Research in Developmental Disabilities 62 (2017) 184–196

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Research in Developmental Disabilities

Language comprehension in children, adolescents, and adults

with Down syndrome
Bernadette Witecy ∗ , Martina Penke
Department of Special Education and Rehabilitation, University of Cologne, Cologne, Germany

a r t i c l e i n f o a b s t r a c t

Article history: Background: There is conflicting evidence as to whether receptive language abilities of indi-
Received 5 October 2016 viduals with Down syndrome (DS) continue to improve into adulthood, reach a plateau in
Received in revised form 4 January 2017 late adolescence, or even start to decline.
Accepted 20 January 2017
Aim: The study aims to shed light on the question whether receptive syntactic skills change
Number of reviews completed is 2 from childhood/adolescence to adulthood and provides a detailed qualitative analysis of
the receptive abilities of adults with DS.
Keywords: Methods: 58 individuals with DS participated in the study: 31 children/adolescents (aged:
Down syndrome 4;6–19;0 years) and 27 adults (aged: 20;8–40;3 years). They completed measures of gram-
Intellectual disability
mar comprehension, nonverbal cognition, and phonological working memory.
Sentence comprehension
Results: There was no significant correlation between comprehension performance and
chronological age in the overall sample. Separate correlational analyses for the subgroups of
children/adolescents and adults yielded a significant positive result for the former subgroup
but not for the latter. We also found significant positive correlations between grammar com-
prehension scores and nonverbal mental age as well as measures of phonological working
memory. Qualitative analyses showed various limitations in the receptive syntactic abilities
of adults with DS. Difficulties increase with sentence length and grammatical complexity,
but are also apparent in simple sentences.
Conclusion: The results suggest that syntactic comprehension abilities of individuals with
DS continue to improve through childhood and adolescence and that thereafter a plateau is
reached and maintained. Language comprehension in adults with DS is impaired for a vari-
ety of grammatical structures and receptive performance seems to be related to nonverbal
cognitive abilities, phonological working memory, and grammatical complexity.
© 2017 Elsevier Ltd. All rights reserved.

1. Introduction

Down syndrome (DS) is the most common neurodevelopmental disorder causing intellectual disability. The prevalence
in live births in Europe is approximately 1 in 900 (Loane et al., 2013). Among the main characteristics of DS are impaired
language abilities. Despite considerable interindividual variability, the language phenotype has been described as follows:
later onset and slower pace of language development, relative strength in vocabulary knowledge (especially receptive),
particular difficulties in morphosyntax, better language comprehension than production abilities (Abbeduto, Warren, &
Conners, 2007; Martin, Klusek, Estigarribia, & Roberts, 2009). Given the late onset and slower pace in language development,

∗ Corresponding author at: Department of Special Education and Rehabilitation, University of Cologne, Herbert-Lewin-Str. 10, 50931 Cologne, Germany.
E-mail address: bwitecy@uni-koeln.de (B. Witecy).

http://dx.doi.org/10.1016/j.ridd.2017.01.014
0891-4222/© 2017 Elsevier Ltd. All rights reserved.
 B. Witecy, M. Penke / Research in Developmental Disabilities 62 (2017) 184–196 185

a crucial issue is whether language development in DS, in particular the development of grammatical abilities, continues
throughout adolescence or whether it stagnates at a certain point.
Some studies have provided evidence for an ongoing development of language skills into adulthood. Schaner-Wolles
(1985, 2004) reported findings of a cross-sectional investigation assessing the abilities of German speaking children, adoles-
cents, and adults with DS (age range: 7;3–41;10 years) on tasks of phonology, lexicon, and semantics as well as morphology
and syntax. The author stated that “even the adults with DS showed continuing syntactic development” (Schaner-Wolles,
2004, p. 116). The data supporting this claim, however, are not presented in these papers. Likewise, Sanoudaki and Varlokosta
(2015) found improvement with age in the comprehension of certain sentence structures with reflexive pronouns in a
cross-sectional study with Greek speaking adolescents and adults with DS (ages: 10–34 years).
Another study, in contrast, has found no evidence of progress in language beyond adolescence. Rondal and Comblain
(1996, 2002) studied language abilities of French speaking children and adolescents as well as younger and older adults
with DS (ages ranging from 6 to 46 years) using tasks on receptive and productive vocabulary, grammar comprehension,
and language production (mean length of utterance (MLU)). Based on their data, they suggested that there is no change in
language capacities between late adolescence and about 50 years of age.
Moreover, ongoing development might be restricted to language production. Some studies have indicated that syntactic
comprehension is likely to reach a plateau in late adolescence or even to decline with age, starting in older adolescents or
young adults, whereas acquisition of expressive language capacities seems to continue throughout adolescence and possibly
into adulthood (Chapman, Hesketh, & Kistler, 2002; Laws & Gunn, 2004; Thordardottir, Chapman, & Wagner, 2002). Thus,
although the aforementioned literature on the language phenotype in DS reports a dissociation between better language
comprehension and more impaired language production, the studies by Chapman et al. (2002) and Laws and Gunn (2004)
indicate that the window for development in the receptive modality might be more restricted, at least for receptive grammar.
Studies that have focused on language abilities in adults with DS also report heterogeneous findings. Most of the available
evidence stems from assessments of adaptive behavior that include the domain of communication or from verbal IQ mea-
sures, whereas direct language measures beyond the single word level are rare. Some studies have found declining abilities
in both language comprehension and production in adults aged 45 or older (Hawkins, Eklund, James, & Foose, 2003; Roeden
& Zitman, 1997). Other studies, in contrast, have observed no change with age in communication skills in subjects ranging
from 20 to 69 years (Tsao, Kindelberger, Fréminville, Touraine, & Bussy, 2015) or no differences in verbal IQ scores between
individuals younger than 45 years and individuals of 45 years and older (Devenny & Krinsky-McHale, 1998). A number of
studies have only found receptive language abilities to decline, starting around the age of 40 years (Carter Young & Kramer,
1991; Cooper & Collacott, 1995; Ghezzo et al., 2014; Rasmussen & Sobsey, 1994), or, according to Couzens, Cuskelly, and
Haynes (2011) already around the age of 20 years. In one of the rare investigations that employed direct measures of lan-
guage abilities, Iacono, Torr, and Wong (2010) studied the relation between language and age in 55 adults with DS (19–58
years). They found significant negative correlations between chronological age and measures of receptive (vocabulary and
grammatical structures) and expressive language (MLU). However, only the latter remained when nonverbal cognition and
scores on an assessment of dementia were controlled. Thus, the results of this study indicated that language production
is affected by aging independent of the onset of dementia or cognitive decline, while declines in language comprehension
seem to be associated with symptoms of dementia and/or decreases in nonverbal cognition.
In conclusion, language abilities of individuals with DS may change over time, but the evidence to date is inconclusive as to
whether affected individuals still improve in their grammatical abilities in the transition from adolescence to adulthood and
whether respectively when a plateau is reached or declines begin. As the review of the available literature has indicated this
issue is particularly debated for receptive language skills where some studies have found evidence of ongoing development
into adulthood whereas others have reported the building of a plateau in late adolescence and again others have described
declines starting as early as the age of about 20 years. A possible explanation for the varying and conflicting evidence
is that different aspects of language were assessed and a variety of measures was used. That was particularly the case
for adults with DS for whom language abilities have only rarely been investigated by specifically designed tests targeting
circumscribed language abilities. To contribute to the available data on receptive language abilities in DS, we decided to
focus on one core aspect of language, that is, syntax. The aim of our paper is to shed light on the issue whether receptive
syntactic skills change from childhood/adolescence to adulthood and within adulthood. To this end, we will present data on
the comprehension abilities of a large group of German speaking individuals with DS ranging in age from 4;6 to 40;3 years.
Grammar comprehension was assessed using the TROG-D (Fox, 2011), the German adaption of the TROG (Test for Reception
of Grammar (Bishop, 1983, 2003)), which is a well-established instrument both for diagnostic and research purposes. The
TROG tests a broad array of grammatical structures and allows for a quantitative as well as a qualitative analysis. To the
extent of our knowledge, detailed qualitative analyses of the receptive abilities of adults with DS as measured by the TROG
do not exist so far. Thus, the current study aims to enlarge the existing database on the comprehension of grammatical
structures for this group. We will use correlational analyses to investigate the relationship between language comprehension
and chronological age. We will also evaluate the influence of nonverbal cognition and phonological working memory on
comprehension abilities. Both have been found to be related to language outcome in DS in earlier studies (e.g. Abbeduto et al.,
2003; Chapman, Schwartz, & Bird, 1991). Especially phonological working memory is often discussed as a critical factor which
might, at least, be partly responsible for the language deficits in DS. An impairment of phonological working memory is a
well-described feature of the cognitive phenotype in DS (Baddeley & Jarrold, 2007; Jarrold, Baddeley, & Hewes, 2000; Laws &
Gunn, 2004). It is hypothesized that there is a deficit in the phonological loop component of the working memory system. The
186 B. Witecy, M. Penke / Research in Developmental Disabilities 62 (2017) 184–196

phonological loop is responsible for the temporary storage of phonological information while it is being processed (Baddeley
& Jarrold, 2007) and might play a crucial role in acquiring vocabulary as well as in the comprehension of sentences (Baddeley,
Gathercole, & Papagno, 1998; Laws & Gunn, 2004).

2. Material and methods

2.1. Subjects

In total, 58 individuals with DS participated in our study. Of these, 31 were children or adolescents (13 females, 18 males)
aged 4;6 to 19;0 years (mean: 10;10 years) and 27 were adults (12 females, 15 males), who ranged in age from 20;8 to 40;3
years (mean: 28;5 years; for individual subject characteristics see Appendices A and B). They participated in a larger study
assessing a variety of receptive and productive language abilities via standardized tests and specifically developed elicitation
experiments. Participants were included in the study if they were monolingual German, if oral language was their primary
means of communication, and if they produced at least two-word-utterances.
Our aim was to investigate development and changes in language comprehension without pathological influences. Indi-
viduals with DS have a high risk of developing dementia (in most cases Alzheimer’s disease). As language comprehension
might be critically influenced by the onset of dementia (Iacono et al., 2010), we did not include subjects older than 40
years. After this age the likelihood of developing not only neuropathological but also clinical signs of dementia increases in
individuals with DS (Head, Powell, Gold, & Schmitt, 2012; McCarron, McCallion, Reilly, & Mulryan, 2014).
All children and adolescents with DS were recruited through local parent support groups and postings on websites or in
journals of organizations concerned with DS. Adults with DS were recruited through sheltered employment facilities, group
homes, and among the writers of a magazine created by people with DS.
We also contacted the legal guardians, in all but one case the parents, of the individuals participating in our study to
give their consent to the study and to provide additional information on participants. Guardians were asked to fill out a
questionnaire to confirm the diagnosis of DS and to gain information on hearing and ear infections, socioeconomic factors,
and, for the adult subjects, changes in behavior that might be related to the onset of dementia. Questions on the latter issue
were based on the Dementia Screening Questionnaire for Individuals with Intellectual Disabilities (DSQIID; Deb, Hare, Prior,
& Bhaumik, 2007). Two of the children and adolescents and one adult were reported to have mild hearing loss. In addition,
according to the questionnaire, five adult participants had been diagnosed with moderate hearing loss at some point, but
only for three of these this was still persistent. Two of them were wearing hearing aids. For all other participants, the parents
either stated that there had never been a diagnosis of hearing impairment or that there had only been temporary hearing
loss associated with ear infections.

2.2. Measures

2.2.1. Nonverbal cognition

Nonverbal cognition was assessed by the Reasoning Scale of the Snijders-Omen Nonverbal Intelligence Test (SON-R 2.5-7)
(Tellegen, Laros, & Petermann, 2007; reported reliability: 0.83). It contains three subtests (Categories, Analogies, Situations)
and can be applied without using written or spoken language. Raw scores were used to calculate nonverbal mental age
equivalents.

2.2.2. Grammar comprehension

The TROG-D (Fox, 2011), a German adaption of the Test for Reception of Grammar (Bishop, 1983, 2003), was used as a
standardized measure of grammar comprehension (Cronbach’s ␣ = 0.90). Out of a choice of four pictures the participants
are required to identify the one that matches a word or sentence spoken by the experimenter. The test includes 21 blocks
of four items each. Each block tests a different grammatical structure, increasing in grammatical complexity (see Table 1 for
examples).
Data obtained from the TROG-D was analyzed in the following way:

(i) Quantitative analysis: Following the evaluation procedure described in the manual, the number of correct blocks was
determined in a first quantitative analysis. According to the manual, a block is only scored as correct if responses to all
four items in this block are correct. A stop criterion is reached if the participant produces at least one incorrect reaction
in five consecutive blocks. The number of correct blocks until the stop criterion is reached is counted. Raw scores were
used for statistical analyses.
(ii) Error analysis: The TROG-D also allows for a classification of errors as either lexical or grammatical by using lexical and
grammatical foils. In five blocks only lexical errors are possible (Blocks A–E) and nine blocks allow only grammatical
errors (G, J–L, P, R–U). The remaining seven blocks (F, H, I, K, N, O, Q) include both lexical and grammatical distractors.
(iii) Qualitative analysis of adult data: For a comprehensive insight into the receptive syntactic skills of the adult participants,
we performed a detailed qualitative analysis of all sentence structures included in the TROG-D. Therefore, the complete
test was run with the adult participants, neglecting the stop criterion. For clarity of exposition and for statistical analyses,
we grouped the blocks into four categories according to shared lexical or grammatical aspects (see Table 1): content
 B. Witecy, M. Penke / Research in Developmental Disabilities 62 (2017) 184–196 187

Table 1
Classification of structures tested in the TROG-D.

Block Sentence structure Example

Content words
A nouns Schuh ‘shoe’
B verbs trinken ‘drink’
C adjectives groß ‘tall’

Simple sentences
D sentences with two elements Der Junge läuft.
E sentences with three elements ‘The boy is running.’
Der Junge schaut das Pferd an.
‘The boy is looking at the horse.’
O double-object constructions Der Mann gibt die Katze dem Hund.
‘The man is giving the cat to the dog.’

Inflectional morphology and function words

F negation Das Mädchen springt nicht.
‘The girl is not jumping.’
G prepositions in ‘in’ and auf ‘on’ Das Messer ist auf dem Schuh.
‘The knife is on the shoe.’
H perfect tense Das Mädchen hat ein Bild gemalt.
‘The girl has painted a picture.’
I noun plural Die Katzen schauen den Ball an.
‘The cats are looking at the ball.’
J prepositions über ‘over/above’ and unter ‘under/below’ Der Stift ist über der Blume.
‘The pen is above the flower.’
L personal pronouns (nominative case) Sie pflückt die Blumen.
‘She is picking flowers.’
N personal pronouns (accusative/dative case) Das Pferd schaut sie an.
‘The horse is looking at her.’
R disjunctive conjunction weder noch ‘neither nor’ Weder der Hund noch der Ball ist braun.
‘Neither the dog nor the ball is brown.’

Complex sentences
K passive voice (reversible) Das Mädchen wird vom Pferd gejagt.
‘The girl is chased by the horse.’
M relative clauses (pronoun in nominative case) Der Junge, der das Pferd jagt, ist dick.
‘The boy that is chasing the horse is fat.’
P subordinating conjunctions während ‘while’ and nachdem ‘after’ Während der Junge isst, liest er.
‘While the boy is eating, he is reading.‘
Q topicalization Den braunen Hund jagt das Pferd.
‘The brown dog[ACC] chases the horse[NOM] .’
S relative clauses (pronoun in accusative/dative case) Der Hund, den die Kuh jagt, ist braun.
‘The dog that[ACC] the cow is chasing is brown.’
T coordination with und ‘and’ Der Junge schaut das Pferd an und steht.
‘The boy is looking at the horse and standing.’
U subordination and pronoun binding Die Frau sieht, dass das Mädchen auf sie zeigt.
‘The woman sees that the girl is pointing at her.’

Note: Structures are grouped in four categories according to grammatical phenomena tested. Order of presentation in the TROG is indicated by alphabetical
letters.

words, simple sentences, sentences relying on the correct interpretation of inflectional markers or function words,
and complex sentences. Complex sentences were defined as sentences either containing non-canonical word order
of subject/agent and object/theme (e.g. passive) or consisting of a main clause as well as a coordinate or subordinate
clause. For statistical analyses, we determined the number of correct items achieved per block for each participant
and calculated group means for each block. Further, we computed percentages of correct items per category for each
participant.

2.2.3. Phonological working memory

For children and adolescents with DS phonological working memory was assessed by the nonword repetition subtest
of the SETK 3–5 (Grimm, Aktas, & Frevert, 2001). It consists of 18 items of two to five syllables. The test was administered
according to the manual: the nonwords were read to the participants who were instructed to repeat these unknown words
as accurately as possible. A raw score for each participant was then computed by counting the absolute number of correctly
repeated nonwords.
For the adult subjects the number recall subtest of the K-ABC (Melchers & Preuß, 2006) was used. It requires the repetition
of number sequences ranging in length from two to eight. Number sequences are grouped in blocks of two or three of the
same length each. Testing is discontinued when the participant fails to respond correctly to all sequences within one block.
Each sequence recalled correctly is scored. Statistical analyses were run over raw scores.
188 B. Witecy, M. Penke / Research in Developmental Disabilities 62 (2017) 184–196

18
16
number of correct blocks

14
12
10
children and adolescents
8
adults
6 overall
4
2
0
0 50 100 150 200 250 300 350 400 450 500
chronological age (in months)

Fig. 1. The relationship between chronological age (in months) and number of correct blocks in the TROG-D including trendlines for subgroups and overall
participants.

2.3. Procedure and ethical considerations

Testing was conducted in a quiet room at the University of Cologne, at the sheltered employment facilities, or at par-
ticipants’ homes. Four examiners were involved in data collection. The same examiner applied all measures to one and the
same participant after making herself and the situation familiar to the participant. All tests were administered according to
the test manuals. Each session was videotaped. The videos were used to ensure that all tests were presented the same way
and to check the scoring of subjects’ responses.
Approval was obtained from the Ethics Commission of the Faculty of Medicine of the University of Cologne. Informed
written consent was given by the parents of all children and adolescents in the study as well as by the legal guardians of the
adults with DS. The adult participants themselves also gave verbal or written assent.

3. Results

3.1. Nonverbal cognition

Nonverbal mental ages ranged from 2;11 to 6;7 years (M: 56.24 months, SD: 11.67), with three exceptions (one ado-
lescent and two adults) whose mental ages exceeded the norming sample (>7;11 years; individual results in Appendices A
and B). For these subjects, no exact reference ages could be determined and they were therefore excluded from all analyses
including mental age. A correlational analysis yielded a significant positive correlation between chronological and nonver-
bal mental age in the overall sample (Pearson’s correlation: r[53] = 0.376, p = 0.005), indicating that mental age increases
with chronological age. However, when the subgroup of children/adolescents and the subgroup of adults were regarded
separately there was only a positive correlation in the younger participants (children/adolescents: r[28] = 0.478, p = 0.008;
adults: r[23] = 0.079, p = 0.706, n. s.). Thus, the increase in nonverbal cognitive abilities seems to cease after adolescence.

3.2. Grammar comprehension

3.2.1. Quantitative analysis

Number of correct blocks ranged between 2 and 16 (M: 6.0, SD: 3.08). The large range and high standard deviation indicate
a high variability between individuals (individual raw scores presented in Appendices A and B). To investigate the relationship
between chronological age and comprehension performance, a Pearson’s correlation was used. There was no significant
correlation between the number of correct blocks and chronological age in the overall sample (r[56] = 0.133, p = 0.321, n. s.).
As the data (see trendlines in Fig. 1) indicated a different relationship between chronological age and comprehension scores
in children/adolescents on the one hand and adults on the other hand, correlational analyses were calculated separately for
these two subgroups. These analyses yielded a significant relationship for the younger subgroup (r[29] = 0.521, p = 0.003),
but no relationship for the older participants (r[25] = −0.113, p = 0.574, n. s.), indicating that comprehension performance
improves in children and adolescents with DS whereas there is no change in adults.
Overall performance on the TROG-D was strongly correlated with nonverbal mental age in the overall sample (Pearson’s
correlation: r[53] = 0.552, p < 0.001) (see Fig. 2), indicating that performance improves with increasing nonverbal cognitive
abilities.
Because nonverbal mental age was also correlated with chronological age, partial correlations between chronological
age and TROG-D scores were computed controlling for mental age to exclude nonverbal cognition as a possible confounding
factor. However, the results remained the same. Comprehension performance and chronological age again did not correlate
 B. Witecy, M. Penke / Research in Developmental Disabilities 62 (2017) 184–196 189

18
16
number of correct blocks

14
12
10
8 children and adolescents

6 adults

4
2
0
30 40 50 60 70 80
mental age (in months)

Fig. 2. The relationship between nonverbal mental age (in months) and number of correct blocks in the TROG-D including the overall trendline.

in the overall sample (r[52] = −0.129, p = 0.354, n. s.) and in the adult participants (r[22] = −0.053, p = 0.807, n. s.), but in the
subgroup of children and adolescents (r[27] = 0.401, p = 0.031).
Pearson’s correlations were also used to test if there is a relationship between overall performance on the TROG-D and
phonological working memory. Mean raw score for nonword repetition in the subgroup of children and adolescents was 4.39
(SD: 3.89, range: 0–13; for individual scores see Appendix A). The correlation between nonword repetition scores and number
of correct blocks in the TROG-D was significant (r[29] = 0.516, p = 0.003). The adult participants recalled on average 4.63
number sequences correctly (SD: 2.32, range: 1–9; for individual scores see Appendix B). The correlation between correctly
recalled number sequences and TROG-D performance was again significant (r[25] = 0.672, p < 0.001). The correlation in the
adult subgroup remained significant when nonverbal mental age was partialled out (adults: r[22] = 0.525, p = 0.008). The
partial correlation in the group of children and adolescents, however, fell just short of significance (r[27] = 0.361, p = 0.054).
A correlational analysis over the whole group of participants could not be calculated since different tests were used in
children/adolescents and adults.

3.2.2. Error analysis

The TROG-D allows a classification of errors as either lexical or grammatical, thus providing information about the nature
of comprehension deficits. A deficit in vocabulary knowledge is likely to be the cause when errors are predominantly lexical. A
high amount of grammatical errors, on the other hand, indicates grammatical difficulties (Fox, 2011). In total, the participants
produced mainly grammatical errors (86.3%: 594 out of 688 errors overall). A paired t-test confirmed that the difference
between the two error types was significant in the overall subject group (t[57] = −18.620, p < 0.001). In those blocks that
contain both lexical and grammatical distractors and where both error types are possible, grammatical errors constituted
95.4% of the errors (311 out of 326). Also, there was no participant with more lexical than grammatical errors in those blocks
as well as in the overall test. The error analysis thus suggests that the observed difficulties in sentence comprehension can
be attributed to grammatical problems.

3.2.3. Qualitative analysis of sentence structures

For a closer inspection of the receptive grammatical abilities, we focused on the subgroup of adult participants who
completed all blocks of the TROG-D, neglecting the stop criterion. Mean percentages of correct items for each of the above
described categories – content words, simple sentences, sentences relying on the correct interpretation of inflectional mark-
ers or function words, and complex sentences (cf. Section 2.2.2) – are displayed in Fig. 3. They decrease from content
words, where the mean percentage of correct items is approaching 100%, to complex sentences, to which there are only
38.76% correct responses on average. To compare the performance on grammatical structures classified into the four cate-
gories a one-factorial repeated measures ANOVA was used. There was a significant main effect (F[3, 78] = 222.995, p < 0.001,
␩p 2 = 0.896). Pairwise post-hoc comparisons with Bonferroni adjusted alpha levels revealed significant differences between
the correctness scores of all four grammatical categories (p < 0.001 each).
Further one-factorial repeated measures ANOVAs were calculated to compare the constructions within each category. All
post-hoc comparisons were Bonferroni corrected. The group means for items answered correctly for each block are depicted
in Fig. 4. Although the ANOVA on content words indicated a significant difference between nouns (Block A), verbs (Block
B) and adjectives (Block C) (F[2, 52] = 4.000, p = 0.024, ␩p 2 = 0.133), pairwise comparisons did not yield significant results
between the three lexical classes (p > 0.05 each).
For simple sentences there was a significant main effect (F[2, 52] = 48.351, p < 0.001, ␩p 2 = 0.650) and post-hoc compar-
isons showed that double-object constructions (Block O) were significantly more difficult than both two- (Block D) and
three-element sentences (Block E) (p < 0.001 each). There were also significantly more correct answers for two-element
sentences (Block D) than for three-element sentences (Block E) (p = 0.008).
190 B. Witecy, M. Penke / Research in Developmental Disabilities 62 (2017) 184–196

100.00% 97.22%

90.00%

Percentage of number of correct items

80.00% 77.47%

70.00%

60.00% 55.44%

50.00%
38.76%
40.00%

30.00%

20.00%

10.00%

0.00%
content words simple sentences function words + complex sentences
inflectional
morphology

Fig. 3. Mean percentages of correct items for the four grammatical categories.

3.5

3
Mean number of correct items

2.5

1.5

0.5

0
A B C D E O F I G H J N L R P K M T Q U S
Content words Simple sentences Function words + inflectional morphology Complex sentences

Fig. 4. Mean number of correct items achieved by the adult subjects for all structures included in the TROG-D. Structures are grouped according to
grammatical categories.

Sentences targeting the comprehension of function words and inflectional morphology included eight different con-
structions. There was considerable variability between them. The mean number of correct items per block ranged from 3.33
(Block F – Negation) to 0.48 (Block R – Disjunctive conjunction). The repeated measures ANOVA again indicated a significant
difference (F[7, 182] = 32.672, p < 0.001, ␩p 2 = 0.557). Pairwise comparisons showed that sentences with negation (Block F)
and noun plurals (Block I) did not differ from each other (p = 1.000) and resulted in significantly more correct responses than
all other sentence types in this category (p < 0.05 each), except sentences with the prepositions in and auf (in and on) (Block
G) (p > 0.05 each). Most challenging were constructions with the disjunctive conjunction weder noch (neither nor) (Block
R), which differed significantly from all other blocks (p < 0.001 each). All other comparisons in this category did not yield
significant results (p > 0.05 each).
 B. Witecy, M. Penke / Research in Developmental Disabilities 62 (2017) 184–196 191

A significant main effect was also observed in the category of complex sentences (F[6, 156] = 7.899, p < 0.001, ␩p 2 = 0.233).
Post-hoc analyses revealed significantly less correct answers on relative clauses with pronouns in accusative or dative case
(Block S) compared to sentences with the subordinating conjunctions während and nachdem (while and after) (Block P),
passive sentences (Block K), or relative clauses with pronouns in nominative case (Block M) (p < 0.05 each). Sentences with
subordination and pronoun binding (Block U) were also significantly more challenging than sentences in Blocks P and
K (p < 0.01 each). There were no significant differences between all other constructions within the category of complex
sentences.
As the quantitative analysis (cf. Section 3.2.1) yielded a significant relationship between overall performance on the
TROG-D and phonological working memory, we tested whether the performance on individual sentence structures, content
words excluded, was related to sentence length. We found a significant negative relationship between mean sentence length
per block in words and the number of correct items per block (Pearson’s correlation: r[16] = −0.731, p = 0.001), indicating
that performance decreases with increasing sentence length. Often, increasing sentence length is accompanied by increasing
grammatical complexity and thus it is hard to differentiate between the impact of these two factors on comprehension per-
formance. Looking at structures that are comparable in sentence length and semantic content and differ only in grammatical
aspects is one way to disentangle the two variables. Some of the structures included in the TROG-D serve this purpose.
Relative clauses with pronouns in nominative case (Block M) and relative clauses with pronouns in accusative or dative
case (Block S) differ in pronoun case and in word order, canonical SVO vs. non-canonical OVS order. In all other aspects,
including sentence length, they are comparable. As described above, the more complex non-canonical sentences (Block S)
were significantly more difficult than the canonical sentences (Block M). Likewise, sentences in Blocks E, I, L, and N all consist
of a subject, a transitive verb, and an object (see Table 1). However, the sentences in Blocks E and I only contain content
words, whereas sentences in Blocks L and N include personal pronouns in subject or object position. A one-factorial repeated
measures ANOVA was used to compare the four structures. It yielded a significant main effect (F[3, 78] = 28.088, p < 0.001,
␩p 2 = 0.519). Pairwise post-hoc comparisons showed that there was neither a significant difference between sentences with
full nouns (Block E vs. I), nor between the two blocks on personal pronouns (Block L vs. N) (p > 0.05 each). However, there
were significantly more correct responses on Blocks E and I than on Blocks L and N (p < 0.001 each), indicating difficulties
with the correct interpretation of personal pronouns. These findings hint at variation in performance that is independent of
sentence length but due to differences in grammatical complexity.

4. Discussion

4.1. Overall performance and chronological age

The aim of our study was to find out if overall performance on a test of receptive syntactic abilities changes from ado-
lescence to adulthood and within adulthood in a sample of German subjects with DS. By using correlational analyses we
looked for evidence of ongoing development or beginning decline indicated by relationships between chronological age and
comprehension abilities. We found a positive correlation between chronological age and performance on our measure of
receptive grammar, the TROG-D, in the group of children and adolescents with DS, but not in the adult participants or the
overall sample. The correlation also remained when nonverbal mental age was controlled as a possible confounding factor.
This suggests that the development of receptive syntactic skills comes to an end in the transition from adolescence to adult-
hood. In contrast to Chapman et al. (2002) or Couzens et al. (2011) we did not find evidence of a decline in the adult subjects.
Rather, it seems that a plateau is reached in grammar comprehension in adolescents and that the abilities are preserved
throughout the 20s and 30s. These results are in line with other cross-sectional studies using direct language measures
that did not find changes in receptive language abilities beyond adolescence or only in connection with Alzheimer’s disease
(Iacono et al., 2010; Rondal & Comblain, 1996, 2002). They are also in accordance with the observation of Laws and Gunn
(2004) that there is a slowdown in the acquisition of receptive grammar in adolescence and the suggestion that a ceiling
level in grammar comprehension might exist.
Chapman et al. (2002) reported a beginning decline in language comprehension abilities before the age of 20 years in
individuals with DS. If receptive language skills started to deteriorate around the age of 20 years and the process went on
throughout adulthood one would expect this to be reflected in our and other cross-sectional data. The adult subjects should
perform worse than adolescents on the respective measures of receptive language and there should be a negative correlation
of language comprehension and chronological age. This is, however, not what we found. One might argue that this is due to
cohort differences that always pose a challenge to the interpretation of cross-sectional data. However, the cohort differences
in DS only add to the expectation that older subjects should achieve lower performance levels because over the last decades
medical care as well as the educational and interventional conditions have continuously improved for individuals with DS
(Chapman & Hesketh, 2000; Rondal & Comblain, 1996).

4.2. Relationship between comprehension performance and nonverbal cognition

We detected a positive correlation between nonverbal mental age and TROG-D scores, indicating a relationship between
grammar comprehension abilities and nonverbal cognition. Moreover, the observed data on nonverbal cognition and recep-
192 B. Witecy, M. Penke / Research in Developmental Disabilities 62 (2017) 184–196

tive language abilities show a similar pattern – increases with chronological age in children and adolescents, no changes in
adults. Both findings point to a link between the two domains. A variety of other studies on DS has also reported evidence for
a relationship between nonverbal cognition and receptive language abilities (Abbeduto et al., 2003; Chapman et al., 1991;
Iacono et al., 2010). However, up to date the exact nature of this relationship is unclear. Although it is conceivable that
general cognitive processes, like problem solving, reasoning, or attention, might assist in sentence processing, the relation
does not need to be causal. Further studies are required to explore the relationship between nonverbal cognitive abilities
and grammar comprehension.

4.3. Qualitative analysis of sentence structures

A further aim of our study was to achieve a more detailed picture of the comprehension abilities of individuals with DS.
An analysis of the errors made in the TROG-D yielded that the participants produced significantly more grammatical than
lexical errors. This finding is in line with other studies (Laws & Bishop, 2003; Oakes, Kover, & Abbeduto, 2013) that have also
found predominantly grammatical errors in their English-speaking subjects with DS and implies that the comprehension
deficits observed in the TROG-D can be attributed to grammatical rather than lexical problems.
An analysis of the error-proneness of the structures tested in the TROG-D, based on the data of the 27 adult participants,
yielded that performance was best on content words. In a recent study Loveall, Channell, Phillips, Abbeduto, and Conners
(2016) conducted a detailed analysis of vocabulary comprehension in individuals with DS using the PPVT-4 (Dunn & Dunn,
2007). They found that comprehension of nouns was better than that of verbs which were better understood than adjectives
by English speaking adolescents with DS (aged 10–21 years). A clear difference between nouns, verbs, and adjectives did not
show up in our data. This might be due to the fact that the simple words tested in the TROG-D are very frequent in German,
and performance was, therefore, at ceiling.
With respect to performance on simple sentences, we found that as the number of constituents increases, comprehension
becomes more difficult. Sentences with three elements (Block E) were understood worse than those with two elements (Block
D) and double object constructions (Block O) were especially challenging for our participants with DS. In addition to the
increase of constituents, the reversibility of thematic roles in the sentences with two objects might have adversely affected
the performance.
Regarding the comprehension of inflectional morphology, we observed that the comprehension of sentences in perfect
tense (Block H) was more error-prone than the comprehension of noun plural morphology (Block I). This is consistent with
the results of Joffe and Varlokosta (2007a), who tested the comprehension of plurals and past tense with picture selection
tasks as well as the production of these forms using elicitation tasks. Their English speaking subjects with DS (aged 5–14
years) performed altogether better on plurals than on past tense.
The comprehension of function words proved to be challenging for the adult participants with DS. Sentences with the
negative element nicht (not) (Block F) were understood best, whereas sentences with the disjunctive conjunction weder
noch (neither nor) (Block R) were most error-prone. The latter also was the structure with the least number of correct items
of all structures included in the test, indicating particular problems with this sentence type. Moreover, the subjects had
considerable difficulties with the comprehension of sentences containing personal pronouns, be it subject (Block L) or object
pronouns (Block N). Further analysis showed that sentences containing pronouns were understood significantly more poorly
than similar sentences not containing pronouns (Blocks E und I). This finding is in contrast to other studies which found
problems with pronoun comprehension to be restricted to reflexives (Perovic, 2006; Ring & Clahsen, 2005; Sanoudaki &
Varlokosta, 2015). An explanation for our differing results might lie in the methods used to test the comprehension of
pronouns. The aforementioned studies contrasted the comprehension of reflexive and non-reflexive pronouns. Subjects had
to either choose between two pictures or answer a yes/no-question to a single picture. The TROG-D, on the other hand,
requires the selection out of a choice of four pictures. Foils differ from the target either in gender, number, thematic role
assignment, or lexical content. Reflexive conditions are not included. Interpreting the pronoun as singular instead of plural
or vice versa and choosing the wrong gender were the most frequent errors in our study. Further research should look
into the matter more closely to find out whether and how pronouns are affected in DS and whether problems in pronoun
comprehension are due to a lexical or a grammatical problem.
Complex sentences were in general understood poorly. Participants showed particular difficulties in the comprehension of
subordination and coordination. Problems with the interpretation of subject relative clauses, one type of subordination tested
in the TROG-D, were also reported by Oakes et al. (2013) for children and adolescents with DS (aged 10–15 years). Further,
non-canonical word ordering seems to have a negative impact on comprehension performance. Sentences with passive
voice (Block K) or topicalization (Block Q) and relative clauses with pronouns in accusative or dative case (Block S) proved
to be problematic in our study with the latter being the most challenging structure in this category. With respect to passive
sentences, a number of other studies has found difficulties with passives in individuals with DS (Bridges & Smith, 1984; Joffe
& Varlokosta, 2007b; Miolo, Chapman, & Sindberg, 2005; Ring & Clahsen, 2005; Rubin, 2006). Impaired comprehension of
non-canonical sentences has also been reported for language disorders in other populations, for example specific language
impairment (e. g. Friedmann & Novogrodsky, 2004) or aphasia (e. g. Grodzinsky, 1989; see Penke, 2015 for overview).
In conclusion, a detailed analysis of the grammatical structures contained in the TROG-D revealed that comprehension of
a broad range of structures is compromised in adults with DS. Problems are not confined to syntactically complex sentences,
but are also apparent in grammatically relatively simple sentences. Also the correct interpretation of function words and
 B. Witecy, M. Penke / Research in Developmental Disabilities 62 (2017) 184–196 193

inflectional markers is impaired. Because of the variety of the sentence structures tested in the TROG-D, different factors
might be responsible for the observed deficits in comprehension. Apart from nonverbal cognitive abilities as well as syntactic
and lexical limitations, which need to be explored further, phonological working memory might also play a role.

4.4. Relationship between comprehension performance and phonological working memory

Phonological working memory was positively correlated with performance on the TROG-D. This is consistent with other
studies that found performance on language comprehension tasks to be related to performance on tasks of phonological
working memory (Abbeduto et al., 2003; Chapman et al., 1991; Finestack, Sterling, & Abbeduto, 2013).
In accordance with the assumption that phonological working memory influences performance in sentence comprehen-
sion is our observation that the number of correct responses decreased as sentence length increased. One can assume that
the longer a sentence, the longer it has to be held in the phonological loop to extract all the relevant information.
Data analysis, however, also indicated that comprehension is not only influenced by sentence length but also by grammat-
ical factors. Increasing grammatical complexity is often accompanied by increasing sentence length. This makes it difficult to
differentiate between the effects of mere sentence length and of grammatical complexity on comprehension performance.
Our finding that sentences of comparable length but different grammatical complexity, such as sentences with full nouns
and sentences with pronouns, or relative clauses with canonical and non-canonical word order, led to different amounts
of correct responses speaks for deficits that are independent of sentence length. Future studies are needed to disentangle
the effects of sentence length and grammatical complexity on language comprehension in DS and to explore how these fac-
tors interact with deficits in phonological working memory or nonverbal ability. That way, a detailed picture of the causes
underlying impaired sentence comprehension in DS could be established and used as a basis for intervention.

4.5. Limitations of the study

There are some limitations of the current study, we would like to address. Using a cross-sectional design to investigate
changes with age is problematic as cohort differences might influence the results (Carr, 2005; Rondal & Comblain, 1996).
As has already been discussed in Section 4.1, older participants might be disadvantaged because of lower educational and
interventional conditions. However, this primarily poses challenges to the interpretation of negative correlations with age,
which were not found in this study.
Apart from cohort differences, there is also the problem of choosing appropriate age groupings. Previous research indi-
cated that the development of language comprehension comes to a halt in late adolescence and our interest was in what
happens from that point on throughout adulthood. Therefore, we regarded adults separately from children and adolescents
in some analyses. Nonetheless, the partition of our subject group into these two subgroups is somewhat arbitrary and the
data do not allow to pinpoint an exact age at which a plateau in grammar comprehension abilities is reached. To achieve
this, longitudinal studies would be ideal. However, they would have to cover adolescence as well as adulthood which is
hardly feasible. Studies spanning periods this long face various problems related to subject recruitment, practice effects by
repeated testing, and selective sample attrition in that less abled individuals are more likely to drop out than more abled
participants (Carr, 2005).
It seems advisable to include experimental measures in future studies as changes with age might only affect some
grammatical structures and can only be detected by specific and detailed testing. Also, it would be desirable to incorporate
language production measures to investigate the question if there are dissociative patterns across the different modalities
as suggested for example by Chapman et al. (2002).
One focus of this study was to determine, what can be expected of individuals with DS with regard to grammar compre-
hension – what they can and cannot understand – in order to help establish a detailed picture of their receptive language
abilities, thus providing a starting point for further research. Since this evaluation is independent of mental age, we did not
include control groups of typically developing children or individuals with other developmental disabilities.
In evaluating the data obtained by our adult subjects with DS, we adopted a positive approach in assuming that a correct
response equals understanding of the sentence. However, in a sentence-picture matching design as employed in the TROG-D
a correct response might also come about by guessing. In the TROG-D this danger is addressed by the stop criterion that
enhances the probability that correct responses are due to the correct comprehension of the given sentence. However, to
achieve a comprehensive insight into the receptive syntactic abilities we included all sentence structures in the qualitative
analysis and ignored the stop criterion for the adult subjects. Thus, it is possible that the adult subjects’ performance was
overestimated by our approach and that the described deficits in syntactic comprehension are even more pronounced.
Although we chose an age limit of 40 years to minimize the likelihood of our subjects being affected by dementia, we
cannot completely exclude the possibility that some subjects already suffered from a cognitive decline due to an early onset
of dementia. To minimize this possibility, relatives of the adult participants answered questions taken out of a dementia
screening questionnaire, the DSQIID (Deb et al., 2007). Only for one subject (age: 30;8 years) a number of changes in behavior
that are often associated with dementia was reported and might thus indicate an early onset of dementia in this subject.
194 B. Witecy, M. Penke / Research in Developmental Disabilities 62 (2017) 184–196

4.6. Conclusions and clinical implications

The results of the current study indicate that a plateau in grammar comprehension is reached and maintained in adults
with DS. The inspection of a broad number of grammatical structures showed various limitations in the receptive syntac-
tic abilities of adult individuals with DS. Difficulties increase with sentence length and with grammatical complexity, but
are also apparent in simple sentences. The nature of the deficit is grammatical rather than lexical. The finding that lan-
guage comprehension in DS is compromised for a wide spectrum of structures emphasizes the importance of targeting
not only expressive abilities in language intervention but also receptive skills. This applies to individuals with DS of all
ages. Diagnostic instruments that test a wide spectrum of sentence structures, like the TROG-D, offer a good overview of
the grammar comprehension abilities and give information on which structures should be targeted in intervention. Future
studies need to show whether language therapy is still effective in adults with DS and whether reaching of a plateau in
syntactic comprehension abilities can thereby be delayed or prevented. A further question that needs to be answered is
whether phonological working memory can be improved in individuals with DS and if so, whether this has a positive effect
on grammar comprehension.

Acknowledgments

We would like to thank all participants and their families as well as everyone who was involved in the recruitment of
participants and in data collection. This research was supported by the German Science Foundation (DFG, grant PE 683/3-1).

Appendix A.

Individual subject characteristics of the children and adolescents with DS

Gender CA (years;month) MA (years;month) TROG raw score nonword repetition score

A01 female 4;6 4;5 3 4

A02 male 10;8 3;5 4 2
A03 male 7;4 3;8 3 1
A04 female 8;6 4;2 11 8
A05 male 5;8 2;11 3 1
A06 male 11;3 6;2 9 10
A07 male 16;0 >7;11 4 2
A08 female 7;6 3;7 4 4
A09 male 9;2 3;9 5 8
A10 male 7;8 3;9 3 7
A11 female 11;8 3;8 2 3
A12 female 5;5 3;8 4 8
A13 female 9;6 6;0 7 7
A14 male 13;5 4;6 7 1
A15 male 11;3 3;7 2 0
A16 female 12;11 5;0 8 13
A17 male 19;0 5;8 15 7
A18 male 17;4 3;5 7 7
A19 male 14;7 5;6 9 9
A20 male 12;0 4;10 5 0
A21 female 11;2 4;0 7 8
A22 female 13;6 3;7 5 0
A23 female 11;7 5;1 4 0
A24 male 12;0 5;10 10 4
A25 male 6;10 3;8 3 3
A26 female 11;4 4;6 6 0
A27 female 12;9 5;2 5 0
A28 male 6;10 3;8 3 0
A29 male 10;4 4;5 7 2
A30 male 17;1 6;5 7 11
A31 male 6;11 4;8 7 7

mean 10;10 4;5 5.77 4.39

range 4;6–19;0 2;11–6;7 2–15 0–13
SD 43.95 months 11.4 months 2.94 3.89
 B. Witecy, M. Penke / Research in Developmental Disabilities 62 (2017) 184–196 195

Appendix B.

Individual subject characteristics of adults with DS

Gender CA (years;month) MA (years;month) TROG raw score number recall score

B01 female 31;3 4;8 6 5

B02 female 20;9 4;4 6 3
B03 male 29;4 5;5 7 5
B04 female 26;9 3;7 3 2
B05 female 33;7 6;7 10 9
B06 male 35;0 4;4 6 9
B07 male 37;11 4;10 5 3
B08 male 20;9 3;3 2 4
B09 male 29;5 5;2 2 3
B10 female 22;10 4;0 2 3
B11 female 34;7 5;6 5 1
B12 female 27;3 4;2 5 3
B13 male 25;3 6;0 2 4
B14 female 23;11 6;5 16 9
B15 male 27;6 5;2 6 4
B16 male 40;3 4;2 7 4
B17 male 23;1 4;8 7 5
B18 male 35;8 5;11 7 4
B19 male 22;0 >7;11 9 8
B20 female 23;9 6;0 5 6
B21 female 30;8 4;1 4 1
B22 male 25;1 5;5 8 3
B23 female 26;6 4;8 7 4
B24 male 27;8 5;4 6 6
B25 male 24;9 >7;11 14 8
B26 male 25;10 6;7 6 3
B27 male 36;5 4;11 6 6

mean 28;5 5;0 6.26 4.63

range 20;8–40;3 3;3–6;7 2–16 1–9
SD 70.48 months 11.0 months 3.27 2.32

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