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AUTUMN 2000

Groups
Adapting the
environment
Sensory
integration
Getting in synch
Home
programmes
Reducing risk
In My Experience
Valuing voice
ISSN 1368-2105
R E F L E C T I V E L E A R N I N G
http://www.speechmag.com
Student training
a unique
partnership
How I manage
early feeding difficulties
My Top Resources
In the community
Two great
reader offers
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http://www.speechmag.com
In 1999, Professor Sally Byng spoke to
speech and language therapists from all
over Scotland about her vision of aphasia
services. A year on she was back with
Carole Pound to hear first-hand the
changes that have been made. Annette
Cameron reports.
SIGNALONG researcher Kay Meinertzhagen
recently spoke to a group of learning
disabled adults as part of a project to
establish signing vocabulary for self-
advocacy. What they told her has
implications for the project and for service
providers generally.
The Autumn2000 speechmag web-
site includes:
www.speechmag.com
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practical value and information about writing for the magazine. Pay us a visit soon.
Now available: subscribe or renew online!
Reprinted articles
Student teachers recognise their voice needs (Roz
Comins, 2 (4), August 1993)**
At last...stammerers get the right prescription from
their GPs (Lena Rustin and Elaine Kelman, 4 (1),
Nov/Dec 1994)**
A service resource - New ventures in group
placements for students. Part 2 - Group placements
with adults with a learning disability (Ann Parker
and Rachel Farazmand, Winter 1997)***
From Speech Therapy in Practice* / Human Communication**,
courtesy of Hexagon Publishing, or from Speech & Language
Therapy in Practice***
tel: 01561 377415 www.speechmag.com
reflective. creative. hardworking.
original. energetic. friendly.
approachable. thoughtful.
interesting. realistic. up-to-date.
reliable. the magazine thats you.
SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2000 1
20 Home programmes
...when parents understand more fully the nature of
their childs stammering and their role in its
remediation, they are often very resourceful in
making arrangements so they can attend therapy.
However, for a minority, there may be reasons...which
mean regular attendance is impossible.
Sharon Millard, Frances Cook and Jane Fry
explain how a new approach is benefiting children at
risk of persistent stammering who are unable to
attend a clinic for therapy.
24 Further Reading
Early intervention, hearing impairment,
dysarthria, AAC, dementia.
25 How I manage
early feeding
difficulties
Feeding management should always be
seen as multidisciplinary. This is sometimes
difficult to put into practice in community
caseloads but, the more we consult our
colleagues such as dietitians and
psychologists for advice, the more we gain
professionally - as do they.
There are many questions about the speech
and language therapists role with early
feeding difficulties. Sue Strudwick,
Joanne Marks and Sara Russell provide some of
the answers.
30 My Top Resources
Recent groups have been either language disability-
focused or project-based;
for example people with
aphasia produced a leaflet
for others with aphasia.
For the near future we are
hoping the service will be
able to replicate a model
of effective group
intervention via
conversational analysis.
Linda Armstrong and
Alison Parsons have to
adapt their working practice
to take account of the
geographical spread of their
clients - adults with acquired
neurological problems.
SUMMER 2000
(publication date 28th August)
ISSN 1368-2105
Published by:
Avril Nicoll
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Avril Nicoll 2000
Contents of Speech & Language
Therapy in Practice reflect the views
of the individual authors and not
necessarily the views of the publish-
er. Publication of advertisements is
not an endorsement of the adver-
tiser or product or service offered.
Any contributions may also appear
on the magazines Internet site.
2 News / Comment
4 Groups
As therapists, we were reminded how little we
normally adapt our usual working practice, as we are
often unaware that our clients have particular
sensory impairments... We found small changes made
a big difference when enabling clients to achieve
success.
Christine Griffiths and Alison Gedling investigate
the efficacy of speech and language therapy for
people with learning disability and sensory
impairment attending a Day
Centre.
8 Sensory
integration
Speech and language therapy
assessment and intervention
techniques with, for example,
children with speech disorders,
have the potential to be
informed and transformed by
sensory integrative theory and
practice.
Olwen Pate reveals how
getting suck, swallow, breathe
in synch can facilitate progress
in oral motor skills and speech.
11 Reader Offers
Win CELF and Speech Sounds on Cue
12 Reviews
Adult neurology, syndromes,
dysfluency, progressive
neurological, language
development, education,
articulation, autistic spectrum,
child development.
18 In my
experience
The cry of a teacher in vocal
distress should not fall upon deaf
ears; rather we should seek to
ensure it is never raised at all.
Caroline Cornish on the case for
a national policy of preventative
voice care for student teachers.
Contents
AUTUMN 2000
Cover picture:
See page 14, Competence, confidence
and commitment.
Photo from: www.johnbirdsall.co.uk
www.speechmag.com
IN FUTURE ISSUES
FRAGILE X PROGRESSIVE NEUROLOGICAL DISORDERS DOWN SYNDROME
PHONOLOGICAL AWARENESS DYSPHAGIA TRAINING
Training
We have been moving towards
emphasising reflective cycles of learning
which integrate practice, theory and
rehearsal, rather than the traditional
linear model with its expectation that
theory and observation should always
precede practice.
Suzanne Beeke and Ann Parker are
behind an innovative programme
where speech and language therapy
students become temporary volunteers
for the Stroke Association.
14 COVER STORY
Please note our new address!
Inclusion and autism
SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2000 2
news
People with aphasia
are being encouraged
to demand an ade-
quate service.
Members of the
charity Speakability
have developed a
Charter for People
with Aphasia
based on their
own experiences
and reflecting
clinical guide-
lines endorsed
by the
Depar t ment
of Health. It
includes a list
of speech
and lan-
guage ther-
apy rights.
A recent
survey by
Speakability draws attention
to the paucity of aphasia services and the drain
dysphagia care places on resources.
Helpline Freephone 080 8808 9572 Mon-Fri 10am-4pm
Speakability, tel. 020 7261 9572.
A new report slams the quantity, organisation and targeting of care and treatment
for people with disabilities.
As a result of the reports findings, the Royal College of Physicians has produced a
set of recommendations for commissioners of healthcare, NHS managers, medical
educators and doctors aimed at redressing the balance towards the needs of dis-
abled people. Specifically, they want to see the specialty of rehabilitation medicine
developed, adequate staffing levels and a change in medical attitudes so doctors pro-
mote disabled peoples abilities and empower them to participate in society.
However, a British Society of Rehabilitation Medicine survey of NHS resources sug-
gests there is a long way to go to meet the recommendations. The tenfold or greater
differences in access of disabled people to NHS consultants in rehabilitation they
identify lends support to the theory of rationing by postcode, and they call for
inequities to be addressed urgently.
Medical rehabilitation for people with physical and complex disabilities, RCP,
www.rcplondon.ac.uk
BSRM, tel. 01992 638865.
The charity Scope has welcomed an Audit Commission report highlighting waste and
failure within NHS disability services, and urged an immediate crackdown.
However, Scope says the government should have introduced national standards
years ago and is disappointed that the report still fails to emphasise the need for NHS
providers to listen to disabled people. Its campaigns officer says, If the providers of
such services had a duty to take on board the views of equipment users, there would
be far less waste and inefficiency. For disabled people to achieve equality and inte-
grate into mainstream society, the government has to ensure that the right equip-
ment gets to the right people right now.
Fully Equipped (28/3/00) from the Audit Commission.
Scope, tel. 020 7619 7100, www.scope.org.uk
Children with autism and Asperger
Syndrome are on average twenty
times more likely to be excluded
from school than their peers.
According to a report commissioned
by the National Autistic Society, the
situation is even worse for more able
children with autism, of whom 29 per
cent have been excluded from school
at one time or another. The Society is
calling for urgent action to address
the lack of expertise, time and spe-
cialist help thought to lie at the root
of the problem. Its education adviser
points out that Parents of children
in autism-specific units and schools -
where exclusions rarely arise - are
twice as likely to be satisfied with
provision than those whose children
attend mainstream or special educa-
tion needs schools.
The report also finds there is less
awareness by the time a child reach-
es secondary age and that exclusion
continues into adulthood. Although
many adults cited a job as one of the
most important issues for their
future fulfilment, only two per cent
of adults with autism, including
graduates, are in full-time paid work.
Inclusion and Autism: Is it Working?
From the National Autistic Society,
393 City Road, London EC1V 1NG,
www.oneworld.org/autism_uk
Disability services
slammed
Dementia vision
People around the country are being asked for their views and experiences
of services and their vision of dementia care.
Alzheimer Scotland - Action on Dementia is working on a major project to
create a Scottish Dementia Care Services Template. At its core will be targets
for the range and volume of services which should be available to people
with dementia and their carers from the start of the illness to the final stages.
Essential services listed include memory clinics and rehabilitation / therapies.
Contact: Public Policy Department, Alzheimer Scotland - Action on
Dementia, 22 Drumsheugh Gardens, Edinburgh EH3 7RN.
Dementia Helpine (Scotland), freephone 0808 808 3000.
Partnership between carers, people with dementia and the research community
is also the aim of the Alzheimers Society which is recruiting people
for an advisory network to inform its research programme,
Quality Research in Dementia. Focusing on cause, cure and
care projects, 1 million per year has been com-
mitted, the largest investment by any
charity into dementia-related research.
Alzheimers Helpline: 0834 300 0336.
S.M.A.R.T. moves
An assessment to prevent misdiagnosis of vegetative state in patients with pro-
found brain injury will be available to rehabilitation units by the end of the year.
The Sensory Modality Assessment and Rehabilitation Technique (S.M.A.R.T.)
has been developed over a ten year period by occupational therapy staff at
the Royal Hospital for Neuro-disability. The hospitals brain injury unit treats
the largest concentration of patients in a vegetative state in the UK. Using
S.M.A.R.T., one study of patients admitted with a referring diagnosis of veg-
etative state found 43 per cent had been wrongly diagnosed. Such misdiag-
nosis can lead to a patient with the potential ability to communicate their
needs - such as someone with locked-in syndrome - spending the rest of their
life trapped in a damaged body. Vegetative state is the most profound form
of brain damage where the person is awake but completely unaware of
what is happening around them or within their own body.
The assessment provides a structured sensory programme which assesses the
five senses, movement, communication and wakefulness. The multidiscipli-
nary team and the patients relatives and friends are a key part of this
process.
www.neuro-disability.org.uk
Aphasia
charter
National screening
A programme to screen for deafness in new-born
babies is to be phased in from September this year
before being rolled out nationally.
The Royal National Institute for Deaf People has wel-
comed this development, saying The test can be
carried out within 48 hours of birth and does not dis-
turb the baby. It involves an instrument sending a
sound into the babys ear and measuring the level of
returned sound which calculates the level of hearing
function. The test is proven to be cost effective and
reliable. The organisation believes a comprehen-
sive national screening programme will enable earli-
er provision of aids, introduction to sign language
and development of communication. Health visitor
distraction tests used currently have a poor record in
identifying children who are born deaf.
RNID, tel. 020 7296 8000, www.rnid.org.uk
SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2000 3
news & comment
Jane Austen knew
In a scene in Pride and Prejudice, Elizabeth Bennet observes that Mr Darcy
must comprehend a great deal in his idea of accomplished if he knows only
six such women. He and Caroline Bingley list the numerous qualities and skills
they consider necessary and Lizzy is forced to conclude I am no longer
surprised at your knowing only six accomplished women. I rather wonder
now at your knowing any.
What makes an accomplished speech and language therapist? A number of
clues come from Sue Strudwick. A therapist must be knowledgeable,
competent, empathetic, enthusiastic, honest and realistic, as this builds a
client or carers trust and confidence and contains their anxieties. How I
manage early feeding difficulties demonstrates this is enhanced when our
goals are patient-led, when we work with other professionals as a team and
when the organisation of our posts allows us to cross boundaries to provide
the consistency clients need.
Like teachers, our voice is the tool of our trade, but do we appreciate the
potential we all have to improve it? Caroline Cornish believes we should be
committed to development of the voice to make it the source of real
inspiration to others.
Initiative and flexibility are needed to carry out speech and language therapy
in challenging environments. For Linda Armstrong and Alison Parsons this
means some rather unusual top resources, as they work in a large rural area
where their adult clients are spread out and not easy to reach.
We need to remember to apply what we know. Christine Griffiths and Alison
Gedling refer back to their own guidelines as a reminder of small
environmental changes that can make all the difference to a client with
learning disability and sensory impairment.
We have to be responsive. Sharon Millard, Frances Cook and Jane Fry
understand that attendance at a clinic is not always possible and use other
methods - such as telephone contact - to ensure timely therapy can still be
provided to those who are motivated.
However, as Olwen Pate has found, the key to success is in the integration of
skills, and the challenge for us is how to facilitate this not only in our clients
but in ourselves. Suzanne Beeke and Ann Parker give us an example with
their innovative programme of student training based on reflective cycles of
learning which integrate practice, theory and rehearsal through active
participation.
As Jane Austen knew, we can pick out individual qualities and skills that are
important - but that wont tell you what distinguishes the Elizabeth Bennet
from the Caroline Bingley.
...comment...
Avril Nicoll,
Editor
33 Kinnear Square
Laurencekirk
AB30 1UL
tel/ansa/fax 01561
377415
e-mail
avrilnicoll@speechmag.com
Online consultation
A website is providing a groundbreaking method of
responding to a public consultation exercise.
Visitors to the Disability Rights Commission site can
respond online to a joint consultation with the
Department for Education and Employment on a
new draft Code of Practice for making goods and ser-
vices more accessible to disabled people. The draft
Code is posted on the website, along with a response
document which can be filled in and returned online.
The site meets high standards for accessibility and has
approval from the Royal National Institute for the Blind.
DRC, tel. 020 7211 3000, www.drc-gb.org
Education training
The national educational charity for children with
speech and language difficulties has extended and
developed the training it offers.
In addition to extra courses focusing on integrating
speech and language targets and approaches into the
classroom and curriculum, a series of seminars present-
ed by internationally regarded experts will provide an
up-to-date review of a range of topics. If distance is a
problem, workplace training encourages authorities to
purchase I CANs multidisciplinary training at a local
venue - significantly reducing the cost per person.
Details: Jaszia Lindon, Training Administrator, 0870
010 7088.
New chiefs plans
The new chief executive of the charity which helps
families who care for children with a disability or
special need brings extensive experience in the par-
liamentary and public affairs field to her role.
Francine Bates plans include the expansion of advice
and information services to parents and professionals.
She is also particularly looking forward to the imple-
mentation of legislation which brings forward new
entitlements for carers of disabled children in the field
of social care and special needs education. On the
health front, we are working closely with NHS Direct
Online and will be launching our new directory of spe-
cific conditions and rare syndromes in January 2001.
Contact a Family, tel. 020 7383 3555,
www.cafamily.org.uk
groups
SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2000 4
e have been carrying out a
research project looking at
the efficacy of speech and
language therapy with peo-
ple with learning disability
and sensory impairment
(Griffiths and Gedling, 1999). Research suggests
the incidence of visual and hearing problems in
people with learning disability is high, particularly
those with Downs syndrome (Yeates, 1989; Kwok
et al, 1996; van Schrojenstein Lantman-de Valk et
al, 1994). A large study of 45,000 adults indicates
a prevalence of sensory impairment among adults
with intellectual disability comparable to or
greater than that found in the general population
and that these sensory deficits occur with increas-
ing frequency with advancing age (Janicki and
Dalton, 1998). Research also indicates that carers
are not reliable in identifying these deficits (Haire
et al, 1991) and that there is a need to heighten
awareness among staff and other carers with
regard to vision and hearing problems and the
consequent problems which may develop in inter-
personal communication and adaptive function-
ing. Aitken and Buultjens (1992) also point out
the effects on communication, including pragmat-
ics and non-verbal communication, and many
studies further recognise the changes in behav-
iour that can occur (Stafron, 1995; Castane and
Peris, 1993).
Part of our work is with people with learning
disability who attend a Day Centre. We felt the
focus of our intervention should be social com-
munication skills and targeted three common
areas we deemed feasible to work on with people
with a wide range of learning disability:
1. eye contact
2. initiation
3. turn-taking.
In our planning we considered the above research
findings: the high incidence of hearing / visual
difficulties, the effects of ageing, the need to
raise staff awareness, and the effects of sensory
W
A (sight and)
sound
foundation
We may be aware of the
effects of visual and
hearing impairments on
communication, but how
often do we routinely allow
for them when planning
therapy? Christine Griffiths
and Alison Gedling tell us
how small changes made a
big difference to their clients
with a learning disability.

Read this if you:


work with any client with
sensory impairment
offer staff training
want social skills therapy
ideas
impairment on communication and behaviour.
All the clients had their vision and hearing
assessed at the Day Centre prior to communication
assessment and intervention. Results, including a
breakdown of degree of impairment, are in tables
1-3 (page 6). This information was then taken into
consideration when carrying out the intervention
programme, particularly in terms of positioning,
size of materials and environmental factors.
Guidelines were also written for staff (figure 1).
Small steps
Clients were assessed using the Background infor-
mation and Social Communication skills sections
of the Personal Communication Plan for People
with Learning Disability (PCP) (Hitchings and
Spence, 1991). We felt, however, that any poten-
tial progress in the people with more severe/pro-
found learning disability may not be identified
from the PCP rating scale, as it is not broken down
into small enough steps. We therefore decided to
include video of client/carer interactions. These
were then analysed by:
Using observation checklists and momentary
sampling to identify the individuals levels of
engagement (Bunning, 1991).
Identifying particular aspects within each level of
engagement, such as awareness, initiation and rec-
iprocation. These could then be matched against
appropriate sections of the PCP - eye contact, open-
ing a conversation (initiation) and turn-taking.
The focus of intervention was the same for all
the clients who received treatment: eye contact,
initiation and turn-taking. However, we felt it
was appropriate to develop two programmes to
respond to the cognitive level of those involved.
In practice we found that, whilst one distinct pro-
gramme was better for one person, another
might benefit from a mixture of the two, and so
the programmes were meant to be flexible in this
respect. The intervention was offered as a regular
weekly session over a ten-week period (figures 2
and 3).
SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2000 5
groups
Figure 1 - Communication
Guidelines
8 rules when speaking to
people who have vision
and / or hearing loss
1. Make sure you have the
persons attention first.
2. Make sure that
distractions are kept to a
minimum.
3. Prepare the environment.
4. Make sure there is
appropriate lighting.
5. Look directly at the
listener and dont turn
away while talking.
6. Make sure that your face
and mouth are not hidden.
7. Value the persons
communication.
8. Adapt your
communication to enable
the person to
communicate better.
Figure 2 Treatment plan (Profound group)
Each week - develop a routine. Begin the session with an object of reference (for example a bean bag) and music.
Finish with music and put all items away together.
Weeks 1 to 3 - eye-contact
The aim of these three weeks was to attract the clients attention and maintain it. Activities included the use of a
variety of glittery objects and a torch (or auditory objects), the task increasing in complexity as follows:
1) Say the clients name.
2) Hold the object in front of their line of vision. Use a torch to refract the light.
3) When they have focused on it, move it towards your eyes.
4) When achieved say Hello.
The session finished by building a tower of blocks. The client was encouraged to look at each block (held near the
speech and language therapists face).
Weeks 4 to 6 - turn-taking
These sessions encouraged the client first to copy actions and then to take turns in a variety of activities; for exam-
ple taking an object out of a feely bag and doing an action with it, using peg-boards, jigsaws, colouring paper sil-
houettes on black card, using bubbles.
The session finished by taking turns to build the tower of blocks.
Weeks 7 to 9 - initiation
These sessions encouraged the client to make a choice between three musical instruments and imitate an action.
The instruments were then put out of reach, the client having to use physical contact - such as a tap on the arm or
vocalisation - to be given one of them. This was initially facilitated. Other activities included selecting
crayons/chalks, different coloured paper for contrasts and chalkboards.
The session finished by encouraging the client to use eye contact, vocalisation, reaching or tapping our arm to
attract our attention to get a block for building the tower.
Week 10 - eye-contact, turn-taking and initiation
Clients were encouraged to participate in cake decorating using a variety of toppings and icing pens.
Figure 3 Treatment Plan (Mild/moderate/severe group)
Weeks 1 to 3 - eye contact
Activities included:
1) Ball games and signing/saying each others names, what you like to eat, and so on.
2) Dressing-up items - hats, glasses, red noses, masks. Look in the mirror and at each
other.
3) Describe yourself. (Talkabout)
4) Happy/sad masks - choose the mask that is the same as me.
5) Describe family members - colour of hair etc.
6) Make up faces with Magnetic Way To Language (now Magnetic Storyboard)
7) Cut out eyes, ears, noses etc. from various materials and make up faces on paper
plates.
8) Eye pointing to particular pictures.
Weeks 4 to 6 - turn-taking
Activities included:
1) Copy rhythms on a tambourine or drum.
2) Select an item from a feely bag and do an action with it. Copy each other.
3) Take turns to trace around place setting shapes and colour them in.
4) Take turns with jigsaws, peg-board patterns etc.
5) Whats my mime? game - guess the animal being mimed.
6) Pelmanism.
Weeks 7 to 9 - initiation
Activities included:
1) Using greetings and responses.
2) Choice of musical instrument - client encouraged to initiate the rhythm for us to
copy.
3) Feely bag - initiate action with item pulled out.
4) Client to finish the last bit of a task; for example, the last piece of jigsaw, place set-
ting (no fork), drum and stick. Attract our attention to do this.
5) Model food - select what you like to eat.
6) Decorating a Christmas tree.
7) Making paper chains.
8) Making gift tags.
Week 10 - eye-contact, turn-taking and initiation
The final week encouraged the client to use eye contact, take turns and initiate con-
tact whilst participating in cake decorating. A selection of toppings and icing pens
were available and fairy cakes.
Figure 4 Environmental programme for staff
Week Staff programme
1 gaining attention
2 attention and positions
3 contrasts and zones
4 reduce distractions
5 carer communication
6 carer communication
7 carer communication
8 environmental
9 environmental
10 task for staff to evaluate the
effectiveness of guidelines given
In our planning we considered the high
incidence of hearing / visual difficulties,
the effects of ageing, the need to raise
staff awareness, and the effects of
sensory impairment on communication
and behaviour.
Staff were also given information every week
advising them of various environmental aspects
that should be considered (figure 4) and sugges-
tions for activities were given. All information
was recorded in an exercise book, which was also
available for staff to note their own comments
along with a pictorial reminder of the guidelines.
Flexibility
We found this approach very useful when work-
ing with adults with a wide range of learning dis-
abilities and additional sensory impairments. Two
programmes which focused on the same areas of
intervention allowed us the flexibility to adapt
the sessions to the appropriate cognitive ability of
the client. They also gave us a solid structure on
which to build the additional requirements neces-
sary for the particular sensory impairment of that
client. Staff also found it much easier to focus on
themes.
As therapists, we were reminded how little we
normally adapt our usual working practice, as we
are often unaware that our clients have particular
sensory impairments. We may automatically try
to reduce noise levels, too much visual stimulation
on the walls and so on, and position for optimum
communication. However, we rarely routinely
groups
SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2000 6

consider the effects of glare, contrasts between


our visual material and the table or the effects of
open windows and doors - even though we are
aware of them. It was therefore certainly benefi-
cial to us to look through our own guidelines and
consider these whilst preparing the equipment
beforehand. We found small changes made a big
difference when enabling clients to achieve suc-
cess.
As with any course of intervention ours was not
without problems, which generally were con-
cerned with factors we couldnt change such as
absence of clients and staff, clients health, and
attendance at respite care. We also experienced
some difficulty in disseminating information
amongst staff, which obviously affected the conti-
nuity of care to our clients.
This approach required some forethought, par-
ticularly from staff, and therefore could have
been seen as time-consuming. Whilst there
remain many aspects that will require encourage-
ment to be routinely carried out, changes were
made where possible. There was definitely
heightened awareness regarding the sensory
needs of individual clients amongst staff and
nearly all the clients receiving intervention made
progress. This has given us a sound foundation on
which to build further work on social communica-
tion skills with our clients in Day Centres.
Christine Griffiths is Deputy manager and Alison
Gedling a speech and language therapist for the
Learning Disabilities Directorate, Bro Morgannwg
NHS Trust.
Acknowledgements
Our thanks go to Maggie Woodhouse, Senior Lec-
turer of Optometry and Jonathan Joseph,
Principal Audiologist who carried out the sensory
assessments at the relevant Day Centres and
therefore made this study possible.
References
Aitken, S. & Buultjens, H. (1992) Vision for Doing:
Assessing Functional Vision of Learners who are
Multiply Disabled. Moray House Publications,
Edinburgh.
Bunning, K. (1991) Individualised Sensory
Environments: Assessment and Intervention.
Unpublished.
Castane, M. & Peris, E. (1993) Visual problems in
people with severe mental handicap. Journal of
Intellectual Disability Research 37(Pt 5): 469-78.
This approach
required some
forethought,
particularly from
staff
Table 1 Level of learning disability; clients level of vision
Clients level of vision
normal mild normal moderate severe profound uncooperative Total
with own
glasses
Learning mild 3 1 2 0 0 0 0 6
disability moderate 19 37 11 15 5 0 0 87
severe 4 16 0 10 7 1 11 49
profound 0 3 0 2 1 3 4 13
Total 26 57 13 27 13 4 15 155
Table 3 Clients level of hearing; clients level of vision
Clients level of vision
normal mild normal moderate severe profound uncooperative Total
with own
glasses
normal 20 40 10 11 8 2 2 93
Clients mild 1 5 0 2 2 0 2 12
level of moderate 2 11 1 7 2 1 4 28
hearing severe 1 0 0 0 0 0 0 1
profound 0 0 1 1 0 0 0 2
uncooperative 0 1 0 5 1 1 7 15
Total 24 57 12 26 13 4 15 151
Table 2 Level of learning disability; clients level of hearing
Clients level of hearing
normal mild moderate severe profound uncooperative Total
Learning mild 5 0 1 0 0 0 6
disability moderate 66 7 11 1 1 1 87
severe 24 5 14 0 1 7 51
profound 2 0 5 0 0 7 14
Total 97 12 31 1 2 15 158
Griffiths, C. & Gedling, A. (1999) A longitudinal
study to evaluate the efficacy of Speech and
Language Therapy interventions on social com-
munication skills in those individuals with sensory
impairment and learning disabilities.
Unpublished.
Haire, A. P., Vernon, S. A. & Rubinstein, M. P.
(1991) Levels of visual impairment in a day centre
for people with a mental handicap. Journal of
the Royal Society of Medicine 84 (9): 542-4.
Hitchings, A. & Spence, R. (1991) The Personal
Communication Plan for People with a Learning
Disability. NFER-Nelson, Windsor.
Janicki, M. P. & Dalton, A. J. (1998) Sensory impair-
ments among older adults with intellectual dis-
ability. Journal of Intellectual and Developmental
Disability 23 (1) 3-11.
Kwok, S. K., Ho, P. C., Chan, A. K., Gandhi, S. R. &
Lam, D. S. (1996) Ocular defects in children and
a dol e s c e nt s
with severe
mental defi-
ciency. Journal
of Intellectual
D i s a b i l i t y
Research 40 (pt
4) 330-5.
Stafron, J.
( 1 9 9 5 )
Unpubl i s hed
excerpts from
study day into
dual sensory
impairment -
SENSE.
v a n
Schrojenstein
L ant man- de
Valk, H. M.,
Haveman, M.
J., Maaskant,
M. A., Kessels,
A. G., Urlings,
H. F. &
Sturmans, F.
(1994) The
need for
assessment of
sensory func-
tioning in age-
ing people
with mental
h a n d i c a p .
Journal of
Intellectual Disability Research 38 (pt 3): 289-98.
Yeates, S. (1989) Hearing in people with mental
handicaps: a review of 100 adults. British Institute
of Mental Handicap 17 (March).
Resources
Magnetic Storyboard from Winslow, 59.95.
Talkabout by Alex Kelly from Winslow, 32.00.
Whats my mime? LDA (discontinued).
SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2000 7
groups
Reflections
Do I find out the
extent of a
clients sensory
impairments and
adapt therapy
accordingly?
Do I consider
how to measure
for small
changes which
would not be
identified by
standardised
assessments?
Do I differentiate
the same task
when planning
therapy to allow
for the different
abilities of group
members?
...RESOURCES...RESOURCES...RESOURCES...RESOURCES.
Everyday Lives, Everyday
Choices
The ways in which the choices of people with
severe learning disabilities can be understood and
implemented are explored in a new book.
Themes include communication, work, citizen
advocacy and staff development and training. It
makes recommendations for government, local
and health authorities, service providers and staff
responsible for individual assessment.
Everyday Lives, Everyday Choices, 22.50 + p&p,
from The Foundation for
People with Learning
Disabilities, tel. 020
7535 7441/7455.
Hearing aid choice
A free, independent information pack explains the
potential pitfalls of choosing a hearing aid and
gives information on the full range of options.
Developed by a national charity with the support
of top hearing aid specialists, the guide is aimed at
ensuring people make an informed choice and
avoid a costly or disappointing mistake.
From Defeating Deafness, tel. 020 7833 1733.
MND Resource File
A comprehensive patient and carer-centred
guide has been produced to support profes-
sionals in achieving quality of life for people
with motor neurone disease.
Areas covered include nutrition and dyspha-
gia, speech and communication and pallia-
tive care. The guide aims to facilitate multi-
disciplinary working and provide practical
help to professionals facing the challenge of
the rapid progression of this disease and the
complex needs of sufferers.
Motor neurone disease kills three people
every day in the UK. Average life expectancy
from diagnosis to death is just 14 months.
MND Resource File 10 + 2 p+p, tel. 01604
250505, e-mail care@mndassociation.org
The MND Association Helpline, Mon-Fri, 9am-
10.30pm, 08457 626262.
Turn your back
The forthcoming European Week for Safety and
Health is themed Turn your back on back pain.
An accompanying pack includes posters, stickers,
fact sheets, a range of booklets and ideas for
action. Musculoskeletal disorders and back pain
are the biggest single cause of absence from work.
16-22 October, 2000 InfoLine: tel. 08701 545500
Our Mum has Parkinsons
A former schoolteacher has written a book explain-
ing Parkinsons to children.
Karen Goodall (40) was diagnosed with Parkinsons
eight years ago and saw a real need to help other
younger sufferers in this way. She says, I want chil-
dren whose parents have the condition to know that
there is help available and theres no need to be con-
fused, embarrassed or shocked by Parkinsons.
One in twenty people with Parkinsons are under
40 at the time of diagnosis.
Our Mum has Parkinsons, 1 inc.p&p, tel. 01473
212115. Parkinsons Disease Society, tel. 020 7931 8080.
Money Talks!
A new educational soft-
ware pack provides four
simulations for children
to practise money skills.
The activities cover cost
of items on a till, shop-
ping and selling, paying
bills and money in a
safe. Text is also spoken.
Money Talks! on CD
ROM is suitable for 7 - 15 year olds. A single user
pack is 35 + VAT.
From Topologika, tel. 01326 377771, www.topol-
gka.demon.co.uk
Stroke Association
The Stroke Association has revised Learning
to Speak Again and replaced it with a 12
page booklet, Communication problems
after stroke. It provides explanation of the
common difficulties, assessment and treat-
ment, and includes practical suggestions.
Tel. 01604 623933/4/5/7/8.
Stroke Awareness Week, 1-7 October 2000,
will focus on the importance of continuing
with medication to lower blood pressure. An
information pack is available.
Tel. 020 7566 0319 / e-mail Sue Knight on
sknight@stroke.org.uk
Inspiration
A CD ROM to develop
ideas and organise
thinking is now avail-
able in a UK version.
This visual learning soft-
ware tool includes facili-
ties to create and modi-
fy concept maps and
webs and to prioritise and arrange ideas.
A 30 day trial of Inspiration can be down-
loaded from www.tagdev.co.uk
Seaside Signalong
Two resources from Signalong aim to help
with planning and enjoying a trip to the sea-
side. A manual of 233 signs is accompanied
by an activity pack to help organise the day
and enable people in your care to learn from
their experiences.
Signalong by the Sea and Activity Pack - tel.
Signalong, 01634 819915.
Jobs on the net
The growing market of web-based services
for employers and job-seekers includes a site
dedicated to health jobs. Templates allow
employers to post vacancies online and appli-
cations can also be forwarded in this way.
www.healthjobcentre.co.uk
sensory integration
SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2000 8
pproaches to assessing and man-
aging oral and speech motor
deficits in children usually include
tasks to evaluate and practise iso-
lated and sequenced oral and
speech motor movements. Such
end-product assessment of motor function sup-
ports the view that oral and speech motor deficits
are evidence of a peripheral motor output diffi-
culty. Intervention that follows this assessment
approach is likely to aim to develop specific out-
put skills to a given level, for example, the ability
to lick lips all the way round, or increasing the
speed and accuracy of /t/ production in isolation.
These techniques, while providing information on
deficits at a motor output level, do not identify
deficits that may be present at an earlier sensory
input level. Sensory input deficits may also cause
and / or contribute to oral and speech motor
deficits.
Sensory integrative theory (from the
Occupational Therapy field) emphasises sensory
inputs/deficits when assessing and developing
motor function. Motor planning and coordina-
tion difficulties are considered to be manifesta-
tions (end-products) of interference in the organ-
isation and processing of tactile, proprioceptive
and vestibular sensations. In sensory integrative
theory, then, an end-product behaviour, such as
developmental dyspraxia, is indicative of underly-
Read this if you
work with any client with
a speech disorder
find oral motor work
ineffective for improving
speech
want to learn more about
sensory integration
A
ing sensory difficulties and a sensory integrative
disorder (Ayres, 1979). Sensory integrative theory
and research provides the evidence for practice
using sensory integrative approaches with clients
with sensorimotor difficul-
ties. Speech and language
therapy assessment and
intervention techniques
with, for example, children
with speech disorders,
have the potential to be
informed and transformed
by sensory integrative the-
ory and practice.
Since the control of artic-
ulatory movements for
speech demands the coor-
dination and integration
of multiple structures
(Smith et al, 1995), it is fundamental that assess-
ment and intervention reflect and treat these
structures and their function. The level and
nature of breakdown in planning, coordinating
and integrating oral, pharyngeal, laryngeal and
respiratory function is not likely to be clear when
isolated oral motor skills are assessed. That is,
when we ask a child to touch their nose with their
tongue, we are simply identifying the presence,
absence and, at times, the quality of a particular
movement. It is unclear as to how this movement
When faced with a speech disordered client, therapists often
recommend oral motor activities. While these may produce specific
splinter skills, any generalised benefit - particularly for speech - is
dubious. Olwen Pate explains how an approach using sensory
integrative theory has the potential to transform speech - even before
any work on speech is undertaken.
affects or relates to another, and particularly how
it may influence the way in which articulators pro-
duce a target speech sound in an integrated fash-
ion. This is to say nothing of how a sound is then
produced in a word or sequence of words.
Developing isolated oral motor skills may
result in ongoing difficulties with the
integration of sensorimotor information
for the purposes of adapting to changing
oral and speech output demands (Pate &
Pinkstone, 1996).
Essential
Early oral sensory motor experiences are
essential for developing oral motor plan-
ning skills (Pate & Pinkstone, 1996). They
also enhance the coordination of the
refined movement patterns required to
produce subtle sound changes forming
speech (Laurel & Windeck, 1989). Oetter et al
(1995, p3) have stated that Suck Swallow Breathe
(SSB) Synchrony is the fundamental sensorimotor
pattern and the primary oral motor mechanism.
As such, SSB synchrony is potentially a mechanism
by which skills that affect articulatory control can
be assessed and developed.
Rhythmical, coordinated sucking, swallowing
and breathing - or SSB synchrony - is the first
developmental pattern that requires timing and
sequenced movements (Oetter et al,1995, p3).
Getting
in synch
with suck,
swallow, breathe
The level and nature
of breakdown in
planning, coordinating
and integrating oral,
pharyngeal, laryngeal
and respiratory
function is not likely to
be clear when isolated
oral motor skills are
assessed.
SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2000 9
sensory integration
Since suck, swallow and breathe are survival
based, anatomically and functionally related
processes (Wolf & Glass, 1992), they are critical to
many elements of a childs development. Oetter
et al (1995) state that without the presence of
intact, underlying neuro-motor physiology (for
example, SSB; postural control) the development
of sound production and language may by dis-
rupted or disordered. In agreement, Selley et al
(1990, p326), when identifying factors common to
feeding and speech production (for
example, rhythm; oral and respirato-
ry control) have stated that a nor-
mally co-ordinated feeding mecha-
nism is an essential milestone in nor-
mal development, both for more
mature swallowing and for speech.
Pinkstone (1995), in a single case
study, hypothesised that SSB syn-
chrony is fundamental to competen-
cy in and the development of oral
sensorimotor and speech production
skills. A subject with developmental
verbal dyspraxia was provided with
increasingly complex oral sensori-
motor play experiences to facilitate SSB syn-
chrony. Statistically significant changes in the
subjects oral motor output resulted. Sound sys-
tem developments also occurred. Both develop-
ments were achieved without working directly on
oral motor or speech production skills. The inter-
vention used was based on the M.O.R.E. tech-
nique, developed by Oetter et al (1995).
Complexity
The M.O.R.E. technique provides a method for
assessing and developing suck swallow breathe
synchrony. This technique classifies oral play
materials in terms of the complexity of Motor (M),
Oral (O), Respiratory (R) and Eye/hand (E) involve-
ment. The oral and respiratory com-
ponents of the technique are most
important for clinicians working
with speech disordered children.
Each element of M.O.R.E. can be
graded in terms of 4 grades of diffi-
culty, with 1 representing the lowest
level of skills required, and 4 the
highest level. For example, the def-
inition of Grade 1, Respiratory
Demand (R), is: very little pressure
increase over regular breathing
required to produce sound or action
from toy; while Grade 4,
Respiratory Demand (R), is: consis-
tent deep breath and grading of air flow required
to change or produce sound or action (Oetter et
al, 1995, Ch 3, p5).
Using M.O.R.E., clinicians are able to:
assess oral (O) and respiratory (R) organisation
and coordination while a child is using a range of
oral play materials (motor (M) and eye/hand (E)
coordination and control can also be assessed).
choose materials appropriate to a childs level of
oral and respiratory organisation and coordina-
tion.
plan intervention to facilitate sensory experi-
ences of increasing complexity and specificity to
the oral, pharyngeal, laryngeal and respiratory
areas.
directly shape the development of a childs suck,
swallow, breathe synchrony.
Intervention for suck swallow breathe asyn-
chrony does not require the subject to consciously
consider or monitor in isolation the initiation and
maintenance of breath support, voicing, articula-
tory movement and sound/word production. The
intervention programme aims to provide sensory
stimuli to the entire oral area, the pharynx, larynx
and the respiratory system and to replicate the
synergy characterising SSB synchrony. The provi-
sion of specifically tailored oral sensory input to
individual clients needs enables them to seek and
use more difficult oral sensory motor materials in
an adaptive manner. This is achieved as clients are
ready and able to do so and in a consistently moti-
vating, challenging and enriching context.
For an example of how an intervention pro-
gramme using the MORE approach and seeking to
facilitate SSB synchrony may look, see table 1.
The provision of
specifically tailored
oral sensory input
to individual clients
needs enables them
to seek and use
more difficult oral
sensory motor
materials in an
adaptive manner.

Stage
1
2
3
4
Sensory experiences
Clients are provided with a range of sensory experiences through oral play.
Opportunities to:
a) initiate and maintain
* blow and suck
* oral motor and respiratory control.
b) adapt responses to activity demand with more control and consistency.
Oral toys are now chosen for the
* level of SSB synchrony they can facilitate; for example, a flute versus a kazoo.
* specific sensory experiences they can provide. For example, if a client has dif-
ficulty grading blow (that is, moving from hard to soft blowing), then oral toys
and sensory experiences which assist in this adaptation are made available.
Toys for facilitating grading of blow may include a range of bubble blowers,
peashooters, blow-darts/pens, flip-flap balls.
Appropriate support to achieve optimal functioning is also provided, such as
jaw support to encourage less bite and more lip closure/control on toys.
If the client is able to move from one adaptation to another, for example hard
to soft to hard blowing, then it is time to move on to sensory experiences that
reinforce the ability to
a) initiate and maintain
* oral and respiratory organisation at the same level; for example, when asked
to blow harder, the client can maintain oral control; when asked to change lip
posture, the client is able to do this without losing respiratory control - for
example, lips behind the mouthpiece of a trumpet versus lips over a trumpet.
* oral and respiratory control across oral play materials, that is, not losing the
level of control already achieved when moving from one toy onto another oral
toy, for example, from a penny whistle to a bubble blower.
b) modify the grading of suck and blow according to specific demands.
c) increase endurance and strength of suck, swallow and breathe.
Once SSB synchrony is achieved at most levels of demand and across a variety
of oral play materials - that is, it is an integrated, generalised skill - then it may
be appropriate to focus again on specific sensory experiences for the purposes
of sound system development. For example, encouraging sucking and experi-
mentation in the back of the mouth, to improve sensation to this area and to
prepare the client for establishing placement for the velar plosives /k/ and /g/.
Outcome
* Observations reveal the level to which the client can
initiate and maintain control of oral and respiratory
function under differing circumstances. As a result,
more specific input can now be planned.
* Clients are highly motivated for a range of experi-
ences with a wide range of oral play materials.
* Grading of oral and respiratory control may require
differing levels of support from the clinician.
* A specific response may only be achieved following
some attempts at achieving the target.
* If the client has difficulty initiating a suck, different
means for eliciting a suck are attempted. The ability
to initiate a suck should be established by the end of
this stage.
* Clients become more confident and are more likely
to seek different sensory experiences spontaneously.
* The client is now able to grade with minimal sup-
port from the clinician and usually as soon as a specif-
ic response is requested.
* For clients with difficulties initiating a suck, it may
be possible at this stage to move from drinking-based
suck to other suck activities, for example sucking on a
straw to move pieces of paper from one location to
another.
* The following are increasing:
==> Self-generated experimentation with oral play
materials.
==> Strength and endurance of oral and respiratory
control and coordination.
==> Ability to modify oral and respiratory control to
changing demands with speed and accuracy.
The sensory experience of the feature/s of a sound -
such as length (plosive vs fricative) - before that
sound is targeted, is likely to result in increased accu-
racy and speed of target sound production. This may
then generalise to sound production in words and to
other sounds with similar features.
Table 1: Stages of development in establishing and developing suck swallow breathe synchrony
sensory integration
SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2000 10
Functional change
Using this approach over a five year period, I have
found that, by developing SSB synchrony with
children with speech disorders (particularly motor
speech disorders such as developmental verbal
dyspraxia), more effective oral sensori-
motor planning and coordination has
resulted. Provision of appropriate and
high quality sensory experiences has
increased the clients ability to inte-
grate their sensory and motor respons-
es. The effect of the latter is to pro-
duce a marked refinement in oral
function both as a whole and for spe-
cific oral and speech movements.
Importantly, functional changes are
achieved without developing splinter
skills such as the ability to lick lips, and
in a setting where clients are not being asked to
produce oral motor or speech movements in isola-
tion (see case example).
Sensorimotor deficits potentially impact on oral
motor and sound system development and may
contribute to the continued presence of
speech/phonological impairments. The approach
presented in this paper may provide the basis for
the future development of assessments used with
speech disordered children. Certainly, interven-
tion strategies for speech disordered children pre-
senting with sensorimotor deficits can be
informed and challenged by the approach.
With many researchers agreeing that sensory
information or input is an integral part of move-
ment control and co-ordination (Van
der Merwe, 1997, p3), this approach
can potentially be used in the man-
agement of adult clients presenting
with speech motor difficulties, partic-
ularly where the sensory deficit is
clearly identified. The materials used
to facilitate SSB synchrony may differ
but the basic premise of utilising the
synchrony to elicit ever increasing
control and integration of oral motor
skills remains.
Future research into developmental
speech disorders should seek to
further investigate the relationship between
sensorimotor input deficits and motor/speech out-
put deficits.
provide diagnostic markers for the type and
level of sensorimotor breakdown in children pre-
senting with a range of speech disorders, particu-
larly motor speech disorders such as developmen-
tal verbal dyspraxia.
determine assessment techniques that more
directly measure sensorimotor skills of speech dis-
ordered children.
provide normative data regarding the develop-
ment of suck swallow breathe synchrony.
provide the evidence base to support the use of
sensory integrative assessment and intervention
strategies when managing developmental speech
disorders.
Olwen Pate is Principal Speech and Language
Therapist (Paediatrics) with Croydon and Surrey
Downs Community Health NHS Trust at
Sanderstead Clinic, 40 Rectory Park, Sanderstead,
CR2 9JN.
References
Ayres, A.J. (1979) Sensory Integration and the
Child. Western Psychological Services, USA.
Laurel, M. & Windeck, S. (1989) A Theoretical
Framework combining Speech-Language Therapy
with Sensory Integration Treatment. Sensory
Integration Special Interest Section Newsletter 12
(1) 1-5.
Oetter, P., Richter, E. & Frick, S. (1995) M.O.R.E.
Integrating the Mouth with Sensory and Postural
Functions. Hugo, MN: PDP Press, Inc.
Pate, O. & Pinkstone, M. (1996) Suck Swallow
Breathe Synchrony (SSB) and its Relationship to
Case example
Gary, 4.3 years, has a severe oral motor dyspraxia and phonological disorder. He
was seen intensively for nine 30 minute sessions. Prior to intervention, his oral
and respiratory organisation/control was limited and he was unable to suck.
During intervention, once he had mastered oral play materials that required
increasing levels of oral and respiratory organisation and coordination for blow,
he sought SSB activities that relied on the development of his suck. In the final
therapy sessions he was able to suck drink up lengthy tubing (one to two metres
long) while standing up. The latter entailed him coordinating his breathing while
maintaining suck over periods of up to three to four minutes. Following interven-
tion, oral motor assessment revealed there was an increase in Garys:
postural, head and neck stability and control.
jaw stability, allowing for isolation of oral movements.
respiratory control and coordination.
ability to initiate and sustain oral movements more effectively and to
coordinate oral movements with respiratory support.
Assessment of Garys sound system revealed his phonetic inventory and phonetic
distribution had expanded. These expansions were integrated into Garys system
in both an idiosyncratic and appropriate fashion, as would be expected for a
sound system that continued to be disordered.
Examples of word initial position changes
Target Pre Post Target Pre Post
House a Thumb n Ltn
Sun n tn Saucer a s7a
Clown n gn Sugar d: da
Sock q 7 Jam n n
Teeth i Li Zip I Ip
Chair a Mouth b n
Dress g Girl d grl
Examples of word initial cluster developments
Smoke na7 na Three i: wi
Snake neI7 sneI7 Sleeping i7pI eIpIn
Swimming InIn InIn Spoon u:n pu:n
Bridge bId bwId Sweeties i7i7 wIi
Flower :wa aw Sky daI LaI
Blue bju blu Green i:n qwin
Examples of other changes
Money nni ntni Baby bbi beIbi
Pushing p phIn Watch nw7 wL
Doll da dl Fork u
this approach
can potentially
be used in the
management of
adult clients
presenting with
speech motor
difficulties
SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2000 11
sensory integration
Oral Sensory
Motor Control
and Speech
P r o d u c t i o n
Skills. Proceedings of the First International SI-
NDT Congress, Cape Town, South Africa.
Pinkstone, M. (1995) Suck Swallow Breathe
Synchrony: A single case study investigating the
relationship between oral sensory-motor control
and speech production in a dyspraxic child.
Unpublished project.
Selley, W., Ellis, R., Flack, F. & Brooks, W. (1990)
Coordination of sucking, swallowing and breath-
ing in the newborn: Its relationship to infant
feeding and normal development. British Journal
of Disorders of Communication 25 (1) 311 - 327.
Smith, A., Goffman, L. & Stark, R.E. (1995) Speech
Motor Development. Seminars in Speech and
Language 16 (2) 87 - 99.
Van der Merwe, A. (1997) A Theoretical
Framework for the Characterisation of
Pathological Speech Sensorimotor Control. In
McNeil, M.R. (Ed) (1997) Clinical Management of
Sensorimotor Speech Disorders. Theime, New
York.
Wolf, L.S. & Glass, R. P. (1992) Feeding and Swallowing
Disorders in Infancy, Assessment and Management.
Tucson, AZ: Therapy Skill Builders.
Reflections
Do I give sufficient
consideration to
the benefits of
input as well as
output therapy for
clients with oral /
speech motor
deficits?
Do I have the
range of equipment
necessary for
clients to develop
oral motor skills?
Do I explore the
potential of
theoretical
approaches
embraced by
related professions?
Do your clients want more speech work than your time allows? Carol Bishops clients did, so she
developed Speech Sounds on Cue. This CD ROM provides multimedia cues for 531 consonant/
vowel and consonant/vowel/consonant words covering 19 consonant sounds in initial position.
Carol, senior speech pathologist at the Aged Care Rehabilitation Unit in Hobart, Tasmania,
designed the software for adults with dyspraxia, but it may also be suitable for children with dys-
praxia or Autistic Spectrum Disorder and people with a hearing impairment.
Speech & Language Therapy in Practice has a copy of Speech Sounds on Cue to give away FREE
to a lucky subscriber, courtesy of its UK distributor, Propeller Multimedia Ltd. It normally costs 90
+ 5 delivery + VAT for single copies.
To enter, simply send your name and subscriber number / address marked Speech Sounds on
Cue to Avril Nicoll, 33 Kinnear Square, Laurencekirk AB30 1UL, tel. 01561 377415, e-mail avrilni-
coll@speechmag.com by 14th October, 2000. The winner will be drawn randomly from all valid
entries.
*The program is operated using a mouse, touchscreen or simple keyboard control.
Recommended specifications: IBM PC running Windows 95 and above. Pentium 200 Mhz with 32
MB RAM, 24 bit true colour, 16 bit sound card and speakers and 16 speed CD-ROM drive.
Will also run on Apple Macintosh G3, 32 MB RAM, System 8 or later, 16 speed CD-ROM.
Speech Sounds on Cue is available from Gordon Russell, Propeller Multimedia Ltd. P.O.
Box 27028, Edinburgh, EH10 6WD, Scotland, tel/fax. 0131 446 0820,
www.propeller.net/react
Do you want a comprehensive measure of language skills for
clients in the age group 6-21 years? The Clinical Evaluation of
Language Fundamentals (CELF) has now been adapted and stan-
dardised for use in the UK, and Speech & Language Therapy in
Practice has a copy to give away FREE to a lucky subscriber, cour-
tesy of The Psychological Corporation. It normally costs 345.20.
To enter, simply send your name and subscriber number / address marked CELF to Avril Nicoll,
33 Kinnear Square, Laurencekirk AB30 1UL, tel. 01561 377415, e-mail avrilnicoll@speechmag.com
by 14th October, 2000. The winner will be drawn randomly from all valid entries.
CELF-3
UK
is available from The Psychological Corporation, FREEPOST WD147, Harcourt
Place, 32 Jamestown Road, London NW1 1YA, tel. 020 7424 4456.
1. Entrants must subscribe personally or as one of a department to Speech & Language Therapy in
Practice, and only one entry per subscriber number is allowed.
2. Entries must be received by the editor on or before 14th October, 2000.
3. The winner will be randomly selected from all valid entries.
4. The winner will be notified by 21st October, 2000.
5. The winner will have access at work to suitable computer hardware.*
6. The winner will review Speech Sounds on Cue for Speech & Language Therapy in Practice by a date
agreed with the editor.
1. Entrants must subscribe personally or as one of a department to Speech & Language Therapy in
Practice, and only one entry per subscriber number is allowed.
2. Entrants must be registered speech and language therapists.
3. Entries must be received by the editor on or before 14th October, 2000.
4. The winner will be randomly selected from all valid entries.
5. The winner will be notified by 21st October, 2000.
6. The winner will review the CELF-3
UK
for Speech & Language Therapy in Practice by a date
agreed with the editor.
Win Speech Sounds on Cue
Win CELF3
UK
Congratulations to Carol-Anne Murphy who
won Clicker 4, and to Mrs L. Collier, Debbie Rai, Margaret Rooney and Hilary Jarvie who
won photocopiable resources from Black Sheep Press in the Spring 00 issue of Speech &
Language Therapy in Practice.
Previous winners...
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Colorcard resources
EDUCATION
All from Winslow
Pocket Colorcards
Early Objects, Early Actions, Early Sequences, Early
Opposites
19.95 for four
The best thing about these is their size as the playing-card
sized photographs fit inside fishing games and post-boxes
with ease! They have been produced especially for chil-
dren so the objects, actions, concepts (pairs of pictures
such as big/little) and sequences (three-part, for example
having a haircut) are all appropriate to this client group.
These are excellent value and a must for anyone working
with preschool or primary-aged children.
Whats Inside?
24.95
This set contains pairs of cards, one of which shows the out-
side of a container (such as a fridge, school bag, first-aid
kit) and the other its contents. Children enjoy using this
resource to work on vocabulary, categorisation, prediction
and descriptive skills and it will be most useful to therapists
working in mainstream and special school settings.
What Is It?
28.75
These are object photographs with two smaller pictures
that show parts of the object (a computer has smaller pic-
tures of the keys and the mouse) or the object from an
unusual viewpoint (a wellington boot is viewed from
below and behind). This provides effective but limited
ways to work on vocabulary, descriptive skills and spatial
concepts with school-aged children.
Sequencing Sounds
35.50
This activity involves matching sequences of sounds (sup-
plied on cassette tape) to pictures. The two and three-
sound sequences include eating crisps and scrunching up
the packet and playing a drum, xylophone and maracas.
Although useful for working on listening skills there are
limited ways in which this material could be presented.
Using Colorcards in the classroom
ISBN 0 86388 188 2 9.95
This book provides a practical collection of ideas for using
Colorcards (or similar resources) to develop listening and
attention, comprehension, vocabulary, expression,
sequencing, and social skills. The aim of each activity is
clearly stated along with suggestions for varying the level
of difficulty. The index allows you to select activities to
link in with the National Curriculum (Key Stage 1 and 2).
This book is most useful as a resource for teachers and
assistants working in mainstream or special schools but is
also worth a glance by speech and language therapists
looking for some new ideas.
Diane Stanger is a speech and language therapist with
Sussex Weald & Down NHS Trust.
Essential reading
Parkinsons Disease - Studies in
Psychological and Social Care
Ed. Ray Percival and Peter Hobson
The British Psychological Society, tel. 0116
254 9568
ISBN 1 85433 299 6 12.95
This interesting and readable book opens with an
excellent introduction to the nature and course
of Parkinsons Disease. The following chapters
represent a sample of recent research into the
needs of people with Parkinsons and those of
their carers and families.
The second half covers assessments and inter-
ventions including psychological groups, support
networks, communication, swallowing, and a
useful chapter on driving.
This book describes in detail the full impact of
Parkinsons Disease on peoples lives. It should be
essential reading for anyone who provides, or is plan-
ning to provide, a service to people with the disease.
Sue Chorlton is a speech and language therapist
at Weston General Hospital, North Somerset.
reviews
SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2000 12
A revelation
Have I Got Views For You!
Joan Murphy
University of Stirling, tel. 01786 467645,
e-mail joan.murphy@stir.ac.uk
ISBN 1 85769 0990 25
For people with Motor Neurone Disease whose
ability to communicate is limited, this framework
to enable them to discuss their quality of life is a
revelation. As such it is very relevant to the
speech and language therapists work. The
instructions for its presentation to the MND suf-
ferer are clear. The delightful materials do not
take an inordinate amount of time to prepare.
As a retired speech and language therapist who
now works as a Volunteer Visitor for the Motor
Neurone Disease Association, my role is about
quality of life issues in particular. Thus I found
this easy to administer framework an excellent
way of helping sufferers reveal needs which
could not have surfaced in any other way.
A future edition could include details of the
Motor Neurone Disease Association as well as the
Scottish Motor Neurone Disease Association, as it
provides services and information for people liv-
ing in the rest of the UK.
I consider this package value for money and rec-
ommend it thoroughly.
Adrianne Marks is a retired speech and language
therapist, formerly at St Marys Hospital, London and
the Domiciliary Service of Parkside Health Authority.
REVIEWS. . . . . . . . . . . . . .
r e v i e w s
Help me Talk Right
How to Correct a Childs
Lisp in 15 Easy Lessons
(0-9635426-0-5)
How to Teach a Child to Say
the R Sound in 15 Easy
Lessons (0-9635426-1-3)
How to Teach a Child to Say
the L Sound in 15 Easy
Lessons (0-9635426-4-8)
Mirla G. Raz.
Gersten Weitz Publishers, tel.
(480) 951 9707,
www.speechbooks.com /
www.thinkingpublications.com
$32+shipping (each)
These three books are designed
so non-professionals can use them
under a therapists supervision. It
is not dynamic therapy - and the
sixteen small black-and-white pic-
tures per page are not inspiring -
but they are easy to follow with
useful trouble shooting sections.
They progress logically from
teaching tongue positions, to pro-
duction of each sound in isola-
tion, in different positions in sylla-
bles and words, then in sentences
and consonant blends and finally
carry-over into conversation.
However, placing the tongue
behind the bottom teeth for /s/ is
controversial and the emphasis on
motivating through monetary
gain questionable.
Another limitation is the
American vocabulary with which
most English children will be
unfamiliar. Most therapists
already have a wide range of
materials for these sounds. Given
budget limitations and the high
number of serious communication
disorders on most caseloads, I
would not recommend these
books for UK therapists.
Nevertheless it is useful to have a
relatively tailor-made package for
minor speech problems and they
are reasonably priced.
Janet Farrugia runs an indepen-
dent speech and language thera-
py practice in Bookham, Surrey.
Easy to follow,
but not dynamic
ARTICULATION
PROGRESSIVE NEUROLOGICAL
PROGRESSIVE NEUROLOGICAL
Easy to read and use
Cognitive Neuropsychology and
Conversation Analysis in Aphasia. An
Introductory Casebook.
R. Lesser and L. Perkins
Whurr
ISBN 1 86156 068 0 24.50
This practically-based workbook does not dwell
on theory and is easy to read and use. The aim is
to demonstrate how the integration of
Cognitive Neuropsychology and Conversation
Analysis can provide rationally motivated apha-
sia therapy. A basic working knowledge of the
approaches is assumed although brief overviews
of both are given.
The authors present six real case studies and
ask the reader to suggest initial hypotheses,
assessments, interpretation of results and
approaches to therapy. Photocopiable work-
sheets are provided. At each stage, the reader
can compare their ideas to those presented by
the authors. Answers are therefore provided
but the authors clearly expect and encourage
variations.
This book is a valuable and reasonably-priced
resource for aphasia therapists aiming for a
structured balance between impairment-
focused therapy and a more functional interac-
tion-based approach. It is designed to provide a
constant source of reference and would benefit
experienced practitioners, newly-qualified ther-
apists and students on placement.
Kit Barber is a specialist speech and language
therapist working with community-based adults
for North East Wales NHS Trust.
ADULT NEUROLOGY
Enthusiastic and personal
Reasons and Remedies
Patricia Sims
Mortimore Books, PO Box 156, Barnstaple,
EX33 1YN
ISBN 0-9536209-0-5
12.95 (10.95 if ordered directly)
Speech, language, learning and social prob-
lems, such as stammering, dyslexia and autism,
need no longer be puzzling. If we enquire in
some depth into the personality traits of young
children, we will discover mechanisms which lie
behind such problems.
In her long career with special needs children,
Patricia Sims has developed her holistic method
of working which she says has increased success
of therapy as well as her own job satisfaction.
The book includes a very comprehensive,
detailed checklist for case history taking and many
vignettes from cases to illustrate her theories.
A very enthusiastic and personal book. Easy to
read, it should stimulate creative thought, how-
ever experienced the reader.
Rosemary Fisher specialises in dysfluency in
adults and children. She works in Derby.
SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2000 13
reviews
Raises awareness
Fragile X Syndrome - An Introduction
Fragile X Society, tel. 01424 813147
Video+booklet 5.00
This twenty minute video aims to help profes-
sionals know when to suspect Fragile X may be
present, understand its effects, and initiate early
multidisciplinary evaluation, intervention and
support.
Interviews with professionals and parents,
together with film of those affected, demon-
strate and explain the characteristics effectively.
The accompanying booklet explains more about
speech and language than does the video. The
many benefits and implications of diagnosis are
discussed, and there is a positive emphasis
throughout.
A useful and good value resource to share with
colleagues, and to raise our own awareness of
the condition, the characteristics of which have
management implications.
Fiona Ashford is a speech and language thera-
pist working in the Special Needs Team in
Portsmouth Healthcare NHS Trust.
Enjoyable, with excellent
illustrations
More Than Words (Helping Parents
Promote Communication and Social Skills
in Children with Autistic Spectrum
Disorder)
Fern Sussman
The Hanen Centre; available from Winslow
ISBN 0-921145-14-4 26.95 + p&p
This is a valuable resource book for any therapist
who has contact with children with autistic spec-
trum disorder.
Following a similar format to the original
Hanen It Takes Two To Talk, it establishes the dif-
ferent stages of communication and essentials
for good communication (OWLing - observing,
waiting, listening - and additional new
acronyms) and then moves on to useful exam-
ples of how to develop play and share books or
music.
In addition, it addresses specific aspects associ-
ated with autistic spectrum disorder, such as
explaining sensory-motor preferences and the
way the children acquire information. Especially
useful are the examples of adapting language
and using augmentative communication.
A well-priced, easy and enjoyable read with
excellent illustrations, it has well structured
examples of functional ideas for parents to try.
Fiona Coughlan works for Warrington
Community Health NHS Trust with preschool and
primary school children with special needs.
AUTISTIC SPECTRUM
Informative and inspiring
Fluency courses at the Apple House,
Oxford, 1966 - 1998 - An Evaluation
Dr Rosemary Sage
The Stammer Trust
ISBN 0 9534807 0 4 7 inc. p&p
This clear, readable account of thirty years of
evolving stammering therapy at Apple House
begins with a succinct history of stammering and
goes on to give brief summaries of recent
research. Results of different approaches to ther-
apy are included and discussed.
The second half concerns itself with the numer-
ous aspects of running the courses at Apple
House. Four case histories are included with a
summary and evaluation of the therapy program.
This report combined the scientific with the
therapeutic in an informative and inspiring for-
mat. The richness of the therapists and clients
experiences was quite enviable. This report is
excellent value for money and I recommend it to
students and therapists alike.
Amanda Mozley is head speech and language ther-
apist at Chelsea and Westminster Hospital, London.
Invaluable software
Boardmaker
Mayer-Johnson plc
250 plus VAT
Available for Apple Macintosh or Windows
Version evaluated: Boardmaker for Windows
This computer programme, containing over 3000
picture communication symbols, allows you to
make attractive communication boards and dis-
plays suitable for use with children and adults. It
comes with a clearly written users guide and an
excellent 60 minute instructional video.
With the programme you arrange cells - boxes
in which you place picture symbols - anywhere
on a page; make them different sizes; change
their border colours - useful if you want to say
colour code nouns and verbs; display text with
your symbol in up to two languages -
Boardmaker comes with ten; plus you can add
your own text and other language fonts. You
can also make your own symbols or bring pho-
tographs into the programme.
As with any programme there were one or two
initial headaches in using it, and some of the sym-
bols arent quite appropriate for the UK; for exam-
ple the word goal produces a picture symbol quite
unlike any set of goal posts Ive seen in this country.
Verdict: an easy to use and invaluable piece of
software which produces attractive materials.
Neil Thompson is a speech and language thera-
pist in mainstream schools and schools resourced
for children with medical needs/physical disabili-
ties. He works for Newham Community Health
Services NHS Trust, East London. He won
Boardmaker in the Winter 99 reader offer of
Speech & Language Therapy in Practice.
DYSFLUENCY
LANGUAGE DEVELOPMENT
CHILD DEVELOPMENT
SYNDROMES
or the past six years the Department of
Human Communication Science at
University College London (UCL) has been
developing an approach to speech and
language therapy students professional and clin-
ical learning which emphasises active participa-
tion from the earliest stages of clinical placements
(Morris, 1998; Parker & Kersner, 1998). We have
been moving towards emphasising reflective
cycles of learning which integrate practice, theory
and rehearsal, rather than the traditional linear
model with its expectation that theory and obser-
vation should always precede practice (Schon,
1983, 1987; Kolb, 1984; Stengelhofen, 1993;
Morris & Parker, 1998). Speech and language ther-
apy students reported experience of learning
more effectively through active participation is
supported by Erauts work on the relationship of
practice with theory in professional learning (for
example Eraut, 1994). Real responsibility helps the
development of confidence and allows students
to gain a deeper understanding of related theory
(Kersner & Parker, 1999).
One application of this approach has involved a
partnership with the Stroke Association Dysphasia
Support Service in London. The placement was
first set up in 1997, and is completed by under-
graduate Speech Sciences students as a prepara-
tion for their main final year placement with
speech and language therapy services for clients
with acquired disorders of speech, language and
cover story
SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2000 14
Read this if you:
want innovative
ideas for training
believe student
training should
also benefit
clients
are interested in
working with the
voluntary sector
Research shows individuals learn more
effectively when given responsibility and
encouraged to participate actively. Suzanne
Beeke and Ann Parker are behind an innovative
programme where speech and language
therapy students become temporary volunteers
for the Stroke Association. Here, they explain
how this has benefited the people living with
dysphasia as much as the students.
F
voice. The design and organisation of the place-
ment has just been revised in the light of an audit
carried out in the summer of 1999.
Students are assigned, in pairs, to work with one
of the London Stroke Associations Dysphasia
Support groups, which are affiliated with the
Stroke Association Dysphasia Support Service. The
dysphasia support organiser acts as their supervi-
sor for the duration of the four week placement.
Non-local speech and language therapy supervi-
sion is provided by a member of the clinical staff
at UCL.
Support and practice
Each pair of students assists the dysphasia support
organiser in planning and running the weekly
stroke group, and also makes visits to certain
group members who have requested that a
Stroke Association volunteer visit them at home.
Each pair of students visits two people twice a
week for approximately one to one and a half
hours per visit. During this time students work as
Stroke Association volunteers, fulfilling the objec-
tives of the Dysphasia Support Service by provid-
ing support with, and practice of, communication
for the stroke person in their own home (The
Stroke Association, 1999). Verbal and written
information which clearly states that students are
not qualified or expected to provide speech and
language therapy is given to the dysphasic indi-
viduals, their family members, the dysphasia sup-
port organiser and the students before the place-
ment begins. The programme specifies that stu-
dents must only visit individuals who are not
being treated by a speech and language therapist
during the time when visits will take place.
The placement aims for students to:
1.develop the ability to interact with adult
clients
2. experience working as a volunteer within a
community-based service for clients with
dysphasia
3.be aware of the psychosocial and practical
aspects of life for people with dysphasia, and
for their families
4.develop a problem-solving approach to
clinical work
5.continue to develop independent learning
skills
6. enhance the ability to seek and act on
feedback on performance from a range of
sources, including the client, family members
and professional colleagues
7.enhance the ability to take responsibility for
day-to-day organisation of home visits,
session planning, administration tasks and
report writing
8.continue to develop pair-work skills
9.experience a model of clinical supervision
other than the traditional one-to-one student
and speech and language therapist approach.
Comp
confid
and
comm
SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2000 15
cover story

At the end of the placement each student will:


a) have had experience of interacting with
dysphasic individuals
b) understand the nature of the Stroke
Association Dysphasia Support Service
c) understand the nature of the job of a Stroke
Association dysphasia support volunteer
d) have had experience of interacting with
carer(s) of dysphasic individuals
e) have insight into the psychosocial effects of
stroke
f) have administered and analysed language,
communication and psychosocial
assessments of dysphasia
g) have developed skills in planning and
running a stroke group
h) have consolidated the ability to
independently manage their own time and
complete administration tasks
i) be aware of the practicalities of domiciliary
work with dysphasic clients
j) have consolidated team work skills
k) have consolidated skills in giving and
receiving peer feedback
l) have reflected on their current clinical skills
and areas for future development with the
help of peer and supervisor feedback.
Before the placement begins students attend an
induction session at the north London regional
centre of the Stroke Association. During the first
half of the two hour meeting stu-
dents hear presentations giving
information on the history of the
Stroke Association, the causes and
incidence of stroke in the UK popu-
lation, the prevalence of dysphasia
after stroke and the services pro-
vided by the organisation. Students
also watch the official Stroke
Association information video, and
have the opportunity to ask ques-
tions of the presenters, the north
and south London regional man-
agers of the Dysphasia Support
Service.
The second half of the session focuses on the
background, aims, objectives and organisation of
the placement, as detailed in the placement hand-
book. Students take part in a practical exercise
during which they are encouraged to use their
knowledge of communication and therapeutic
techniques to generate ideas for language and
communication tasks for use during group sessions
and home visits. Dysphasia support organisers are
invited to attend to meet the students they will be
supervising.
Following the induction meeting, students visit
the stroke group to which they have been
assigned. The purpose is to meet the members,
particularly those they will be visiting at home in
weeks to come. Students also use this initial visit to
liaise with the dysphasia support organiser
to finalise their timetable of home visits,
planning and administration sessions.
Flexible
Students are given a suggested format for
their working week (table 1) which includes
sessions allocated for visits, the group, peer
feedback, planning and report writing. This
timetable is designed to be flexible and
ultimately students are responsible for
planning their own working week in col-
laboration with the dysphasia support
organiser, the dysphasic people they visit
and their student partner.
Each student writes a communication report for
one of the dysphasic people they visit at home. To
do this, students complete:
PALPA 53 assessment of spoken picture
naming (Kay et al, 1992)
Picture description assessment of sentence
structure
Analysis of one minute of conversation
between the student and the dysphasic person
A questionnaire dealing with disability and
handicap issues in dysphasia (see example
in table 2)
A questionnaire on pre-stroke conversation
habits (excerpt from CAPPA - Whitworth et
al, 1997).
Students take
part in a practical
exercise during
which they...
generate ideas
for language and
communication
tasks for use
during group
sessions and
home visits.
petence,
dence
mitment
cover story
SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2000 16
The report is written for the dysphasia support
organiser, and provides a short summary of the
dysphasic persons language and communication
skills and the individuals and familys views on liv-
ing with dysphasia (see example in table 3). The
placement handbook provides students with
background to the assessments plus administra-
tion and analysis guidelines, and a suggested for-
mat for the report.
Dysphasia support group members comments,
passed on to us by the group organisers, indicate
they enjoy working with the students, and value
their enthusiasm and commitment. Members
report liking the challenge of having new people
to communicate with. Those who no longer have
a volunteer who visits at home appreciate the
opportunity for extra support of this kind which
the students presence affords. The husband of
one dysphasic individual communicated to us the
couples view that, as well as receiving support,
they wished to contribute to the learning experi-
ences of speech and language therapy students,
and felt great satisfaction in the knowledge that
they were helping to train new speech and lan-
guage therapists who would, in turn, help others
like themselves.
The north and south London Regional Managers
of the Dysphasia Support Service, Sue Wayne and
Sandra Field, write:
Over the past three years we have worked with
UCL on developing the placement link to the ben-
efit of the student, the stroke person and the dys-
phasia support organiser. From the onset it was
imperative that the stroke people gained, and
that the organisers felt comfortable with the
union. As the project has developed, and with
information gathered from the audit carried out
by UCL in 1999, the team has been able to improve
areas of delivery and reporting. The one-to-one
working and patient monitoring enables the stu-
dents to give our organisers more detailed feed-
back, which empowers the organiser to develop
and individualise the service they are offering to
the stroke person. We have all gained from the
placement project and feel very positive that it is
beneficial to all, especially to the stroke person.
Insight
After completing the placement, students are
asked to give written feedback (see example in
table 4) which has contributed to improvements
in the programme, as well as confirming the view
that it is a useful learning experience. Many
report the programme of work gives them valu-
able insight into how stroke affects peoples lives,
which complements their theoretical knowledge
of the speech, language and communication
impairments associated with dysphasia. Students
have voiced their appreciation of the combina-
tion of support and independence this learning
experience provides, and report increased confi-
dence in their ability to interact with people with
dysphasia and their families. Each year a number
of students make a personal decision to continue
to work with the group they met through this
placement. One student has become a permanent
volunteer for the Stroke Association as a result of
her experiences.
The work placement we have described provides
an example of an alternative model of supervision
for speech and language therapy students which
may be applicable in other settings. It is not
intended as an alternative to placements where
the on-site clinical supervisor is a practising
speech and language therapist, but rather to aug-
ment and enhance the existing programme of
placements at UCL. In addition to developing stu-
dents competence and confidence with adult
clients before they undertake core placements
with speech and language therapy services for
adults, it also provides a resource for the Stroke
Association and its members. Careful planning,
preparation and joint supervision of students by
university-based speech and language therapists
and Stroke Association staff are key features of
this programme. Feedback from all parties
involved indicates that students learn more effec-
tively when they are given real responsibility for
an aspect of service provision. We hope this arti-
cle will be of practical use to supervising speech
and language therapists who wish to consider
ways in which students may provide a resource for
a service as they develop their clinical skills.

Table 1: Suggested weekly timetable example


MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY
am am - one hour am - one hour am - one hour am - one hour
Stroke Group Client 1 Client 2 Client 1 Client 2
peer feedback peer feedback peer feedback peer feedback peer feedback
Admin: Admin: Admin: Admin: Admin:
tasks/planning/ tasks/planning/ tasks/planning/ tasks/planning/ tasks/planning/
report writing report writing report writing report writing report writing
Table 2: Extract from a communication report
Jo, a speech and language therapy student, writes about his discussion of disability and handicap issues with Rob, a 56 year old man
with dysphasia.
Disability & Handicap Questionnaire*
How would you describe your speech and language problems?
Rob feels that his speech and reading have been greatly affected since the stroke. He says he finds reading very difficult, has word
finding difficulties and often has problems with pronunciation.
How do these problems affect your ability to have a conversation with other people?
Rob used the word terrible to describe the effects of his stroke on his communication with others. He tries to avoid situations with
strangers, who he believes have difficulty understanding him. He believes his friends understand him better, and so he feels more com-
fortable communicating with them. Robs home help said that there were often long pauses in Robs speech, but if given time he usually
succeeded in getting his message across. Rob reports that the people in the local supermarket know him and help him when he shops.
*informal assessment compiled by UCL for use by students on the Stroke Association Placement
We have all gained from the
placement project and feel very
positive that it is beneficial to all,
especially to the stroke person.
Sue Wayne and Sandra Field
The Stroke Association (1999) Dysphasia Support
Service. Leaflet DS1.
Whitworth, A., Perkins, L. and Lesser, R. (1997)
Conversation Analysis Profile of People with
Aphasia - CAPPA. Whurr.
Contacts
The Stroke Association
Stroke House
123 Whitecross Street
London EC1Y 8JJ
Tel: 020 7566 0300
www.stroke.org.uk
Stroke Helpline 0845 30 33 100
North London Regional Centre
The Stroke Association
Mitchell House
433 Chiswick High Road
London W4 4AU
Tel: 020 8994 2847
email Swayne@stroke.org.uk
South London Regional Centre
The Stroke Association
St Lawrence Community Centre
37 Bromley Road
London SE6 2TS
Tel: 020 8697 1636
email Sfield@stroke.org.uk
SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2000 17
cover story
Suzanne Beeke (tel 020 7679 4215, e-mail
s.beeke@ucl.ac.uk) is a Clinical Tutor and the
Acquired Placements Co-ordinator and Ann
Parker (tel. 020 7679 4228, e-mail
a.parker@ucl.ac.uk) is Senior Lecturer in
Professional Studies at the Department of Human
Communication Science, University College
London, Chandler House, 2 Wakefield Street,
London WC1N 1PF.
Acknowledgements
We would like to thank the London Regional
Managers of the Dysphasia Support Service, Sue
Wayne and Sandra Field, for their hard work and
continuing support for this venture. We extend
our thanks also to Jane Beeden, David Brisacher,
Nigel and Ann Hay, Gwen Knight, Wilma Leroy,
Georgina Overell and Gill Ritchie, Dysphasia
Support Organisers, all the stroke people and
their families who have been involved, and the
students who have worked so hard to make the
programme such a success. Photographs are
reproduced with the permission of Jane Beeden,
members of the Southwark Dysphasia Support
group and students on placement there in 1999.
References
Eraut, M. (1994) Developing Professional
Knowledge and Competence. The Falmer Press:
London.
Kay, J., Lesser, R. and Coltheart, M. (1992)
Psycholinguistic Assessment of Language
Processing in Aphasia. Lawrence Erlbaum.
Kersner, M. and Parker, A. (1999) An integrated
approach to speech and language pathology stu-
dents learning. Poster presented at American
Speech-Language-Hearing Association Convention,
November, San Francisco, USA.
Kolb, D. (1984) Experiential Learning: Experience
as a Source of Learning and Development.
Prentice Hall: New Jersey.
Morris, C. (1998) The hidden determiner of student
learning opportunity on clinical placement.
International Journal of Language and
Communication Disorders, 33, supplement 238-243.
Morris, C. and Parker, A. (1998) Exploring the cri-
sis in clinical training: looking to the future.
International Journal of Language and
Communication Disorders, 33, supplement 244-
249.
Parker, A. and Kersner, M. (1998) New approaches
to learning on clinical placement. International
Journal of Language and Communication
Disorders, 33, supplement 255-260.
Schon, D.A. (1983) The Reflective Practitioner:
How Professionals Think in Action. Morris Temple:
London.
Schon, D.A. (1987) Educating the Reflective
Practitioner. Jossey-Bass: San Francisco.
Stengelhofen, J. (1993) Teaching Students in
Clinical Settings. Chapman and Hall: London.
Reflections
Do I consider models of learning
when planning training for myself
or others?
Do I include time for induction,
planning, brainstorming, peer
support and reporting when
organising student placements?
Do I base service delivery on an
understanding of the real-life
impact of communication disability?
Table 3: Extract from a communication report
Speech and language therapy students Katrina and Ciara write
about JP, a 65 year old man with dysphasia.
Spoken Picture Naming
JP completed this task without difficulty. He succeeded in scor-
ing 18/20 correct without any cue and 20/20 with a further two
semantic cues. The test took only five minutes to administer.
Conversation
JP has had previous speech and language therapy which is
evident in his strategies to compensate for articulation
difficulties. He taps out the syllables of multi-syllabic words
which pose a problem for him. An example was the word
Wednesday. Other techniques observed were breath control
techniques.
Some word finding difficulties are evident. JPs speech is slow
and effortful, and pauses are evident in the conversation
transcription.
All turn-taking is appropriate and he can hold a reasonable
conversation, and communicate his intentions.
A comparison
Comparing JPs performance on the picture naming and his
general conversation skills, the behaviours observed were
similar, with subtle differences evident. These included his
improved performance on set tasks (picture naming, work-
sheets) over free speech. This may be because the set tasks
only required one word answers, and not fluent speech.
Further areas to develop
JP communicated his desire to improve his spelling. He
consistently completed worksheets with accuracy and speed
(for example crosswords eliciting semantically linked words
related to concepts, such as time). More challenging work-
sheets may cultivate his existing skills.
Table 4: Example of written feedback
Please note at least one thing you enjoyed about this placement:
working as a team/pair
felt it a challenge to have two clients to visit
saw a different side to the healthcare system - the community role, a good
change from the acute hospital setting
an interesting and confidence building experience
Please note at least one thing that you learned on this placement:
about issues that a stroke patient must deal with as a result of their loss of
communication skills
the role of the carer of a stroke patient
how to adapt knowledge and skills to an adult client group
how to take group sessions
how to adjust communication to suit individual members abilities
in my experience
SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2000 18
when the owner is without the knowledge to
help him or herself.
There is no question that classroom teachers are
having a harder time these days. Our changing
society means children bring different attitudes
and behaviour patterns into school. In general,
these changes cause more noise, more disruption
and present a greater challenge to the voice of
the teacher than a generation ago. Add to that
the shifting nature of teaching methodology, the
pressures of delivering the National Curriculum
and the testing which that demands. This is the
equation which teachers must balance.
Too much
The challenges are enormous. Many teachers pick
them up in their stride, work incredibly hard and
do an excellent job in the circumstances. But what
of those who dont? Those for whom the daily
grinding noise in the workplace and the strain of
keeping up with the pressures is just too much.
First symptoms are frequently sore throat, hoarse
voice and exhaustion. The voice is a very common
casualty and thats not to be wondered at. As pro-
fessional voice-users teachers are obliged, by the
very nature of their work, to talk throughout the
ery early in life I resolved to
become a teacher. Perhaps I was
simply following in my mothers
footsteps, or maybe it was the
natural outcome of a bossy
nature. As a teenager this ambi-
tion was overtaken by another - to become an
actress. In the event, the two merged seamlessly
and I became a teacher of Speech & Drama. Fate
took a hand when I was offered work at a teacher
training college. It was there that I became so con-
cerned with the teachers voice - its vital impor-
tance, its besetting problems and the crying need
there is to address them.
Voice teachers and speech and language thera-
pists are constantly exercised by a problem which
does not go away. Once there was a considerable
amount of anecdotal evidence, then a kind of per-
ceived wisdom, and now a growing body of
research to show quite clearly that teaching is
tough on the voice (Bufton, 2000; Morton and
Watson, 1998). What is needed is a proper policy
to provide advice and guidance at the point of
training to ensure that students of education are
equipped vocally to enter their chosen profession.
For the truth is, the voice may begin to suffer
V
Inspiring
or
expiring?
Raising
the teachers
voice
Do you want more
teachers on your caseload?
Do you want your children
taught by dysphonic
teachers? Caroline Cornish
calls on all speech and
language therapists to
back the case for a
national policy of
preventative voice care for
student teachers, before
the situation gets
out of hand.
Read this if you:
have any contact
with teachers
are interested in
health promotion
want to influence
teacher training
day. They must also use their voic-
es to establish authority and keep
order. They must control their
own responses to situations and
maintain some semblance of dig-
nity. When we rein in our irrita-
tion and anger - feelings not
unknown to the hard-pressed
teacher - we tend to lock them in
the throat.
To cope with both the physical
demands laid on the voice in the
sheer amount of phonation
required to do the job adequate-
ly, and the emotional factor of dealing with stress
which is part and parcel of the job, a teacher
needs a strong, flexible and well cared-for voice.
Without timely advice and training, bad habits
laid down - often in the first year of a teaching
career - can establish a pattern of vocal misuse.
At the start, the problem may simply mean days
off work and sucking large quantities of pastilles.
This may develop into recurring voice loss and
prolonged absences from school. The next step
may be a chronic condition requiring therapy or
even surgery: a major interruption to both
teacher and school.
In addition to vocal fatigue and persistent sore
throat, teachers may have inadequate volume,
lack of projection, poor articulation and, perhaps
most of all, the sense that the vocal failure they
feel is somehow hopeless, irredeemable. Not
infrequently those referred to me
are already burdened, having
been told by a well-meaning
tutor, Your voice is too shrill / too
high / too soft or You squeak.
This often means my first task is
to soothe a bruised ego. Only
then can I get down to explain-
ing that the voice is a wonderful
instrument capable of myriad
changes, made of flexible materi-
al needing care and considera-
tion, and a vitally important tool
of the trade. Once they discover
that quite small changes in strate-
gies and techniques have critical
effects, they can begin to grasp at
the confidence they seek, to relax
into better ways of being and
sounding. Laying down healthy
vocal habits at this stage can lead
to a lifelong commitment to releasing its full
potential - as a means of expressing thoughts and
feelings, a powerful influence on the recognition
of and delight in language, and the source of real
inspiration to others.
High price
Who cares for the teachers? You care, I care ... but
there are more questions. Do speech and lan-
guage therapists want an increasing number of
teachers on their caseloads? After all, in a sense,
SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2000 19
in my experience

these are people with self-inflicted
injuries. Youre sorry for them, but
you also know the problem was
largely preventable. Voice teachers
know that too and they are the
ones who could, and should, pro-
vide the help in time. Why arent
student teachers given the train-
ing they need in the use and care
of the voice before they are
despatched into the classroom?
Why arent they alerted to the
need to recognise themselves as
professional voice users? The right
time to learn the basic elements of good posture,
breath support, decent articulation and projec-
tion is before the voice is put to the test. It ought
to be possible and in the long run would certain-
ly be more economical: preventing trouble invari-
ably is. The price is already high in terms of days
lost to school (supply teaching is not cheap), NHS
charges for therapy and surgery, loss to the pro-
fession (many teachers press for early retirement)
and thats without accounting for the human cost
of managing with a voice below par on a regular
basis.
Is the situation getting out of hand? Lord
Puttnam is on record with plans for sending out-
of-work actors into schools to teach teachers how
to use their voices and speak better. Concern in
high places is good but there needs to be a policy
implemented across the board to ensure all stu-
dent teachers have
1. help and advice at the point of
training,
2. monitoring to identify those at
risk, and
3. a back-up programme for those
whose need is greatest.
At the moment this provision is far
too vague and haphazard.
After many years working with
student teachers, I wrote a hand-
book for them (Cornish, 1996) to
offer, in a more permament form,
the advice and guidance I had
been giving in taking care of the
voice, its best practice, and the
deployment of effective strategies.
My intended market was both stu-
dent teachers and those already at
the chalk-face. But who now is
buying it in the greatest numbers?
- speech and language therapists. Not for them-
selves, for they well know its content, but for
their clients, an indication of how many of those
are teachers.
Enriched
In 1993, concern about the numbers of teachers
attending speech and language therapy led to a
new voice being heard: the Voice Care Network
UK, an organisation (and a registered charity since
1998) which brings together voice teachers and
speech and language therapists. Apart from the
invaluable exchange of dialogue, the expertise
from two different angles is immensely support-
ive (Martin and Darnley, 1998). This professional
partnership brings considerable rewards, and not
just for those on the receiving end. Im sure Im
not alone in feeling enriched by it.
The Voice Care Network UK provides workshops
run by a teacher and a therapist together, and it
works very hard to raise the profile of voice-train-
ing for teachers. Members are united in a com-
mon cause, namely to care for the human voice
and those for whom it is the essential tool of their
trade. Speech and language therapists specialis-
ing in voice are gathering the evidence needed to
bring about action (Bufton, 2000), but all of you
can play your part. For example, if you are pro-
viding teachers with in-
service training on any
subject, or visiting a
teacher training college
as an outside lecturer,
mention the importance
of voice care and give
details of the Voice Care
Network and suitable
publications. Your
department can establish
links with local voice /
speech & drama teachers
and encourage teachers
to get help at an early
stage to prevent more
serious problems arising.
We can all use the media to lobby for change
(Brooks, 2000).
The cry of a teacher in vocal distress should not
fall upon deaf ears; rather we should seek to
ensure it is never raised at all.
References
Brooks, F. (2000) Alarming sound levels in schools.
Scotland on Sunday Letters to the Editor, 11 June.
Bufton, E. (2000) The voice curriculum. Bulletin of
the Royal College of Speech & Language
Therapists. June.
Cornish, C. (1996) CAN YOU HEAR ME AT THE
BACK? BiVocal Press.
Morton and Watson (1998) The Teaching Voice: prob-
lems and perceptions. Log Phon Vocol 23 133-139.
Martin and Darnley (1998) Conflict and collabora-
tion: The dynamics of a working partnership. Log
Phon Vocol 23 (Suppl 1) 4-6.
Resources
CAN YOU HEAR ME AT THE BACK?, a hand-
book on voice for teachers by Caroline Cornish
from BiVocal Press, PO Box 246 Exeter EX1 2YF,
price 7.50 + 1.25 p&p.
More Care for Your Voice (single copy 4.50, 10
or more copies 3 each, 50 or more copies 2
each, all inc. p&p) and other booklets from the
Voice Care Network UK, 29 Southbank Road,
Kenilworth CV8 1LA.
Why arent student
teachers given the
training they need in
the use and care of
the voice before they
are despatched into
the classroom?
Speech and language
therapists specialising
in voice are gathering
the evidence needed
to bring about action
(Bufton, 2000), but
all of you can play
your part.
Reflections:
Do I recognise
opportunities
for health
promotion?
Do I get
involved with
multidisciplinary
organisations?
Do I value my
own voice?
home programmes
SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2000 20
number of clinic based speech and lan-
guage therapy programmes are avail-
able for use with preschool children.
The most widely implemented within
the UK are probably Parent-Child Interaction
Therapy (Rustin et al, 1996), Working with
Dysfluent Children (Stewart and Turnbull, 1995)
and, more recently, the Lidcombe Programme
(Onslow, 1993). Generally speaking, we have
found that, when parents understand more fully
the nature of their childs stammering and their
role in its remediation, they are often very
resourceful in making arrangements so they can
attend therapy. However, for a minority, there
may be reasons such as availability of services,
travelling distance and cost, work pressure and
childminding difficulties, which mean regular
attendance is impossible.
Therapy could be delayed until attendance is
possible. However, there is now almost universal
agreement - and mounting evidence (Nicholas
and Millard, 1998) - that the treatment of stam-
mering in young children is more effective and
less time-consuming than therapy that is delayed
until a child is older. As a consequence, speech
and language therapists need to be more
resourceful and flexible in their management of
young stammering children to increase the avail-
ability and ease of access to services. In addition,
the outcome of early referral campaigns, such as
that conducted by the British Stammering
Association, may mean that the number of dysflu-
ent children presenting in speech and language
therapy clinics will rise (Christie and Evesham,
1998). To address the increasing demand and the
varying needs of individual families, speech and
language therapists will require a wider range of
Read this if you:
need
alternatives to
clinic based
therapy
are interested
in interaction
approaches
are experiencing
an increase in
referrals
A
Preschool dysfluent children identified as
being at risk of persistent stammering
need individualised help before it is too
late. A new home based programme
offers hope to those who cannot access
a speech and language therapy clinic on
a regular basis. Sharon Millard, Frances
Cook and Jane Fry explain.
Homebase -
but not
DIY
I still find myself in awe
of the work you did
with me and Charlotte
and the transformation
in her speech and our
lives. I find it difficult to
even remember how
Charlotte was when her
dysfluency was at its
worst even though it
was a relatively short
time ago. There has been no
hint of a stammer since the last
time we attended the Centre
and people who now meet us
would have no idea that
Charlotte once stammered.
SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2000 21
home programmes

therapy and management strategies at their


disposal.
One method of managing families unable to
attend the speech and language therapy clinic is
through the use of self-help advice sheets and
programmes which parents may implement at
home. There are many available, the majority of
which focus on advising parents how to interact
with their stammering child. There are many
aspects of this literature that are valuable. For
instance, parents may feel they can take responsi-
bility for managing the problem, perhaps gain an
understanding of the issues
that are important in rela-
tion to stammering, while
providing some input for a
child who is unable to
access or who is on the
waiting list for a clinical ser-
vice. However, this self-help
literature also has consider-
able limitations, arising in
particular from the neces-
sarily general nature of the
advice and its failure to
address the individual
needs of the child or par-
ents. Parents have
described feeling over-
whelmed by the amount of
advice, as well as having dif-
ficulties in implementing
changes and monitoring
progress. In addition, some
have reported feelings of isolation and frustra-
tion resulting from the lack of professional advice
and support. Importantly, when the advice is
to understand the complexity of this disorder and
to find ways of interacting with the child which
will facilitate fluency (Rustin et al, 1996, p97). It
is carried out by the parents over a period of six to
eight weeks and is closely monitored by a speech
and language therapist.
The Programme is recommended for families of
children up to approximately six years of age,
who are identified as being at risk of persistent
stammering, but who are unable to attend a
speech and language therapy clinic regularly. The
parents must be committed to the therapy
process, since they take on the responsibility of
the therapy, and have average literacy skills and
access to a telephone. Both parents, if a two par-
ent family, are considered essential for the suc-
cessful implementation of the programme and
are equally involved throughout. While it is there-
taken to extremes, there may be a loss of the nor-
mal social rules of communication. For example
advice not to interrupt the
child and allow the child to
interrupt others, could lead to
poor turn taking and listening
skills on the part of the child.
Advantages
The new Home Based Fluency
Programme for Young
Stammering Children, devised
by speech and language thera-
pists at the Michael Palin
Centre for Stammering
Children, aims to exploit the
advantages of both home
based self-help literature and
clinic therapy, and is seen as an
additional tool for managing
preschool dysfluent children.
It is designed for use by speech
and language therapists who
have a working understanding
of the principles and methods of parent-child
interaction therapy, which aims to help parents
restore their confidence in their parenting skills,
...speech and language
therapists need to be
more resourceful and
flexible in their
management of young
stammering
children to increase the
availability and ease of
access to services.
Table 1: Implementation of various aspects of the Programme on a weekly basis
Week number Consolidation period
1 2 3 4 5 6
Target 1: Special time x x x x x x x x x x x x
Target 2 x x x x x x x x x x x
Target 3 x x x x x x x x x x
Target 4: Praise x x x x x x x x x
Target 5 x x x x x x x x
Target 6 x x x x x x x
Attend clinic x x
Telephone contact x x x x x
Return special time diary sheets x x x x x x x x x x x x
Carol and daughter Charlotte (pictured)
who attended the Michael Palin Centre.
home programmes
SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2000 22
fore not suitable for use with every family, it has
effectively increased the availability of services to
a number of families of this client group.
In accordance with the view that stammering is
a multifactorial, dynamic disorder, each child is
assessed in the clinic with regard to the physio-
logical, linguistic, psychological and environmen-
tal factors which indicate whether they are at
risk of persistent stammering. The format of this
assessment is described in detail by Rustin et al
(1996) and is made up of a parent interview, a
child assessment and interview and an analysis of
parent child interaction. Therapy is indicated for
the children who are identified as being at risk of
persistent stammering and / or whose parents
express concern in relation to the dysfluency.
Following the assessment, both parents attend
the clinic to set up the Programme. Each parent
devises his or her own Individual Therapy
Programme, which consists of up to six targets
(table 1). The targets are introduced one at a
time, with one added each week for approxi-
mately six weeks.
Foundation
The first target for all parents is to establish
Special Time (Rustin et al, 1996). This is the foun-
dation of the therapy programme and comprises
a five-minute playtime which each parent has
with the child, once a day, between four and six
times each week. The child chooses the activity
for Special Time (which should not be television,
reading or rough and tumble games), and the
parent plays with the child while focusing on his
or her own interaction. Following each Special
Time session, the parent completes a Special Time
Diary Sheet, which is posted to the speech and
language therapist at the end of each week.
During week two to six, targets are practised
within the Special Time. These may be manage-
ment targets or interaction targets. The interaction
targets are identified from each parents analysis of
their own interaction video recorded as part of the
initial assessment. Parents rate their own behav-
iours using an interaction checklist which focuses
on features which have been demonstrated to be
important in relation to stammering, These
include parental rate of speech and dominance in
play. From this checklist, each parent identifies
three or four aspects of their interaction to target
for change. This may include:
1) Speaking at the same rate as the child
2) Following the childs lead
3) Using comments rather than questions

Table 2 Example of The Individual Therapy Programme Form


Name: Mother Childs Name: Matthew
Number of Special Times to be carried out each week: 5 x weekly
Telephone contact day and time: Wednesdays @ 10.30 am
EACH WEEK:
1) Fill in your worksheet with someone else, if possible
2) Make telephone contact with your therapist at the agreed time
3) Focus on your target during special time
4) Write up your Special Times after each session
5) Send your diary sheets to: Clinic
Address
Table 3 Parents comments
Excellent. It has made the issues be
with us on a daily basis and there-
fore she receives more therapy.
We were really pleased we got the
home pack as we were doing the
work ourselves.
I think the therapy was more natur-
al for V by being at home and inte-
grated into her normal routine - as it
was for me. The
ultimate analysis must be in the
results and V has definitely been
helped by the process.
I thought the programme was
excellent. The weekly contact was,
for me, vital.
Even though I is still stammering, I
am very pleased with the therapy
and feel we are all doing the best for
her.
TARGET AREAS
Special Time
Praise
Slow rate of speech
Taking turns
Being more involved
Listening
TARGETS
1) Setting up Special Time
2) Being more involved
3) Slow rate of speech
4) Praise
5) Taking Turns
6) Listening
You may find that you wish to
spend more than one week on a
particular target. Move forward
at your own pace.
SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2000 23
home programmes
4) Listening to the child
5) Taking turns in the conversation
6) Establishing and maintaining appropriate eye
contact
7) Being more involved
8) Using appropriate language for the level of the
child.
In week four, the target is to enhance the par-
ents use of praise. The aim is to improve the
childs self esteem and confidence, and to encour-
age parents to focus on positive attributes of the
child as a behaviour management strategy. The
advice and techniques are described by Faber and
Mazlish (1980), who advocate that parents should
describe the behaviour they are praising and
incorporate a word which gives the child a posi-
tive label for him or herself. For example, I
notice that you have put all your toys in the toy
box, that was very helpful of you.
The management targets are select-
ed on the basis of the information
acquired as part of the parent inter-
view and may include:
1) Responding to Dysfluency
2) Behaviour Management
3) Bedtimes.
Consultation
The targets are added to the parents
Individual Therapy Programme (Table
2). The order in which the targets are
addressed is decided in consultation
with the speech and language thera-
pist who advises the parents about the
impact of one target on another and
the potential difficulty of each target.
Both factors may influence the order
in which the targets are tackled. A
pack is given for each target identified
containing:
i) A worksheet - to be completed
before beginning a new target. It asks
the parent to consider why it might be
helpful to make changes in a particu-
lar area in relation to the stammering
child. In addition, the parent is
requested to propose ways in which the changes
can be made.
ii) Information sheets - these provide some possi-
ble answers to the questions in the worksheet.
Parents are advised to complete the worksheet
before reading the information sheets.
iii) A Special Time Diary Sheet - to be completed at
the end of each Special Time session and returned
to the therapist at the end of each week.
In addition to the Special Time Diary Sheet, the
speech and language therapist monitors the par-
ents progress through a weekly telephone con-
versation. This formal weekly telephone appoint-
ment time takes the place of the weekly clinic
visit. It is arranged in advance between the ther-
apist and the parents, who may make contact
individually or as a couple. The aim is to provide
the parents with an opportunity to feed back
about the previous weeks target, to discuss any
concerns they may have about issues that have
arisen during the week and to discuss the impend-
ing weeks target. Through the telephone contact
time and the Special Time Diary Sheet, it is possi-
ble for the parents to raise any queries or difficul-
ties that they encounter as the programme
unfolds, thereby maximising the possibility of a
successful outcome.
Following completion of all the targets, the par-
ents continue to implement Special Time for an
additional six-week consolidation period.
Although there is no further structured telephone
contact time, the parents continue to return the
Special Time Diary Sheet to the therapist on a
weekly basis. The therapist replies to these, pro-
viding feedback and further advice as required.
At the end of the consolidation period, the par-
ents and the child attend the
clinic for a review of the
childs progress and to nego-
tiate further management.
Positive change
A number of families have
successfully completed the
Home Programme and modi-
fications have been made on
the basis of their feedback,
including the addition of
new target packs.
Preliminary findings indicate
the outcomes for children
are comparable to clinic
based therapy, both in terms
of positive change in dysflu-
ency and in the parents rat-
ing of change (see comments
in table 3).
We feel the Home Based
Fluency Programme for
Young Dysfluent Children
will enhance the range of
therapy options available to
therapists and families, fur-
ther enabling therapists to
select approaches based on the individual therapy
needs of the child and family, as well as increasing
access to therapy services for some families.
While the Programme was not devised to reduce
patient contact time with individual families or to
increase the number of families who can be treat-
ed by an individual therapist, the Programme
does clearly facilitate this. However, it is impor-
tant it is not selected on the basis of time man-
agement factors alone, as it is not suitable for
every family.
Training of generalist therapists who have expe-
rience of working with this client group using
parent-child interaction therapy methods has
begun and we expect that further modifications
may be made on the basis of their feedback.
Translation of a slightly modified version of the
Programme for use by families whose first lan-
guage is not English has just started and we aim
to expand this as the needs and opportunities
present themselves.
We anticipate The Home Based Therapy
Programme for Young Dysfluent Children will be
available in a published format in the near future
and short training sessions will be offered to coin-
cide with this.
Sharon Millard, Frances Cook and Jane Fry are
speech and language therapists at The Michael
Palin Centre for Stammering Children, Finsbury
Health Centre, Pine Street, London EC1R 0LP, Tel:
0171 530 4238, e-mail arsc@dial.pipex.com.
References
Christie. E, and
Evesham, M. (1998)
Changing referral
patterns to ensure
earlier identification
of dysfluent
p r e s c h o o l e r s .
International Journal
of Language and
C o mmu n i c a t i o n
D i s o r d e r s :
Proceedings of the
RCSLT 1998
Conference. 33
Supplement, 352-358.
Faber, A. and Mazlish,
E. (1980) How To Talk
So Kids Will Listen
and Listen So Kids
Will Talk. New York:
Avon Books.
Nicholas, A. and
Millard, S.K. (1998)
The case for early
intervention with
preschool dysfluent
c h i l d r e n .
International Journal
of Language and
C o mmu n i c a t i o n
D i s o r d e r s :
Proceedings of the
RCSLT 1998
Conference. 33 Supplement, 374-377.
Onslow, M. (1993) Behavioural Management of
Stuttering. San Diego, London: Singular
Publishing Co.
Rustin, L., Botterill, W. and Kelman, E. (1996)
Assessment and Therapy for Young Dysfluent
Children: An Interaction Therapy Approach.
London. Whurr Publishers.
Stewart, T. and Turnbull, J. (1995) Working with
Dysfluent Children. Bicester, Oxon: Winslow Press Ltd.
Contacts
The British Stammering Association is at 15 Old
Ford Road, London E2 9PJ, tel. 020 8983 1003.
Reflections
Do I plan for the
increase in
demand for
therapy
generated by
early intervention
and awareness
campaigns?
Do I take
sufficient
advantage of
the telephone
and post as
methods of
therapy contact?
Do I select
therapy options
on the basis of
clinical need
first and time
management
second?
Preliminary findings
indicate the
outcomes for
children are
comparable to
clinic based
therapy, both in
terms of
positive change in
dysfluency and in
the parents rating
of change
SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2000 24
further reading
EARLY
INTERVENTION
Fair, L., Louw, B. (1998)
Early communication inter-
vention with young chil-
dren with Pierre Robin
sequence. S Afr J Commun
Disord 45 p51-60.
Young children with Pierre
Robin sequence are at consid-
erable risk to develop delayed
or disordered communication
development. This study inves-
tigated the effectiveness of
early communication interven-
tion with four young children
with Pierre Robin sequence,
aged 5 to 28 months. The
Proportional Change Index
(Wolery, 1983) was used to
determine the amount of child
progress that took place dur-
ing the intervention period.
The results indicated that reg-
ular early communication
intervention sessions over an
extended period of time pro-
duced positive results, espe-
cially for expressive language
abilities. The presence of a
slight hearing loss due to otitis
media seemed to have influ-
enced the effectiveness of
early communication interven-
tion. One subject displayed an
associated disorder and evi-
denced the slowest rate of
development for receptive and
expressive language abilities
as well as a limited phonetic
repertoire for consonants. All
but one subject had limited
phonetic repertoires possibly
due to velopharyngeal incom-
petence. Early communication
intervention services should be
delivered regularly over an
extended period of time and
the hearing abilities and
speech production skills of
young children with Pierre
Robin sequence should be fol-
lowed closely during early
communication intervention.
f
u
r
t
h
e
r

r
e
a
d
i
n
g

f
u
r
t
h
e
r

r
e
a
d
i
n
g

f
u
r
t
h
e
r

r
e
a
d
i
n
g

f
u
r
t
h
e
r

r
e
a
d
i
n
g

f
u
r
t
h
e
r

r
e
a
d
i
n
g
AAC
Lembo, L. (2000) A case
study from Italy: AAC
and Marden-Walker
syndrome. Commun
Matters 14 (1) 31-4.
This case study describes
the approach adopted to
assist the communication
efforts of a boy of 15
affected by Marden-
Walker syndrome.
Because he didnt show
any interest in his com-
munication board, a dic-
tionary of the gestures he
was using spontaneously
was constructed with the
help of his brother. He
quickly understood the
importance of such a dic-
tionary, and through this
experience was enabled
to understand what the
use of a communication
board would offer. After
improving yes/no
responses, he was taught
the use of the communi-
cation board with picture
communication symbols.
He began to take the ini-
tiative and was now able
to describe or demand
favourite activities and
describe significant
events in his life. The use
of the communication
board was extended
beyond the familiar
home and school environ-
ment and he is being
encouraged to use it to
express feelings and emo-
tions. Attempts are being
made to stimulate read-
ing and writing, but this
has proved difficult for
him. It will be necessary
to work on phonological
competence using soft-
ware with voice output
to make him aware that
every written symbol has
a sound.
DEMENTIA
Runci, S., Doyle, C., Redman, J.
An empirical test of language-
relevant interventions for
dementia. Int Psychogeriatr 11
(3) 301-11.
The focus of this report is the
treatment of persons with
dementia who are of a non-
English-speaking background
(NESB). Noisemaking is one
behavioral manifestation associ-
ated with severe dementia. It can
have devastating effects on per-
sons with dementia by limiting
their access to activity programs
and social interaction, and is also
very distressing for professionals
and family carers. It can be espe-
cially difficult for carers when
they do not speak the first (non-
English) language of the person
with the noisemaking problem,
when the person has lost his or
her ability to speak English as the
dementia progresses. Behavioral
interventions have been found to
be successful in decreasing the
occurrence of noisemaking in
some people with severe demen-
tia. This article reports on a study
of an elderly Italian woman with
dementia. The study used a ran-
domized, alternating-treatments
design in order to determine
whether an Italian-language
intervention would be more
effective in reducing her noise-
making than the same interven-
tion given in English. The main
result of the study was that the
Italian intervention was found to
be significantly more effective in
reducing noisemaking than the
English intervention. Therefore,
this exploratory study provides
empirical evidence for the
increased effectiveness of an
intervention program in the
patients original language. The
study also demonstrates the need
for individualized intervention
programs, particularly for NESB
patients living in predominantly
English-speaking institutions.
HEARING
IMPAIRMENT
Lancioni, G.E., Markus, S. (1999) A
deaf woman learning to control
her excessive vocal loudness
through a portable feedback sys-
tem. Percept Mot Skills Jun 88 (3
Pt 2)1347-9.
A deaf woman learned to control her
excessive vocal loudness through a
portable feedback system, which pro-
vided vibratory stimulation when her
voice was too loud. The mean per-
centage of excessively loud talking
decreased from 45 prior to the use of
feedback to 3 during the use of feed-
back. This improvement (document-
ed by formal observation) was con-
firmed by normally hearing people
sharing the work environment with
the woman. The woman preferred a
system with a contact microphone
since this was virtually unaffected by
environmental noise.
This regular feature aims to provide information about articles in other journals
which may be of interest to readers.
The Editor has selected these summaries from a Speech & Language Database compiled by Biomedical Research Indexing. Every article in over
thirty journals is abstracted for this database, supplemented by a monthly scan of Medline to pick out relevant articles from others.
To subscribe to the Index to Recent Literature on Speech & Language contact Christopher Norris, Downe, Baldersby, Thirsk, North Yorkshire
YO7 4PP, tel. 01765 640283, fax 01765 640556.
Annual rates are
Disks (for Windows 95): Institution 90 Individual 60
Printed version: Institution 60 Individual 45. Cheques are payable to Biomedical Research Indexing.
DYSARTHRIA
Levin, K. (1999) Babbling in
infants with cerebral palsy. Clin
Linguist Phonet Jul-Aug 13(4)
249-67.
This study quantitatively describes
the babbling of eight 1-year-old
infants with cerebral palsy. Ninety
minute samples of vocalisation were
analysed in terms of the well-formed-
ness of the syllables and phonetic
structure of canonical syllables. The
onset of canonical babbling was
delayed in most subjects, all had
restricted phonetic repertoires and
produced monosyllabic utterances
only. The importance of the develop-
ment of controlled expiration to
drive the speech system for babbling
is highlighted. The findings challenge
the robustness theories of babbling
development, point to evidence of
dysarthria in babbling, and justify
early intervention. Methodological
issues in the study of babbling are
discussed, and suggestions for further
research are offered.
further reading...
SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2000 25
how I
manage
early feeding
difficulties
Early days of parenting are
fraught at the best of times,
especially when it comes to a
childs feeding habits. But when does
within normal limits cross the boundary
and become a problem requiring
speech and language therapy
involvement? Cerebral palsy and cleft
palate carry known risks of feeding
disorders, but speech and language
therapists are also increasingly
involved in working with families where
the child has a feeding difficulty that is
a result of prematurity, or is less easily
defined. This raises many questions.
How much of a part does communication
play? What sort of teams should we be
operating in? Is early intervention
effective in preventing later problems?
And what do we do about the
increasing number of children referred
with non-organic failure to thrive?
Three contributors share their
experiences.
Sue Strudwick is a specialist
speech and language
therapist with Kingston and
District Community NHS Trust.
She also lectures at
postgraduate courses,
including the Royal College of
Speech & Language
Therapists approved course
on paediatric dysphagia.
Joanne Marks is a specialist
speech and language
therapist with Mancunian
Community NHS Trust based
at Booth Hall Childrens
Hospital in Manchester.
Sara Russell is a specialist
speech and language
therapist with Yorkhill NHS
Trust based in the neonatal
unit at the Queen Mothers
Hospital in Glasgow.
Read this if you:
question our
involvement with
feeding difficulties
believe in
multidisciplinary
teamwork
are interested in
early intervention
SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2000 26
how I
eeding a baby or young child is a central part of par-
enting and, if there is a problem, the effect can have
profound consequences on the mother/child relation-
ship and on the wider family. The most important fea-
tures of intervention must be to
1. ensure feeding is safe
2. maximise nutrition
3. support the parents, whatever the feeding problems.
I am fortunate to work in a post that includes a small
amount of time on the neonatal and childrens ward and the
majority of time in the community, visiting families in their
homes. Our service is flexible enough that I am sometimes
given the opportunity to start intervention at a very early
stage on the ward, then follow this through when the child
goes home. The advantages of this are clear:
The mother has already established a relationship with the
therapist and has someone familiar coming into the home.
There is consistency of advice. Many parents of young children
are inundated with good advice from a variety of
professionals, friends and family members. This can lead to
the mother not following through particular strategies,
confusion for the child and a sense of not getting anywhere.
Early intervention can hopefully prevent some of the
behavioural difficulties that may occur later.
The common feeding disorders referred to me include
motor difficulties (such as are seen in cerebral palsy), sensory
problems (such as inability to move onto more challenging
textures), non-organic failure to thrive and behavioural prob-
lems. All these can co-exist and all benefit from a multidisci-
plinary team approach. The team predominant on the ward
includes the paediatrician, nurses, paediatric dietitian, spe-
cialist speech and language therapist and parent.
In the community our core feeding team includes specialist
speech and language therapist, paediatric dietitian, commu-
nity paediatric nurse and clinical psychologist. The involve-
ment of the health visitor is very important as are other mem-
bers of the child development team: physiotherapists, occu-
pational therapists and medical staff. The core members of
the feeding team - as well as the child and family - have ben-
efited from joint working. We have learned from each other
and shared skills. The team works on joint goals which are pri-
marily led by the needs of the child and parent and are there-
fore most likely to be adhered to. This coordinated approach
reinforces strategies and helps to eliminate conflicting advice.
Subtle
The first approach, following assessment, is to help the mother observe
her childs cues carefully and respond appropriately in terms of when
to offer food, the technique involved, and when to stop. Babies and
children, particularly those with special needs, often use very subtle
communication cues and the mother may have to watch for changes
in the babys colour, facial expression, body and limb movements,
breathing rate and eye movements. These indicate how the baby is
coping with the feeding process. Apart from leading to more success-
ful feeding, this gives the mother a positive role to play, at which she
is likely to succeed. This then boosts her confidence in dealing with her
child in all situations. Some parents can feel very deskilled by the hos-
pital stay and are not sure what their role is, as there has always been
someone on hand to deal with their baby until they get home.
All the medical intervention often required with special needs
babies and children can leave the mother very anxious about the
feeding process. If the normal feeding process is disrupted, the
mother/child dyad is also affected. Therapy is structured around
building up this dialogue and ensuring that mothers feel in con-
trol, safe and confident in their role. They can be taught to look
for signs of aspiration and reflux. Showing parents how to give
pleasant and normal sensations round the face and mouth, using
stroking, patting and touching to nursery songs, can be both encour-
aging and successful, and can allay further sensory problems later on.
Working to get a good feeding position is crucial. Choosing the right
bottle, teat, spoon or cup, as well as the right type of food and tex-
ture, are fundamental tools of feeding therapy. Examples include:
1. ensuring the child has lateral tongue movements before
offering chewable foods
2. using a shallow bowled plastic spoon for a child with oral
motor difficulties and bite reflex
3. giving external pacing for a bottle fed baby who has a poor suck-
swallow-breathe rhythm. The feeder decides how many sucks the
baby does before making it pause, and uses rocking, walking and
patting at the rhythm of one per second - the same speed and
rhythm babies suck at - to help build an internal rhythm for the baby.
Apart from seeing babies and children at home for individual
therapy, I see children in our feeding clinic. This is held once a
month at the childrens centre. Joint assessment often involves
one of the team members visiting at home and making a video
of a mealtime. This can then be used to evaluate behaviours,
feeding position, timing, utensils, textures, oral motor skills,
interaction between mother and child and whether the childs
communication cues are being responded to. Intervention can
then be prioritised around the childs needs. Joint aims are set
and these are written down as a feeding plan for the parent to
take away and to share with other people involved with the
child. Follow-up may take the form of visits by individual mem-
bers of the team, play therapy around messy food, phone calls
to support the parent and further appointments to the feed-
ing clinic to discuss progress and re-evaluate the goals.
Confident
Many children are referred to the feeding clinic from about 10
months with a strong aversion to the feeding process. Through
taking a careful case history, it often emerges that the child has had
a period of negative oral experiences, such as nasogastric feeding,
or vomiting. Concern about the childs weight has also contributed
to the parents anxiety. Many mothers have been overly persuasive
or forceful in their attempts to get the child to eat. Work then must
be centred around the child becoming confident with food. Giving
textures and tastes the child enjoys and can cope with is the start-
ing point. Looking at timing and pacing of feeds is important,
while the dietitian will use her creative skills to ensure the child is
safe nutritionally and reassure the mother. I use messy play with-
in the clinic and at home to help the child explore food and even-
tually to taste it. The clinical psychologist has helped us see that
choosing small steps is often the key to success. Improvement in
the feeding situation can take a very long time and it is impor-
tant to change one thing at time and slowly but surely move
towards the agreed goals. Motivation and enthusiasm can then
be maintained by both therapist and parent.
The speech and language therapist involved with early
feeding problems needs to be
knowledgeable and competent to make the parent feel
safe and trust the therapist
empathetic, so parental fears and worries are contained
enthusiastic to give confidence that the therapy will work,
but
honest and realistic about what can be achieved.
That way, progress and a safe feeding situation is most likely
to be the outcome.
Useful books
McCurtin, A. & Kennedy, G. (1997) The Manual of Paediatric
Feeding Practice. Winslow. ISBN 0863881734.
Evans-Morris, S. & Dunn Klein, M. (1987) Pre-feeding Skills.
The Psychological Corporation. ISBN 0761674063.
Wolf, L. S., Glass, R. P. & Glass, R. P. (1992) Feeding and
Swallowing Disorders in Infancy : Assessment and Management.
Therapy Skill Builders. ISBN 0761641904.
F
Small steps over a
long period may be
needed to resolve
early feeding
difficulties, so
professionals must
gain the confidence
and trust of parents.
Sue Strudwick
demonstrates why a
team approach is
best.
Consistency
of
advice
Sue Strudwick
SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2000 27
how I
While the debate
about the diagnosis
of non-organic
failure to thrive goes
on, Jo Marks argues
speech and
language therapists
have much to offer
parents who may be
resorting to extreme
measures to get their
children to eat.
From
vicious to
virtuous
circle
ver the past couple of years there has been a sig-
nificant increase in the number of referrals of chil-
dren - born full term with no medical difficulties
- who appear not to have taken advantage of the
window of opportunity to establish appropriate feeding
patterns at a number of crucial developmental stages. They
are often hospitalised and undergo numerous tests which
come back negative. The common factors are weight loss and
difficult feeding behaviour.
While many of us are aware of the effects of tube feeding,
prematurity and gastro-oesophageal reflux on early oral
feeding experiences, there has been much debate regarding
the existence and diagnosis of non-organic failure to thrive.
Batchelor (1999) states: Non-organic failure to thrive is due
to inadequate intake of nutrition, whilst recognising that the
routes to inadequate intake may be wide-ranging and result
from a complex interaction of environmental and individual
factors. There has been a great shift in the literature and
research from identifying non-organic failure to thrive as a
result of emotional deprivation towards whatever the pri-
mary aetiology, inadequate energy intake is the final com-
mon pathway of the growth failure in non-organic failure to
thrive (McCann et al, 1994).
Ideally, referrals to the specialist speech and language thera-
pist and multidisciplinary team should be made as soon as pos-
sible but it is often months from the initial onset of the prob-
lem to the child being seen for a specialist paediatric assess-
ment. By this time parents may be resorting to extreme mea-
sures to get some form of nutrition into their child - syringing
food, feeding babies/toddlers whilst asleep or force feeding.
Advice
As a clinician who works both in an acute and community set-
ting, I receive referrals from a variety of sources, primarily
community consultant paediatricians or paediatricians within
the acute setting. By the time the referral has reached me the
child and mother/carer have seen - and been given advice by
- a long list of professionals including health visitors, GPs and
paediatricians, often reinforcing the vicious circle (figure 1).
Typically, these children present with common factors:
1. real concern about weight gain
2. good early feeding pattern not established - parents
describe difficulty with bottle/breast feeding
3. difficulty weaning
4. limited range of diet, faddy eater
5. a preference for fluids (often take a large fluid intake)
6. child never requests food and shows little or no interest in food
7. parents always feed child; no self-feeding instigated
8. child fed independent of family and social setting
9. mother-child interaction has changed over time.
Bachelor (1999) states the nutritional and psychosocial
dimensions must be addressed at assessment and interven-
tion, because of this a multidisciplinary perspective, assess-
ment and intervention is extremely valuable. In an ideal world
a multidisciplinary team approach is essential but access to an
appropriate team is not always available. In my working prac-
tice, initial assessment is routinely carried out with a colleague
from dietetics whether it be an outpatient/inpatient appoint-
ment. The mother/carer is asked to keep a food diary prior to
the appointment and to bring weight history information to
the session. Parents are also asked to bring a range of food
and drink with them to be used in the oral feeding assessment.
A detailed case history is taken alongside a full nutritional
assessment. An oro-motor examination is carried out and the
childs feeding pattern observed. Being very aware of the
artifical nature of this, a subsequent home visit may be
arranged to coincide with a mealtime. Ideally a videotape
recording of the child feeding is made. Observations are also
made regarding mother-child interaction. Referral may be
made to the clinical psychology service to continue interven-
tion.
Realistic
Therapy is moulded to meet the needs of the individual child
and their family on the basis of assessment and is ideally car-
ried out in a combination of the clinic and home. The team
aims to implement a change both nutritionally and environ-
mentally. The primary concern is to attempt to increase nutri-
tional intake through diet modification, often in parallel with
a behavioural approach to feeding as a whole. A number of
joint goals are set with parents/carers that are achievable and
limited initially in number, as offering a lengthy list of options
results in very little change and a negative review session at
a later date. It is essential to explain to parents that any imple-
mentation of change takes time and positive results are
unlikely to be seen overnight. Often parents arrive feeling
very disheartened, anxious and low, wanting a magical cure.
With this in mind we take time to define our role and give a
realistic length of time for treatment, negotiating the timing
of further appointments depending on individual need.
Inevitably there is a high level of anxiety, often serving to
reinforce the whole feeding pattern. Direct guidance is neces-
sary to change actual actions and behaviours at mealtimes.
Playing back pre-recorded video material is an excellent way to
demonstrate this to parents. In some cases families are asked
to keep written records/diaries in specific relation to target
goals. Follow-up is essential and a repeat video session may be
useful. Weight is monitored, as appropriate, by the dietitian.
A key to success is involving appropriate professionals to
support the family. These include health visitors, nursery
nurses, play therapists, social services, nursing staff, auxiliary
staff, preschool support workers, community paediatric nurs-
ing team and extended family.
How we manage this population within current resources -
and in the context of the continuing debate about its diag-
nosis - is an important issue. We must evaluate outcomes and
question our effectiveness, and, given the increasing role of
both specialist and generalist speech and language thera-
pists, work collaboratively within our departments as well as
within multidisciplinary teams. The importance of clearly
designed referral guidelines/criteria cannot be emphasised
enough. Hopefully, with these in place, inappropriate refer-
rals of children who are simply faddy eaters within normal
limits will not be made.
References
Batchelor, J. (1999) Failure to thrive in young children. The
Childrens Society.
Hampton, D. (1996) Resolving the feeding difficulties associ-
ated with non-organic failure to thrive. Child: Care, Health &
Development 22 (4) 261-271.
Hanks & Hobbs (1993) Failure to thrive - a model for treat-
ment. Baillieres Clinical Paediatrics 1 (1) Feb 1.
McCann, Stein, Fairburn & Dinger (1994) Eating habits and atti-
tudes of mothers of children with non-organic failure to thrive.
Archives of Disease in Childhood 70: 234-236.
O

Figure 1 Vicious circle of non-organic failure to thrive


Joanne Marks
SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2000 28
how I

colleagues, particularly at this very early stage which can deter-


mine so much of a babys future development.
It is interesting to note that feeding has progressed, not only
in terms of quality, but also in the number of breastfed pre-
mature babies. Glasgow has traditionally had a poor percent-
age of mothers discharged home breastfeeding but, in line
with an overall increase, our special care rates have improved.
With increase in survival rates across the board, much of my
input is now with babies/infants who may not necessarily
have been premature but who have undergone surgery and
been in surgical wards for long periods, for example children
with cardiac defects, diaphragmatic hernias, necrotising ente-
rocolitis and renal failure. These children have been ill and
therefore tube fed for substantial periods of time. Our man-
agement is to educate nursing staff and parents so that pos-
itive oral stimulation takes place throughout the childs stay
in hospital. Many of these children go on to have huge aver-
sive reactions to mealtimes and food and, in these cases,
working alongside a clinical psychologist is invaluable. I try
to incorporate tactile play (specifically with food, unless a tac-
tile defensiveness to other textures is also observed) as early
as possible and encourage parents to allow their children to
get messy as they introduce solids.
One other disorder - which often goes unrecognised but
which can have major effects on eating behaviour - is Gastro-
Oesphageal Reflux. Often a baby will not have the overt symp-
toms of vomiting and so therefore is not tested for reflux early
enough. In the meantime the discomfort of reflux persists, often
leading to a complete food aversion. These children typically look
hungry, seek out the bottle / breast and start feeding normally,
but very quickly pull away. If in any doubt I tend to ask for a ph
test to be carried out because - although we can recommend all the
messy play, finger feeding and building confidence with food - as
long as the discomfort persists, feeding will not dramatically improve.
Treatment varies from adding thickeners to prescribed medication.
Having worked for the same trust for six years, always focusing
on feeding difficulties in young children, I see a huge change
in referral trends. Particularly because of our involvement with
young babies and neonates, other professionals are more
ready to refer other infants with feeding problems that we
may not be seeing routinely. Research findings over the past 15
years suggest failure to thrive is a common feature of early
childhood, usually occurring in isolation (Wright, 2000).
Toddlers with failure to thrive often have a low intake of
immature, low energy foods - usually pureed/stage 1 (4 month)
- with a high fluid intake. Some are referred to speech and lan-
guage therapy but I feel ours is more of a screening role to
ensure the child can deal with stage 2/lumpier and finger foods
and, of course, to rule out any physical cause of their failure to
thrive. The aim of management is to expedite their progres-
sion onto more energy dense solid foods (Wright, 2000).
Feeding management should always be seen as multidisci-
plinary. This is sometimes difficult to put into practice in com-
munity caseloads but, the more we consult our colleagues
such as dietitians and psychologists for advice, the more we
gain professionally - as do they.
References
Als, H., Lawhon, G., Duffy, F.H., McAnulty, G.B., Gibes
Grossman, R. and Blickman, J.G. (1994) Individualized devel-
opmental care for the very low-birth-weight preterm infant.
JAMA Sep, 272:11, 853-8.
Field et al. (1982) Non-nutritive sucking during tube feedings.
Effects on Pre-term Neonates in an Intensive Care Unit.
Paediatrics 70 (3).
Wright, C. Identification and Management of Failure to
thrive: a community perspective. Archives Disease Childhood
2000 82: 5-9 (January).
s part of my role in a Special Care Baby Unit I am
responsible for the assessment and management of
early feeding problems. In the past, premature
babies, particularly those born at less than 32
weeks gestation, were at high risk of developing
feeding problems in the immediate neonatal period and in
later years. However, with the increase in developmental sup-
portive care throughout the modern world, we have seen a
decrease in feeding problems both initially and in early child-
hood.
Developmental Supportive Care (Als et al, 1994) seeks to
promote a less stressed baby by positioning appropriately -
providing containment / boundaries similar to utero, reducing
environmental stimuli (bright lights and loud noises) and providing
non-nutritive sucking experiences (Field et al, 1982). By employ-
ing these and other principles, babies sleep for longer and there-
fore grow quicker, are less agitated and more motorically stable
and tend to feed orally earlier with less aversive behaviours.
In assessing a babys suck feed, I categorise in one of three
patterns:
1. normal term
2. immature (normal for a premature baby) or
3. disorganised.
A disorganised suck pattern is most often seen in those
babies who either have some neurological component or are
severely respiratorily compromised (bronchopulmonary dyspla-
sia) as a result of their prematurity. Those babies presenting
with an immature pattern of suck-swallow-breathe should
require no intervention as they will continue to mature at their
own pace. Disorganised patterns of suck-swallow-breathe do
require some intervention but my first variable is always to
look at environmental and positioning aspects in conjunction
with developmental physiotherapy and nursing colleagues.
By ensuring our neonates develop more stability, are less
agitated and acquire a normal pattern of oral feeding, we
can prevent some future milder problems that we used to see
in the community such as poor attention skills and poor later
eating skills. Five and six years ago the vast majority of my
feeding referrals were ex-premature babies who had failed
ever to make the transition to seven month/stage 2 type foods
(mashed / small lumps) or who, indeed, were still tube fed.
As a result of the implementation of Developmental
Supportive Care in two of our major neonatal units in
Glasgow, the number of children being referred for failure to
move on to lumpier foods has dra-
matically reduced. I believe this is
due to a reduction in oral hypersen-
sitivity because of non-nutritive
sucking and promotion of hand
mouth positioning similar to utero
in the infants early days, regardless
of medical condition. In conjunc-
tion with this, better positioning
ensures more stability which in turn
goes on to promote more normal
patterns of movement. For example,
it is interesting that trunk rotation
(rolling) ties in with rotation of the
tongue and ability to deal with
lumpier foods. Typical problems of
a pre-term baby used to be failure
to move from one position to
another (for example by rolling or
crawling) and problems coping with
lumpier foods. Because feeding is so
dependent on motor stability, it is
vital that speech and language thera-
pists work alongside physiotherapy
Developmental
supportive care has
led to a reduction
in early feeding
difficulties in
premature babies.
Sara Russell tracks
how referral
patterns and her
role have changed
as a result.
Changing
the
pattern
A
PRACTICAL POINTS
1. Promoting early referral and providing a neonatal
service prevents difficult feeding patterns and disrupted
parent / child interaction becoming established.
2. Parental anxiety can best be allayed if they have
continuity and confidence in the competence of the
professional they are dealing with.
3. Parents are empowered by consistent, clear advice,
with only one or two changes suggested at a time.
4. Multidisciplinary teamwork - including across the
acute / community boundary - is important, with the
members of the team shifting depending on age,
stage and setting. Working with a clinical psychologist
can be particularly useful.
5. Children with early feeding difficulties need a lot
of messy play experience with food.
6. Video can be a useful tool to provide real-time,
objective and specific feedback.
7. Be alert to problems such as reflux which may not
have obvious symptoms.
8. We should continue to debate and define our role
in the management of early feeding difficulties for
ourselves, other professionals and parents.
Sara Russell
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EVENTS
Post registration paediatric dysphagia course
September 14/15 and 26/27 plus follow-up day in 2001
Birmingham
Details: Jo Frost, tel. 0121 628 2813
e-mail jfrost@ukgateway.net
www.quest-training.com
Royal College of Physicians - Conference
The Interface Between Doctors, Patients and
Patient Support Groups
27 September, 2000
Addresses the moves away from medical pater-
nalism towards more patient centred healthcare.
Details: Conference Office, tel. 020 7935 1174 ext 436.
Millennium Festival of Medicine Conference
Interrelationships in healthcare
Thursday 9 November
Queen Elizabeth Conference Centre, London
Debates include: the patient as expert (living with
long term problems), teamworking, socio-economic
differences in healthcare and patients and research.
Details: tel 020 7383 6047 / www.medicine-2000.org
10th ACPS Study Day
(Augmentative Communication in Practice:
Scotland)
Aberdeen Exhibition and Conference Centre
Thursday 2 November, 2000
Keynote speeches Nick Hine, University of Dundee
and Dr Martine Smith, Trinity College, Dublin
Details: SCTCI, WESTMARC, Southern General
Hospital, 1345 Govan Road, Glasgow G51 4TF,
tel. 0141 201 2619.
N
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TA
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IN
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PA
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E
!
MY TOP RESOURCES
and
Alison Parsons
work in the Perth
and Kinross area
of Tayside
Primary Care NHS
Trust. Lindas
post is full-time in
the community
with adults who
have acquired
neurological
communication
and/or swallowing
problems while
Alisons also
includes
paediatric and
voice clients.
Many of their top
resources reflect
the challenge of
serving adult
clients spread
over a large
geographical
area.
1. Car
Our very top resource has to be our cars.
Lindas post covers an area of about 2500
square miles, so she cannot rely on buses or
trains - services in the rural area are limited
and infrequent, and routes rarely run directly
between community hospitals and nursing
homes. Alisons community adult neurological
caseload is over 30 miles away from the base
at Perth Royal Infirmary and can involve jour-
neys along single track roads. As well as trans-
porting us, our cars act as travelling equip-
ment stores; the boots are often loaded with
assessments, therapy materials and alternative
and augmentative communication devices.
5. Motivation
We are not able to visit clients on a daily basis to
check that advice is being implemented or ther-
apy activities are being undertaken regularly, so
we have to rely heavily on both the clients them-
selves when possible and, more often, on their
significant others such as family, residential or
nursing home staff or hospital nurses. Without
their individual and combined motivation we
cannot be effective. Increasingly, level of moti-
vation appears to be one of the most significant
prognostic indicators, so our persuasion skills
have to be well-honed.
8. Photocopy-free workbooks
Alison finds these an excellent resource for
several reasons. They save preparation time,
which is already reduced when the driving
time to get to the client can be more than 50
minutes. Why reinvent the wheel? It takes
less time to adapt than to develop therapy
tasks, even including watching out for
American spelling and cultural bias in vocabu-
lary and content. The exercises in published
workbooks can be used as a template, with
variation in level of difficulty possible for indi-
vidual clients - especially those with mild apha-
sia. A selection of pages can be photocopied in
advance so that appropriate therapy tasks can
be to hand far from base and when the client
seeks more activities to undertake between
sessions. Alisons particular favourites are
Susan Howell Brubackers Workbook for
Cognitive Skills and Workbook for Aphasia
available from Winslow priced 44 each.
9. Management of Speech and
Swallowing in Degenerative Diseases
As many of Lindas clients are people with
progressive neurological disorders, this book
is very useful. Its four chapters cover the
more common progressive neurological con-
ditions encountered in clinical practice:
motor neurone disease, Parkinsons disease,
Huntingtons disease and multiple sclerosis.
Each chapter begins with a clearly-organised
description of the nature of the disorder
followed by sections on speech and swallow-
ing, all sub-divided by different questions.
There are extensive reviews of relevant
research evidence for each disorder - for
example, on concomitant physical, cognitive
and linguistic changes - but these are quite
short and readable. Other issues such as
medication are also discussed. Practical
assessment and management information is
offered as well as many examples of severity
rating scales, with suggested interventions at
the various stages of the disease process. It
concludes with a series of photocopiable
handouts for families which describe both
symptoms of speech and swallowing disor-
ders and ways to help. These are very
American in style but could easily be adapt-
ed into British English.
Yorkston, K.M., Miller, R.M., and Strand, E.A.
(1995) Management of Speech and
Swallowing in Degenerative Diseases.
Communication Skill Builders (45).
2. Phones
As neither of us is able to visit our clients
daily, the phone allows us to
a) check with nursing staff or family
whether swallowing advice has been helpful
or client status has changed
b) receive urgent referrals
c) make short-notice appointments and
d) keep in contact with our base on days we
arent there.
Our area has mobile phone signal holes so
we have to be careful about where we break
down or get stuck in roadworks.
3. Colleagues
Several sets of Trust colleagues help us to do
our jobs better.
a) Our speech and language therapy col-
leagues based at Perth Royal Infirmary - and
who have more experience in assessing and
managing acquired swallowing disorders -
are constantly used for second opinions,
either by phone or through case discussions.
b) The departmental secretary, who looks
after all 20 of us, ensures urgent messages
are received and maintains our administra-
tive efficiency while
c) our assistant helps us produce profession-
al-looking therapy materials, laminated com-
munication books and advice sheets.
d) Trust specialist nurses for progressive neu-
rological diseases are a major resource, both
as a referral agency and as a key-worker for
our mutual clients.
e) Community hospital receptionists/clerical staff
are also very important as they coordinate
accommodation in hospitals where there is no
designated speech and language therapy room.
4. In-service training and link nurses
The department has been offering a rolling
programme of well-received seminars for GPs
and in-service training seminars and workshops
for nursing and paramedical staff in the com-
munity hospitals for two years. As well as
increasing other staff groups knowledge of
acquired communication and swallowing dis-
orders, these have a huge benefit in raising our
personal and the services profile. In one area
we had more referrals in the month following
a GP seminar than we had received in the pre-
vious year. Alongside the in-service training,
we are gradually developing a role for link
nurses in the various localities in the Trust.
10. Groups, conversational
analysis and SPPARC
Alison usually leads our group therapy ses-
sions for people with aphasia. These are par-
ticularly difficult to organise in an essentially
rural area - where matching clients may live
50 miles apart - so do not run continuously.
However, group therapy has a valuable place
in the rehabilitation of some people with
aphasia. Recent groups have been either
language disability-focused or project-based;
for example people with aphasia produced a
leaflet for others with aphasia. For the near
future we are hoping the service will be able
to replicate a model of effective group inter-
vention via conversational analysis, to which
we were converted at a two-day in-service
course presented by Sarah Lock and Ray
Wilkinson earlier this year. We look forward
to the forthcoming publication of the pack
describing their approach: S. Lock, R.
Wilkinson and K. Bryan The SPPARC
Programme: Supporting Partners of People
with Aphasia in Relationships and
Conversations (provisional title) (Winslow)
ISBN: 0 86388 278 1.
6. Cool bag
So far, no assessment or equipment has been
mentioned. In the fifteen months of Lindas
post, the most regularly used piece of equip-
ment has been the cool bag (see photo) which
houses a bedside swallowing assessment.
Contents include spoons, gloves, torch, tongue
depressors, long cotton buds, medi-wipes,
gauze, puddings and sometimes biscuits, as
well as a written reminder of what should be
included in the assessment. Whilst most of
these items can be gathered if the client is seen
in a hospital setting, scrounging is not always
the best way to develop good relationships
with other staff. Also just picking up the bag
when necessary, in the knowledge that what is
likely to be needed is there, saves lots of time.
7. Assessment
Since the caseload is very varied - ranging from
people in their 20s with progressive neurological
disorders to a lady in the week of her 100th
birthday referred for swallowing assessment -
our assessments will initially be informal and
then, if appropriate, followed up at a future visit
by formal testing. We are both fans of Pyramids
and Palm Trees and PALPA and find very often
that it is not the scores achieved on these and
other tests which inform us as much as how the
client has approached the task. We are both as
interested in the quality of responses as in scores
- analysis of error types and discussion about dif-
ficulties on a task as well as discussion of client
priorities give our therapy more substance.
Pyramids and Palm Trees (David Howard and
Karalyn Patterson), Thames Valley Test
Company, tel. 01284 728608.
Psycholinguistic Assessment of Language
Processing in Aphasia (Kay, Lesser and
Coltheart), Lawrence Erlbaum Associates.
Linda Armstrong