean, and also allows the parent to ask questions that guided their child's interest to the main idea of the book. For example, both mothers asked, "Who do you think this is?", "Why is he/she dressed that way?", "What kind of place do you think this is?" These questions helped to set the scaffold for the story.

During the first part of the second week, both mothers read the story two times. This activity was repeated again at the end of the week, with the addition of "Think Alouds." Think Alouds are questions designed to ask children to think about things that are confusing in the book. For the purpose of this training, materials for the Think Alouds and the art activity were obtained from "The Magic of Stories" [9]. The Think Alouds encouraged Nicholas and Michael to think about confusing information in the story. Parents were asked to read to a certain point in the book and then ask a question, for example, "I don't understand why all of the people whisper and say mean things about Strega Nona. She seems like a nice person. Why do you think people say mean things or whisper about her?" These questions allow for more discussion about the book and the opportunity to talk about the parts of the story as well as to continue in defining vocabulary that is not clear. Both mothers indicated that they had to do a lot of explaining and leading in their questions to help the children understand what was meant. However, overall with repetition, there was good dialogue that occurred as a result of using the Think Aloud strategy.

The third week began with rereading the story and reviewing the Think Alouds. The latter part of the week included rereading the story and introducing the concept of story grammar elements. Story grammar was presented using Merrit and Liles' story grammar elements[10] including:

  1. description of the setting,
  2. description of the characters,
  3. sequential presentation of events,
  4. description of the goal and the consequences, and
  5. description of the attempts to reach the goal.

Laminated pictures of the characters (Strega Nona and Big Anthony) as well as the setting (the town) were used to provide a stimulus for responses. Parents asked their children to describe where the story took place, who the main characters in the story were, what took place first, second, and so forth, what problems existed in the story, and what the consequences were, and how the problem(s) were solved. As a result of the multiple readings of the story, the parents reported that their children knew the story very well and required minimal prompting. In addition, the pictures provided adequate cues to help the children formulate their responses. In addition to presenting the story grammar elements, parents asked their children to retell the story as completely as possible. During this week, parents both reported midweek that their children were bored with rereading the story, but could recite the story back fluently. Both mothers were encouraged to continue in the prescribed format, as the repetition was key in internalising the events in the story.

Finally in the last week, parents were asked to reread the story and to retell the story using the laminated pictures for story grammar prompts. Parents were also given a set of index cards that included cohesive words, such as first, then, next, and finally. These cards were placed in between each laminated picture clue and read several times by each mother who emphasized the cohesive term with pronounced intonation. By including these cohesive terms in the training, the children would begin to develop narrative style including narrative cohesion, precise vocabulary, and fluency (the story is told without garble). Both children were prompted to retell the story using these cohesive terms. Finally, an art project using pasta was included in the packet as a final culminating activity to the training. This activity was provided to reinforce the vocabulary that was learned and to provide an extension for parents and children to interact while reinforcing the concepts learned during the unit.

Both mothers then completed a survey that evaluated the following:

  1. Did each parent feel that she had an understanding of the basic concepts of narrative language development?
  2. Did she understand how to implement the narrative language strategies with her child?
  3. Did she feel able to continue this type of intervention using other books?
  4. Did she feel that her child made gains having participated in this intervention?

Results and discussion

Michael

Michael was asked to retell a story about a genie at the beginning of the study and again at the end. Initially, Michael's mean length of utterance (MLU) was 2.6. His overall length of utterance increased to 6.5 by the conclusion of the intervention, which is a notable gain. In addition, when asked to generate a story given pictures as prompts, Michael's initial MLU was 2.8, and at the end of the study had increased to 5.3, again, indicating an increase in vocabulary. In addition, vocabulary gains were noted from pre-test to post-test, with Michael knowing 2 of the vocabulary words on pre-test to 14 out of the 16 on the post-test. The narrative stories, both the retell and the generation, were also analysed for narrative development using communicative units (CUs), which were defined as independent clauses with modifiers[6]. For story generation, Michael initially had 0.8 CUs, which increased to 1.0 CUs at the end of the study, and for story retell, increased from 0.75 to 1.00. Again, in both tasks, Michael showed an increase in the complexity and the overall number of words that were used. In addition, further analysis was completed to evaluate the presence of story grammar elements and narrative style (both described above). At initial testing, Michael was unable to produce any of the story grammar elements except for providing a label for the characters (e.g. "There is a girl"). He did not use any cohesive terms and the narratives lacked fluency, having frequent false starts and repetitions. By the end of the study, Michael increased his use of temporal concepts, cohesive and transition terms from zero to 14 (see Figure 1). Michael's mother reported on the parent survey that she had adequate knowledge of narrative language development and how to implement the intervention, and was able to continue it beyond the study with the highest response, "strongly agree". She reported that she agreed that there were gains in Michael's overall performance.

Figure 1 | Changes in Michael's performance pre- and post-testing

Nicholas

Nicholas was asked to complete the same story generation and retell tasks prior to the study and again at the conclusion. His MLU for the story retell activity was 3.3 initially and 8.2 at the end of the training, which is a significant gain. For story generation using the picture cards, initially Nicholas' MLU was 3.8, and at the conclusion was 6.2, with significant progress noted in overall number of words as well as types of words. Additional gains in vocabulary were noted from pre-test to post-test in the vocabulary specific to the story Strega Nona, with Nicholas knowing two words prior to the training and at post-test knowing 11 of the 16 total vocabulary words. As with Michael, the narrative stories were analysed for narrative development. For story generation, Nicholas initially had 1.0 CUs, which increased to 1.2 by post-test. Story retell showed an increase in CUs from 1.0 initially to 1.2 by the conclusion of the training. Further analysis was completed to evaluate the presence of story grammar elements and narrative style. Nicholas was able to provide labels for the pictures in the story generation task, but did not identify any type of plot or sequence of events. He simply provided a basic description of each picture by naming or labelling objects and people. His narrative lacked cohesive and transition terms and was not fluent, in that he had multiple revisions and false starts. Following the conclusion of the training, Nicholas had increased his use of temporal concepts, cohesive and transition terms from zero to 30 (see Figure 2). Nicholas' mother reported that she agreed that there were gains in his overall performance following the study on the parent survey. She strongly agreed that she understood the goals of narrative development and intervention, and that she felt competent to continue implementation beyond the study.

Figure 2 | Changes in Nicholas' performance pre- and post-testing

Clinical implications

In evaluating these results, these case studies showed that overall gains were made in narrative language development following parent training. Both cases make use of an evidence-based intervention procedure, narrative language therapy, in combination with parent training as a method to increase overall vocabulary and narrative language development skills. The two children were good candidates for this type of intervention based on their overall level of readiness for the literacy tasks involving narrative language. They made notable strides in the areas of vocabulary and transition words used, as well as in story generation and story retell abilities. They also made gains given the repetition and the types of activities highlighting story grammar elements and transition words. In addition, both parents consistently asked questions and reported in with feedback on success experienced to the investigator on a weekly basis. Both parents were receptive and willing to adjust the training for the child and felt competent in the training and their ability to continue the intervention beyond the experimental period. These case studies also showed that parents are excellent partners in the intervention process and should be used to enhance concepts introduced in speech language therapy. With the proper method of communication between the speech language pathologist and the parent, whether it is via email, phone, or face-to-face, a partnership can be formed that provides the link for maintenance and generalisation beyond the therapy setting.

Limitations and future research

The results highlighted through these case studies both depict positive results with parent training and intervention for narrative language skills with children with Down syndrome. Further research should be conducted with more parent-child dyads to replicate the findings in these case studies. Future studies may implement the use of an internet-based method of parent training which would allow for greater participation. In addition, these case studies concluded at the end of the four-week training. It would be of interest to follow parents and children beyond the actual intervention period to monitor whether parents were able to continue the intervention. The mothers in the current study asked the investigator for suggestions of appropriate types of literature to continue and were given a list of possibilities, but no further follow-up was continued. Finally, teachers could also be participants in training, thus allowing for a more solid format for providing intervention in the area of narrative language development.

References

  1. Chapman R, Hesketh L. The behavioral phenotype of individuals with Down syndrome. Mental Retardation and Developmental Disabilities Research Review. 2000;6:84-95.
  2. Thordardottir E, Chapman R, Wagner L. Complex sentence production by adolescents with Down syndrome. Applied Psycholinguistics. 2002;23:163-183.
  3. Miles S, Chapman R. Narrative content as described by individuals with Down syndrome and typically developing children. Journal of Speech, Language, and Hearing Research. 2002;45:175-189.
  4. The same old story, told by individuals with Down syndrome (2002, February 14). American Speech Language Hearing Association (ASHA); 2002 February 14. [cited 2008 November 12]. Available from: http://www.asha.org/about/news/2002/down_syndrome_narratives.htm
  5. Engel S. The stories people tell: Making sense of narratives of childhood. New York: WH Freeman; 1995.
  6. Hughes D, McGillivray L, Schmidek M. Guide to narrative language. Wisconsin: Thinking Publications; 1997.
  7. Liles B. Narrative discourse in children with language disorders and children with normal language: A critical review of the literature. Journal of Speech and Hearing Disorders. 1993;54:356-365.
  8. Roth F. Oral narrative abilities of learning disabled children. Topics in Language Disorders. 1986;7:21-30.
  9. Strong C, North K. The magic of stories. Eau Claire, WI: Thinking Publications; 1996.
  10. Merritt D, Liles B. Story grammar in children with and without language disorder: Story generation, story retelling, and story comprehension. Journal of Speech, Language, and Hearing Research. 1987;30:539-552.

Received: 27 June 2007; Accepted: 31 July 2008; Published online: August 2009

Appendix 1

Parent Training of Narrative Language Skills

Child Name:

Parent Name:

Activities are to be completed on Monday or Tuesday AND Thursday or Friday. Please write the day each activity was completed and provide comments regarding performance.

MONDAY/TUESDAY WEDNESDAY THURSDAY/FRIDAY
Week 1 Pre-story
• Semantic word map
NO INTERVENTION Pre-story
• Present vocabulary
• Pre-test
• Think Alouds
Completed
Comments: E-mail Dr. Schoenbrodt at lschoenbrodt@loyola.edu with progress update
Week 2 During Story
• Read story
• Re-read story
NO INTERVENTION During Story
• Read story
• Think Alouds
Completed
Comments: E-mail Dr. Schoenbrodt at lschoenbrodt@loyola.edu with progress update
Week 3 During Story
• Read story
• Think Alouds
NO INTERVENTION During Story
• Read story
• Story Grammar
• Retell Story
Completed
Comments E-mail Dr. Schoenbrodt at lschoenbrodt@loyola.edu with progress update
Week 4 During Story
• Read story
• Retell story with story grammar prompts
NO INTERVENTION During Story
• Read story
• Comprehension questions
• Art project (with retelling story)
Completed
Comments E-mail Dr. Schoenbrodt at lschoenbrodt@loyola.edu with progress update

Art activities

1. Art materials needed:
  • Different types of uncooked pasta that have holes (e.g., macaroni, rigatoni, penne, mostaccioli)
  • String or elastic
  • Scissors

Direct students to make a pasta bracelet or belt. Show students a model of a bracelet or belt that you have made. Direct students to measure the amount of string needed and cut the appropriate length. Have students select the types of pasta they wish to use and to string these on their bracelets or belts. Assist students with tying their string ends. Have students display their bracelets or belts and describe the types of pasta used and the sequences they used in their designs.

2. Art materials needed:
  • Different shapes and sizes of uncooked pasta
  • A sheet of construction paper for each student
  • Glue

Allow students to make a pasta picture. Direct them to glue the pasta onto construction paper to make a picture. Have them label their pictures and describe them to the group.

Post-story presentation

Comprehension questions

The following are examples of questions to test students' comprehension of Strega Nona (question type is indicated in parentheses after each example).

  • What chores did Big Anthony have to do for Strega Nona? (Right There)
  • When Strega Nona left, what did she tell Big Anthony he could eat? (Right There)
  • What things did Big Anthony and the townspeople do to try and stop the pasta? (Think and Search)
  • How many days passed from the time Big Anthony heard the magic song to when he used the pot to make pasta? (Think and Search)
  • Why did Big Anthony touch the pasta pot when he was told not to? (Author and You)
  • Why did the men of the town want to "string Big Anthony up"? (Author and You)
  • Why is it important to obey parents and teachers when they tell you not to do something? (On Your Own)
  • What should the punishment be for throwing your trash on the ground instead of in a trash can? (On Your Own)

During-story presentation

Think Alouds

Confusing Information - Read to where all the people in town talked about Strega Nona in whispers and say, "I don't understand why all of the people in the town whisper about Strega Nona. She looks very nice and pleasant. This is different than what I would expect. I would expect that all of the townspeople would like her and say only good things about her. What would you expect? Why do you think everyone talks about her in whispers?"

Repair Strategy - Read to where everyone at the town square laughed at Big Anthony because he told them about Strega Nona's pot and say, "I don't understand why the townspeople are laughing at Big Anthony. They all know that Strega Nona is magical. I'd better read on to see how Big Anthony convinces them that the pot can really make magic. What do you think he will do?"

Mental Picture - Read to where Big Anthony does not blow three kisses to stop the pot from making pasta and say, "The pasta pot is overflowing because Anthony does not know the magic spell. The idea that I have is that he will stop the pot from cooking by finding Strega Nona's magic book. He will look up the magic words and stop the pasta pot from cooking any more pasta. How do you think he will get the pasta pot to stop?"

Analogy - Read to where the pasta is filling the town and the people are making a barricade to hold it back and say, "This reminds me of the time it rained so hard that our town flooded. There were sandbags lining the streets to barricade the water, but it didn't help. All of the stores and some of the houses flooded. Have you ever seen a flood or had to make a barricade to hold something back?"

Strega Nona Vocabulary

Pre-test

Post-test

Date:

Date:

magic

magic

valuable

valuable

boiled

boiled

applause

applause

compliment

compliment

protect

protect

barricade

barricade

halt

halt