Child Language Teaching and

Therapy
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Sign-supported Dutch in children with severe speech and language impairments: A

multiple case study
Inge Wijkamp, Betsy Gerritsen, Freke Bonder, Hinke Haisma and Cees van der Schans
Child Language Teaching and Therapy 2010 26: 273 originally published online 27 May 2010
DOI: 10.1177/0265659009349983

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 Child Language Teaching and Therapy
26(3) 273–286
Sign-supported Dutch in children © The Author(s) 2010
Reprints and permission: sagepub.
with severe speech and language co.uk/journalsPermissions.nav
DOI: 10.1177/0265659009349983
impairments:  A multiple case study http://clt.sagepub.com

Inge Wijkamp
Hanze University Groningen,  The Netherlands

Betsy Gerritsen
Tine Marcus School, Groningen,  The Netherlands

Freke Bonder
Royal Kentalis/Pon TeM R&D – Breaking Language Barriers, Sint Michielsgestel,  The Netherlands

Hinke Haisma
Hanze University Groningen,  The Netherlands

Cees van der Schans

Hanze University Groningen,  The Netherlands

Abstract
In the Netherlands, many educators and care providers working at special schools for children
with severe speech and language impairments (SSLI) use sign-supported Dutch (SSD) to facilitate
communication. Anecdotal experiences suggest positive results, but empirical evidence is lacking. In
this multiple case study the changes that occur in the way children with SSLI (n = 8) communicate after
SSD is offered to them in an educational setting were explored.Video-recordings of teacher–student
interactions were made at two-month intervals, starting with a baseline observation followed by six
months of SSD input. The samples were analysed for mode of communication, and special attention
was given to the gestures and signs used by the children.The way in which the children supplemented
or replaced speech with hand movements, and the frequency in which they did so, varied and seemed
to be associated with the form of their underlying speech problem. After six months of SSD input,
the children did use early gestures more frequently, although they rarely used signs.

Keywords
augmentative and alternative communication (AAC), gesture, mode of communication, sign
system, severe speech and language impairments (SSLI)

Corresponding author
Inge Wijkamp, Hanze University Groningen, Eyssoniusplein 18, 9714 CE Groningen,  The Netherlands
Email: j.s.wijkamp@pl.hanze.nl

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274 Child Language Teaching and Therapy 26(3)

I   Introduction
Speech and language impairments can hinder children from participating in their education and
from engaging within society. For this reason, educators and care providers at schools for children
with severe speech and language impairments (SSLI) constantly seek ways to facilitate communi-
cation. The use of augmentative and alternative communication (AAC) can prove to be helpful in
improving communication. One example is the use of supportive signs as a temporary aid to stimu-
late the communication skills of these children. In the Netherlands, the most commonly used sign
system is sign-supported Dutch (SSD). SSD originated from the deaf community, where it is used
as a communicative ‘bridge’ during social intercourse with hearing people.
The term ‘children with severe speech and language impairments’ refers to a heterogeneous
group of children that have speech- and language-disorder-related communication difficulties.
Children diagnosed with specific language impairments (SLI) are included in this group, as are
children who, for example, experience communicative problems as a result of mild autistic spec-
trum disorders (ASD). This heterogeneous group also includes children whose speech is unintel-
ligible, for instance as a result of organic factors like cleft palate, pharyngeal dysfunction, or
childhood apraxia of speech. Both the underlying causes of the language problems and the forms
in which the speech disorders are revealed may differ.
Prevalence rates on speech and language disorders vary widely. About 7% of toddlers are at risk
of SLI (Leonard, 1998). The average birth rate in the Netherlands is about 185,000 children per
year (Statistics Netherlands, 2009). Thus, if 7% of children are at risk of SLI, then about 13,000
new-born Dutch children would be expected to develop SLI. Because SSLI is more broadly defined
than SLI, the expected number of children at risk for SSLI could be even higher.

1   Sign systems and SSD

In a sign system, spoken words are supported by hand movements that include signs derived from
a sign language (Morris, 2005; Baker, 2008). A sign system is not a language in itself and has no
linguistic characteristics of its own. It is a combination of two communication systems – speech
and sign language – but it is the spoken language that provides the linguistic structures. In the
Netherlands, the sign system most commonly used by children with SSLI is SSD, which combines
spoken Dutch and sign language of the Netherlands (SLN).
In this context, two types of hand movements are relevant, namely gestures and signs. According
to McNeill (2000: 6) ‘gesticulation accompanies speech, is non-conventionalized, is global and
synthetic in mode of expression, and lacks language-like properties of its own.’ Research about
gestures in normal developing children demonstrated that gestures not only support communica-
tion but also form an integrated system of communication with speech (Goldin-Meadow, 1998;
Iverson and Goldin-Meadow, 2005). In 2004, Capone and McGregor published a narrative review
on gesture development. Different types of gestures were described, including deictic gestures like
pointing to a person or an object, and giving an object to a person to gain the attention of a conver-
sational partner. Iconic or representational gestures were defined as hand movements that express
underlying meanings. Children’s gestures serve several functions, including those of communica-
tion, compensation, and transition to spoken language (p. 173). Furthermore, the authors stated that
gesture development emerges in a predictable way and is related to speech development, leading
them to propose a ‘timeline of gesture development’ (p. 183).
McNeill (2000) described signs as follows: ‘they are conventionalized, segmented and analytic and,
therefore, possess language properties, while they are obligatorily not performed with speech’ (p. 6).

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Wijkamp et al. 275

A sign conveys meaning by simultaneously combining hand shapes, place, orientation, non-manual
information, and movement of the hands (Baker, 2008). In some instances, signs and iconic gestures
are difficult to differentiate, since the intuitive hand movements that people make to express a meaning
are sometimes identical to the form of the sign used for that concept, e.g. drinking.
In summary, SSD comprises gestures and gesture-like iconic signs as well as non-iconic SLN
signs. These hand movements accompany spoken Dutch, which is used at all times when commu-
nicating with a child.

2   Sign systems, gestures and signs in children with speech disorders
Sign systems are used with children who suffer from severe hearing loss, e.g. in the case of a deaf
child surrounded by hearing people, or in children who are hard of hearing (Goldin-Meadow,
2005). Using a sign system in children with speech disorders is thought to facilitate and stimulate
their communicative skills. Typically, developing infants exposed to a sign language acquire their
first signs at an earlier age than children utter their first spoken words (Thompson, Cotnoir-
Bichelman, McKerchar, Tate, and Dancho, 2007). This observation led to the notion that support-
ive signs advance child behaviour and development, although evidence to support this claim is not
yet conclusive (Johnston, Durieux-Smith, and Bloom, 2005).
Signing is taught to children who have difficulty using expressive language or whose speech is
significantly unintelligible (Morris, 2005). An example of a sign system used worldwide, in which
supportive signs derived from the British Sign Language (BSL) play a major role, is Makaton (The
Makaton Charity, 2008). Next to signs and gestures, graphic symbols are used as well to support
communication. Makaton is used by and with people who have communication and learning dif-
ficulties, e.g. people with cognitive impairments, autism and/or articulation problems.
Studies that examine the effectiveness of signs in children with SSLI are scarce. In 2002, Bode
and Knoors concluded that the use of supportive signs in children with SLI (n = 10) while training
picture-naming skills is effective. The words trained using speech and signs were remembered bet-
ter than the words that were supported by speech only. No other studies on signs and sign systems
in children with SSLI were found, but recently Schlosser and Wendt (2009) published a review on
the use of AAC, including signs, in children with related speech disorders, namely autism. Most of
the reviewed studies ‘yielded some gains in speech production for most participants. However, the
data indicated that most of these gains were of modest magnitude’ (p. 226).
The use of gestures in children with communication impairments was also investigated. In
1993, Weismer and Hesketh stated that the acquisition of novel words in children with normal
language development as well as children with SLI was significantly affected by alterations in
speaking rate and by the use of gestures accompanying spoken language. Evans, Alibali, and
McNeil (2001) found that 7- to 9-year-old children with SLI, more often than normal developing
children, expressed information that was not present in their speech through gestures, indicating
that gestures are linked to the cognitive concept development of children. Furthermore, these chil-
dren expressed more advanced knowledge when speech and gestures were combined. Capone and
McGregor (2004) suggested that both the language ability and gestural performance of children
with SLI parallel those of younger children. Different patterns were observed in gestures used by
late talkers and late bloomers, in that true late talkers used fewer initiating and responding com-
municative gestures than late bloomers. Late bloomers used gestures early on to compensate for
their deficits in oral expression, whereas true late talkers did not.
In 1988, a speech therapist introduced SSD at a Dutch special school for children with hearing
impairments and children with SSLI. The aim was to improve communication with the children

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276 Child Language Teaching and Therapy 26(3)

who were hard of hearing (Gerritsen and Wijkamp, 2004a). Surprisingly, the children with SSLI
picked up the signs and started to use them actively. Presently, supportive signs are used in working
with children:

• when a child does not have any verbal means of communication;

• when a child’s speech is unintelligible;
• when a child feels insecure about using verbal communication;
• as a means to make contact;
• as a means to stimulate language development.

Practical experience in using SSD indicates that this type of AAC positively influences the com-
munication skills of children with SSLI (Gerritsen and Wijkamp, 2004a). However, there is a lack
of evidence to support this conclusion. To explore how the introduction of SSD offered in an edu-
cational setting affects the communication of children with SSLI, a multiple case study was carried
out. The main objective was to describe what mode of communication children with SSLI prefer
after SSD is introduced to them: Do they communicate verbally, by using gestures or signs, or by
combining both modes?

II   Methods
In this multiple case study, eight children with SSLI were followed in their communicative func-
tioning, from September 2005 to May 2006. Initially it was estimated that the amount of data
gathered by observing 10 children could be handled in the available time frame. However, two of
the children did not meet the inclusion criteria for this study and were excluded from the sample.
School policy at the participating special school for hearing impaired children and children with
SSLI aged 4 to 12 years, and an affiliated kindergarten for children aged 2 to 4 years, requires that
teachers, speech therapists and other staff members use SSD when working with the children.
While carrying out daily activities like class conversation, singing songs and reading aloud, mean-
ingful words are supported with gestures and signs (Gerritsen and Wijkamp, 2004b). When imple-
menting specific communication-based interventions, in class or at speech and language therapy,
the use of the signs is trained more explicitly, e.g. by offering topic-related signs in picture-naming
exercises or by supporting specific syntactic elements for training in sentence production. All staff
members are expected to use SSD in communicative situations with all individual children.
During the study period, all participating children received SSD input according to this policy.
Due to time and organizational factors further specific observations on this variable could not be
made. As a result, the amount and quality of SSD input each individual child received probably
somewhat varied over time and depended on the unique needs of each child and on the skills of the
teachers, speech therapists and other team members. Although the parents of all eight children
were given the opportunity to attend a signing course, the parents of only five of the eight children
attended the course.

1   Participants
The first eight children – four boys and four girls – who were admitted to either the school for chil-
dren with SSLI or the affiliated kindergarten, starting 1 September 2005, and who met the inclusion
criteria (see below) were included into this study. The inclusion criteria were as follows:

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Wijkamp et al. 277

• younger than five years of age;

• no hearing impairment exceeding 35 decibels hearing level (dB HL);
• no severe visual or motor impairments;
• first language is Dutch;
• not having been offered signs before referral.

At the start of the study, each child was tested for language comprehension, language production
and intelligibility. The results of these tests are summarized in Table 1.
For language production, the productive lexicon of some children consisted of 50 words or
fewer. These children were categorized as ‘hardly speaking’ or ‘not speaking at all’. The reason for
this is that literature states that in a child that produces less than 50 words, the development of the
phonological system (e.g. the ability of a child to perceive phonological contrasts) has not yet
started (Beers, 1995; Stes, 1997). The children who had the disposal of a productive lexicon of 50
words or more, and whose verbal skills could be tested with the suitable instruments, were catego-
rized as ‘having verbal communication skills’. Children were labelled as ‘unintelligible’ if their
speech was not understandable by their parents and other persons in their environment and if their
test results reflected a phonological deficit of more than 12 months.
A preliminary classification based on the level of language production skills led to a classifica-
tion of the children into three categories:

1. two children who had verbal communication skills;

2. three children who spoke unintelligibly due to severe phonological impairments; and
3. three children who hardly spoke or did not speak at all.

2   Classification system

The classification system used in the present study was an adaptation of a system used in previous
gesture studies (Butcher and Goldin-Meadow, 2000).

a  Verbal communication:  Verbal communication represented meaningful utterances, words and

vocalizations that were recognizable in Dutch and were consistently used by a child to refer to a
specific object or event.

b   Gestures and signs:  A hand movement was classified as a sign when it matched a description in
the Dutch sign lexicon (Nederlands Gebarencentrum, 2000). Hand movements that were not rec-
ognizable as a sign but that referred to an object or person, were classified as gesture. In addition,
hand movements were defined as communicative if the following criteria were met:

• Hand movements could not be a direct manipulation of some relevant person or object (e.g.
talking into a telephone), except when the child manipulated the object to express a meaning
by it (e.g. to bring it to someone’s attention).
• The hand movement did not imitate the communication partner.
• Hand movements could not be a part of a ritual act or game (e.g. blowing a kiss to someone)
or be an imitation of the communication partner’s preceding gesture or sign.

c   Combination:  This included all gestures or signs that augmented spoken messages.

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 278

Table 1  Participants
Child School Age Comprehension Word production Phonology Remarks
number (months) TBQa WQb age (months)c
1    TM 54 90 55 20 hardly speaking
2    TT 32 80 < 50 words < 15 hardly speaking (ASD)
3    TM 50 100 98 29 unintelligible
4    TT 40 72 76 30 speaking
5    TM 54 71 71 32 speaking
6    TM 48 80 < 50 words < 15 hardly speaking
7    TM 55 105 102 26 unintelligible
8    TT 42 89 92 26 unintelligible
Notes: TM = Tine Marcus School, special school for children with SSLI; TT = Taaltrein, special kindergarten for children with SSLI; a TBQ: Receptive Language Quotient; M=100,
sd=15; measured with Reynell (Van Eldik, Schlichting & lutje Spelberg, 1995); b WQ: Word Quotient; M=100, sd=15; measured with Schlichting (Schlichting,Van Eldik, lutje
Spelberg,Van der Meulen & and van der Meulen, 1995); c Measured with Fonologische Analyse voor het Nederlands [Phonological Analysis for Dutch] (Beers, 1995)

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Child Language Teaching and Therapy 26(3)
Wijkamp et al. 279

3   Procedure
Almost immediately after the children were admitted to one of the participating schools, a baseline
assessment of the child’s mode of communication was conducted. At this point, the children had
not been exposed to supportive signs. Video-recordings were made to determine whether each
child communicated verbally, by using gestures or signs, or by combining both modes of commu-
nication (i.e. verbal plus gestures or signs). Subsequent recordings were made after exposing the
children to SSD for two, four and six months. The video-recordings were made in a therapy room.
Two speech therapists (one being one of the researchers/authors) worked with four children each.
The subject of conversation was not controlled. In most cases, the toys present in the therapy room
served as topics of conversation. Sometimes a conversation emerged spontaneously, independent
of the toys. During the baseline recordings, the speech therapist did not use SSD, but during sub-
sequent sessions she did. The recordings were made by a student who did not participate in the
communicative situation.
Speech therapy students transcribed the video-recordings into samples of 50 communicative
utterances, a number in line with a much-used method for spontaneous speech analyses in the
Netherlands (Schlichting, 1987). To prepare for the transcription and classification procedure, the
students participated in introductory training conducted by one of the researchers/authors. During
the transcription period, pairs of students checked each other’s transcripts and discussed transcrip-
tion issues. Transcription issues were also discussed among all students and, if needed, with the
researchers. At the end of the study, one of the two researchers/authors checked all the transcriptions
and classifications, resulting in a 90% agreement rate. The communicative utterances were classi-
fied as ‘verbal’, ‘gesture/sign’ or ‘combination’. For each sample, the number of times a child used
a mode was counted. The number of gestures or signs used by a child was counted separately.

III   Results
1   Mode of communication

At the start of the study, before SSD was introduced as part of their language input, all of the chil-
dren used the verbal mode while communicating (see Figure 1). Even the children in the ‘hardly
speaking’ category relied on the little verbal skills they had to communicate with their conversa-
tional partner by using one-word-sentences like ja (‘yes’), nee (‘no’), mama (‘mommy/mummy’)
and papa (‘daddy’). The frequency of verbal communication varied across the group of children.
Child 3 and Child 7, both unintelligible speakers, used more than 40 verbal utterances out of the
total 50 utterances, making them the ‘top users’ of this communication mode at this point in time.
Their speech consisted of 3- to 5-word utterances. However, these children hardly used the ‘ges-
ture/sign’ mode to communicate. The other six children expressed about 30 verbal utterances,
consisting of a diversity of one-word to multiple-word sentences. All of these children, except
Child 5, used the ‘gesture/sign’ mode 10 to 16 times. Child 5 displayed a distinct pattern of com-
munication, using ‘verbal’ and the ‘combination’ form more frequently than gestures or signs with-
out speech.
After establishing baseline communication mode levels, each child’s communication skills
were measured two (t1), four (t2) and six months (t3) after exposure to SSD. Even after supportive
signs were added to the children’s language input, verbal communication was the preferred mode
of communication for all the children. Again, large individual variations were observed. For clar-
ity, the results are presented according to the three categories of children described above.

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280 Child Language Teaching and Therapy 26(3)

Child 1
50

40

Frequency verbal
30
combination
20 gesture/sign

10

0
t0 t1 t2 t3

Child 2
50

40
Frequency

30 verbal
combination
20 gesture/sign

10

0
t0 t1 t2 t3

Child 3
50

40
Frequency

30 verbal
combination
20 gesture/sign

10

0
t0 t1 t2 t3

Child 4
50

40
Frequency

30 verbal
combination
20 gesture/sign

10

0
t0 t1 t2 t3

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Wijkamp et al. 281

Child 5
50

40

Frequency
30 verbal
combination
20 gesture/sign

10

0
t0 t1 t2 t3

Child 6
50

40
Frequency

30 verbal
combination
20 gesture/sign

10

0
t0 t1 t2 t3

Child 7
50

40
Frequency

30 verbal
combination
20 gesture/sign

10

0
t0 t1 t2 t3

Child 8
50

40
Frequency

30 verbal
combination
20 gesture/sign

10

0
t0 t1 t2 t3

Figure 1  Mode of communication of each child

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282 Child Language Teaching and Therapy 26(3)

a   Children who had verbal communication skills:  The level of language comprehension for the chil-
dren in this category (Child 4 and Child 5) was below average and corresponded to their level of
expressive verbal skills. Both children for the most part communicated verbally throughout the
study period. Child 4 rarely used the ‘gesture/sign’ mode or the combination form. At t1, Child 5
showed decreased verbal communication, which was compensated by increased ‘gesture/sign’
communication. At t2 and t3, her communication pattern revealed a strong preference for verbal
communication. Moreover, she used almost no gestures or signs.

b   Children who spoke unintelligibly:  These three children (Child 3, Child 7 and Child 8) also displayed
a strong preference for verbal communication throughout the study. Their level of language compre-
hension skills was average to above average, indicating that a phonological disorder was their main
disability. For Child 3, the frequency of verbal communication remained unchanged throughout the
study. However, for Child 7 and Child 8 modes of communication varied throughout. They used more
gestures or signs and more combination forms over time, but no distinct pattern was recognizable.

c   Children who barely spoke or did not speak at all:  The level of language comprehension in these
children was normal to subnormal but was at variance with their expression skills. Even though the
verbal expression skills of Child 1 were limited, he exhibited a strong preference to communicate
verbally throughout the study, with just a slight decrease at t3. At first, the other two children
(Child 2 and Child 6) preferred to communicate verbally. From the moment SSD was introduced
to them, they increasingly made use of the ‘gesture/sign’ mode and the combination form. At the
end of the study, both children used all three modes almost equally.

2   Gestures and signs

In addition to mapping the mode of communication, the number of gestures and signs used by the
children at all measurements, including the baseline assessment, were counted (see Table 2).
Almost no signs were observed during the study period. All children – some more than others –
used gestures, and just a few children actually used signs to supplement or complement their
speech. Both gestures and signs were used with and without speech.

IV   Discussion
The aim of this multiple case study was to explore how the introduction of SSD affects the com-
munication of children with SSLI. Before and after the introduction of supportive signs, all eight
children used ‘verbal’ as their main mode of communication. The use of the ‘gesture/sign’ mode

Table 2 Number of gestures and signs produced by each child

Verbal and gestures Verbal and signs Gestures Signs
Child 1 25 1 41 0
Child 2 45 1 60 1
Child 3 19 0 20 0
Child 4 18 5 39 0
Child 5 32 4 36 5
Child 6 28 3 58 3
Child 7 38 0 23 0
Child 8 32 0 22 0

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Wijkamp et al. 283

fluctuated in parallel with this verbal mode. Over time, the use of combination form was relatively
unchanged. The observation that ‘verbal’ remained the main mode of communication after the
children were introduced to SSD could indicate that no changes occurred in the children’s com-
munication. However, closer examination of the findings showed that changes did occur, and that
they varied across individuals.
More than any other factor (e.g. intelligibility and language comprehension), the level of verbal
expression skills was the factor that most influenced the communication choices of each child. It
appears that ‘verbal’ children did not feel the need to change their way of communicating after SSD
was introduced to them. Their level of verbal communication remained high over time, without
notable changes in their use of gestures and/or signs. This seems plausible: Why use an alternative
means of communication when you have the skills to communicate verbally? More variation was
observed in the communication patterns of the three children whose speech was unintelligible.
These children, who did not exhibit any major language disorders other than a phonological deficit,
preferred also to communicate verbally, but their use of the gesture/sign and combination modes
differed from that of the verbal group of children. The video-recordings of two of these children
showed that they, more than the other children, added deictic gestures to their speech – like point-
ing and showing – to support key words. On some occasions these children used gestures during
specific interchanges, e.g. when their conversational partner misunderstood them. While repeating
their verbal message, they emphasized content words by supporting them with deictic and iconic
gestures. Practical experience shows that children with phonological disorders are often unaware
of their speech problems. These children believe that the message ‘in their heads’ actually comes
out just as they had intended. The conversational partner has to point out to the child that his or her
message was unclear. The possibility of using gestures or signs to supplement or compensate their
unintelligible speech may give them the opportunity to clarify their message if needed.
The most distinct changes were observed in the children who, at the start of the study, hardly
spoke or did not speak at all. In two of these children, a decrease in the use of the ‘verbal’ mode
was observed. An increase in ‘gesture/sign’ usage compensated for this decline in speech. At first
glance, this observation reflects a contraindication for SSD. After all, the aim of SSD is to stimu-
late the verbal communicative skills of children with SSLI. However, a closer look into the sam-
ples led to the notion that, although verbal communication decreased, the complexity of their
communication increased: The children compensated the deficits in their verbal skills by using
deictic and iconic gestures, and also SLN signs, in order to express their message. Most hand
movements were used in a communicative function without the presence of speech. In other
instances the verbal message was supplemented with gestures or signs to enable the child to insert
more complex elements into his or her message. Similar to the findings of Evans et al. (2001), it
seems that using gestures and signs enabled children with very limited verbal skills to express
concepts that were already present cognitively, but which they could not yet express verbally.
The results indicate that the increase in using gestures and signs did not occur at the expense of
the ability to use speech. At all times speech remained the preferred mode of communication. One
of the children, who started out with very limited verbal skills, did not display a similar matching
pattern. During the six-month study period his preference for verbal communication remained
unchanged. A more qualitative analysis reflects the image of a ‘late bloomer’. While his verbal
communication skills improved rapidly, finding an alternative means of communication was no
longer needed.
All children used gestures to express their communicative intents before as well as after they
were introduced to SSD. Not all of them actually used signs. The number of signs used by all chil-
dren was far fewer than the number of gestures used. This is a notable observation, because signs

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284 Child Language Teaching and Therapy 26(3)

were expected to be an important factor in determining the nature of SSD. Both gestures and signs
were used with and without speech.
In the present study, the data obtained were quantitative by virtue of the classification system
used. This helped us to gain insight into the forms of communication children used. On the other
hand, translating something as complex as communication in terms of numbers can be awkward
and may be too simplifying. Much information is lost, such as the observed changes in the com-
plexity of the children’s verbal and nonverbal communication over time, and different functions in
which the children use the gestures or signs. The classification procedure was controlled, but the
process of analysing the subtle movements the children made and determining the meaning of
these movements was somewhat open to interpretation. However, having transcribers standardize
their scoring ameliorated this potential problem.
Due to organizational factors, we could not provide a controlled description of the quality and
quantity of SSD input each child received over the six-month study period. Consequently, the
influence of this variable on the communicative behaviour of the eight children with SSLI could
not be included. This also applies to the influence of the parental SSD input of the children.

V   New insights

The results of this multiple case study generated new ideas. From clinical experience, it is per-
ceived that some children would not start to use supportive signs after these signs are offered to
them. The results of this study not only confirmed this perception but also suggest a possible expla-
nation for this observation: A child’s level of verbal expression skills could be a factor that influ-
ences whether the child will adopt supportive signing. Gestures and signs seem to have little added
value to children whose verbal skills are sufficient to express their communicative intents. On the
other hand, gestures and signs may function as an alternative means of communication in children
with limited verbal expression skills. The most likely scenario is that these children make use of
SSD for a limited amount of time, until they reach a level in which they can adequately communi-
cate verbally. It seems that the children with unintelligible speech only looked for an alternative
when they were misunderstood and needed a complementary mode of communication to support
their verbal message.
Offering SSD directs explicit attention to the gestures produced more than standard conversa-
tion does. This can explain why all children in this study, even the highly verbal ones, started to use
more gestures after SSD input was implemented. In this study, all types of gestures were found to
be used, but deictic gestures were seen the most. Some children used signs after they had been
offered SSD, but for a limited number of times. In contrast, almost all the children increased the
number of gestures they used. Capone and McGregor (2004) proposed a gesture timeline for nor-
mally developing children, which could also provide a context for our findings. This gesture time-
line includes a description of increasingly complex types of gestures combined with the functions
they fulfil in relation to speech. The representational gesture is the most complex type distin-
guished and shares one important characteristic with a sign, namely, that they both convey the
concept or meaning a child wants to express. This joint function, in combination with its usage
with and without speech, led us to hypothesize that the signs offered to children with speech disor-
ders in the context of a sign system behave like a type of well-described, conventionalized gesture.
This hypothesis might also explain why the children in this study did not use many signs six
months after being exposed to SSD. For some children with SSLI, due to their specific disorder, a
period of six months may be too short to acquire the concepts involved. On the other hand, some
of the children did use signs to communicate. It could well be the case that these children are the

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Wijkamp et al. 285

ones Capone and McGregor (2004) describe as ‘late bloomers’, i.e. children who possess sufficient
conceptual language abilities but lack the skills to express them. The additional input of gestures
and signs affords them the opportunity to express themselves.
More research is needed to examine the effectiveness of SSD as a means of AAC intervention
in children with SSLI. The exact role that gestures and signs play in the special care of children
with SSLI has to be determined. Similarly, what function they serve and how this is influenced by
the nature of the SSD input is also yet to be determined. Expert opinions and studies on signing in,
for instance, deaf children indicate that variables like quality and quantity are crucial factors that
affect the communicative skills of children (Kouwenberg, Slofstra-Bremer and van Weerdenburg,
2008). Consequently, this element should be included in future studies on SSD in children with
communicative disorders.
From a clinical and educational point of view, it is relevant to explore how other subgroups of
children with communicative disorders – such as children with intellectual disability or autism –
take advantage of SSD and how this affects their well-being. Future research can contribute to a
more child-based decision-making process to determine whether SSD should or should not be
offered to a specific child.

Acknowledgements
We thank the children, their parents and the staff of both schools for their cooperation and support.
We also wish to thank the students of the Department of Speech Therapy, Hanze University
Groningen, for the energy they invested in this project, and Claartje Slofstra-Bremer for her com-
ments and advise during publication of this article. This study was financed by Royal Kentalis,
Zwolle and Hanze University, Groningen.

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