AJSLP
Research Article
Maternal Input and Child Language
Comprehension During Book Reading
in Children With Down Syndrome
Andrea Barton-Hulsey,a Emily Lorang,b Kallie Renfus,b and Audra Sterlinga,b
Purpose: Communication interactions between parents
and children during shared book reading impact a child’s
development of both language and literacy skills. This study
examined maternal language input and child expressive
communication during a shared book reading activity in
children with Down syndrome (DS) and children with typical
development (TD). Additionally, children’s receptive language
was examined to understand the relationship between
maternal language input and child receptive language ability.
Method: Participants included 22 children with DS and 22
children with TD between 22 and 63 months of age and
their mothers. Each mother–child dyad participated in a
7-min naturalistic shared book reading activity.
Results: Compared to mothers of children with TD, mothers
of children with DS used significantly more utterances with
S
hared book reading between parents and young chil-
dren is important for the development of language
and literacy skills (Scarborough & Dobrich, 1994).
Books provide a structured context for language learning
where parents can teach novel words, concepts, and refer-
ence conventions of print. Gilkerson et al. (2017) found in-
creased parent–child language engagement during book
reading when compared to other routines within a typical
day for children between 26 and 61 months of age, making
it an ideal context for language learning. At this age, par-
ents play a key role in scaffolding information when read-
ing in order to ensure the language of the book is accessible
to their child, thus supporting continued engagement.
a
Waisman Center, University of Wisconsin–Madison
b
Department of Communication Sciences and Disorders, University
of Wisconsin–Madison
Correspondence to Andrea Barton-Hulsey, who is now at Florida
State University, School of Communication Science and Disorders:
abartonhulsey@fsu.edu
Editor-in-Chief: Julie Barkmeier-Kraemer
Editor: Krista Wilkinson
Received June 25, 2019
Revision received October 17, 2019
Accepted February 13, 2020
https://doi.org/10.1044/2020_AJSLP-19-00156
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less grammatical complexity, but a similar range of vocabulary
diversity. Mothers of children with DS used more questions,
descriptions, gestures, and labels, whereas mothers of
children with TD used nearly half of their utterances to
read directly from books. Children with DS communicated
at a similar frequency compared to their peers with
TD; however, they produced significantly fewer spoken
words.
Conclusions: This study reveals important differences
between early shared book reading interactions and
provides implications for future research targeting
parent-coached intervention strategies that may enhance
children’s learning during shared book reading by
providing access to expressive language and print
instruction.
Engagement during reading becomes particularly
important for children who are at risk for language delays
and impairments. Children with Down syndrome (DS) rep-
resent a significant group of individuals at risk for language
impairments. DS is the leading genetic cause of intellectual
disability, with a prevalence of one in 737 births (Parker
et al., 2010). Children with DS have delays in both recep-
tive vocabulary and oral language development, which are
known predictors of reading performance during the pre-
school and early elementary years in children with typical
development (TD; Abbeduto et al., 2007; Chapman, 1997).
Books provide a context in which children with DS can
develop language and early literacy skills and are an im-
portant naturalistic routine to use when providing early
intervention or preschool instruction (Partridge, 2004;
Scarborough & Dobrich, 1994).
Research to date with families of children with DS
who are both preschool and school age found that parents
of children with DS reported print-rich environments at
home and engaged frequently in shared book reading ac-
tivities (Al Otaiba et al., 2009; Ricci, 2011; van Bysterveldt
et al., 2010a). Limited studies, however, have directly ob-
served parent–child interactions during shared book reading
Disclosure: The authors have declared that no competing interests existed at the time
of publication.
1475
to describe both the quantity and function of language input
and print referencing between parents and their children
with DS (van Bysterveldt et al., 2006). Print referencing is
the explicit use of nonverbal and verbal cues to guide a child
to attend to the form, function, and features of written lan-
guage (Justice & Ezell, 2004). Shared book reading has a
number of positive effects on the language development of
children with TD; however, little is understood about the
kinds of print referencing and language input provided to
children with DS by their parents during early intervention
and the transition to preschool. The current study examined
both the quantity and function of maternal input provided
during shared book reading in a group of children with DS
between 22 and 63 months of age compared to a group of
children with TD. Doing so provided an understanding of how
mothers interacted with their children with DS when reading
and provided insight into potential areas for intervention
that can support language and literacy development.
Shared Book Reading and Language
Recent work by Gilkerson et al. (2017) included
36 families of children with TD between 26 and 61 months
of age and showed that book reading interactions elicited
greater conversational turns and a greater amount of lan-
guage input compared to other daily routines. This study
provided an initial look at the quantity of language input
given to children with TD and defined adult language input
as the number of words spoken to the child. Results found
that child age was positively correlated with the number
of words spoken to them; specifically, adults spoke more
words to children if they were older than if they were younger.
No differences were found between the amount of child vocal-
izations, nor were there correlations with age and child
vocalizations. Given that child vocalizations were stable
across children between 26 and 61 months of age, it was in-
ferred that very young children were equally as engaged as
older children. However, the complexity of children’s commu-
nication was likely changing, and parents may have adapted
to this increased complexity by providing greater input.
In a longitudinal study that followed children’s de-
velopment through infancy and toddlerhood, Landry
et al. (2012) taught 80 mothers of children born at term
and 86 mothers of children born at very low birth weight
(≤ 36 weeks gestational age, ≤ 1,600 g) specific strategies
to enhance responsive behavior during book reading. The
training included specific language input strategies such as
how to scaffold language concepts, provide verbal prompts,
expand on their child’s communication, and praise their
child. Landry et al. found that, over time, mothers learned
to use the language facilitating strategies, which positively
impacted child gesture use and verbal communication dur-
ing their toddler and preschool years. Study findings re-
vealed that, in order for shared book reading to support
child language growth, a parent must not only read the text
but must also make reading engaging by scaffolding the
language of the book for optimal engagement and recipro-
cal communication (Landry et al., 2012).
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It is not yet clear whether the same strategies from
the Landry et al. (2012) study are beneficial for young chil-
dren with DS. Given that children with DS have impairments
in many of the linguistic skills that provide the foundation
for reading development (e.g., vocabulary, syntax, and oral
language; Abbeduto et al., 2007), they may have different
support needs during shared book reading than children
with TD. Our current study is an initial step toward under-
standing maternal language behaviors during shared book
reading with children with DS by describing the quantity
and function of maternal input at one point in time.
Shared Book Reading and Literacy
In addition to facilitating receptive and expressive
language growth for children, shared book reading during
the infant, toddler, and preschool years provides an intro-
duction to important literacy skills through print referencing.
The use of print referencing has been the focus of a num-
ber of intervention studies to understand the relationship
between strategies that target explicit use of print referenc-
ing and literacy development in children both with and
without language delays (Justice et al., 2008, 2002; Piasta
et al., 2018). Ezell and Justice (1998) measured differences
in parent language in a pilot study including 12 parents
and their children ages 3–5 years. They examined the use
of parent questions when looking at pictures versus print
in books. The parents asked more questions about the pic-
tures in the book instead of the print in the book. However,
a significant negative correlation was found between the
rate at which parents asked questions about pictures and
children’s expressive vocabulary skills (Ezell & Justice,
1998). Interestingly, parents of children with the lowest
vocabulary skills were found to ask the most questions, per-
haps in an attempt to engage their child in greater com-
munication because they were talking less. Given their
children’s lower vocabulary skills, parents may have felt
that questions about pictures were a natural place to en-
gage with their child rather than engaging in questions
about print concepts.
Justice et al. (2008) explored attention to print dur-
ing shared book reading in 44 preschool-age children with
TD. They found that the children rarely looked at print
when read to verbatim or when provided language input
regarding the pictures in the book. When adults both ver-
bally acknowledged print and pointed to the print on the
page, preschoolers significantly increased their attention to
print. In a sequential analysis of parent–child interactions
with preschool-age children with TD, Justice et al. (2002)
found that prompts related to print referencing were more
likely to elicit child responses than comments. In a longi-
tudinal randomized controlled intervention study of five
hundred fifty 4-year-old children at risk for delayed lan-
guage and literacy development, children who were pro-
vided instruction that explicitly referenced print showed
greater gains in early literacy skills of reading, spelling,
and reading comprehension for the 2 years following par-
ticipation compared to children who were not provided
explicit print instruction (Piasta et al., 2018). These find-
ings provide evidence for the importance of direct in-
struction of print conventions during the preschool years.
Shared Book Reading in DS
Previous research has demonstrated that parents of
children with DS positively impact their child’s language
development (Dimitrova et al., 2016; Sterling & Warren,
2014; Yoder & Warren, 2004). Much of the research to date
regarding parent–child interactions during shared book
reading with children with DS has been through studies of
parent-coached reading interventions where child outcomes
were the primary variable of interest (van Bysterveldt et al.,
2010b, 2006). Van Bysterveldt et al. (2006) found that chil-
dren learned to identify initial sounds in words and name
letters and sounds after 6 weeks of a shared book reading
intervention in seven 4-year-olds with DS. Parents used ex-
plicit print referencing strategies of naming letters, letter
sounds, and the first sounds in words with fidelity. A later
study by van Bysterveldt et al. (2010b) found that 4- and
5-year-old children with DS improved their letter knowl-
edge and phonological awareness skills after a combined
parent-implemented home program, center-based speech
therapy sessions, and computer-based intervention. These
results suggest that parents of children with DS can success-
fully implement early reading instruction regarding print at
the age during which we would expect all children to begin
reading instruction. Greater attention is warranted, however,
to understand how mothers’ ability to learn print referen-
cing strategies impacts other types of language input during
book reading. Our current study provided an explicit look
at maternal language input with this focus—to understand
what mothers are naturally doing with children with DS in
terms of print referencing and language input.
Previous work has found that parents of children
with DS actively engage in literacy activities at home. Al
Otaiba et al. (2009) surveyed parents of children with DS
aged 3 months to 6 years and found that parents incorpo-
rated more literacy-based activities into the home environ-
ment compared to earlier research findings and valued the
importance of promoting literacy early in their child’s devel-
opment. Trenholm and Mirenda (2006) surveyed 224 parents
of children, adolescents, and adults with DS and found that
more than half of parents reported learning to read as a pri-
ority for children between ages 5 and 13 years. In addition,
parents reported that most children demonstrated high in-
terest in learning to read, and by 19 years of age, approxi-
mately 94% of individuals with DS were reading at least
simple text, with some obtaining a Grade 7–8 reading level.
This evidence that children with DS demonstrate the ability
to read is counter to historical perspectives that reading
was a nearly impossible goal for children with DS.
Understanding the underlying linguistic components
that contribute to reading development in young children
with DS is important for developing interventions. Vocab-
ulary knowledge is one important linguistic factor in devel-
oping a child’s early phonological inventory. The lexical
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restructuring model has been tested in children with TD
and suggests that phonological awareness skills—the ex-
plicit understanding that words are made up of component
sounds and a foundational skill for reading development—
are an outgrowth of vocabulary knowledge (Metsala &
Walley, 1998). It is important to identify if shared book
reading is a setting in which rich vocabulary input may be
naturally supported by parents of children with DS and
thus encourage phonological development. Contextualizing
this evidence within our current study, there is a need to
understand how parents are supporting reading develop-
ment early on in order to capitalize on their strengths and
identify areas of further support needed to develop their
child’s reading skills to their fullest potential.
In order to best understand how parents are support-
ing reading development, the current study examined both
the quantity and function of maternal input provided dur-
ing shared book reading in a group of children with DS
between 22 and 63 months of age compared to a group
of children with TD, matched for chronological age. The
goal of this study was to understand how early shared
book reading interactions compared between groups. Our
current study built on the work of Gilkerson et al. (2017)
by quantifying parent input beyond total number of words
spoken to the child. Specifically, our study included mater-
nal syntactic complexity, measured by mean length of
utterance in morphemes (MLUm), and maternal lexical
diversity by measuring the number of different words
(NDW) used. The total number of maternal utterances
was also measured to understand maternal talkativeness.
We explored these questions within a group of children
with DS as compared to a group with TD in order to un-
derstand if there were unique ways in which mothers of
children with DS modified their language input differ-
ently than mothers of children with TD to support learning.
Evaluating language input at a microstructural level using
measures of MLUm, NDW, and total utterances of mothers
and children allowed for a greater understanding of the lin-
guistic features associated with shared book reading. Prior
research with children with DS has largely focused on mater-
nal and child communication at macrostructural levels by
characterizing maternal interaction style (Seager et al., 2018;
Sterling & Warren, 2014). Given the known delays in both
receptive and expressive language in children with DS, un-
derstanding the diversity of vocabulary input as well as the
grammatical complexity used by mothers of children with
DS is an important step in refining targets of early language
intervention during shared book reading.
Different from the work of Gilkerson et al. (2017),
this study examined the relationship between child recep-
tive language rather than chronological age and variables
of maternal language input. Maternal input can vary both
with age and receptive language. Comparing these mater-
nal linguistic variables to child receptive language ability
in each group instead of chronological age provided us
with an understanding of the relationship between maternal
language input and child receptive language given the
known delays in receptive language relative to chronological
Barton-Hulsey et al.: Language and Shared Book Reading 1477
age in children with DS. We selected child receptive rather
than expressive language skills in a sample of preschool-
age children with DS for multiple reasons. Children with
DS often speak their first words around 21 months on aver-
age compared to children with TD who often speak their
first words a year earlier at 12–15 months of age (Abbeduto
et al., 2007). Furthermore, many children with DS often
do not begin using consistent two or more word combina-
tions until they are of preschool age (Draghi & Zampini,
2019). In contrast, receptive vocabulary in children with
DS is often far more developed relative to what children
are able to produce at the ages described above (Abbeduto
et al., 2003). While children with DS have relatively stron-
ger receptive vocabulary skills, they have greater difficulty
with receptive syntax (Chapman, 1997). Shared book read-
ing is a context in which communication input is provided
that may reinforce a child’s known receptive vocabulary,
introduce new vocabulary concepts, and model develop-
mentally appropriate syntax to build language comprehen-
sion. Therefore, looking closely at ways in which mothers
may modify language input for children with DS who have
varying levels of receptive language could provide implica-
tions for intervention across children with DS to improve
receptive skills (Fidler, 2005). Three main questions were
asked:
1. Are there differences in the quantity of maternal and
child expressive communication for mothers and
their children with DS versus mothers and their chil-
dren with TD? It was expected that mothers of chil-
dren with DS would use fewer words and utterances
and shorter utterances than mothers of children with
TD given the expected differences in receptive lan-
guage ability of children with DS (Abbeduto et al.,
2007). Because children with DS have known delays
in the development of spoken language early in de-
velopment and during preschool, it was expected that
children with DS would use more gestures for com-
munication compared to children with TD and that
children with TD would use a greater NDW and
MLUm and more intelligible utterances (Abbeduto
et al., 2007; Fidler, 2005).
2. Are there differences in the function of communica-
tion used by mothers of children with DS compared
to mothers of children with TD? It was expected that
mothers of children with DS would use utterances
that ask more questions, label vocabulary more often
in books, read less verbatim from the text, and use
fewer print references than mothers of children with
TD. These findings were expected given the negative
correlations found between the rate parents asked
questions about pictures and children’s expressive vo-
cabulary skills in the prior work of Ezell and Justice
(1998). Additionally, their findings reported that par-
ents used more questions about pictures and limited
referencing of print.
3. What is the relationship between maternal expressive
communication and child receptive language in children
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with DS and children with TD? It was expected that
the use of maternal utterances to provide labels and
descriptions of words in the book would be nega-
tively correlated with receptive language for children
in each group based on the findings related to age
and parental input from prior work (Gilkerson et al.,
2017). It was expected that mothers would use fewer
labels and descriptive information when their chil-
dren had greater receptive language.
Method
Participants
Participants were part of a larger study comparing
maternal responsivity in children with DS (n = 22) to ma-
ternal responsivity in peers with TD (n = 22; Sterling &
Warren, 2014). All children were between 22 and 63 months
of age. Groups were matched on chronological age (t = 0.37,
p = .715). Table 1 reports the variance ratio and Cohen’s
d for child chronological age to further support matching
recommendations by Kover and Atwood (2013). All original
study procedures were approved by the institutional review
board at the University of Kansas, with secondary analysis
of the data approved by the University of Wisconsin–
Madison.
Groups were matched on child chronological age for
both theoretical and clinical reasons. At the theoretical
level, the transactional model of development recognizes
the cumulative impact that parent–child interactions have
on development (Sameroff & Chandler, 1975). Thus, in or-
der to account for the cumulative history of each mother–
child dyad’s experience with book reading, the groups were
matched on child chronological age. Comparing groups at
this same chronological age provided information regard-
ing the types of print referencing and linguistic input that
would be expected of mothers with their children with TD
and provided a preliminary understanding of what sup-
ports may be appropriate to test and implement in future
work with children with DS during the early intervention
period. To our knowledge, previous work has not provided
an in-depth descriptive look at maternal input during shared
book reading in terms of both the quantity and function
of input. Including an age-matched comparison group is
necessary to first determine whether mothers of children
with DS interact similarly to mothers of children with TD
of the same chronological age. Matching on child chrono-
logical age in studies of parent–child interactions including
children with neurodevelopmental disabilities is consistent
with previous work (Brown et al., 2003; Carvajal & Iglesias,
2000; Lorang et al., 2018; Slonims & Mcconachie, 2006;
Sterling et al., 2012; Sterling & Warren, 2014; Thiemann-
Bourque et al., 2014).
In addition to children being matched on chrono-
logical age, mothers had similar levels of maternal education
(t = −0.88, p = .383; also reported in Table 1). Comparing
mothers of similar maternal education allowed for control
regarding factors related to socioeconomic status that we
Table 1. Participant demographic information.
Down syndrome
(n = 22)
Variable M (SD)
Chronological age (months) 42.82 (12.44)
MSEL Composite Score 56.41 (8.86)
MSEL Receptive Language t score 28.73 (9.38)
MSEL Receptive Language raw score 26.50 (8.19)
MSEL Expressive Language t score 24.00 (5.03)
MSEL Expressive Language raw score 21.32 (7.42)
Maternal education (years completed) 15.57 (1.55)
Note. Bolded values represent significantly greater results. MSEL = Mullen Scales of Early Learning (Mullen, 1995).
a
Independent-samples t tests.
know may influence the amount of linguistic input provided
to young children in order to adequately compare the groups
and interpret the results (Hart & Risley, 1995).
Eleven male and 11 female children with DS partici-
pated. Twelve male and 10 female children with TD partic-
ipated. Nineteen children with DS were White, two were
African American, and one was Latino. All 22 children with
TD were White. Children with DS were recruited from early
intervention agencies, support groups and clinics for children
with DS in Kansas, and the greater Kansas City Down
Syndrome Guild. Parent report indicated that 21 children
had trisomy 21 and one child had mosaicism. Children
with TD were recruited from surrounding preschools and
day cares in Lawrence, Kansas, and Kansas City, Kansas,
and from the Infant Cognition Research Laboratory at the
University of Kansas.
Procedure
The assessments took place at the participant’s home,
in a single 1- to 2-hr visit. Each mother–child dyad partici-
pated in a book reading activity. Participants were pre-
sented with a standard set of books ranging in type from
rhyming books, books that employed manipulatives and
sound effects, and books that told a simple narrative. Mothers
were instructed to read as they normally would with their
child. Interactions were video-recorded for approximately
10 min. Some of the interactions were shorter than 10 min
due to the directions, the time it took to begin the inter-
action, or child attention; thus, normalizing all interactions
to 7 min allowed for direct comparison of the frequency of
mother and child communication. The first 7 min once the
interaction began (and following the examiner’s directions)
were used for the coding detailed below and in Table 2.
Measures
Global development and receptive and expressive
language were assessed using the Mullen Scales of Early
Learning (MSEL; Mullen, 1995). The MSEL is a stan-
dardized developmental assessment for children ages birth
to 68 months. Subscales of Visual Reception, Fine Motor,
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Typical development
(n = 22)
Group Variance
M (SD) comparisonsa p Cohen’s d ratio
44.09 (10.39) 0.37 .714 0.11 2.05
115.33 (18.41) 13.48 .000 4.08 0.05
58.43 (10.45) 9.82 .000 2.99 0.65
39.76 (6.43)
62.00 (10.15) 15.66 .000 4.74 0.06
41.48 (7.65)
16.14 (2.06) 0.88 .383 0.31 0.32
Receptive Language, and Expressive Language were ad-
ministered. Subscale raw scores were used to calculate a
standardized t score for each subtest (M = 50, SD = 10).
An overall early learning composite standardized score
was calculated using all four subtests (M = 100, SD = 15).
The MSEL was typically administered at the end of the
home visit in order to allow for adequate time for the child
to become familiar with the examiner. All children with
DS completed the MSEL. Two children with TD did not
comply with the assessment. Table 1 includes average re-
ceptive and expressive language raw and standard scores as
well as overall composite scores for children in each group.
Transcription and Coding
The recorded mother–child interactions were tran-
scribed by four student research assistants trained in tran-
scription methods using Systematic Analysis of Language
Transcripts (SALT) software (Miller & Iglesias, 2012). All
child and maternal utterances were first transcribed into
communication units (C-units). C-units segment utterances
into an independent clause with its modifiers such that the
utterance cannot be further divided without the disappear-
ance of its essential meaning (Miller & Iglesias, 2012). SALT
software was used to calculate the total number of utterances,
MLUm, and NDW used by mothers. Child total number
of utterances, MLUm, NDW, and percent intelligible utter-
ances were also calculated.
Two research assistants used SALT in conjunction
with the videos to independently code maternal and child
communication based on the function of maternal utter-
ances as well as the form of the child’s communication as
described below and summarized in Table 2 with exam-
ples. Maternal and child utterance codes were adapted
from those used by Justice et al. (2002).
Maternal codes. Maternal utterances were first coded
to note if the utterance was a verbatim reading from the
book. Utterances that did not consist of verbatim reading
were coded to note their function as one of the following:
(1) a question/prompt to the child; (2) a comment that la-
beled pictures in the book; (3) a comment that described
Barton-Hulsey et al.: Language and Shared Book Reading 1479
Table 2. Child and maternal codes and definitions.

Child codes Description Example

Verbalization Words or phonetically consistent forms that function as words Child says, “Whoa” or “Thanks”
Vocalization Intentional sounds used for communication Child says, “da” when looking at an image
Gesture Sign or gesture used for communication Child signs “ball” when looking at an image
Combination Any combination of the above codes Child signs and says, “more” at the same time
Communication attempts Total number of the above codes
Maternal codes
Read Reads text verbatim Mother says, “Once upon a time…”
Question/prompt Asks a question or uses a command to direct child Mother says, “Where’s a dog?”
Comment: label Names a picture in the book Mother says, “Here’s a tree”
Comment: describing Uses an adjective or verb to describe a picture or action in Mother says, “Blue truck”
the book
Comment: print concept Points out letters, letter sounds, words, author/illustrator, or Mother says, “This word says ‘sing’”
title of book
Gesture: point Identifies a picture in the book or an object in the environment Mother points to a picture in the book
by pointing
Gesture: sign Baby sign, ASL, or hand-over-hand sign to identify object or Mother signs “eat” when a character is eating
action in book food

Note. ASL = American Sign Language.

pictures, actions, or events within the book; or (4) a com-
ment that named a print concept such as a letter, letter
sound, word, author or illustrator name, or title of the
book. The last code (4) was used to note the amount of
print referencing done by mothers different than reading
verbatim. Maternal utterances also included a gesture code
if they included one of the following: (a) a gesture used to
point to a picture during communication, (b) a sign in
the form of baby sign or American Sign Language, and/or
(c) a gesture that served a descriptive function alongside
the adult linguistic utterance.
Child codes. Each child communication utterance was
assigned one of four codes, again adapted from the work
of Justice et al. (2002): (a) verbalization, (b) vocalization,
(c) gesture, or (d) combination (any combination of a ver-
balization, vocalization, or gesture). Verbalizations consisted
of words or phonetically consistent forms that functioned
as a word (e.g., “uhoh” or “moo”). Vocalizations were in-
tentional communicative sounds children used and were
coded if the child looked at their mother within 3 s of vo-
calizing. Vocalizations did not include screaming, crying,
or whining noises. Gesture codes were used to note the use
of sign language or body movements to intentionally com-
municate an idea from the child to their mother during
the interaction (e.g., point, head nod, head shake, or wave).
Gestures could be symbolic or nonsymbolic. Combination
codes were used to note utterances that consisted of a com-
bination of verbalizations, vocalizations, or gestures that
were communicative (e.g., verbalization + gesture would be
coded if the child said “yes” while nodding).
Transcript and coding reliability. To calculate reliabil-
ity for SALT, approximately 20% of the total transcripts
were chosen at random (20% from the group with DS,
20% from children with TD) and independently transcribed
by a second trained transcriber. To determine a measure
of intelligibility, transcribers (i.e., unfamiliar listeners) were
instructed to listen to the utterance 2 times, and if they
could not determine the word after two passes, then they
were to mark the word as unintelligible. Reliability was
calculated utterance-by-utterance separately for mothers
and children. For mothers, overall agreement for five vari-
ables including the appropriate segmentation into C-units,
intelligibility, number of morphemes, number of words, and
word identification was 91.29% (range: 87%–99%). For the
children, overall agreement across those same five variables
was 85.40% (range: 77%–93%).
Prior to coding the transcripts for child communi-
cation and maternal function of utterances, two student
research assistants reached a training criterion of 80% agree-
ment across all codes on three language samples independent
of the files used in this study. Once criterion was met, tran-
scripts were randomly assigned to be coded. Each student
independently coded approximately 50% of the files. In
addition, approximately 20% of the coded transcripts were
chosen at random (20% from the group with DS and
20% from children with TD) and coded by both students
to determine reliability for maternal and child language
codes. Cohen’s kappas were calculated using R based on
both groups combined to determine if there was agreement
between the two coders for all child and maternal codes.
Cohen’s kappas were calculated based on the presence
or absence of each code. Cohen’s kappas were then calcu-
lated for each code separately based on the frequency with
which each code was identified by each coder (i.e., the
number of question/prompt codes identified by the first
coder and the number of question/prompt codes identified
by the second coder across the entire file) from the total
utterance set. Cohen’s kappas are reported in Tables 3
and 4 for all child and maternal codes. Guidelines from
Bland and Altman (1999) suggest that, overall, there was
good to very good agreement between coders across all
variables.

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Table 3. Group comparisons for quantity of maternal and child expressive communication.

DS TD
Variable M (SD) M (SD) t p 95% CI d Cohen’s kappa

Maternal communication
Total number of utterances 135.41 (48.33) 86.05 (33.20) −3.95 <.001 [−74.59, −24.14] 1.19 —.
MLUm 3.52 (0.37) 4.11 (0.77) 3.23 .002 [0.22, 0.95] 0.98 —.
Number of different words 134.91 (27.42) 131.91 (36.45) −0.31 .759 [−22.63, 16.63] 0.09 —.
Child communication —.
Total number of utterances 22.41 (28.55) 40.23 (17.91) 2.48 .017 [3.32, 32.32] 0.75 —.
MLUm 1.21 (0.70) 2.03 (0.49) 4.48 <.001 [0.45, 1.18] 1.36 —.
Number of different words 15.23 (16.08) 42.41 (16.64) 5.51 <.001 [17.22, 37.14] 1.66 —.
Proportion of intelligible utterances 0.41 (0.35) 0.97 (0.04) 7.37 <.001 [0.40, 0.70] 2.25 —.
Verbalization 13.05 (16.25) 28.91 (13.81) 3.49 .001 [6.69, 25.04] 1.05 .94
Vocalization 12.82 (11.13) 2.09 (3.38) −4.33 <.001 [−15.73, −5.72] 1.30 .87
Gesture 12.78 (9.39) 3.59 (3.11) −4.35 <.001 [−13.44, −4.93] 1.31 .93
Combination 21.82 (18.68) 13.00 (7.59) −2.05 .046 [−17.49, −0.14] 0.61 .93
Total communication attempts 60.45 (26.37) 47.59 (19.68) −1.83 .074 [−27.02, 1.29] 0.55 —.

Note. Bolded values represent significantly greater results when a Bonferroni correction of .017 was applied for multiple comparisons of
maternal communication and a Bonferroni correction of .006 was applied for multiple comparisons of child communication. Cohen’s kappa
values are reported for interrater reliability on 20% of the transcripts across both groups. DS = Down syndrome; TD = typical development;
CI = confidence interval; d = Cohen’s d; MLUm = mean length of utterance in morphemes.

Data Analysis When examining these variables within each group,

RQ 1: Quantity of Maternal and Child
Expressive Language
Independent-samples t tests were first completed on
the maternal language variables including total number of
utterances, MLUm, and NDW to examine group differences.
A Bonferroni correction was applied for these three com-
parisons with the alpha value set at .05/3 = .017. In order
to identify if there were differences in the quantity of child
expressive communication, independent-samples t tests were
done using children’s total utterances, MLUm, NDW, and
percentage of intelligible utterances. Additionally, the codes
noting the form of child communication (verbalization, vo-
calization, gesture, or a combination of forms) were quanti-
fied and examined using independent-samples t tests to
note differences between groups. A Bonferroni correc-
tion was again applied for these nine comparisons with
the alpha value set at .05/9 = .006.
there were few outliers in the data noted by inspection of
box plots. Because an independent-samples t test is considered
robust to violations of normality, the data had few outliers and
equal sample sizes, and groups had relatively normal distri-
butions, a t test was considered appropriate to determine
if there were significant differences between groups on
maternal and child language variables that quantified their
language use.
RQ 2: Maternal Communication Function
In order to identify if there were differences in the
function of expressive communication used by mothers of
children with DS compared to children with TD, independent-
samples t tests were run to test for differences in each
maternal utterance code represented in Table 2. A Bonferroni
correction was applied for these seven comparisons with
the alpha value set at .05/7 = .007. Because the length of
the book reading interaction was the same across all dyads,

Table 4. Group comparisons for function of maternal expressive communication.

DS TD
Maternal communication function M (SD) M (SD) t p 95% CI d Cohen’s kappa

Read 42.73 (24.67) 67.81 (29.47) 3.06 .004 [8.56, 41.63] 0.92 .98
Question/prompt 63.72 (31.57) 36.68 (19.07) −3.44 .001 [−42.92, −11.17] 1.04 .96
Comment: label 12.91 (9.93) 6.41 (5.59) −2.68 .011 [−11.40, −1.60] 0.81 .91
Comment: describing 38.73 (15.85) 25.91 (13.04) −2.93 .005 [−21.65, −3.99] 0.88 .81
Comment: print concept 0.18 (0.39) 0.64 (1.00) 1.98 .054 [−0.01, 0.92] 0.60 .78
Gesture: point 23.95 (16.29) 19.68 (17.09) −0.85 .401 [−14.43, 5.89] 0.26 .98
Gesture: sign 3.31 (4.23) 0.14 (0.64) −3.48 .001 [−5.02, −1.34] 1.05 .90

Note. Bolded values represent significantly greater results when a Bonferroni correction of .007 was applied for multiple comparisons of
maternal communication. Cohen’s kappa values are reported for interrater reliability on 20% of the transcripts across both groups. DS =
Down syndrome; TD = typical development; CI = confidence interval.

Barton-Hulsey et al.: Language and Shared Book Reading 1481

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each mother had the same amount of time to provide the
child with input. Therefore, we used the total number for
each dependent variable. There were very few outliers for
maternal function of utterances for children with TD or DS.
Because an independent-samples t test is considered robust
to violations of normality, the data had few outliers and equal
sample sizes, and groups had relatively normal distributions,
a t test was considered appropriate to determine if there were
significant differences between groups for the function of
maternal communication.
RQ 3: Relationship Between Maternal Expressive
Communication and Child Receptive Language
Pearson correlations were completed in order to iden-
tify any relationships between child receptive language and
maternal input. Raw scores from the MSEL Receptive
Language subtest were used to represent child receptive
language. Raw scores were used in correlation analyses
due to floor effects that frequently occur for children
with DS in obtaining a standard score on the MSEL. In
addition, raw scores are a more sensitive index to note the
performance of children with DS on the Receptive Language
subtest of the MSEL and have been used in other studies
including children with intellectual and developmental
disabilities (Brady et al., 2014; Luyster et al., 2008). SALT
variables as described above were used to represent the
quantity of maternal language input. Total number of
each code per transcript as defined in Table 4 were used
to represent the function of maternal communication in
analyses.
Results
RQ 1: Quantity of Maternal and Child
Expressive Language
A Bonferroni correction of p = .017 was used to adjust
for multiple comparisons of maternal expressive communica-
tion, and a correction of p = .006 was used for multiple com-
parisons of child expressive communication. Overall, mothers
of children with DS used significantly more utterances than
mothers of children with TD (p < .001, d = 1.19, 95% CI
[−74.59, −24.14]), yet a smaller MLUm than mothers of
children with TD ( p = .002, d = 0.98, 95% CI [0.22, 0.95]).
There were no significant differences in the NDW used by
mothers of children in either group (p = .759, d = 0.09, 95%
CI [−22.63, 16.63]). Children with TD used a significantly
greater MLUm (p < .001, d = 1.36, 95% CI [0.45, 1.18]) and
NDW (p < .001, d = 1.66, 95% CI [17.22, 37.14]) than chil-
dren with DS and were significantly more intelligible (p <.001,
d = 2.25, 95% CI [0.40, 0.70]). In terms of the form of com-
munication used by children in each group, children with
DS used significantly more nonword vocalizations (p < .001,
d = 1.30, 95% CI [−15.73, −5.72]) and gestures (p < .001, d =
0.93, 95% CI [−13.44, −4.93]) than children with TD.
Children with TD used significantly more verbalizations or
words/word-like forms than children with DS ( p = .001,
d = 0.94, 95% CI [6.69, 25.04]). Table 3 reports means
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and standard deviations, t tests with Bonferroni corrections,
effect sizes, and 95% CIs for each group.
RQ 2: Maternal Communication Function
A Bonferroni correction of p = .007 was used to adjust
for multiple comparisons of maternal communication func-
tion. In terms of the function of maternal communication
input, mothers of children with DS used significantly more
questions/prompts ( p = .001, d = 1.04, 95% CI [−42.92,
−11.17]), descriptions ( p = .005, d = 0.88, 95% CI [−21.65,
−3.99]), and gestures in the form of signs (p = .001, d = 1.05,
95% CI [−5.02, −1.34]) during shared book reading. Using
the Bonferroni correction, mean values for the frequency of
labeling were not significant ( p = .011); however, the effect
size for this difference between groups was large (d = 0.81),
with a 95% CI of [−11.40, −1.60], suggesting that mothers of
children with DS did comment using labels more than mothers
of children with TD. Mothers of children with TD used sig-
nificantly more utterances to read verbatim to their child
than mothers of children with DS ( p = .004, d = 0.92, 95%
CI [8.56, 41.63]. The use of utterances that included print
referencing was limited by mothers of children in each group,
with no significant differences found ( p = .054, d = 0.60,
95% CI [−0.01, 0.92]). Only four mothers of children with
DS and seven mothers of children with TD used utterances
that referenced print concepts. Of these parents, they only
referenced print between 1 and 3 times during the 7-min in-
teraction. There were no significant differences in the amount
of pointing used by mothers of children in either group
( p = .401, d = 0.26, 95% CI [−14.43, 5.89]). See Table 4 for
means, standard deviations, t tests, effect sizes, and 95% CIs.
RQ 3: Relationship Between Maternal Expressive
Communication and Child Receptive Language
When looking at correlations between the quantity
of maternal expressive communication and child receptive
language, there was a marginal negative relationship between
the total number of utterances mothers of children with DS
used and their child’s receptive language raw score (r = −.42,
p = .054). The higher a child’s receptive language raw score,
the fewer utterances their mother used. No significant cor-
relations between receptive language and NDW or MLUm
were found for children in either group (see Table 5).
There were no significant relationships found between
receptive language and the function of maternal utterances
during shared book reading for children with DS. For
mothers of children with TD, there was a significant neg-
ative relationship found between the use of labels during
book reading and child receptive language (r = −.58, p =
.006) and the use of pointing gestures and child receptive
language (r = −.71, p < .001).
Discussion
This study identified important similarities and differ-
ences in maternal expressive communication during book
Table 5. Correlations between child receptive language and maternal expressive communication by group.
Group Read Question/prompt
DS Receptive Language r = −.41 r = −.38
TD Receptive Language r = .11 r = −.39
Note. DS = Down syndrome; Receptive Language = Mullen Scales of Early Learning Receptive Language raw score; TD = typical development.
*p < .010.
reading with children with DS and children with TD during
the earliest stages of reading development. Additionally, it
confirmed important differences in expressive communica-
tion skills of children with DS compared to children with
TD during the preschool period as discussed by Fidler
(2005). The current study specifically identified spoken
communication as an area of difficulty for children with
DS compared to same-age peers with TD during shared
book reading interactions. However, this study found
that children with DS used a significantly greater number
of gestures and vocalizations than their peers with TD, per-
haps as a compensatory strategy for their difficulty with
spoken communication. Consistent with previous findings
investigating communication input (Kay-Raining Bird &
Cleave, 2015), mothers of children with DS simplified their
input compared to mothers of age-matched peers, used more
descriptions, but maintained the same lexical diversity as
mothers of children with TD during shared book reading.
Additionally, this study found that children with DS were
communicating at similar frequencies as their peers with TD
during shared book reading, although children with DS used
fewer spoken words.
In terms of maternal communication, it was expected
that mothers of children with DS would use fewer words
and utterances and also a shorter MLUm than mothers of
children with TD. Consistent with previous findings inves-
tigating maternal communication input (Kay-Raining Bird
& Cleave, 2015), we found that mothers of children with
DS reduced their MLUm but used a greater number of ut-
terances with a similar range of vocabulary as compared
to mothers of children with TD. These findings provide
evidence that, within a shared book reading context,
mothers of children with DS provide vocabulary input
that is similar to mothers of children with TD. The book
reading context may have been particularly facilitative be-
cause the book provided a set of pictures and events to
label, describe, and sequence when communicating with
their child. Book reading inherently provides a context to
use diverse vocabulary by introducing language relevant
to the book’s story.
The findings supported our expectation that children
with DS would use more gestures for communication than
children with TD and that children with TD would use a
greater NDW, MLUm, and more intelligible utterances than
children with DS. Although communication using spoken
words by children with DS in this study was limited to
15 words on average, children with DS were communicating
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Label Describing Print concept Point Sign Total utterances
r = −.02 r = −.00 r = .09 r = .03 r = −.42 r = −.42
r = −.58* r = −.03 r = .13 r = −.71* r = −.35 r = −.35
using vocalizations and gestures. The combination of
gestures, vocalizations, and spoken words resulted in chil-
dren with DS using the same amount of communication at-
tempts as children with TD during the 7-min interactions.
Thus, the overall amount that the children actively commu-
nicated in the interactions was similar, but the modality by
which the children communicated differed. This finding is
particularly important given previous work suggesting chil-
dren with DS tend to take on a more passive role during
free-play interactions compared to children with TD (Linn
et al., 2000). Our findings suggest that the context of shared
book reading elicits just as much expressive communication
from children with DS as children with TD and is counter
to the more passive role found in free-play from children
with DS. Further research is warranted to confirm these
findings by directly comparing shared book reading to a
free-play setting.
In terms of mothers in this study, we hypothesized
that mothers of children with DS would use utterances that
asked more questions and would label vocabulary more of-
ten in books. We also hypothesized that they would read
less verbatim from the text and use fewer print references
than mothers of children with TD. Mothers of children
with DS did ask more questions on average and used more
descriptions during the interactions than mothers of chil-
dren with TD. When adjusting for multiple comparisons,
mean values for the frequency of labeling vocabulary were
not significantly different; however, the effect size for this
difference between groups (12.91 vs. 6.41 on average) was
large (d = 0.81), suggesting that mothers of children with
DS did label vocabulary in the book more than mothers of
children with TD. Mothers of children with DS also read
verbatim from the text very rarely. By reading less and
using simplified utterances, mothers of children with DS
may have adapted their language to meet not only the lan-
guage needs but also the engagement needs of their child
as found in the previous work of Ruskin et al. (1994).
In the work of Ezell and Justice (1998), parents of
children with TD overwhelmingly asked more questions to
their children about the pictures rather than the print in
the book. While our study did not explicitly ask about dif-
ferences in questions related to pictures in the book versus
print, we found that mothers of children in both groups
more frequently asked questions related to the shared book
reading interaction rather than commenting and referenced
print very little. Additionally, Ezell and Justice found a
significant negative correlation between the rate at which
Barton-Hulsey et al.: Language and Shared Book Reading 1483
parents asked questions about pictures and children’s expres-
sive vocabulary skills, speculating that perhaps the parents
of children with smaller vocabularies viewed the purpose of
the reading session differently than parents of children with
larger vocabularies. The findings in our current study reflect
these findings as well. Children with DS used very little
expressive spoken vocabulary; however, their mothers
asked significantly more questions during book reading than
mothers of children with TD.
The use of utterances that included print referencing
was limited by mothers of children in each group. Only
four mothers of children with DS and seven mothers of
children with TD referenced print concepts. Of the parents
who referenced print, they only referenced print between 1
and 3 times during the 7-min interaction. While the mothers
of children with TD did not often reference print explicitly,
they did read verbatim frequently. Over half of the utter-
ances spoken by mothers of children with TD were reading
verbatim from the text. For mothers of children with DS,
less than half of the utterances spoken during shared book
reading included reading verbatim from the text, with very
little explicit print referencing. Mothers of children with
TD may not have felt the need to explicitly reference print
by naming letters, sounds, or specific words, because they
were largely reading verbatim from the text. Mothers of
children with DS used more spoken utterances to label
pictures, describe the story, and ask questions to their
child rather than reading verbatim. We did not find sig-
nificant correlations between these functions of language
input and receptive language skills of children with DS;
however, it is important to note that the majority of the
children with DS in this study were receiving language in-
tervention services. While we did not ask specific questions
regarding the type of parent coaching received, parents in
this study may have been using strategies largely learned
from interventions. Mothers of children with DS may have
been using the book as a context for building language
skills, rather than explicit print input or reading the text
verbatim to their child.
Results regarding the relationship between maternal
expressive communication and child receptive language in
children with DS and children with TD were unanticipated.
It was expected that the use of maternal utterances to pro-
vide labels and descriptions of words in the book would be
negatively correlated with receptive language for children
in each group based on the findings related to age and pa-
rental input from prior work of Gilkerson et al. (2017). We
found a marginal negative relationship between the total
number of utterances mothers used with their children with
DS and receptive language. These findings, as mentioned
previously, were not specific to the use of labels versus de-
scriptions used by mothers of children with DS but rather
related to the overall frequency of maternal input. Different
relationships were found in the mother–child dyads with
children with TD. Specifically, mothers used a greater
amount of labels and points when communicating with
children with TD who had lower receptive language and
again had a marginal negative relationship between total
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number of utterances and receptive language. Because all
children with TD had receptive language skills within the
normative range, this significant relationship for labeling
and pointing reflects the age range of 22–63 months in our
sample. Mothers of younger children with TD who had
lower receptive language used a greater amount of labeling
and pointing than mothers of older children with higher re-
ceptive language. This finding suggests that, for children
with TD, having lower receptive language may result in a
need for more direct input in the form of labels and points
to maintain engagement with a book, whereas children
with higher receptive language may need less of this type
of input.
We did not find this same relationship in children with
DS, perhaps because of the limited variability in receptive
language in this sample relative to the variability found in
maternal language input provided in each of these areas.
All mothers of children with DS used significantly more
questions/prompts, comments, and gestures with their
children who had significantly lower receptive language
skills than children with TD. Future work should track
maternal input during shared book reading over time in
children with DS compared to children with TD to better
understand these different relationships as their receptive
language develops.
Limitations and Future Directions
Evidence from this study, namely, the clear engage-
ment by children with DS, suggests that shared book reading
is one context for intervention that could support vocabulary
teaching for children with DS at the earliest stages of liter-
acy development, as was found by Burgoyne et al. (2012) in
children with DS in Grades 1–5. Future work should also
critically examine how children with DS develop compre-
hension of this vocabulary. As the lexical restructuring model
notes in children with TD, it is vocabulary comprehension
that is important for semantic analysis of words when seg-
menting and blending phonemes for phonological develop-
ment as children enter kindergarten (Metsala & Walley,
1998). Future work should critically evaluate the role of
maternal vocabulary input and child vocabulary compre-
hension as children with DS develop, and the role of each
in the development of phonological awareness as children
enter preschool and kindergarten. These descriptive vari-
ables could be tested in future longitudinal work as compo-
nents of intervention to understand the impact of each on
child language and literacy outcomes.
This study analyzed the presence of questions among
other functions of maternal utterances but did not break
down questions into specific forms or functions. Previous
work found that, for children with TD, asking questions
about target words improved children’s comprehension
and production of words and their referents (Blewitt et al.,
2009). Another work has found that asking children ques-
tions that repeat or require them to say new words also is
associated with receptive and expressive word knowledge
(Walsh & Blewitt, 2006). Future research should examine
the impact different types of maternal questions may have
on language learning in children with DS. Understanding
these relationships could allow us to provide interventions
focused on ensuring the development of vocabulary com-
prehension so that children with DS are best positioned for
literacy development when entering school.
In terms of expressive communication used by chil-
dren with DS in this study, our findings that children with
DS were communicating using combined gesture and vocal-
izations just as often as their chronological age-matched
peers with TD were using spoken words highlights the need
to provide young children with DS with a means of expres-
sive language beyond gestures alone. The coding completed
in the current study combined both symbolic and nonsym-
bolic gestures. Because of this, the findings do not allow
for symbolic gestures (e.g., signs) to be quantified separately
from nonsymbolic gestures (e.g., direct points) for commu-
nication. Information regarding the number of symbolic ges-
tures used would provide more information regarding the
robustness of a child’s language system and could further
support the need for language intervention to increase sym-
bolic communication. Regardless, we found that children
with DS were using significantly more gestures for commu-
nication and only 15 spoken words on average, supporting
the need for augmentative and alternative communication
(AAC) supports using speech-generating devices (SGDs).
AAC is a valid means of intervention for children during
early intervention (Romski et al., 2010) and should be used
with children with DS during the earliest stages of language
learning. AAC is a language teaching tool for symbolic com-
munication and provides an output method for communica-
tion during shared book reading. When children do not have
a means to take a conversational turn by producing vocabu-
lary related to that context, the development of those vocabu-
lary skills can be negatively impacted (Romski et al., 2015).
Providing children with an opportunity to learn how to
use symbolic language and expressively communicate via
an SGD during shared book reading can provide children
with a similar conversational experience as their peers with
TD and enhance vocabulary learning (Romski et al., 2010).
The use of print referencing has been the focus of a
number of intervention studies to understand more about
the relationship between early print referencing and literacy
development in children both with and without language
delays (Justice et al., 2008, 2002; Piasta et al., 2018). Find-
ings from the current study regarding the type and function
of communication during shared book reading suggest that
shared book reading contexts for children with DS may
also be an appropriate focus of future intervention studies
to understand how providing a greater emphasis on print
referencing may impact future language and literacy de-
velopment. We know that, when children with DS enter
school, they have a range of letter and letter sound knowl-
edge that may lead to differences in phonological develop-
ment for reading (Cupples & Iacono, 2000). Additionally,
we know that phonological awareness develops as an out-
growth of children’s vocabulary knowledge (Metsala &
Walley, 1998). Vocabulary knowledge and letter knowledge
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are highly dependent on experiences children with DS have
had during shared book reading. Our findings highlight the
positive interactions that mothers and their children with
DS were engaged in for language learning but suggest that
mothers are not providing reference to print during these
interactions. These findings support the exploration of addi-
tional explicit instruction strategies related to print referen-
cing, including building on the work of van Bysterveldt
et al. (2010b) and incorporating the use of AAC systems.
SGDs could be used to target vocabulary, letter names,
and letter sounds during book reading interactions and,
as Romski and Sevcik (1996) found, may not only serve as
a mode of expressive communication but may also serve as a
mode of input, extending this use of AAC for teaching letter
names and letter sounds.
Our current study focused only on the context of
shared book reading to understand differences in commu-
nication and print referencing between groups of children
with DS and with TD. Future work should compare settings
to identify similarities and differences in communication
between groups of children with DS and children with TD,
with the role of the context best facilitating this interaction
as a question of interest. The book reading context may be
particularly facilitative for caregivers because the book pro-
vides a structured set of pictures and events to label, de-
scribe, and sequence during their interaction. A limitation
of our current study, however, is that, while parents had ac-
cess to a range of book types, we did not control for the
specific book characteristics and content to be read across
all children (e.g., books with manipulatives, sound effects,
rhyming books, books that told a narrative). Book type
may have had an effect on the language parents used to
provide input to their child and thus also impacted child
expressive communication. Findings from Cameron-Faulkner
and Noble (2013) suggest that the linguistic content of chil-
dren’s books may play a role in grammatical input to support
language development. Research regarding the impact of
book characteristics that may yield the greatest positive im-
pact for both parent communication input and child lan-
guage and literacy outcomes is warranted. Additionally,
sequential analyses of mother–child communication (Justice
et al., 2002) within the book reading context itself may pro-
vide insight into what specific kinds of maternal input dur-
ing book reading were most facilitative of child interaction.
Factors such as children’s joint attention, social interest,
and the type of books used (e.g., repeated line, simple story,
rhyming) may have all contributed to the ability of mothers
to provide language input and impacted the expressive
communication of children with DS via both spoken and
nonspoken means. This study did not investigate the rela-
tionship between child expressive language skills and mater-
nal input. While the sample size was in line with previous
studies, the relatively small sample did not allow for the in-
clusion of child variables beyond the scope of our major re-
search questions. This is a limitation of the current study,
and future work should examine the role of child expressive
language ability in maternal input during shared book read-
ing interactions. It is important to identify if mothers of
Barton-Hulsey et al.: Language and Shared Book Reading 1485
young children with DS adapt their language input based
on child expressive language skills, including the use of ges-
tures, during early parent–child interaction. In addition,
given the differences identified between children with DS
and TD matched on chronological age, an important next
step includes including mother–child dyads with children
with TD matched to children with DS on other variables,
such as receptive vocabulary, developmental age, or expres-
sive language ability.
Children with DS are just one group of children that
represent a spectrum of language and literacy skill. Future
work should explore these same questions in children with
different etiologies of intellectual or developmental disabil-
ities from those with DS in order to parse out the role of
the book reading context for supporting language and liter-
acy development versus intrinsic factors of the child that
may be at play. It is important to understand if shared book
reading supports maternal engagement and child communi-
cation in similar ways across other groups of children with
developmental disabilities when compared to peers with
TD. Key differences in child factors between these groups
may differentially impact maternal input. These differences
may be important when tailoring early interventions during
shared book reading for children and parents that come
with unique sets of relative strengths and areas of need. It is
important that we understand these different factors early
in development so that literacy interventions can be created
and tested to maximally support children with DS in reach-
ing their fullest potential.
Acknowledgments
This project was supported in part by grants from the
Eunice Kennedy Shriver National Institute of Child Health and
Human Development under Award Numbers T32HD007489
(awarded to Hartley), P30 HD03352 (awarded to Messing), P30
HD002528 (awarded to Colombo), and T32 DC005359 (awarded
to Ellis Weismer). The content is solely the responsibility of the
authors and does not necessarily represent the official views of the
National Institutes of Health. The authors would like to thank the
participants and their families for making this research possible.
The authors would also like to thank the students and staff of the
Research in Neurodevelopmental Disabilities Lab lab for their
work on this project.
References
Abbeduto, L., Murphy, M. M., Cawthon, S. W., Richmond, E. K.,
Weissman, M. D., Karadottir, S., & O'Brien, A. (2003). Recep-
tive language skills of adolescents and young adults with
Down or fragile X syndrome. American Journal on Mental Re-
tardation, 108(3), 149–160.
Abbeduto, L., Warren, S. F., & Conners, F. A. (2007). Language
development in down syndrome: From the prelinguistic period
to the acquisition of literacy. Mental Retardation and Develop-
mental Disabilities Research Reviews, 13(3), 247–261. https://
doi.org/10.1002/mrdd.20158
Al Otaiba, S., Lewis, S., Whalon, K., Dyrlund, A., & McKenzie,
A. R. (2009). Home literacy environments of young children
1486 American Journal of Speech-Language Pathology • Vol. 29 • 1475–1488 • August 2020
Downloaded from: https://pubs.asha.org Proquest on 08/06/2020, Terms of Use: https://pubs.asha.org/pubs/rights_and_permissions
with Down syndrome. Remedial and Special Education, 30(2),
96–107. https://doi.org/10.1177/0741932508315050
Bland, J. M., & Altman, D. G. (1999). Measuring agreement
in method comparison studies. Statistical Methods in
Medical Research, 8(2), 135–160. https://doi.org/10.1177/
096228029900800204
Blewitt, P., Rump, K. M., Shealy, S. E., & Cook, S. A. (2009).
Shared book reading: When and how questions affect young
children’s word learning. Journal of Educational Psychology,
101(2), 294–304. https://doi.org/10.1037/a0013844
Brady, N., Warren, S. F., Fleming, K., Keller, J., & Sterling, A.
(2014). Effect of sustained maternal responsivity on later vocab-
ulary development in children with fragile X syndrome. Journal
of Speech, Language, and Hearing Research, 57(1), 212–226.
https://doi.org/10.1044/1092-4388(2013/12-0341)
Brown, J. H., Johnson, M. H., Paterson, S. J., Gilmore, R.,
Longhi, E., & Karmiloff-Smith, A. (2003). Spatial representa-
tion and attention in toddlers with Williams syndrome and
Down syndrome. Neuropsychologia, 41(8), 1037–1046. https://
doi.org/10.1016/S0028-3932(02)00299-3
Burgoyne, K., Duff, F. J., Clarke, P. J., Buckley, S., Snowling, M. J.,
& Hulme, C. (2012). Efficacy of a reading and language inter-
vention for children with Down syndrome: A randomized
controlled trial. Journal of Child Psychology and Psychiatry,
53(10), 1044–1056. https://doi.org/10.1111/j.1469-7610.2012.
02557.x
Cameron-Faulkner, T., & Noble, C. (2013). A comparison of book
text and child directed speech. First Language, 33(3), 268–279.
https://doi.org/10.1177/0142723713487613
Carvajal, F., & Iglesias, J. (2000). Looking behavior and smiling
in Down syndrome infants. Journal of Nonverbal Behavior,
24, 225–236. https://doi.org/10.1023/A:1006693121491
Chapman, R. S. (1997). Language development in children and
adolescents with Down syndrome. Mental Retardation and
Developmental Disabilities Research Reviews, 3(4), 307–312.
https://doi.org/10.1002/(SICI)1098-2779(1997)3:4<307::AID-
MRDD5>3.0.CO;2-K
Cupples, L., & Iacono, T. (2000). Phonological awareness and oral
reading in children with Down syndrome. Journal of Speech,
Language, and Hearing Research, 43(3), 595–608. https://doi.
org/10.1044/jslhr.4303.595
Dimitrova, N., Özçalışkan, Ş., & Adamson, L. B. (2016). Parents’
translations of child gesture facilitate word learning in children
with autism, Down syndrome and typical development. Journal
of Autism and Developmental Disorders, 46(1), 221–231. https://
doi.org/10.1007/s10803-015-2566-7
Draghi, L., & Zampini, L. (2019). The emergence of multiword
utterances in children with Down syndrome syndrome. Clini-
cal Linguistics & Phonetics, 33(5), 406–419. https://doi.org/
10.1080/02699206.2018.1521871
Ezell, H. K., & Justice, L. M. (1998). A pilot investigation of par-
ents’ questions about print and pictures to preschoolers with
language delay. Child Language Teaching and Therapy, 14(3),
273–278. https://doi.org/10.1177/026565909801400303
Fidler, D. J. (2005). The emerging Down syndrome behavioral
phenotype in early childhood. Infants and Young Children,
18(2), 86–103. https://doi.org/10.1097/00001163-200504000-
00003
Gilkerson, J., Richards, J. A., & Topping, K. J. (2017). The im-
pact of book reading in the early years on parent–child lan-
guage interaction. Journal of Early Childhood Literacy, 17(1),
92–110. https://doi.org/10.1177/1468798415608907
Hart, B., & Risley, T. R. (1995). Meaningful differences in the ev-
eryday experience of young American children. Brookes.
Justice, L. M., & Ezell, H. K. (2004). Print referencing: An emer-
gent its clinical applications. Language, Speech, and Hearing
Services in Schools, 35(2), 185–193. https://doi.org/10.1044/
0161-1461(2004/018)
Justice, L. M., Pullen, P. C., & Pence, K. (2008). Influence of ver-
bal and nonverbal references to print on preschoolers’ visual
attention to print during storybook reading. Developmental
Psychology, 44(3), 855–866. https://doi.org/10.1037/0012-
1649.44.3.855
Justice, L. M., Weber, S. E., Ezell, H. K., & Bakeman, R. (2002).
A sequential analysis of children’s responsiveness to parental
print references during shared book-reading interactions.
American Journal of Speech-Language Pathology, 11(1), 30–40.
https://doi.org/10.1044/1058-0360(2002/004)
Kay-Raining Bird, E., & Cleave, P. (2015). Mothers’ talk to chil-
dren with Down syndrome, language impairment, or typical
development about familiar and unfamiliar nouns and verbs.
Journal of Child Language, 43(5), 10772–11102. https://doi.org/
10.1017/S0305000915000434
Kover, S. T., & Atwood, A. K. (2013). Establishing equivalence:
Methodological progress in group-matching design and
analysis. American Journal on Intellectual and Developmental
Disabilities, 118(1), 3–15. https://doi.org/10.1352/1944-7558-
118.1.3
Landry, S. H., Smith, K. E., Swank, P. R., Zucker, T., Crawford,
A. D., & Solari, E. F. (2012). The effects of a responsive par-
enting intervention on parent–child interactions during shared
book reading. Developmental Psychology, 48(4), 969–986.
https://doi.org/10.1037/a0026400
Linn, M. I., Goodman, J. F., & Lender, W. L. (2000). Played out?
Passive behavior by children with Down syndrome during
unstructured play. Journal of Early Intervention, 23(4), 264–278.
https://doi.org/10.1177/10538151000230040601
Lorang, E., Sterling, A., & Schroeder, B. (2018). Maternal respon-
siveness to gestures in children with Down syndrome. American
Journal of Speech-Language Pathology, 27(3), 1018–1029.
https://doi.org/10.1044/2018_AJSLP-17-0138
Luyster, R. J., Kadlec, M. B., Carter, A., & Tager-Flusberg, H.
(2008). Language assessment and development in toddlers with
autism spectrum disorders. Journal of Autism and Develop-
mental Disorders, 38(8), 1426–1438. https://doi.org/10.1007/
s10803-007-0510-1
Metsala, J. L., & Walley, A. C. (1998). Spoken vocabulary growth
and the segmental restructuring of lexical representations: Pre-
cursors to phonemic awareness and early reading ability. In
J. L. Metsala & L. C. Ehri (Eds.), Word recognition in beginning
literacy (pp. 89–120). Routledge.
Miller, J. F., & Iglesias, A. (2012). Systematic Analysis of Language
Transcript. SALT Software.
Mullen, E. M. (1995). Mullen Scales of Early Learning. AGS.
Parker, S. E., Mai, C. T., Canfield, M. A., Rickard, R., Wang, Y.,
Meyer, R. E., Anderson, P., Mason, C. A., Collins, J. S., Kirby,
R. S., Correa, A., & for the National Birth Defects Prevention
Network. (2010). Updated national birth prevalence estimates
for selected birth defects in the United States, 2004–2006. Birth
Defects Research Part A: Clinical and Molecular Teratology,
88(12), 1008–1016. https://doi.org/10.1002/bdra.20735
Partridge, H. A. (2004). Helping parents make the most of shared
book reading. Early Childhood Education Journal, 32(1), 25–30.
https://doi.org/10.1023/B:ECEJ.0000039640.63118.d4
Piasta, S. B., Justice, L. M., McGinty, A. S., & Kaderavek, J. N.
(2018). Increasing young children’s contact with print during
shared reading: Longitudinal effects on literacy achievement.
Downloaded from: https://pubs.asha.org Proquest on 08/06/2020, Terms of Use: https://pubs.asha.org/pubs/rights_and_permissions
Child Development, 83(3), 810–820. https://doi.org/10.1111/
j.1467-8624.2012.01754.x
Ricci, L. (2011). Home literacy environments, interest in reading
and emergent literacy skills of children with Down syndrome
versus typical children. Journal of Intellectual Disability Research,
55(6), 596–609. https://doi.org/10.1111/j.1365-2788.2011.01415.x
Romski, M., & Sevcik, R. A. (1996). Breaking the speech barrier:
Language development through augmented means. Brookes.
Romski, M., Sevcik, R. A., Adamson, L. B., Cheslock, M., Smith, A.,
Barker, R. M., & Bakeman, R. (2010). Randomized comparison
of augmented and nonaugmented language interventions for
toddlers with developmental delays and their parents. Journal
of Speech, Language, and Hearing Research, 53(2), 350–364.
https://doi.org/10.1044/1092-4388(2009/08-0156)
Romski, M., Sevcik, R. A., Barton-Hulsey, A., & Whitmore, A. S.
(2015). Early intervention and AAC: What a difference 30 years
makes. Augmentative and Alternative Communication, 31(3),
181–202. https://doi.org/10.3109/07434618.2015.1064163
Ruskin, E. M., Mundy, P., Kasari, C., & Sigman, M. (1994). Ob-
ject mastery motivation of children with Down syndrome.
American Journal on Mental Retardation, 98(4), 499–509.
Sameroff, A. J., & Chandler, M. J. (1975). Reproductive risk
and the continuum of caretaking casualty. In F. D. Horowitz,
M. Hetherington, S. Scarr-Salaptaek, & G. Siegel (Eds.), Re-
view of child development research (pp. 187–244). University
of Chicago Press.
Scarborough, H., & Dobrich, W. (1994). On the efficacy of read-
ing to preschoolers. Developmental Review, 14(3), 245–302.
https://doi.org/10.1006/drev.1994.1010
Seager, E., Mason-Apps, E., Stojanovik, V., Norbury, C., Bozicevic,
L., & Murray, L. (2018). How do maternal interaction style and
joint attention relate to language development in infants with
Down syndrome and typically developing infants?. Research in
Developmental Disabilities, 83, 194–205. https://doi.org/10.1016/
j.ridd.2018.08.011
Slonims, V., & Mcconachie, H. (2006). Analysis of mother–infant
interaction in infants with Down syndrome and typically de-
veloping infants. American Journal on Mental Retardation,
273(4), 273–289. https://doi.org/10.1352/0895-8017(2006)111
[273:AOMIII]2.0.CO;2
Sterling, A., Barnum, L., Skinner, D. G., Warren, S. F., & Fleming,
K. (2012). Parenting young children with and without fragile X
syndrome. American Journal on Intellectual and Developmen-
tal Disabilities, 117(3), 194–206. https://doi.org/10.1352/1944-
7558-117.3.194
Sterling, A., & Warren, S. F. (2014). Maternal responsivity in
mothers of young children with Down syndrome. Developmen-
tal Neurorehabilitation, 17(5), 306–317. https://doi.org/10.3109/
17518423.2013.772671
Thiemann-Bourque, K., Warren, S. F., Brady, N., Gilkerson, J., &
Richards, J. (2014). Vocal interaction between children with
Down syndrome and their parents. American Journal of Speech-
Language Pathology, 23(3), 474–485. https://doi.org/10.1044/
2014_AJSLP-12-0010
Trenholm, B., & Mirenda, P. (2006). Home and community liter-
acy experiences of individuals with Down syndrome. Down
Syndrome Research and Practice, 10(1), 30–40. https://doi.org/
10.3104/reports.303
van Bysterveldt, A. K., Gillon, G., & Foster-Cohen, S. (2010a). In-
tegrated speech and phonological awareness intervention for
pre-school children with Down syndrome. International Journal
of Language & Communication Disorders, 45(3), 320–335.
https://doi.org/10.3109/13682820903003514
Barton-Hulsey et al.: Language and Shared Book Reading 1487
van Bysterveldt, A. K., Gillon, G., & Foster-Cohen, S. (2010b).
Literacy environments for children with Down syndrome: What’s
happening at home? Down Syndrome Research and Practice,
12(2), 98–102.
van Bysterveldt, A. K., Gillon, G. T., & Moran, C. (2006). Enhanc-
ing phonological awareness and letter knowledge in preschool
children with Down syndrome. International Journal of Dis-
ability, Development and Education, 53(3), 301–329. https://doi.
org/10.1080/10349120600847706
Walsh, B. A., & Blewitt, P. (2006). The effect of questioning
style during storybook reading on novel vocabulary acquisi-
tion of preschoolers. Early Childhood Education Journal, 33(4),
273–278. https://doi.org/10.1007/s10643-005-0052-0
Yoder, P. J., & Warren, S. F. (2004). Early predictors of
language in children with and without Down syndrome.
American Journal of Mental Retardation, 109(4), 285–300.
https://doi.org/10.1352/0895-8017(2004)109<285:EPOLIC>2.0.
CO;2

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