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Readership: primary, secondary, special

MEETING THE EDUCATIONAL NEEDS OF CHILDREN WITH DOWN SYNDROME:

KEYS TO SUCCESSFULINCLUSION
Researchers are agreed that there is a specific social and cognitive profile associated with Down syndrome a profile of strengths and weaknesses rather than general delay. Sue Buckley and Gillian Bird argue that knowledge of these strengths and weaknesses allows educators to develop more effective teaching strategies and learning environments, in both inclusive and special education settings.
An understanding of the specific effects of Down syndrome on learning and development is important in designing effective educational programmes, whether the children are in special or inclusive educational settings, and this is the focus of the present article. However, as evidence for the benefits of inclusive education is growing (2), the final section identifies keys to successful inclusion based on the authors experience of directly supporting the inclusion of children with Down syndrome over the past 14 years. This article provides a summary of key issues. The authors have recently published detailed information for teachers on all these issues, with the practical implications for classroom practice set out in full, giving guidelines to expected levels of achievement and illustrated with examples of childrens work (see Down Syndrome Issues and Information: Development and Education Series 2002: http://www.downsed.org).

INTRODUCTION
Children with the diagnosis of Down syndrome have a chromosome disorder due to the presence of an additional copy of genes on chromosome 21. Children with Down syndrome are at risk for a number of associated health and developmental difficulties and for many years these children were considered ineducable. In the past 25 years, both the health and developmental difficulties have been the focus of extensive research effort and this work is now providing a better understanding of the childrens educational needs and potential. Advances in healthcare have resulted in a much-increased life span and most individuals with Down syndrome can now expect to live to around 60 years of age. Advances in developmental research have led to the recognition that children with Down syndrome have specific cognitive and social profiles. They do not have a global developmental delay i.e. equal delay in all areas of psychological development; rather they have a profile of strengths and weaknesses, with some areas of their development less affected than others. It is increasingly recognised that this knowledge is relevant to designing effective educational programmes, as the childrens cognitive and behavioural strengths can be used to support their learning and development, and their areas of specific weakness can be targeted for intervention (1).

THE SPECIFIC DEVELOPMENTAL PROFILE AND ITS IMPLICATIONS FOR EDUCATORS

All individuals . Before discussing the developmental differences that may result from having Down syndrome, it is important to recognise that children with Down syndrome are all individuals. They have inherited the same range of genes from their parents as other children in their families, plus some extra copies. Therefore the knowledge that a child has Down syndrome does not define the child or predict his/her progress. Like any other child, development is strongly influenced by the social environment that he/she is growing up in and the quality of parenting and education that they are receiving. Children first. Children with Down syndrome vary widely in their progress, and each child must be seen as a child first, with the same psychological, social and emotional needs as any other child, and the same rights to be a full member of the

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community as any other child. Like all other children, children with Down syndrome will flourish when they feel loved, wanted and secure and they develop a positive sense of selfesteem. Specific needs. However, the knowledge that a child has Down syndrome alerts us to consider the extent to which the child is affected by the health and developmental difficulties that are associated with the syndrome. The health issues are considered first, as no child will be able to fully benefit from educational opportunities if he/she is affected by illness or sensory impairments.

SOCIAL DEVELOPMENT AND BEHAVIOUR

Social development is usually an area of relative strength for children with Down syndrome and this has been identified as an attribute which will help them in inclusive school settings (1). Social understanding. From infancy the social interactive skills of children with Down syndrome are good; they make eyecontact, smile and interact effectively using non-verbal communication skills. The children usually show good empathy and understanding of the emotional states and behave with appropriate sensitivity. They are able to behave in a socially appropriate manner and to learn the rules of social behaviour and discourse. However, they can also use this good social understanding to be expert at being difficult, as they know how to get the reaction that they want! Behaviour. Research has shown that the behaviour of children with Down syndrome is generally better than that of other children with similar levels of general cognitive delay, but that they are more likely to display difficult behaviours than typically developing children of the same age. However, there are wide individual differences in the behaviour of children with Down syndrome. Some children show no more difficult behaviours than other non-disabled children of their age, while others have persistent behaviour difficulties. It is not uncommon for behaviour difficulties to arise early in school placements, and to recur with a change of class or of school. In the authors experience, behaviour difficulties in school may be categorised under several headings: x x x cheeky or provocative attention seeking and control games avoidance strategies and communication of distress.

HEALTH ISSUES RELEVANT TO EDUCATION

Heart defects. Nearly half of the children with Down syndrome are born with heart abnormalities, but the majority of these will either be minor or have been corrected by surgery in infancy. However, a small group of children have serious heart defects which cannot be corrected and which will affect their quality of life. In school, this small group of children may be less able to engage in physical activity and may tire easily. They may also use a wheelchair as they get older and will have reduced life expectancy. Thyroids. Children with Down syndrome are also at increased risk for under-active thyroids, and as this could lead to slowness and tiredness in school, thyroid function should be checked annually. Hearing and vision. Children with Down syndrome are at increased risk for sensory impairments. The majority of children need glasses to correct for short or long sightedness and should have their vision assessed annually. Some 80 per cent of children have experienced fluctuating hearing loss due to glue in the middle ear during their pre-school years, and many will still be affected by mild to moderate hearing loss during school years. Some children will also have sensoryneural deafness and wear hearing-aids. Hearing should be assessed at least annually. In the classroom. Teachers should be alert to the possibility of sensory difficulties for a child with Down syndrome in their classroom. If the child wears glasses, it is important that staff ensure that the glasses are kept clean throughout the day. This may seem obvious but in the authors experience it is often not done, in both special and mainstream settings. Similarly, if the child wears aids, it is important that these are properly adjusted, and that the child is seated at the front of the classroom. Some current research indicates that children with Down syndrome may benefit from sound amplification in the classroom. For any child with sensory impairments, specialist advisers for visual or hearing impairment should be consulted.

Prevention . It is important to expect and encourage chronologically age-appropriate behaviour at all times. Difficulties often arise because the child is being babied by staff and other children in all sorts of ways, encouraging the child to behave in immature ways. Communication. It is also important to stress that behaviour may be the only way that a child with limited language can express him/herself; and if a child senses negative attitudes from staff, or if the work is too difficult or the child fears failure, difficult behaviour may be the only strategy available to him/her as a way of communicating about these experiences. In the classroom. Everyone needs to understand that behaviours are learned and that they are maintained by the responses they attract. Teachers and learning support assistants need to be confident in the use of behaviour modification techniques, with an emphasis on calm, clear behavioural modelling of what is expected of the child, and not on verbal explanation or instruction. A team approach is essential, with all those in daily contact with the child, including parents, involved in planning a behaviour change strategy and agreeing to implement it consistently. The main reasons for the failure of behaviour management plans are sabotage (someone not acting in the agreed way) and stopping the plan too soon.

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MOTOR SKILLS
The development of both gross and fine motor skills is usually delayed, but again, there is wide individual variation in progress. Motor skills only improve with practice, and many children with Down syndrome develop considerable skills in sports, dance and gymnastics if given the opportunity. In the classroom. The reasons for the motor skill difficulties are not fully understood, but the advice of an occupational therapist or adviser for children with motor difficulties can be valuable in the classroom. Most children with Down syndrome can achieve legible handwriting if given appropriate help, and many are skilled at using the computer to learn and to record work in primary years and later. The children are usually small in stature and therefore appropriately sized seating is important. Expression lags behind comprehension. Language production skills are more delayed than language comprehension, so most children with Down syndrome understand more than they can say. Speech intelligibility is also a problem. This is a frustrating situation and can lead to the childrens understanding being underestimated. Causes hearing, working memory and speech motor difficulties. The reasons for the speech and language difficulties in children with Down syndrome are not fully understood. Hearing difficulties in the pre-school years and later may be implicated. Auditory short-term (working) memory difficulties are being increasingly identified as a major factor influencing the learning of vocabulary and grammar (see below) (3). The speech motor difficulties that manifest as difficulties with articulation and phonology may reflect the general motor skill difficulties associated with Down syndrome, but there are also suspected difficulties at the level of word finding and sentence formulation. In the classroom. Speech and language development should be a curriculum priority. All children with Down syndrome should receive the support of a speech and language therapist throughout their school career, and the therapist should be able to identify how speech and language targets can be embedded in the regular curriculum activities. Vocabulary and grammar will be developed across the curriculum, particularly through reading and writing activities. Work on phonology and intelligibility can be linked to phonics and spelling work. Inclusion. In a recent study, inclusive education showed significant benefits for the speech and language development of teenagers with Down syndrome: they were more than two years ahead of peers in special education on a measure of expressive language, probably as a result of daily access to literacy activities and to the wider curriculum, as well as the effect of being immersed in a typical language community (2).

COGNITIVE DEVELOPMENT
Most children with Down syndrome will be cognitively delayed and fall within the range of mild to moderate learning difficulty. Some 10 per cent have more severe cognitive impairments, often accompanied by additional medical problems, and will have severe or even profound and multiple learning difficulties. There is wide variation in cognitive development and therefore in academic progress among children with Down syndrome. It is helpful to consider separately the skills that contribute to cognitive development.

SPEECH AND LANGUAGE DEVELOPMENT

Centrality to cognitive development. In typical development, speech and language skills underpin the ability to think, reason and remember. Thinking, reasoning and remembering are mental activities carried out by means of silent or overt speech. Vocabulary learning is concept learning: the more words a child understands, the more knowledge he or she has gained about the world. All areas of the curriculum provide opportunities to learn new vocabulary and to develop language skills. Literacy activities, in particular, can be linked to the childs speech and language needs. Specific speech and language impairment. For most children with Down syndrome, speech and language skills are their area of greatest difficulty. Their speech and language skills are more delayed than the childrens non-verbal cognitive or mental abilities, identifying a specific impairment and not just delay (3). An uneven language profile of strengths and weaknesses. Speech and language skills comprise of four components: pragmatics or discourse skills; vocabulary; grammar; and speech production or speech motor skills. Typically, these four components are not equally delayed for children with Down syndrome. Grammatical development and speech motor skills are more delayed than pragmatic skills and vocabulary development.

Motor skills only improve with practice.

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WORKING MEMORY
Effects on all learning. The working memory system is an immediate memory system and it supports all conscious activity and mental processing. It is considered to play an important role in language learning in all children. Impairment in this system will affect any childs ability to follow spoken instruction in the classroom, to read with comprehension and to do mental arithmetic, for example, and it has been shown to affect academic progress in typically developing children. Specific difficulty. Children with Down syndrome have a specific deficit in the auditory component of the working memory system (4) and this could explain many of the speech, language and learning difficulties experienced by children with Down syndrome (3). In the classroom. The limited working memory skills of children with Down syndrome will affect all aspects of learning in the classroom. There is some evidence that memory training activities can improve memory skills but teaching strategies in all areas of the curriculum should take account of this weakness and support all learning with visually presented information (see (2)). Visual processing and visual memory skills are areas of relative strength for children with Down syndrome, and can be used to overcome their auditory processing and auditory memory weaknesses. Inclusion. Inclusive education seems to provide a more effective literacy teaching environment for pupils with Down syndrome as teenagers in inclusion were more than three years ahead of peers in special education on a literacy measure (2).

NUMBER AND MATHS

A basic knowledge of the number system to 100 and place value is important for understanding money and measurement in daily life. Children with Down syndrome tend to find number, time and money difficult to understand, but will often make progress in their teenage years when the applications become more apparent to them. Specific difficulty. At present, number seems to be an area of specific difficulty for children with Down syndrome and often reading skills are significantly ahead of number skills. However, there is little research on this issue, and language delays and working memory delays could be contributing to the childrens maths difficulties. Though many struggle with number, time and money, some children with Down syndrome do well in maths and more research is needed in this area. In the classroom. Visual and tactile approaches are important. All teaching should be supported with visual number aids (e.g. number lines, number cards, etc.), and initial research is suggesting that the recently developed Numicon system will help children with Down syndrome. The core of the system is a cleverly designed set of coloured shapes which accurately represent the nature of the number system (i.e. that each next number is one more equal unit and that there is an orderly set of relationships between numbers). The shapes provide visual and tactile imagery to support childrens understanding of number, and the Numicon materials come with a full set of activities to lead children into number using imagery.

READING AND WRITING

Learning to read. The ability to read and write and to be included in the literate community is the right of all children. Despite significant language delays, reading ability is often a strength for children with Down syndrome, with reading ages two years ahead of language ages and number ages on average. A number of case studies have identified that children as young as two years of age are able to learn a sight vocabulary, often with surprising ease and significant positive effects on their spoken language development. Cognitive benefits. For all children, learning to read is an important cognitive step and reading ability influences language and working memory development in typically developing children. There is some evidence that this is equally the case for children with Down syndrome, as a small group of children of primary school age receiving reading instruction showed significant gains in speech and language and working memory skills, when compared with children not receiving reading instruction over a four-year period. In the classroom. The focus of reading instruction should be on learning whole words and experiencing success in reading for meaning, before stressing phonics. The reading achievements of children with Down syndrome vary widely, but some 80 per cent can achieve some functional literacy skills by their teenage years. Reading activities can be used to support language learning for children throughout their school years, regardless of the childs independent reading skills.

LEARNING STYLES AND ADAPTATIONS

Cognitive profile. To summarise the adaptations for their cognitive profile, children with Down syndrome should be thought of as visual learners, with strengths in visual processing and weaknesses in auditory processing. Learning from listening is particularly difficult for them and all teaching should be supported with visual materials. Showing that they understand by speaking the answers is also difficult and may lead to their comprehension being underestimated. They can show their understanding more easily if able to point to or choose the correct answer. The computer is an ideal teaching aid as it plays to the childs strengths with visual presentation of questions and motor skills used to respond. Learning style. There is some evidence that children with Down syndrome are particularly sensitive to failure and this may be one cause of avoidance behaviour or stubbornness. They also may need more small steps, and repetition of steps, to learn. Teaching approaches which scaffold learning by using modelling and errorless learning techniques should always be

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used (e.g. the LSA takes turns at the task, modelling the correct steps, or prompts success by helping the child to complete the task). The emotional atmosphere should be positive, making learning fun and successful for the child at all times and slowly withdrawing prompts as the child is able to complete more steps successfully without help. Too much classroom teaching is testing, not teaching. In the authors experience, it is easier to meet effectively the specific needs of children with Down syndrome in inclusive rather than special classrooms as their speech, language, literacy and learning needs can be met by daily differentiated access to the National Curriculum. The role models provided by peers are beneficial, and the pace of learning provided is greater than that in a special education classroom. The majority of mainstream schools that the authors have worked with are positive about inclusion and have worked hard to make the placement a success, with recognised benefits for the rest of the pupils.

KEYS TO SUCCESSFUL INCLUSION

The authors own research and a recent review of the literature (see (5)) both identify the significant benefits of inclusion for the language and academic progress of children with Down syndrome. They also find no evidence of educational advantages for special education. In the authors recent evaluation study, there had been no improvements in the educational outcomes for children with Down syndrome from special schools from 1987 to 1999. The expectations for academic progress and the curriculum in the special school studied have changed in that time, however. This would suggest that it is not possible to create the same learning environment in a special class as in a mainstream class for these children, however skilled the teacher. Yet the benefits will be evident only if inclusion is successful for the child. The authors have been supporting inclusion for the past 13 years and identify five main keys to success.

References
1 FREEMAN, S. F. N. and HODAPP, R. M. (2000). Educating children with Down syndrome: linking behavioural characteristics to promising intervention strategies, Down Syndrome Quarterly, 5(1), 19. BUCKLEY, S. and BIRD, G. (2000). Education for Children with Down Syndrome an Overview. Portsmouth: The Down Syndrome Educational Trust. CHAPMAN, R. S. and HESKETH, L. (2001). Language, cognition and short-term memory in individuals with Down syndrome, Down Syndrome Research and Practice, 7(1), 18. JARROLD, C. and BADDELEY, A. D. (2001). Shortterm memory in Down syndrome: applying the working memory model, Down Syndrome Research and Practice , 7(1), 1724. CUNNINGHAM, C. C., GLENN, S., LORENZ, S., CUCKLE, P. and SHEPPERDSON, B. (1998). Trends and outcomes in educational placements for children with Down syndrome, European Journal of Special Needs Education, 13(3), 225237.

1. School attitude. The first key is attitude. Ideally, the whole-school staff needs to be positive, believe that the child should be educated in their school and welcome the child as a full member of the school community. This may require a training session to deal with staff misconceptions and anxieties before the child starts at the school. 2. In-school support . The second key is appropriate provision of learning support assistant time and planning time for the SENCO, teacher and LSA to work together as a team in order to deliver the curriculum and ensure the social inclusion of the child. 3. Differentiation. The third key is the ability to differentiate the curriculum appropriately for the child. 4. Specialist advice. The fourth key is access to a specialist adviser from the LEA who is experienced in the inclusion of children with Down syndrome. 5. Partnership with parents. The fifth key is a good working partnership between parents and school, based on mutual respect.

Weblink
Down Syndrome Issues and Information: Development and Education Series. Over the past two years, Sue Buckley and Gillian Bird, with other education colleagues, have written a comprehensive series of books which provide teachers and assistants in pre-school, primary and secondary schools with evidence-based, practical information covering reading, number, speech and language, memory, social development and behaviour and accessing the curriculum. Information on this series is available at: http://www.downsed.org

About the authors

Sue Buckley and Gillian Bird are psychologists working for the Down Syndrome Educational Trust, Portsmouth, UK. Both have extensive experience of working with children with Down syndrome, their families and teachers, from birth to adult life. They have been supporting children in inclusive education since 1988 and are major providers of training to education authorities in the UK and worldwide. Sue is also Emeritus Professor of Developmental Disability at the Psychology Department, University of Portsmouth.

Copying Permitted
The NFER grants to educational institutions and interested bodies permission to reproduce this item in the interests of wider dissemination.

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