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ISSN 1368-2105

Summer 2006

www.speechmag.com

EXPLORING SPACES

Working with teachers and parents - making information accessible

Partnership in profile

Show and Tell

The space between: Addressing


speech issues

How I used a systematic approach for


Aphasia Phonology

And featuring Male communication

PLUS...The Application keyHeres one I made earlierRecommended reading


and My Top Resources from people with Parkinsons Disease

Reader oers

WIN TALKING MATS BOOKS

WIN NDP3 (2004)


The Nuffield Centre Dyspraxia Programme has been completely updated and revised and we have TWO copies to give away FREE to lucky readers or departments. This 3rd edition includes a detailed therapy manual, an oro-motor and speech assessment procedure, photocopiable therapy worksheets and therapy picture cards. NDP3 with NDP Therapy Cards usually retails at 228 + shipping. For your chance to win a copy, e-mail your name and address to Speech & Language Therapy in Practice editor Avril Nicoll (avrilnicoll@speechmag.com) or post to her at: 33 Kinnear Square, Laurencekirk, Aberdeenshire AB30 1UL. The closing date for receipt of entries is 25th July 2006 and the winners will be notified by 1st August. For details about NDP3, see www.ndp2004.org.

Talking Mats is a research-based low tech communication tool designed to help anyone with communication difficulties think about issues and express their opinions effectively. Talking Mats developers Joan Murphy and Lois Cameron have written a book to explain its uses, incorporating the knowledge and ideas they have gathered from clinical research, practice and training courses. Talking Mats - A Resource to Enhance Communication usually retails at 14.99 but you can win one of THREE copies FREE! To take part, simply send your name and address to: Linda Tierney, AAC Research Unit, University of Stirling, Stirling FK9 4LA, or e-mail linda. tierney@stir.ac.uk. The closing date for receipt of entries is 25th July 2006 and the winners will be notified by 1st August. For more details about this and other Talking Mats resources, see www. talkingmats.com.

The lucky winners of Barbara Prashnigs Learning Styles in Action, offered in our Summer 06 issue courtesy of Network Continuum Education, are Kim Williams (Salford), Jane Baker (Kingsteignton), Liz Fairweather (Cupar), Janice Maughan (Guiseley) and Julie Phillips (Manchester). Congratulations to you all!

Summer06speechmag
NEW ARTICLES ADDED TO WEBSITE - VIEW FOR FREE!
To subscribe to our FREE e-update service for readers of Speech & Language Therapy in Practice, e-mail avrilnicoll@speechmag.com. Your details will not be passed to any third party.

E-UPDATE SERVICE

Westaway, A. (2005) Signing up to inclusion, Speech & Language Therapy in Practice Autumn, pp.7-9. Online at www. speechmag.com/archives/annawestaway.pdf Heneker, S. & MacLaren Page, L. (2003) Functional communication: the impact of PECS, Speech & Language Therapy in Practice Autumn, pp. 12-14. Online at www.speechmag.com/archives/impactofpecs.pdf If you want to find out more about some of the topics in this magazine, you may be interested in the following articles from earlier issues. Remember, if you dont have access to them, check out the abstracts on www.speechmag.com and take advantage of our article ordering service.

Partnership (305) Child, C. (2005) Getting the message. Spring: 4-6. Aphasia (050) Armstrong, L. & MacDonald, A. (1998) Augmentation or extra effort? Using computers with people who have aphasia. Winter: 15-17. (194) Wade, J. & Woodward, S. (2002) This is IT. Summer: 13-16. Phonology (221) Bowen, C. (2002) My Top Resources. Winter: back page. Online version available FREE at http://members.tripod.com/Caroline_Bowen/topten.htm. (020) Ogilvie, M. (Emphasising communication); Stanbury, R. (Maintaining motivation); Williams, P., Corrin, J., Colebourne, S.J., Burrows, S. & Friel, S. (A specialist opinion). All in (1997) How I manage speech sound difficulties. Winter: 24-28. Gender (226) Earle, S. (2003) Barbie & Ken: an unequal relationship. Spring: 21-22. Accessible information (308) Nicoll, A. (2005) The write stuff? Spring: 14-16.

IMPROVED CUMULATIVE INDEX FACILITY

Our cumulative index facilitywill soon be database-driven! This means you will be able to search for articles from the Spring 2004 issue by author, title or text, and we are also grouping articles under new categories. (The index of abstracts from Summer 1997-Winter 2003 is still available online. You can search it by author, category or through using the speechmag sites search facility.) When you find an abstract that inspires you, you can order a copy of the full article for a small charge via our secure server.

www.speechmag.com Pay us a visit soon.

contentssummer06
4 COVER STORY: THE SPACE BETWEEN
I reasoned that the difference(s) between what Jason could and couldnt say would provide a basis for treatment. So I took a word Jason couldnt say, and changed it to something he could say. We continued this process, gradually moving closer to the target, until he could say it correctly. Each change produced a nonsense word, but a possible one nonetheless. Aubrey Nunes explains feature prosodic therapy, where a child with a speech disorder and their therapist explore the space between what the child can say and what they cant.
Cover photo: Paul Reid. Posed by models.

18 KEYS TO WINNING WAYS SERIES (7) THE APPLICATION KEY


I observed the non-stop asking of questions by curious well wishers and loving friends and relatives and learned not to ask. How are you? Are you in pain? Are you being sick? Are you sleeping? Have you lost weight? - all understandable, but so wearing if answered twenty times a day. Life coach Jo Middlemiss did not choose the sad circumstances surrounding this article. But it felt an appropriate time to explore the toughest challenge of all the application of her keys at a time of loss.

20 CONFERENCE CALLS SHOW AND TELL


All participants were invited into small groups to discuss fundamental questions posed by the conference working group: 1. What information is being made accessible? 2. Why is information being made accessible? 3. What are the risks / pitfalls of making information accessible? 4. What is being done to reduce these risks / pitfalls? As demand for accessible information grows, Alison Matthews and Rachel Samuels report on a multi-agency event that kick-started a north west of England forum for sharing good practice.

SUMMER 06 (publication date 27/05/06) ISSN 1368-2105

INSIDE COVER READER OFFERS, SUMMER 06 SPEECHMAG


Win the Nuffield Dyspraxia Programme (NDP3) and Talking Mats a Resource to Enhance Communication Also see reader offer for the new Communication Development Profile on p. 10

Published by: Avril Nicoll 33 Kinnear Square Laurencekirk AB30 1UL Tel/fax 01561 377415 e-mail: avrilnicoll@speechmag.com Design & Production: Fiona Reid Fiona Reid Design Straitbraes Farm St. Cyrus Montrose Angus Website design and maintenance: Nick Bowles Webcraft UK Ltd www.webcraft.co.uk Printing: Manor Creative 7 & 8, Edison Road Eastbourne East Sussex BN23 6PT Editor: Avril Nicoll, Speech and Language Therapist Subscriptions and advertising: Tel / fax 01561 377415 Avril Nicoll 2006 Contents of Speech & Language Therapy in Practice reflect the views of the individual authors and not necessarily the views of the publisher. Publication of advertisements is not an endorsement of the advertiser or product or service offered. Any contributions may also appear on the magazines internet site.

2 NEWS / COMMENT 8 PARTNERSHIP IN PROFILE


Right from the initial transition meetings, parents are clear about what their child needs and recognise the value of interaction approaches, and teachers are clear about their role and responsibility and how the child will be supported by the speech and language therapy service when in school. Charlotte Child reflects on the inspiration, theory and life experience underpinning her newly-published Communication Development Profile - and explains how it has led her to a genuine and rewarding partnership with teachers and parents.

24 HOW I USED A SYSTEMATIC APPROACH


Our authors explain their choice of a systematic and finely graded therapy programme for their clients and highlight the importance of timing when making management decisions.

(1) THE RIGHT TIME TO ACT

11 HERES ONE I MADE EARLIER


Alison Roberts with more low-cost therapy activities: Binocular game; Wedding cake game.

12 REVIEWS
Collaboration, group work (adults; literacy; learning), speech disorder, literacy, software, stammering, signing, adolescents, autistic spectrum disorder.

Mr McDonald expressed through his wife that he now wished to explore new possible communicative means as an alternative to his impaired speech production[and] we agreed that his written language expression would be the focus of the next block of therapy. Ideals of client-centred goal negotiation, outcomes that really make a difference and effective use of limited therapy time can be challenged when we are working with clients with chronic severe aphasia. Linda Armstrong and Jaclyn Dallas discuss the benefits and limitations of introducing a client to Beesons Anagram and Copy Treatment and Copy and Recall Treatment protocols.

(2) NEVER TOO SOON TO START

14 FEATURE FROGS AND SNAILS AND PUPPY DOGS TAILS?


In researching this topic it quickly became clear that, even where boys and men do not have a communication impairment, there are general male communication issues that impact on many areas of life learning, interacting with others, even health. Could we improve therapy outcomes if we had a better understanding of why and how male communication can be different? Editor Avril Nicoll finds out what little (and not so little) boys are really made of.

Caelan took to the programme like the proverbial duck to water. Although features of social communication disorder were less obvious than previously, Caelan still liked routine and predictability. The routines of practice and therapy therefore worked well for him. Heather Saunders on why she believes the third edition of the Nuffield Dyspraxia Programme was the key to improvement made by Caelan, a preschool child with autism and verbal dyspraxia.

BACK COVER MY TOP RESOURCES


Parkinsons is a very individual condition, and many people living with it tell us they feel that health professionals do not know enough about it. The Parkinsons Disease Society ask people with Parkinsons disease to think about the resources they value most in a speech and language therapist

17 RECOMMENDED READING
Dysphagia; collaboration with educational psychologists.

IN FUTURE ISSUESDYSARTHRIA...APHASIA...SOUND THERAPY...USER INVOLVEMENT...STAMMERING


SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2006

NEWS

Return to practice process

Following consultation, the Health Professions Council has published its process for returners to practice. Under legislation the Council cannot carry out individual assessments of returners requirements, but instead must provide information in a way that enables a returner to identify what is required of them. From July 2006, for people with 0-2 years out of practice there are no requirements, while 2-5 years needs 30 days of updating and 5 or more needs 60 days. The updating period should be structured to include supervised practice, formal study and private study, and must be completed within 12 months immediately preceding the date on which they apply to be readmitted to the register. Policy Manager Rachel Tripp explained, Health professionals may take a break in their practice for many reasons. It is vital that we set up a system which allows these people to return to the Register, and to update their knowledge and skills in a personal way which combines flexibility and public protection, so that they can then return to the workplace as safe and effective practitioners. www.hpc-uk.org

Call for more MS specialists


Therapists in MS are calling for an increase in specialist therapy provision to improve quality of life and reduce hospital admissions in people with multiple sclerosis. A project group, which includes Aberdeen based speech and language therapist Clare Laing, says there are only around 100 suitably qualified therapists in the UK, and that specialist therapists will have to take on a greater role if National Institute of Clinical Excellence guidelines on MS are to be successfully implemented. In a report issued by the MS Trust, the group lists a passion for MS management among the key competencies of specialist therapists. They recommend that assessments should take place in the home environment and that therapy services should be holistic, covering work, leisure and personal care, and showing good knowledge of available local resources. They say that speech and language therapy services in particular should be available early enough to prevent a crisis and that there should be timely provision and review of assistive technology and equipment. Treatment should be goal orientated and specialist therapists should have training so they can discuss the impact and management of loss. Shortly after this report was released, the MS Trust drew attention to the financial threat to over a quarter of existing MS Specialist Nurse posts. Spokesperson Nicola Russell said, We are worried that MS may be seen as a soft target for cost-cutting because it has a lower profile than some other diseases. It is outrageous that people with MS, who are already vulnerable, are being penalised for shortfalls within the NHS. www.mstrust.org.uk/downloads/therapists_in_ms.pdf

Wanted: autism advocates

The National Autistic Society Advocacy for Education Service is compiling a database of speech and language therapists with an interest in and experience of working with children on the autistic spectrum. Information on this database will be made available to people with autistic spectrum disorder and their families. The service provides advice, information and support to enable parents who have children on the autistic spectrum to get the most appropriate educational provision for their child. It aims to empower parents to make informed choices and decisions about their childs education. To be included email advocacy@nas.org.uk with the subject Speech and Language Therapist, write to Advocacy for Education Service, 393 City Road, Islington, London, EC1V 1NG, or call 0207 903 3664.

Therapists in MS launch their report. (Clare Laing is in the centre at the back.)

Media message

The Health Professions Council is looking for people to take part in its ongoing media campaign which asks members of the public to make sure they are using registered health professionals. If you would be happy to talk about the importance of being a registered health professional, or if you have treated someone who previously received unsatisfactory treatment from an unqualified practitioner, the Council would like to hear from you (e-mail casestudies@hpcuk.org with your name, profession, contact details and a summary of your experience). Public information leaflets, car stickers and posters are also available. All registrants with the Health Professions Council will be recording their continuing professional development from 1 July 2006. www.hpc-uk.org

Nuffield consultation ends soon

Speech and language therapy views are being sought on the future of the Nuffield Speech and Language Unit in Ealing. While the Royal Free Hampstead NHS Trust is undertaking a public consultation on the future of the specialist unit, it favours the option of closure, citing changes in referral patterns and funding disputes as a result of the political drive for local provision and inclusion. The unit provides intensive, specialist speech and language therapy and teaching to up to 14 children aged from four to seven years who experience such severe difficulties that their needs cannot be met by local services. The typical length of stay is two years, when over 40 per cent of the children go on to mainstream education. The issue has been debated in Parliament, where questions were raised about the integrity of the consultation process and responsibility for specialist, national services. John Bercow MP also pointed out that the unit is inextricably bound up with the Nuffield hearing and speech centre, which receives some 40 requests each weekfrom parents and professionals, by telephone, e-mail and postseeking advice on speech therapy. Concern has been expressed that, should the facility close, it would be impossible to retain the level of expertise and experience it offers. The consultation period closes on 30th June and the decision will be made at the end of July. www.royalfree.nhs.uk/ealingconsultation/Nuffield_consultation.pdf

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2006

NEWS AND COMMENT

Speaking and listening from the start

comment

The independent review of the teaching of reading in early years settings and primary schools has called for more attention to be given right from the start to promoting speaking and listening skills. While general media interest in the Rose report has centred on its support for synthetic phonics, the childrens communication charity I CAN has welcomed its emphasis on language and communication as key components of literacy development. They said that, while they recognise the importance of synthetic phonics as an approach to developing literacy, the emphasis on the need for a range of interventions to meet the needs of all children is of particular importance to children with communication disability who have specific difficulties with learning to read and for whom the interaction between different routes to literacy through language is often unusual and complex. From September 2006, I CAN in partnership with service company SERCO will offer a range of online learning tools and training to support the assessment and development of speaking and listening skills of pupils in key stages one and two. I CANs existing programmes include Early Talk, which focuses on supporting the development of all childrens communication in preschool settings and provides a model of excellent practice to meet the needs of the one in ten children with a communication disability. By 2008 I CAN will be working in partnership with 56 local health and education authorities to reach 60 000 children through Early Talk, providing advisory support, service standards, staff training and information for staff and parents. www.ican.org.uk Note from the Editor: Interestingly, the Rose report calls for greater technical skill from the teacher in enunciating phonemes, as well as an understanding of why this is so important. While the meaning behind the example given will be welcomed by speech and language therapists, it may also leave them scratching their heads wondering where the /r/ appeared from: When sounding out (segmenting) words such as cat and bat, the teacher frequently stretched the consonants, for example by adding the sound ur. What the children heard was cur-a-tur and bur-a-tur thus they found blending (synthesising) the sounds (phonemes) for cat and bat unnecessarily difficult. www.standards.dfes.gov.uk/rosereview/report.pdf)

Exploring spaces
When Jo Middlemiss (p.18) arrived at a natural hiatus in her work commitments she assumed she should immediately set about closing it. However, experience has reinforced for her that we all need to mind the gap and ask ourselves what it might be for. On the other hand, when we realise something needs done, we may have to create the space. For Alison Matthews and Rachel Samuels (p.20) this took the form of a forum for sharing ideas and good practice in the production of accessible information. Challenged by older children with speech issues, Aubrey Nunes (p.4) reasoned that the space between what they could say and what they couldnt say would provide the answers. Therapist and child explored a large number of possible words together and what had been impossible became possible. Our feature on male communication (p.14) finds that such no failure approaches may be particularly appealing to boys. At one point it seemed impossible to Charlotte Child (p.8) that the space between speech and language therapy, education professionals and parents was anything other than a black hole. But several defining moments and a lot of hard work later, her Communication Development Profile is shedding light so that everyone can understand each other and work together. Charlotte mentions that exhilarating feeling when you know youre onto something, which Heather Saunders (p.27) also clearly understands. With verbal dyspraxia occupying the space where expressive language should be, she explains why she believes the new Nuffield Dyspraxia Programme was the launching pad her client Caelan needed. An equally structured approach helped Linda Armstrong and Jaclyn Dallas (p.24) negotiate a client and his family towards discharge so that the space left would not feel like a void. In addition to creating such space for joint planning, we need to give ourselves room to reflect on what clients tell us about our service, and use this information to make it even better. With this in mind, our top resources (back page) are from people with Parkinsons disease telling us what they most value in a speech and language therapist. As our designer tells me, for the magazine to make sense and be read, its spaces are as important as its copy. So whatever your circumstances, go boldly and mind that gap.

Aphasia award
Speech and language therapist Anne Whitworth has received a Health Foundation Leading Practice Through Research award. A Senior Lecturer and Director of Clinical Education at the University of Newcastle upon Tyne, Anne receives personal development training to enhance her leadership skills and over 130,000 to develop a range of effective therapies for people with aphasia. The project will focus on 20 clients who experience difficulties with comprehension or combining words into sentences and evaluate the ability of different strategies to produce improvements in language processing skills. Anne said, This award will allow me to test out hypotheses concerning how language is impaired in the event of neurological damage. It will show whether different underlying deficits respond differentially to specific therapies. She added, The project aims to provide evidence for developing effective integrated aphasia therapies which will fully consider peoples competence, confidence and ability to function in everyday situations. I believe it will make a major contribution to aphasia research and empower other professionals to improve the service they provide to their patients. www.health.org.uk

Cheers?

A research report from the Mental Health Foundation suggests many adults in the UK are using alcohol to deal with feelings of stress, anxiety and depression - and that excessive drinking increases vulnerability to a range of mental health problems. The researchers report that there is a significant relationship between job stress and alcohol consumption, and that people drink more when they experience moderate to high levels of shyness or fear. The Mental Health Foundation believes that the public has a right to information about the hazardous effects that alcohol misuse can have on their mental as well as physical health. www.mhf.org.uk

Avril Nicoll, Editor 33 Kinnear Square, Laurencekirk AB30 1UL tel/ansa/fax 01561 377415 e-mail avrilnicoll@speechmag.com

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2006

COVER STORY: DIRECT THERAPY

The space
READ THIS IF YOU WANT TO EXPLORE THE SPACES BETWEEN WHAT A CLIENT CAN DO AND WHAT THEY CANT THERAPY DEMAND AND SUPPLY LINGUISTICS AND SPEECH AND LANGUAGE THERAPY
no rehearsal, a week later Jason again said it correctly. The therapy implication was obvious. I decided to try it out with more children.

Focusing treatment
At 4;6, Kelvin was mostly incomprehensible. As an example, using a large character in pointed brackets to show a weak articulation, cardigan went to with laterality in the final onset and dorsality in the nasal. By 5;3, when we started therapy, he was more understandable but still had issues. He could now say cardigan, except that the /g/ was . In one session I focused on the stop quality of the /g/. First I opened the final syllable, devoiced the onset, and changed the stress pattern to . Kelvin said this as , so I then tried a sonorant in the stressed onset, which Kelvin could say. After ten trials varying the two sonorants /n/ and /l/ in this position, Kelvin could say forms like with all three syllables beginning with an oral stop. If all the stops were voiceless became , so voicing had to be part of the issue. After two successful trials with a voicing contrast, I tried more dactylls, starting with , but varying the voicing and the length of the stressed vowel. After nine more successful trials, I closed the final syllable with /n/ as . This was correct. After was also correct, I returned to cardigan. This was now correct with three proper stops, two articulators and contrastive voicing in the middle. By 5;6, after just 14 half-hour sessions, with each session consisting of work around one or more different words, and with this as the sole therapy, Kelvins speech was age appropriate. Leo at 6;0 had the speech of a 4 year old. After 11 halfhour sessions over 3 months, following the same approach, with Leo saying around 1,000 nonsense words in all, bearing on a wide variety of relations between the stress pattern and the sound-structure, his speech was age-appropriate. This therapy starts from what the child can do, and builds on this, working towards what the child cant do. All responses get equal praise. The immediate goals are nonsense words, most said just once. The intention is for the child to experience non-stop success and to discover how features and prosody interact. I developed Feature Prosodic Therapy from 1983 to 1989 in NHS clinics with children with specifically phonetic / phonological disorders who were not responding to therapy on the basis of missing or defective sounds, or for whom there was no obvious therapy. It is still rudimentary and open to improvement.

Words like Geronimo and cardigan might not appear in standard articulation or phonology assessments, but for linguist and onetime speech and language therapist, Aubrey Nunes, they are key to the search for more effective and efficient therapy for children with speech disorders. Here, he explains the development and unexpected pedigree of feature prosodic therapy, where the child and therapist explore the space between what children can say and what they cant.

ack in 1983 a father referred his son to me. Jason, then aged seven, had had speech and language therapy and been discharged with the parents getting the idea that any remaining problems should resolve on their own. There were no problems with Jasons school work, but his father felt there were still issues with his speech. On assessment, Jason had a complete phonemic inventory, with no obvious problem in casual conversation, but he could say few words of four syllables or more (for in. At this level of stance, Geronimo became word-complexity, Jasons speech sounded immature. I remember the heady scent of elder in full bloom as I decided to accept Jason for treatment. It seems fitting now, given that we were embarking on a journey that would change my understanding of therapy and on the way pay tribute to the professions own unsung elders. So, what treatment? What caused which errors? I reasoned that the difference(s) between what Jason could and couldnt say would provide a basis for treatment. So I took a word Jason couldnt say, and changed it to something he could say. We continued this process, gradually moving closer to the target, until he could say it correctly. Each change produced a nonsense word, but a possible one nonetheless. This article describes what happened next. It is relevant to speech and language therapy for children with speech-specific issues mostly in mainstream. My aim is to enable therapists working with such children to: Sharpen diagnosis and focus treatment Raise clinical goals Ensure that the most severely affected children are treated accordingly Effect economies. Returning to Jason, starting from a variation of the target word that he could manage, I found I could ask him to say around 100 nonsense words in a session. I gave no correction, just praised his efforts regardless. My purpose was to define the point(s) at which the breakdown occurred and to find a way of working up to that point that would facilitate success. At the end of the first session I again asked Jason to say the original word, and he said it correctly. With no consultation and presumably

Pedigree
What I didnt know then was that such therapy has a pedigree. William Holder was a 17th century teacher of the deaf, John Thelwall treated childrens speech disorders in

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2006

COVER STORY: DIRECT THERAPY

between

where the English stress rule is first fully spelt out. The one way in which Feature Prosodic Therapy may improve on the practice of the pioneers is that it involves an on-line adjustment by the therapist to the way the child is managing or not so as to ensure the child can copy whatever is being modelled by the therapist. Every therapy should be tested rigourously. I ran the first test of Feature Prosodic Therapy with otherwise normally-developing children, and then developed the theoretical rationale - see Nunes (2002). A clinically based pilot test is now in process and I welcome contact from any therapist who would like further information.

Process of learning
This approach is about therapy in relation to the process of learning. It is obvious that children are expected to learn in about 10 years what makes one language different from others. What is less obvious is that such differences are not random and that, despite the variety, there are universals. The first person to see this was Holder, with his early version of distinctive feature theory. Another universal concerns word-stress. If a language has a stress-system like about half the worlds languages do either it is just on the edge of the word or it is by an alternation between heavy and light beats in succeeding syllables. In the French hippopotame, the only stress is on the /a/. In English, as in French, the stress is computed from the right, and some final rimes are ignored, but there is an alternation of beats. So in hippopotamus, there is a light stress on the first syllable and main stress on the third. Because in English stress often falls on the initial syllable, there is an easy inference that scansion is from left to right. Such an inference happens to be correct in Scottish Gaelic but not in English, where stress is defined on three interacting principles: scansion from the right, alternating beats, and a skipping of some final syllables. This of course has to be learned. And it is not easy. There are many other ways in which stress could be organised - but isnt. It could peak in the middle of a word, or words could vary randomly according to whether they have stress or not. But no language like this has been found. Rather, stress is computed from left or right, with alternation or not, and so on. So the learner only needs to consider a particular sub-set of the logically possible options. Because this sub-set is finite, acquisition can be finite too. But in order for this to work, the learner must have a way of telling what counts as evidence and what does not. The simplest way of explaining this learnability is by a Speech and Language Acquisition Module (SLAM), interpreting for the child what they happen to hear. A defect in this module leads directly to a disorder of speech and / or language. This learnability-driven approach: Explains the (otherwise hard to explain) co-morbidities, involving lisps, multiple processes, the loss of vowel distinctions, and syntactic issues. Suggests that what speech and language therapy
SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2006

Cover photo by Paul Reid. Posed by models

the early 19th century, and Alexander Melville Bell treated communication issues in children and adults later in the 19th century. Holder (1669) proposed the essence of what is now known as distinctive feature theory with phonemes as the surface expression of combinations of universal features. Thelwall (1814) used an early version of what is now known as the metrical theory of word stress to describe the characteristic English alternation between stressed and unstressed syllables. Making distinctive feature theory more complete, Bell (1849) showed that English vowels could be defined by height and frontness / backness. As a Scot, Bell was interested in the difference between his trilled /r/ and the English untrilled /r/, and he proposed a feature for this. All three describe their work in terms which make it

easily recognisable as speech and language therapy. From Holder to Bell there is a growing understanding of the significance of linguistics. Significantly, these therapy pioneers all asked children to repeat structured sequences of minimally-different nonsense words. This fits in with the modern idea of possible words from generative phonology. The pioneers dont talk about possible words, as this term only came in during the 1960s, but it is only on the basis of this idea that their practice makes sense. The pioneers legacy was buried in the early 1900s and then lost until Rockey (1977) rediscovered some of it. Duchan and Nunes (forthcoming) find more. The legacy has been greatly advanced by studies of both prosody and distinctive features since Chomsky and Halle (1968),

COVER STORY: DIRECT THERAPY

DOES in such cases is to help a natural process in the childs mind of getting to know what counts as a possible sentence / word. Informs answers to questions like: Is my child braindamaged? Have we as parents done something wrong? If there is a Speech and Language Acquisition Module, the answer to both questions can be a firm no. The implications are both positive and negative. A) POSITIVE IMPLICATIONS: i) By Feature Prosodic Therapy a small but permanent gain can be made in 75% of children with speech specific issues saying between 20 and 100 nonsense words - In this first test of Feature Prosodic Therapy parents were not directly involved. The sole variable was the childrens experience of saying the selected nonsense words. For the sake of replicability, in a way that I would not do in the clinic, the sequence was standardised. - Because gains are by the interaction between elements, these are exponentially greater than by the sum of the sessions, and thus cost-effective. - Parents like to see session-by-session gains which are both permanent and exponential. ii) Diagnosis is sharpened - The diagnosis is defined in terms of the relation between normal competence and the childs speech. So in both cardigan as and Geronimo as , there are limits on which features can be realised outside the foot (underlined). Both of these forms could be described by combinations of processes - in , by a dorsal or back-ofthe-tongue gesture getting wrongly made in the final consonant, sonorance in the final consonant getting wrongly copied into the consonant before, but with a change from nasal to lateral, and so on. But this is mak-

ing the childs speech more complex than competent speech, so it doesnt explain anything. By diagnosing in terms of limits, it is possible to refer to both issues and achievements. This can be nicely and accurately put to parents, for example He / she can only say that back of the tongue bit of the sound at the end of the word. The key word is only. - A positive and non-pressurising speech and language therapy approach is underpinned. - There is a better chance of catching the most severely affected children. iii) If therapy goals are defined in relation to possible words, the long-term goal is likely to be normal speech - None of our elders suggests anything else. This is obviously a much higher goal than one defined on mere improvement or communicative need. B) NEGATIVE IMPLICATIONS There is no reason to: i) Assume that child-directed speech makes all the difference If it did, finite learnability would be impossible as explained earlier, this is contrary to fact. In particular cases, the style of parent-child interaction may be non-optimal and this may impair the process of acquisition. But it does not follow that such an effect is general. You may feel - for this and the other negative implications listed - there is proof-of-the-pudding evidence to the contrary from therapists experience. The problem, though, is telling what is causing what. For example, when parents are coached in the use of child-directed speech and improvement follows, was the child-directed speech the cause, or was it the change in the parents thinking and feelings about talking? ii) Characterise speech issues only by processes (stopping, fronting, initial consonant deletion, assimilation, and so on) The effect is that therapy goals are seen in terms of what is wrong / most difficult for the child. Common pronunciations like little as and soldier as are hard to describe. Complex, subtle and unfamiliar interactions between consonants and vowels can be underestimated and the most serious disorders overlooked or misread. The children concerned can fall through the net. iii) Expect sensori-motor treatments to have a general effect Shoppinglist definitions of speech-specific, or verbal, a/dyspraxia, have multiple (and contentious) secondary characteristics. Without excluding the possibility of a/dyspraxia in exceptional cases, the general treatment of mixed disorders in this way makes it hard to understand what they truly are. By working on sensori-motor issues in isolation, by certain software packages, by

Auditory Integration Training or by oral-motor therapy with its associated materials (approaches that have been marketed before being fully tested), there is a loss of diagnostic focus. iv) Allocate scarce resources by giving priority to younger children This risks diverting resources to minor issues which may resolve naturally, and may deny resources to children with greater issues. Phonetic / phonological development has an irreducible linguistic aspect, is developmentally vulnerable, and is still normally in process at 8;6. Since it is impossible to determine future needs in relation to a process before it is naturally complete, therapy resources should remain available to children of 8;6 and older. v) Expect to treat speech issues by anything other than face-to-face, expert therapy (or think that therapy is ever routine) Law et al. (1998) found that what they call indirect therapy does not work in the case of speech delays. By my claim, it cannot work. This is not to disparage the role of parents, assistants, teachers, volunteers, and others, as observers, helpers, and so on. But they cannot replace therapists. Some speech and language issues are unlikely to resolve spontaneously. Given the space between publiclyfunded therapy demand and supply, such issues deserve to be ring-fenced. Dr Aubrey Nunes is a linguist and director of Pigeon PostBox Ltd, which supplies computer-based educational toys (http://pigeonpostbox.co.uk), e-mail aubrey@pigeonpostbox.co.uk.

References
Bell, A. M (1849) A New Elucidation of the Principles of Speech and Elocution. Edinburgh: The author. Chomsky, N. & Halle, M. (1968) The Sound Pattern of English. New York: Harper Row. Duchan, J. & Nunes, A. (forthcoming) The Awesome Foursome. Holder, W. (1669) The Elements of Speech. London: Scholar Press. Law, J., Boyle, J., Harris, F., Harkness, A. & Nye, C. (1998) Screening for Speech and Language Delay: a Systematic Review of the Literature, Health Technological Assessment 2(9). Nunes, A. (2002) The Price of a Perfect System: Learnability and the Distribution of Errors in the Speech of Children Learning English as a First Language. PhD thesis University of Durham. Rockey, D. (1977) The logopaedic thought of John Thelwall, 1764-1834: First British speech therapist, British Journal of Disorders of Speech 12, pp. 83-95. Thelwall, J. (1814) Results of Experience in the Treatment of Cases of Defective Utterance London: J. McCreery. SLTP

Alexander Melville Bell (Parks Canada / Alexander Graham Bell Historic Site of Canada)

REFLECTIONS
DO I MAKE THE MOST OF MY LINGUISTIC KNOWLEDGE WHEN PLANNING THERAPY? DO I REGULARLY RE-VISIT ASSUMPTIONS OF HOW SERVICES SHOULD BE PROVIDED TO CHECK THEY HOLD GOOD? DO I SET CLINICAL GOALS TO SUIT THE CLIENT OR THE SERVICE?

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2006

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SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2006

EARLY COMMUNICATION

Partnership in Profile
T

he term partnership is heavily used in many local and government directives. But what does it actually mean? How many times do we come away from a situation feeling we have failed to achieve it? How can we work in a true and useful partnership with the families and staff we support? nication Development Profile (Child, 2006) In preparation for a workshop at a READ THIS IF YOU WANT TO hit me. I returned to the medical room in the recent National Portage Conference I special school I covered, from yet another looked up what partnership actually USE DIRECT AND INDIRECT THERAPY APPROPRIATELY one of those teacher liaisons where everymeant. A simple definition is sharing, SHARE THE RISKS AND THE REWARDS OF YOUR WORK thing had gone wrong, and I just sobbed. so on the face of it we all do that rather ENSURE OTHER PEOPLE UNDERSTAND WHERE YOU ARE However, as strong as the urge was to run well. The National Health Service and COMING FROM down the street never to return, I also realthe Education Service seem to be awash ised that I needed to make changes to my with shared paperwork (of varying useversus education. Its a simple fact that teachers observe practice that would begin to tackle these problems. I fulness), and we put a huge effort into sharing our skills and assess a childs performance and we observe and ashad to find a way to explain where I was coming from and ideas. However, for that sharing to be effective, what sess a childs competence. - to have a framework that I could share with the teachwe share needs to be understandable and accessible to ers and use to jointly discuss and plan for a child. In adothers. dition, I needed a way to explain the type of speech and In addition, the definition also refers to the sharing of language therapy intervention that would best support risks and rewards. I smiled when I read this because it is a Secondly, through our observations and assessments the childs communication skills. Before I left that day, key shift in the way my practice has developed over the we make judgements about a childs skills and the level the first version was scribbled down. last sixteen years as I have tried to move towards a betthey are at. But our opinions, however well evidenced, With all great ideas come support and a lot of cake and ter working relationship with parents and teaching staff. may not match the parents views. Think about that alltea. I had that in abundance from my colleague Sue Stronge When I came out fresh from Leeds Polytechnic (now too-familiar sinking feeling as youre told the child can whose office was within walking distance of a rather nice Leeds Metropolitan University), I took on the whole understand everything whilst youre watching them bakery. The first version (1994) worked well and was used responsibility for a childs assessment, therapy, and ulstruggle to respond to a one word level command. The across each of the special schools in South Devon. It began timately any successes and failures. However, once you resulting way that you explain and deal with this can set to address some of the problems I was experiencing in being begin to share those roles, you also begin to share the the tone for the rest of your sessions. Parents can feel an effective and useful resource to teachers and schools. outcomes. As a result your role changes from being that their child hasnt been seen in the best light or been The second most defining moment came with becomin charge to being a resource when things go wrong, seen too briefly and that they have been left with but ing a mum and being forced to live my work. I realised through helping to problem solve and encouraging he can do that at home as their only way to contribute. how wonderful it was to tell people your childs latest everyone to have another go, and to quietly stepping I often wonder what the parents report back to other achievement, to talk about what they do well and how back when things go right. family members and friends after their initial sessions; awful it was to be on the end of assessments not underSo what are the key problems within many partnerhow they were made to feel, whether or not they agreed standing or necessarily agreeing with the other persons ships between speech and language therapists, families with what was said, whether or not they felt listened to, opinion - and knowing that they did indeed do that at and other professionals? whether or not theyll come back home! I began to write down a great deal of how my children were communicating. It started out as a way of me really making sense of what I was experiencing, and Third is the most difficult area regarding the level and Firstly, joint liaison and planning sessions can be incredreflecting on what I offered as a therapist. However, it has type of speech and language therapy provision. Parents ibly frustrating leaving you at best needing to bang your ended up as the core of the 2006 version of the profile. rightly want what is best for their child, and speech and head on the wall and at worst imagining the wine chilling I learnt that my own children could show very clear language therapy seems to be widely viewed - in spite of in the fridge for a mid-week tipple. This for me generally single word understanding and use, but when I sat them enormous changes in policy and provision - as a direct occurs when the other person and I are talking different down with the Derbyshire Language Assessment (yeah, intervention best provided through some sort of facelanguages - particularly speech and language therapy right, Im the only one whos done that!) their attention

Finding the route to true partnership with teachers and parents full of obstacles, Charlotte Child looked for a way through, and the result is to-face contact. Any mismatch between the her newly-published Communication parents expectations of the service and what child needs can cause huge difficulties, Development Profile. Here, she reflects on the their and in some cases lead to a tribunal. inspiration, theory and life experience underpinning the profile - and explains why Defining moment There was an incredibly defining moment 12 genuine partnership feels so great. years ago when the concept of the Commu-

2. He can do that at home

1. Talking different languages

3. Expectations

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2006

EARLY COMMUNICATION

Figure 1 Summary of phases (based on Child, 2006) Phase 1: Early Communicators Children are learning how to be communicators, that they can influence the world around them and that they can interact with and influence other people. Behaviours include crying, facial movements and expressions to reaching, looking and making noises. Children progress from using their behaviours in response to things going on around them, to using them in a planned and deliberate manner to achieve a specific goal. Phase 2: Developing Communicators Children are gaining language-based skills without realising it through the process of closely matched adult - child interactions. This phase is a largely unconscious learning process for children and adults. Phase 3: Established Communicators Because children now understand what language is all about and how it works (sometimes described as meta-linguistic skills) they are able to make direct changes to their language skills, through adding new words or structures and amending others. The whole language learning process has become deliberate and conscious, and children developing within this stage can learn language through language.

and listening was still naturally so single chantence (Gerard, 1987). In it, Kathryn Gerard nelled that they couldnt complete it. I then besummarises three levels of communication gan to look at the Communication Development development: pre-intentional, intentional Profile in a new light and to write it in a way that and linguistic. She makes the point that the I could use not only with teachers but also with first two levels are all about the development parents, so they could tell me what their child of communicative competence with the subwas doing at home and be directly involved in sequent development of linguistic skills betheir childs assessment and planning. ing mapped onto - and their use dependant To make the framework even more useful upon - these core skills. This made a great and relevant in school, I linked each stage of dedeal more sense as a mum with young chilvelopment to the appropriate P-Level. PLevels dren who had a great line in communicating are the performance descriptions set out in the Im a toddler, get me out of here without a Qualification Curriculum Authority (QCA) Curword being spoken, and it led to my interest riculum Guidelines (2005), which outline the in messages (Child, 2005). I then found this Charlotte Child with her own and friends daughters who contributed to the Profile eight levels of early learning and attainment theme expanded in Anderson-Wood and Rae leading up to Level 1 of the National CurricuSmith (1997), with the levels linked to the lum. P-Levels can also be used in conjunction learning style with which the child developed with the Foundation Curriculum (DfEE / QCA, their communicative competence. Ander2003). However, it is important to realise that son-Wood and Rae Smith pointed out the both the Foundation Curriculum and the Pimportance of recognising not only the differLevels have been written for different purposes ing levels of development but their differing and constructed in different ways. For children needs for intervention. This made tremenwith significant special needs, P-Levels provide dous sense and provides what I believe to be a more detailed and specific framework for asa core framework to help define what we do sessment and planning. and why we do it (see figures 1 and 2). Unfortunately the basic Qualification CurricuDirect table-top speech and language lum Authority descriptions are not easy to work therapy is easily identifiable as us doing somewithin as they comprise of a few lines with some thing, and many parents understandably want disjointed examples. However, the P-Levels thema specialist working directly with their child to selves are very relevant to the same framework help them develop their communication skills. of development that we use. P-Levels P1 (i) to P3 Indirect intervention, where we work with (ii) relate to the five stages in the development of teaching teams and parents to change the intentional communication (Coupe OKane and style of interaction or environmental demands Goldbart 1998), and P-Levels P4 to P8 to the Der- Figure 2 A profile screen in progress (Picture courtesy of Speechmark) to support the childs development of skills byshire word levels (Knowles and Masidlover, 1982). and competence, has got very muddled with a teachers more extended descriptions and real examples There are still some difficult areas within the interpretation lack of speech and language therapy provision. Indirect of the P-Levels through videos in order to help them, and descriptions, most notably the use of key words to forms of intervention should not be seen either as a Cinparticularly teachers in mainstream schools who are now describe both comprehension and expression. In addition, derella service or an add-on, but recognised as the most expected to use the P-Levels to plan targets and write rethe division between P7 and P8 is rather ambiguous and appropriate and clinically effective form of intervention ports. It struck me not only how hard it is for mainstream not one that we as speech and language therapists would for a child at that stage. We know that trying to sit a child teachers to take on this level of assessment but, more make - well, certainly not in the way the document presents down (who is around a single word level of comprehensignificantly, how important it is that we make sure we it! However, as again this is all about the process of the joint sion) and do some sort of direct teaching of language fully understand and use the P-Levels ourselves. discussions with the teaching team, these can easily be overskills isnt going to work, but what alternative style of come through discussion and referring to examples. service do we provide and, more importantly, how do I have recently been meeting a team of mainstream we present it? Little wonder that parents and teachers and special school teachers and local authority advisors think they are being fobbed off when we tell them their The final piece of inspiration for the new version came in Devon who are just completing a moderation exercise child wont benefit from weekly one-to-one speech and initially from the Checklist of Communicative Compefor the Speaking and Listening P-Levels. This will give language therapy intervention.

Inspiration

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2006

EARLY COMMUNICATION

news extra Autism excluded


The National Autistic Society is concerned that the governments Education Bill does not take children with autism into consideration. In particular the Society says that the proposals for school discipline will have a disproportionate impact on children with autism and their families. It says that 27 per cent of children with autism are excluded from school - most commonly because the school cant cope with their needs. As parents will have to take complete responsibility for their children for the first five days of an exclusion, the Society is concerned this will be detrimental to families who already struggle to balance employment with caring for their child. It wants schools to review a childs support needs before taking disciplinary action. The Society also believes the bill may disadvantage children with special educational needs including autism through the proposed admissions policy for trust schools. Spokesperson Amanda Batten said, So long as schools can reject children with autism either before or after they have been admitted, we will not address the long tail of under achievement that exists. Getting it right for pupils with autism can mean better outcomes for all children, as all will benefit from improved provision. The National Autistic Society is to launch an Education Campaign to raise awareness of the issues that face children with autism and their families and to call for change. www.nas.org.uk Information about the Education and Inspections Bill 2006 is on www.dfes.gov.uk

Clear about needs


However, this Profiles structure shows people where the childs overall communication development is falling and links this to the best form of speech and language therapy intervention for their child. Using it has been one of the most positive changes I have made to my practice. Right from the initial transition meetings, parents are clear about what their child needs and recognise the value of interaction approaches, and teachers are clear about their role and responsibility and how the child will be supported by the speech and language therapy service when in school. Of course we all have a different way of looking at things but this journey of developing a resource has been fascinating (as Ive learnt so much), exhausting (I had no idea what I was letting myself in for, in spite of tremendous support from Speechmark publishers) exhilarating (that feeling when you know youre onto something) and incredibly satisfying. Although I still get involved in many a heated discussion, I now have a way to show people what I mean, to include them meaningfully in the decision making and to provide a framework for them to make informed choices about what they would like for their child - and it has made a huge difference to the outcomes. I am finally able to provide a genuine partnership with those I work with, and it feels great!

References
Anderson-Wood, L. & Rae Smith, B. (1997) Working with Pragmatics; A Practical Guide to Promoting Communicative Confidence. Bicester: Speechmark. Child, C. (2005) Getting the message, Speech and Language Therapy in Practice Spring, pp. 4-6. Child, C. (2006) Communication Development Profile. Bicester: Speechmark. Coupe OKane, J. & Goldbart, J. (1998) Communication before Speech. London: David Fulton. DfEE / QCA (2003) The Foundation Stage Profile Handbook - Access to the Foundation Curriculum for Children with a range of Special Needs. London: Qualification and Curriculum Authority. Gerard, K. (1987) Checklist of Communicative Competence. Unpublished. Knowles, W. & Masidlover, M. (1982) The Derbyshire Language Scheme. Derbyshire County Council, www.derbyshire-language-scheme.co.uk. QCA (2001) Planning, teaching and assessing the curriculum for pupils with learning disability. London: Qualification and Curriculum Authority. QCA (2005) Using the P-Scales. London: Qualification and SLTP Curriculum Authority.

Charlotte Child is a speech and language therapist with South Devon Healthcare NHS Trust. For further details about the Communication Development Profile or to arrange workshops about this, Choices Changes and Challenges or First Messages, please contact Charlotte on chaos@hgf.eclipse.co.uk

REFLECTIONS
DO I CHANNEL THE ENERGY OF EXTREME FRUSTRATION INTO POSITIVE ACTION? DO I PROVIDE SUPPORT AND A SOUNDING BOARD TO COLLEAGUES WHO ARE DEVELOPING NEW IDEAS? DO I RECOGNISE AND REFLECT ON KEY SHIFTS IN MY PRACTICE?

Parkinsons priorities
The Parkinsons Disease Society says the five key priorities outlined in the second draft of NICE Guidelines would bring much-needed and comprehensive improvements in care but it wants to see greater emphasis on implementation in the final document (expected June 2006). The draft guidelines Diagnosis and Management of Parkinsons Disease in Primary and Secondary Care state that patients should have access to a range of therapies from the beginning of the condition onwards and regular access to a health professional such as a Parkinsons Disease Nurse Specialist. When Parkinsons is suspected, and before any treatment is started, a patient should be referred within six weeks to a specialist, and thereafter have regular clinical reviews once or twice a year. Consideration of palliative care requirements in all phases of the condition is also a key priority. The Society is concerned that there is insufficient emphasis on the implementation of the Guidelines, including the need for development of multidisciplinary working across primary and secondary care. It also hopes to see clear recommendations on drug treatment for people with Parkinsons with dementia, and the recommendation for further applied research focused on alleviation of symptoms and maximising quality of life in addition to cost effectiveness of treatments. The Parkinsons Disease Society is running a national campaign to ensure that people with Parkinsons in hospital or a care home get their medication on time every time. www.parkinsons.org.uk www.nice.org.uk

Reader oer
WIN THE COMMUNICATION DEVELOPMENT PROFILE
Are you looking for a simple shared framework to help you work in a more effective partnership with the families, carers and teachers of children with learning disabilities? Then the Communication Development Profile offer could be your answer! As author Charlotte Child explains, the Communication Development Profile pulls together information from assessments and everyday observations on attention, comprehension, expression, sound system and use of communication to give a visual representation of the childs skills. This can be used to identify any imbalance in the childs overall communication development and can be linked with the most appropriate style of intervention. Most importantly it helps all involved understand each other and set targets. The Communication Development Profile normally costs 39.95 + VAT, but Speechmark Publishing is giving copies away to THREE lucky readers. To enter this free prize draw, send your name and address to Lyn Smith, email lyns@speechmark.net or to Speechmark Publishing Ltd, Telford Road, Bicester, Oxon OX26 4LQ. Your entries must be received by 25th July 2006, and the winners will be notified by 1st August. The Communication Development Profile is published by Speechmark. For a free catalogue, tel. 01869 244644.

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SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2006

HERES ONE I MADE EARLIER...

ALISON ROBERTS WITH MORE LOW-COST, FLEXIBLE THERAPY SUGGESTIONS SUITABLE FOR A VARIETY OF CLIENT GROUPS.

Heres one I made earlier...


II. WEDDING CAKE GAME
MATERIALS

I. BINOCULAR GAME
This is a group activity that promotes awareness of other people, and of social context. It also encourages appropriateness of conversational topic choice.

This group activity is particularly liked by teenage girls, but can equally well be used by boys. It promotes good dating skills by encouraging appropriateness of conversational topic choice. It sets out to be light-hearted; it does not intend to recommend marriage as a necessary or desirable goal! The game is related to the Binocular Game, reinforcing some of the same skills, but presenting them in a new way. (Be warned that, if many cakes have been awarded and mouths are watering, you might need to provide a cake, or at least a biscuit, at the end of the session!)

MATERIALS
Large piece of firm cardboard for the base of your game 2 cardboard tubes loo roll tubes will do Ribbon Plenty of magazine pictures of different types of people Paste

BRAWN
You may need to cut out the pictures yourself, or your clients can, depending on their dexterity. Stick the pictures all over the cardboard base. You dont need to leave any gaps, and it doesnt matter if they overlap a little. You should create the effect of a crowd of people, or a party. Link the cardboard tubes with the ribbon, but leave about 10 cms between the two tubes. The idea is not to look through both lenses at the same time, but to select two separate people on the board. For a superior effect paint the tubes black. You may feel the need to cut them down a bit to around 6 cms.

Large piece of firm cardboard or hardboard for the base of your game. This needs to be really good and flat as you are going to use it as a sort of Shove hapenny board. It also needs to be a bit bigger than your table, or if thats not possible you will need to move it so that one side of the board can hang slightly over the table edge, and then turn it so that the other side can hang over. Plenty of magazine pictures of men and women as dating candidates. (Pictures of just the head and torso are fine, or you can use whole bodies if you can find good photos.) You can use photos of celebrities, and of unknown people. Have some really unlikely-looking candidates too. Pictures of wedding cakes (wedding magazines often contain lots of these or you can draw your own cakes of different types) Pictures of cups of tea / coffee (again, draw your own if you can) Labels saying Never mind. Try again Paste 2p coins Question document - see below

BRAWN
You may need to cut out the pictures yourself, or your clients can, depending on their dexterity. If you are having homedrawn cakes and cups of tea let everyone design one. The same with the Never mind, try again sticky labels everyone can write one. Stick the pictures of the men along one side of the board, and the ladies along the opposite side. Have the tops of the heads towards the outer edge. You dont need to leave any gaps along the edges, and it doesnt matter if they overlap a little. You now have a large piece of board, with a line of ladies on one side, one of men on the other, and a gap between them. Stick the wedding cake pictures in a line right along the middle, dividing the ladies and gentlemen. So there are now three lines of pictures. In the intervening gaps on either side of the cakes, stick a few pictures of cups of tea, and some Never mind, try again labels.

IN PRACTICE
Taking turns as Matchmaker, choose either a man or a woman, and place a coin on that person, with a portion of the coin hanging over the edge of the board. With the flat of your hand, give the coin a sharp shove, so that it travels across the board to a person on the other side. Now your clients need to answer a series of questions: What does she say to him? What does he say to her? What do they go on to talk about? What do they agree about, and where do they disagree? Do you think they will go on a date? If yes, where might they go for this date? Now the group must discuss whether, given the facts, the couple are likely to make good life partners. If they think the Matchmaker has made out a good case for a lifelong commitment between their candidates then the Matchmaker can choose and describe one of the cake pictures. If more information is needed then the group will vote for the cup of tea option, and can go on to discuss what else the potential couple might need to talk about. If its a definite no for that couple, then the Never mind, try again labels are pointed at. (But the matchmaker cant have another go until it is their next turn). Now its the turn of another potential Matchmaker

IN PRACTICE
Place one lens over one person and the other over someone else. Ask your clients a series of questions such as : What does each person look like? Do their clothes suggest any particular interests? How might they introduce themselves to each other? What might they go on to talk about? Will they become friends?

Alison Roberts is a speech and language therapist at Ruskin Mill Further Education College in Nailsworth, Gloucestershire.

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2006

11

REVIEWS

reviews
COLLABORATION
Collaborating for Communication (How to run language groups linked to topics in the National Curriculum - A Manual for Schools and Speech and Language Therapists) Karen Heins Taskmaster Ltd ISBN 1872294 12 X 14.95 ties that require little or no preparation. Some of the activities could be used with individuals to support work on target orientated goals. Carole Smith is a senior speech and language therapist at the Acorn Unit, St Anns Hospital, London. tips. The author clearly has a lot of experience in activity-based learning. Primarily a practical resource, there are strong links to the psychology of individual learning styles and group interaction. Card graphics are cartoon-style, clear and unfussy. The black and white images are easy to reproduce, attractive and easy to understand. The four sets increase roughly in developmental level. The cards cover in words and pictures a huge range of feelings (eg. grumpy), behaviours (eg. listens carefully to others) and qualities (eg. trustworthy), and the author provides guidance on their selection. The language might make the cards less useful for very young or less able youngsters. However, the CD provides silent cards for which more suitable text may be developed to suit different needs. Invaluable for therapists, teachers and others working with groups of children and young people, such as anyone organising activity-based outings or holidays, and the cards appear tough enough to cope with a bit of mud and grubby fingers! Jennifer Reid is a speech and language therapist working with school-aged children with specific language impairment, NHS Fife. Flying start with literacy: activities for parents and children Ros Bayley and Lynn Broadbent Network Educational Press ISBN 1 85539 194 9 8.95

Use judiciously
This sister publication to Foundations of Literacy is intended to provide parents with the same framework for promoting literacy skills, with an emphasis on the balance of skills that need developing, including talk. The information regarding Supporting and extending talk is a delight to speech and language therapy ears: Follow your childs lead, Expand conversations, Avoid correcting what they say, Avoid asking too many questions. Each chapter has a section on parents frequently asked questions which is also useful. However, the tone of the book is sometimes unfortunate, and almost alarmist, as in the opening line Everyone worries about literacy (are parents meant to infer that they wont need to worry now that they have bought this book?) And there are some statements about English phonology which are just wrong. There is useful information here but use judiciously with parents. Sue Greensmith is a community speech and language therapist working in Deeside, Aberdeenshire, with an interest in early years development including literacy.

Practical answers
This book has practical answers to the questions that many speech and language therapists and schools have regarding the best use of speech and language therapy time, training issues and relating programmes to the curriculum. Time saving session plans, sample letters and forms provide a good starting point for delivering this style of intervention and training. The sessions (Understanding Stories, Building Vocabulary, Listening and Following Instructions and Telling Stories) can easily be adapted to the current class topic, although school staff will need time for preparation. Collaboration is the key with information about training for parents as well as school staff. Frustratingly, some areas are not covered in as much detail for example, speech sound groups - but it definitely has some useful ideas and is great value for money. Nicola Waddington is a speech and language therapist working in community and education for Leeds speech and language therapy service.

GROUP WORK (2) LITERACY


Group Games: Playing With Words Rosemarie Portmann & Elisabeth Schneider Speechmark ISBN 0 86388 545 4 14.95

Quick reference
This book provides more than 100 games for use with groups. Aimed at developing literacy skills, the games are simple to organise and need few resources. The introduction gives some useful general advice on selecting and setting up group activities. Most games focus on spelling and require reading and writing skills but this may not always relate to speech and language therapy targets. Some games using word knowledge will be familiar to therapists, many others could be adapted to develop specific skills at word, phrase or sentence level. The games are listed by title only I would find grouping by type of activity more helpful. This resource is aimed at teachers, therapists and youth club leaders and could be a useful quick reference for those working with groups of 8-16 year olds. Sue Brown is a specialist speech and language therapist, working in mainstream schools in West & South Hertfordshire.

LITERACY
Foundations of Literacy A balanced approach to language, listening and literacy skills in the early years Ros Bayley & Sue Palmer Network Educational Press ISBN 1 85539 093 0 17.95

GROUP WORK (1) ADULTS


Communication Activities with Adults Jayne Comins, Felicity Llewellyn & Judith Offiler Speechmark Publishing Ltd ISBN 0 86388 343 5 14.95

SPEECH DISORDER
Differential Diagnosis & Treatment of Children with Speech Disorder Barbara Dodd (Ed.) Whurr ISBN 1-86156-482-1 24.99

GROUP WORK (3) LEARNING


Toon Cards Toolkit Chris Terrell Network Educational Press ISBN 1-85539-145-7 39.95 (inc. VAT)

Does exactly what it says


This book does exactly what it says on the tin. The authors present an early years curriculum (3-6 years) that emphasises language development as an essential precursor to literacy development. Seven strands to this curriculum are detailed with examples of relevant activities or adult support strategies. Additional information is given relating to implementation and monitoring of this curriculum. The book is aimed primarily at early years education providers but would be very helpful to speech and language therapists working with young language delayed children in mainstream settings who can make good use of the information given on supporting oral language development. The presentation is clear and attractive, and will support therapists wanting to ensure advice on language development fits with a childs overall curriculum.

Very good value


Thorough - a comprehensive text for students, but with plenty to stimulate experienced clinicians. Logically and clearly printed and set out with 17 chapters in three sections, Barbara Dodd features in 16 of the chapters (with 14 other authors), so some views may not be universally accepted. Style and content varies - some chapters report detailed research findings and some are more easily readable. A number of relevant case studies are included along with a detailed progression from assessment to diagnosis to therapy. While this high quality paperback can be dipped into it remains a cohesive whole ranging over 50 years of theory and practice. Very good value. Fran Neale is a speech and language therapist with Norwich Primary Care Trust.

Activities require little preparation


This revised and updated version of the Activities and Ideas book published by the same authors in 1983 is a useful therapy resource for those working with groups of adult clients with aphasia, the elderly and in day centres. It contains activities incorporating cued responses, short answers, longer answers, non-verbal activities, reading and writing. It has been updated to make it more contemporaneous with 100 plus graded activities - many needing only a flip chart and a pen. Very good value for money, this book is to be recommended to health professionals and activity providers working with groups of adult clients seeking activi-

Really useful
In schools, we are encouraged to engage young people in reviewing their own learning and developing awareness of their learning needs. This really useful resource primarily provides practical and fun tools for encouraging active learning review. It has potential for developing self-expression, self-esteem, language and communication skills and enjoyment of group interaction in a variety of client groups. The kit includes a manual, 120 A5 cards and a CD-ROM. The 28 session plans have very clear guidance as to aims and potential benefits as well as helpful practical

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SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2006

REVIEWS

SOFTWARE
Team Up With Timo Stories (CD Rom) Animated Speech Corporation ISBN 0 9767299 2 X $99 www.animatedspeech.com

SIGNING
Sign and Do Nursery Rhymes Book 2 (with CD) Kay Meinertzhagen & Gill Kennard The Signalong Group ISBN 1 902317 52 1 29.00

A fun alternative
This software can be used with late preschool to primary school aged children. It provides activities through an animated tutor targeting story comprehension, sequencing, vocabulary, categories, descriptions and problem solving, using non-complex language. It is easy for clinicians or assistants to install and use and can be tailored to individuals. The graphics are appealing and good for maintaining attention, and feedback is clear and pleasant. Children can carry out the tasks independently, using the mouse (although eager clickers may have to be slowed down!) The disadvantages are the use of American vocabulary (such as closet, baseball), the synthesized voice (unclear at times) and that only one users details / progress can be stored at a time. A fairly expensive product, but a fun alternative to table-top therapy. Gayle Jamieson is a paediatric speech and language therapist, Exeter PCT.

Accessible, convenient and fun


This fun, busy pack can be used in different environments - nurseries, schools, individual families, signing groups. The book is divided into three comprehensive sections: nursery rhymes with signs drawn, activities corresponding to the rhymes, and a signing appendix. There is a good range of less familiar nursery rhymes and the signs are well drawn and easy to follow, even if you have very little signing experience. The activities are not particularly innovative but they are accessible and it is useful to have them as ideas and templates to hand. Invaluably, all the activities are provided on an accompanying CD and can be printed out as many times as desired. The introduction to the book gives helpful guidelines. It is possible for any child to join in with the signing activities which extends the use of the resource. I would recommend this as a convenient resource for speech and language therapists, other professionals and families. Caroline Clifford was until recently a Sure Start speech and language therapist in Hemsworth, Kinsley and Fitzwilliam and is currently a stay-at-home mum.

ing difficulties, the result of which is low self-esteem. It is easy to read, with relevant worksheets at the back identified in the course of the text. The price is reasonable given that it is both informative and contains a substantial number of photocopiable sheets. Lorraine McCoull is a speech and language therapist in Lanarkshire working with adolescents in a communication disorder unit attached to a mainstream secondary school.

AUTISTIC SPECTRUM DISORDER


Understanding the Nature of Autism and Aspergers Disorder Edward R. Ritvo MD Jessica Kingsley Publishers ISBN 1 84310 814 3 13.99

A borrow rather than a buy


This is easy to read with useful information for those with little prior knowledge.

Chapter 4 provides interesting insights into the development of research on autism and Aspergers syndrome, and neurological characteristics linked to these conditions. Written in clear language, explaining terminology in a user friendly way, the tone is warm and personal with anecdotal information based on the authors extensive work in the field. Throughout, the attempt is to provide a positive outlook and overview. However the book often lacks a balance of information and objectivity about the very real challenges that those with these conditions and their families can face. The book offers a brief overview of some therapeutic options which would provide limited functional use for a professional working in this area. The author aims to offer an introduction to this subject, however I feel other books have achieved this in a more successful and comprehensive way. Overall, I recommend a borrow rather than a buy. Sam Wickins is a speech and language therapist with East Kent Coastal Teaching PCT.

STAMMERING
The Treatment of Stuttering in the Young School-Aged Child. Roberta Lees & Cameron Stark (Eds) Whurr ISBN 1 861 564864 21.99

Full of ideas
This book should be on clinic bookshelves everywhere. A useful tool to dip into for inspiration, or to read in its entirety to recap basic principles and see reviews of intervention programmes in America, Australia and Europe. The eleven chapters detail a holistic approach to assessment and treatment, both with stuttering in isolation and coexisting with other difficulties. The focus is on children between 7 and 12 years, although reference is made to adults, other children and adolescents. The editors present a valuable critique of widely accepted principles and methods and consolidate a lot of the theory around stuttering intervention today. They also include in detail the methodology and outcomes of research surrounding intervention. An excellent resource full of practical ideas for students and clinic therapists alike. Laura Baker works as part of the paediatric team at Portsmouth City PCT.

ADOLESCENTS
Helping Adolescents and Adults to Build Self-Esteem Deborah Plummer Jessica Kingsley Publishers ISBN 1 84310 185 8 18.95

A good, photocopiable introduction


This book provides a good introduction to self-esteem and offers basic advice on setting up groups, as well as ideas for activities supported by worksheets. Some of the suggested activities are likely to be too challenging for the client group I work with (adolescents with autistic spectrum disorder) because of their abstract nature, but there are others which address many of the issues around self-awareness and awareness of others. The book is not specifically for clients with autistic spectrum disorder, however, and may be better suited to professionals who are working with adolescents with a range of presentSPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2006

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13

FEATURE

Frogs and snails and puppy dogs tails?


Speech and language therapists are mainly female and their clients are mainly male. Could we improve therapy outcomes if we had a better understanding of why and how male communication can be different? To find out, editor Avril Nicoll asks what little (and not so little) boys are really made of
Speech and language therapists strive to offer an individualised service based on clinical need and to avoid unhelpful or limiting stereotyping. Whether we are working with boys or girls, men or women, fathers or mothers should therefore be irrelevant. On the other hand, if we can understand more about why and how male communication may be different, we can potentially find a way in to engaging them in more meaningful and effective therapy. The fact is that, overall, the profession works with more males than females. Caseloads attest to the greater proportion of boys affected by developmental communication disorder. Boys are for example four times more likely to develop autism than girls (www.nas.org.uk). In the under fives, twice as many boys stammer as girls (www.stammering.org). And, in 16 months of monitoring referrals to a paediatric speech and language therapy service, Broomfield & Dodd (2004) found that seventy per cent were boys, with the proportion higher for language diagnostic categories than for the speech category. Males are two to three times more likely to have a head injury than females, rising to a ratio of 5:1 in the age group 15-29 years (www.headway.org.uk). There are 3.5-4 men for every woman who stammers (www.stammering.org). Males represent 94 per cent of the prison population (www.statistics.gov.uk). Bryan (2004) confirmed high levels of speech, language and communication difficulties among a young offender population and suggested this meant, around 40 % of young offenders might have difficulty in benefiting from verbally mediated interventions such as anger management and drug-rehabilitation courses. She continued, This would imply they might be more likely to leave prison with unresolved problems known to contribute to re-offending (p.399). In researching this topic it quickly became clear that, even where boys and men do not have a communication impairment, there are general male communication issues that impact on many areas of life learning, interacting with others, even health. According to Adam Cox (2006), the roots of this may lie in childhood, given male stereotypes and our expectations of our sons: On the time line of human development, our circumstances have changed more quickly than our genes. Genetically, our sons may still be better programmed to defend against predators than to foster co-operation in a town or an office (p.63). Cox argues that the key is teaching boys social communication skills to counteract the insidious effect of the social reinforcement they get for withholding signs of emotion. One of the ways this can be done is through encouraging their fathers to model vulnerability (holding up their hands to mistakes, saying sorry, expressing sadness), asking for help, compromising, learning from others and persevering. Cox explains how vulnerability is a terrifying prospect for many males, and efforts to hide it can result in a mask of indifference, withdrawal or anger. They need to feel they are good at things or they lose interest, confidence and self-esteem. As a result, they have even less opportunity to develop the emotional vocabulary and social skills they need to experience a healthy life. are driving a cultural change in service provision so that we support parenting in general, not just mothers. In speech and language therapy this is put into practice through programmes such as Hanen and ParentChild Interaction Therapy or via Sure Start projects, or through individual therapists involving both parents where possible. Burgess (2006) says it is essential to recognise that a different approach is needed to engage fathers: even when you are seeking to foster the same kind of behaviour from fathers and mothers towards their children, you need to remember that fathers come from a different place (p.5). However, Brid Featherstone says we need to be aware that the involvement of a father is not per se good for a child; the crucial factor is the relationship between the childs parents, and this applies whether or not the parents are together. She suggests we bear in mind that, while many men subscribe to the involved father model, the economic provider role is still important in mens construction of what it is to be a good father, perhaps because it fits with being protective. Working fathers may therefore find it difficult to balance their desire for involvement with their need to put in the hours needed to protect and provide. We also need to be aware of the particular challenges of working with young men as parents. While they have often had bad parenting themselves and express a desire to be a better parent and to be involved, Brid says they struggle with how to do this, especially when it comes to communication issues. Some men who are not used to being interdependent can be threatened by the emergence of this being to whom they feel connected. Some find after the birth that it is far harder than they expected to be an involved father and in their anxiety retreat into gender stereotypes with thoughts such as Im useless, She knows best, Id better keep out of the way. Reactions can be exacerbated by alcohol or when a man finds it difficult to express himself in a nonthreatening way. Compounding the problem with communication is the reported reluctance of men to ask for help from health service providers. Smith et al. (2006) say while the reasons for this are poorly understood, we need to be sensitive to the fact that men tend to view partners and

Compounding the problem with communication is the reported reluctance of men to ask for help from health service providers.
Interestingly, the initial inspiration for this feature was a conference presentation on the importance of fathers, and their changing role as a result of an ever-moving political and social context. Brid Featherstone (2005) said research evidence confirms it is good for men, women and children if men are involved in family life for reasons as diverse as better mental health, less criminality and better exam results. As a result, information groups such as Fathers Direct (www.fathersdirect.com) and documents such as the National Service Framework for Children, Young People and Maternity Services (DH, 2004)

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SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2006

FEATURE

Boys have a natural competitive instinct and it is very important to them to appear confident and knowledgeable. They appreciate opportunities for leadership, risk-taking, role modelling and action, and enjoy cracking codes and finding practical solutions.

Illustration by Graeme Howard

friends as a primary resource for help, so their approach to us may be indirect. In addition, men may be less able to boost their resilience and wellbeing (salutogenesis) through personal social networks, particularly if they are in the lowest household income group or if they belong to certain minority ethnic groups, for example Chinese and Asian men (Matheson & Summerfield, 2001). The sad outcome of this is that suicide is now the single largest cause of death of men aged under 35 in England (www.menshealthforum.org.uk), while older men have the highest suicide rates in the UK, and this is strongly associated with depression, physical pain or illness, living alone, and feelings of hopelessness or guilt (www.samaritans.org.uk/ know/pdf/InfoResourcePack2004web.pdf). We may also be

less likely to recognise the impact of these factors; while depression may occur as often in men as in women, doctors are less likely to diagnose it in men (www.mind.org. uk/Information/Factsheets/Men/). In fact, the average man lives a shorter life than the average woman and for fifteen of those years can expect to be seriously or chronically ill (www.menshealth. co.uk). Ed Garrett, a community health worker in Aberdeenshire, is actively seeking ways to empower men to improve their health through the Mearns Healthy Living Network. Much of his work involves supporting the development of community social and activity groups to counteract isolation and depression in older people. For men specifically, there is a need to provide socially ac-

ceptable alternatives to the pub but, with low numbers and a vulnerable membership, the older mens group is struggling to be viable. This is unfortunate because Ed observes that the men clearly feel comfortable, have a laugh and are not having to play a role. Conversation includes lots of male-orientated banter and discussion of health issues. He says, My feeling is that the group provides a valuable social space which can act as a springboard to involvement in other activities. One member, for example, hadnt been out of his house on his own for three years but the boost to his confidence has allowed him to join other activities too. This older mens group includes men who have difficulty with mobility and self-care. Resources for Rehabilitation (1997, p.17) suggest that Accepting the limitations of a disability or chronic condition is not only psychologically liberating, but also makes daily living easier. Importantly, they warn professionals that, as men may have their masculinity threatened by accepting help, getting to this stage may be difficult and take time. However, The acceptance of realistic limitations and abilities may result in the restoration of self-esteem, the sense of control over life, and pride in achievements for men in all stages of life. Adam Coxs (2006) hooks for Raising Our Sons to Communicate and Connect might give us clues about communicating and connecting with males in general. Boys have a natural competitive instinct and it is very important to them to appear confident and knowledgeable. They like specific direction and explanation. They may have a kinaesthetic learning style which means they get more out of exploring through physical contact, handling and touching things, and moving through space and new territory, than they do out of just listening. They appreciate opportunities for leadership, risk-taking, role modelling and action, and enjoy cracking codes and finding practical solutions. While goal-directed solution making is a good therapy tool, Cox cautions that it tends to inhibit awareness of the more subtle information that enriches social perception and communication (p.23). It is therefore an idea to help boys define and articulate specific goals about things that matter to them and plan actions to achieve
SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2006

15

FEATURE

news extra
Low incidence SEN provision under scrutiny
An audit of how local authorities meet the needs of children with low incidence severe special educational needs flags up the need for the department of health to continue to address recruitment issues in speech and language therapy. Carried out by the Special Needs Consultancy, the national audit considered provision for children with severe autistic spectrum disorders, severe sensory impairment and severe behavioural, emotional and social difficulties. It looked for examples of good practice, explored gaps and made recommendations which would allow more children to have their needs met locally. In addition to addressing recruitment issues, the audit says that therapy services are looking to develop more cost-effective ways of service delivery that will enable their support to be better targeted. It mentions Harrow speech and language therapy services where direct therapy is targeted on children with more complex and long-term needs and other groups are reached indirectly through teachers and teaching assistants. The audit report suggest that there have been significant benefits where different services have come together for multi-agency training, so that there are better common understandings and a common language / repertoire of approaches available. The authors call for priority to be given to development in support and provision for older children as they move towards adulthood. In addition to the need for better support in mainstream secondary schools and local Further Education College provision, gaps relate to broader areas of family support / respite care and support for mental health issues. The National Audit of Support Services and Provision for Children with Low Incidence Needs report is at www. dfes.gov.uk/research/data/uploadfiles/RR729.pdf

them. In addition, it is important to build an emotional dictionary (p.43) by modelling lots of synonyms of emotions, providing opportunities for boys to observe and notice emotional responses and change in others, and reassuring boys that feeling confusion over emotion is normal. Interestingly, Cox adds that expressive depth is at least as important as having expressive breadth (p.234). However, if parents or therapists try to take on full responsibility for changing a boy, Cox says their efforts will fail. Self-esteem is boosted by the hard work that is needed for meaningful change even if the boys dont want to talk about the fact that they have changed! We need to capitalise on boys hunger for parental approval by encouraging adults to notice and thank them when they use social communication skills, and to convey confidence in their ability. The environment is significant too - males struggle to communicate in a one-to-one compared with less personal settings, and a safe place such as home can be a good place to start building bridges.

the teaching of speaking and listening skills is prioritised and practised. None of this is surprising, but reinforces the value of speech and language therapists supporting change in the classroom. Pickering also supports individualised action planning like individual education plans, arguing that through this a boy learns how to learn by taking greater responsibility for his learning, setting clear objectives and getting regular feedback.

Sensitive to individuals
Pickering stresses that boys are particularly sensitive to individual teachers and effective teaching, whatever the sex of the teacher. This is important as only 7 per cent of educational assistants, 13 per cent of primary and nursery teachers, 12 per cent of nurses and 12 per cent of care assistants and home carers are men (2004 figures). This isnt going to change anytime soon. In higher education, just 19 per cent of those studying education and subjects allied to medicine are males (2002/3 figures) (all EOC, 2005). And analysis of the membership of the Royal College of Speech & Language Therapists (Cobb, 2003) found that a mere 1.6 per cent of assistants, 2 per cent of full members and 2.8 per cent of students were male. So frogs and snails meet sugar and spice. But to end up with all things nice, it is clear we need to take an individualised approach that avoids stereotyping but draws appropriately on our understanding of what boys and men might really be made of.

boys are particularly sensitive to individual teachers and effective teaching, whatever the sex of the teacher.
Amidst a wealth of possible clues about the way in to boys minds, Cox includes: Dont force eye contact Avoid sarcasm and criticism Respond positively when a boy takes the initiative to talk Minimise the possibility of failure Avoid overquestioning Use expressive tools from e-mail to the arts Be task / activity orientated to encourage talk Ask more about interests and opinions and pay particular attention to the music / lyrics he likes Distinguish thoughts from feelings Understand that resistance to communication may mean a boy needs more time to understand himself how he is feeling. Many of Coxs strategies resonate with Jon Pickerings (1997) ideas for raising boys educational achievement. Pickering argues that, contrary to media spin, boys care as much about their learning as girls they just show it in a different way. To feel OK about doing well at school, they also need to have balance, with a life outside school and other interests. Rather than blaming outside factors for boys educational shortcomings, Pickering asks teachers to look for answers within their own classrooms, and from their own boys. This may include planning plenty of contrast and change (p.36), formal presentation / public speaking tasks, and having a system that allows for a speculative, risk taking and experimental approach, ending with an exam. Other suggestions include giving praise and punishment in private, capitalising on boys interest in non-fiction, and using project work which includes recording of responses. Pickering stresses that boys learn best when: work is matched to ability there is clear explanation of the task and learning stages with visual reinforcement and opportunity to ask for clarification

Acknowledgement
Thanks to Ed Garrett for his time.

References
Broomfield, J. & Dodd, B. (2004) Children with speech and language disability: caseload characteristics, International Journal of Language & Communication Disorders 39(3), pp. 303-324. Bryan, K. (2004) Prevalence of speech and language difficulties in young offenders, International Journal of Language & Communication Disorders 39(3), pp. 391-400. Burgess, A. (2006) Engaging Fathers in their Childrens Learning: tips for practitioners. Available at: www.fathersdirect.com (Accessed 3 May 2006). Cobb, J. (2003) Sex count. Unpublished: Royal College of Speech & Language Therapists. Cox, A.J. (2006) Boys of Few Words. New York: The Guilford Press. Department of Health (2004) National Service Framework for children, young people and maternity services. Crown copyright. Equal Opportunities Commission (2005) Facts About Women & Men in Great Britain. Available at: www.eoc.org. uk/pdf/facts_about_GB_2005.pdf (Accessed 3 May 2006). Featherstone, B. (2005) Antenatal education for men: Why we should engage fathers in antenatal classes, 3rd Annual Preparing for Parenthood Conference. Edinburgh 5 May. London: The National Childbirth Trust. Matheson & Summerfield (eds) (2001) Social Focus on Men. London: The Stationery Office. Pickering, J. (1997) Raising Boys Achievement. Stafford: Network Educational Press. Resources for Rehabilitation (1997) A Mans Guide to Coping with Disability. Massachusetts: Resources for Rehabilitation. Smith, J.A., Braunack-Mayer, A. & Wittert, G. (2006) What do we know about mens help-seeking and health service use?, Medical Journal of Australia 184(2), pp. 81-83. SLTP

Better communication cuts reoffending


Courses in oral communication and thinking skills not only improve prisoners quality of life in custody, but can significantly reduce their likelihood of reoffending, according to research from the Learning and Skills Development Agency (now the Learning and Skills Network). The researchers found that oral communication courses proved particularly beneficial for certain groups, particularly repeat offenders, those with shorter sentences and those with a high risk of reconviction. Prisoners found the training helped them to communicate more effectively with fellow inmates and prison staff. A scale completed by prison officers produced high ratings for control of temper and thinking before acting or speaking as positive benefits. Speech and language therapists were not involved in this research which looked at the effect of the English Speaking Boards education courses in oral communication, run in HM Prisons since 1999. The researchers recommend that oral communication skills should be given greater prominence and that the courses should be more widely available in prison and in the community. Developing oral communication and productive thinking skills in HM prisons by David Moseley and Kay Livingston see www.lsneducation.org.uk.

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SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2006

RECOMMENDED READING

Recommended Reading
Given the overwhelming amount of information available, we need to be selective in what we read. Even then we find that papers do not always include an explicit link between the theory / experiment and its direct or indirect implications for practice. Articles in journals have gone through a painstaking process of peer review but it is ultimately for you, the reader, to judge whether the stated result is a) valid and b) clinically important in other words, why and how the article will change your practice. In this section, readers explain why they would recommend a particular article from a peer reviewed journal to their colleagues. While this is a personal response that focuses on clinical importance and practicalities, the author may also wish to comment on factors such as study design / validity and statistics / statistical significance. If you are interested in contributing to this section, please contact the editor, avrilnicoll@speechmag.com. We are also happy to feature policy documents and other important papers.

resources
Alzheimer s diagnosis
The Alzheimers Society can provide a research-based training and diagnostic package in text and electronic format free of charge to GPs. Carers and people with dementia tell the Society that better care and understanding of dementia at GP level and early diagnosis would make a big difference by enabling them to plan and ask for support. www.alzheimers.org.uk

DYSPHAGIA
Leopold, N.A. & Kagel, M.C. (1997) Dysphagia ingestion or deglutition?: a proposed paradigm, Dysphagia 12(4), pp. 202206. Paula Leslie is based in the Faculty of Medicine, University of Newcastle and holds specialist NHS speech and language therapy posts in adult swallowing and fluency. She is an RCSLT dysphagia advisor.

Paula says: Despite my base in clinical, often quantitative swallowology research, this paper is one that made me think when it first came out and continues to be there in my mind eight years later! This is a review not a scientific study. Review papers allow us to access a number of papers on a subject quickly but they only offer the interpretation of the authors. To use such a paper I would always advise checking the primary sources to see if the interpretation matches your own. Leopold and Kagel suggest that a paradigm shift is required in the way we think about swallowing, from deglutition to ingestion. I suspect that when you read it, you will think its common sense, but we need more than just common sense to justify our intervention and to direct future research. This paper provides references to back up our common sense hunches. The paper puts together a case for considering what happens before the food or drink gets to the lips. And that this pre oral stage might affect subsequent oral and pharyngeal physiology. As with good research it raises more questions than it answers. Perhaps showing us directions that clinical research should take rather than timing of infinitesimally small movements, or rates of aspiration divorced from long-term outcomes?

Older people

Research into Ageing, the biomedical research arm of Help the Aged, is celebrating 30 years of funding research to lead to better health and independence for older people. Evidence-based resources include free leaflets such as Healthy Bones, Staying Steady and Bladder and Bowel Weakness on www.helptheaged.org.uk/AdviceInfo/InfoPoint/, and the video Be Strong, Be Steady and book How To Thrive Past 55 for sale at http://www.helptheaged.org.uk/acatalog/.

Wall of Words

I CANs Wall of Words was designed to highlight the importance of language in our lives but the result may also provide a useful therapy tool. Older children with phonology and / or language problems might be intrigued by the wide choice of favourite words and the reasons given. www.wallofwords.co.uk/index.asp

Endoscopy ebook
EDITORS CHOICE EDUCATIONAL PSYCHOLOGY
Dunsmuir, S., Clifford, V. & Took, S. (2006) Collaboration Between Educational Psychologists and Speech and Language Therapists: Barriers and opportunities, Educational Psychology in Practice 22(2), pp. 125-140. Editor Avril Nicoll says: I was drawn to this paper because, with one wonderful exception, my most challenging professional relationships have been with educational psychologists. Although this study only involved practitioners from two local authority areas, the results suggest I am not alone and that the feeling is mutual. An open-ended questionnaire asked both professions what information they request from each other, how psychological assessments are used and interpreted and what issues are faced in working collaboratively and sharing information with each other. The main tension grew out of the speech and language therapy need to understand more about a childs cognitive development, and the reasons why the educational psychologist might be unable or unwilling to provide such information. My interpretation is that this acted almost as an impasse, as the speech and language therapists also wanted much wider and better communication. Tellingly, comments from some educational psychologists suggested that restricting opportunities for communication could be used as a tactic to avoid discussion of contentious issues (p.136). The paper reviews the drivers for collaboration, and emphasises the imperative of a strategic approach to change. It recommends joint training and suggests that individuals could be more positive about the potential value of collaborative work.

The voice training company Vocal Process has released a 2 minute video ebook of a healthy voice from the inside using Endoscopy film. The ebook includes a voiceover explaining exactly what the viewer is looking at, and film of a healthy larynx speaking and singing five vowels. Future releases will contain various different vocal tasks. Available at an introductory rate of 5 (10% goes to the British Voice Association and the British Association for Performing Arts Medicine) from www.vocalprocess.co.uk.

Conditions explained

The 2006 edition of Contact a Familys Directory of Specific Conditions, Rare Disorders, and Support Groups is out now. Focused especially on conditions affecting children it aims to provide clear and concise medical information, useful to lay people and professionals. www.cafamily.org.uk/dirworks.html The charity for families with disabled children has also added a new factsheet for gay and lesbian parents caring for a disabled child to its website. www.cafamily.org.uk/FactsheetGayAndLesbianParents.pdf
SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2006

17

KEYS TO WINNIING WAYS (7)

The application key


The sad circumstances surrounding this article were not of life coach Jo Middlemisss choosing. But, having previously advocated keys of awareness, appreciation, abundance, affirmation and authenticity to encourage reflection and personal growth, it felt an appropriate time to explore the toughest challenge of all their application at a time of loss.

read in a childs book once that a black dog was like a hole in the world. I couldnt really imagine it until I saw my own black lab standing against a snowy background. He did look exactly like a hole in the world. It is an image that has come often to me since my sister Mary died on March 30th after a very rapid eight week encounter with cancer. There is a hole in the world where she was and I miss her for many different reasons. Mary is my big sister. We are separated by four years and two brothers, enough to grow up without really getting to know one another. Our love and friendship was one that grew only after the shared experience of motherhood, marriages, separation and maturity. We lost another sister over 20 years ago to another type of cancer and Marys illness, although very different, presented an overlay of dj vu. Mary had gone to Canada and nursed my younger sister almost to the end of her young life at a time when I was not in a position to help at all.

complicated and annoying, although all the people who were inconvenienced were very supportive. In retrospect I could have saved myself time and space if I had used the old adage Mind the Gap. I will in the future. I do now. I will keep myself available for the real tasks of life rather than the endless busyness which can mask our purpose. The next step was to go to Ireland where my sister was and step into her life without stepping onto her life and the lives of her close family. Her husband was absent. After a wearying struggle Mary had really come into her own in her early sixties and was truly joyous for the first time in a long time, so her illness was a confusing irony. There was a great high when she was first diagnosed but when I arrived that had turned to sadness and introspection. Where she had wanted phone calls, letters, presents and flowers, she lost interest in all of those things. She wanted to be silent, she wanted to be safe and she wanted to stay in hospital.

READ THIS IF YOU DEAL WITH LOSS FIND BUSYNESS MASKING YOUR PURPOSE WANT TO STEP INTO NOT ONTO ANOTHERS LIFE
treatment and yet the professionals involved were, for the most part, expert, knowledgeable, skilful and loving. They were adept at pain relief, nausea control and symptom management. As the chemo approached Marys anxiety built and I realised the power of being there. Not talking, just being. Its hard to convey the power of a knowing look, respecting the feelings of fear but not joining in. Although my sister was very ill, not a single one of the fears she fretted about proved to be anything other than a paper tiger. The chemo was manageable (but too late). She was never sick. Her pain was controlled. She was able to go home, meet family members and enjoy a birthday party. Each time, when the storm had passed, she agreed she had been able to come through all the challenges her

Living in the moment I could have saved myself time and space if I had used the old adage Mind the Gap.
I have experienced many of lifes adversities but have developed my work and philosophy to a deeper level in recent years. The speed of Marys illness was a blessing and a wound, and the certain knowledge of where I would be and what we would be for each other at this most challenging time of our lives was to be the biggest test of my keys. Would the keys open the doors to deeper knowledge and understanding? Would they be helpful in dealing with this loss? A course of chemotherapy was prescribed and she was more anxious about that than I had ever seen her. Although we were sisters, I thought that I would have behaved very differently in this circumstance. But I learned not to judge anything that was happening. The truth is, I dont know how I would be, and just know how she was and that is where I had to be, in the moment with her. Living in the moment in a hospital is a challenge for a fresh air loving, active person like me. My sis was on large doses of morphine. She was sleeping a lot. I was sitting a lot. I observed the non-stop asking of questions by curious well wishers and loving friends and relatives and learned not to ask. How are you? Are you in pain? Are you being sick? Are you sleeping? Have you lost weight? all understandable, but so wearing if answered twenty times a day. We developed a strategy where I became the phone fielder and the initiator of a weekly text message which answered the standard questions without being too obvious: Hi there, Mary here. Thank you for your kind message. My pain is under control, my nausea is being well managed. I am sleeping very well although food is not of much interest. Ill keep you posted or you can contact my daughter on [tel. no.]. This way people felt considered but the replies tended to be texts and therefore could be read anytime. A system proved to be essential. Loving interest can be very exhausting and at this stage we were all in the business of building strength not wearing it out. There is so much fear surrounding cancer and its

I learned not to judge anything that was happening. The truth is, I dont know how I would be
illness and treatment presented. In my reflections I reaffirmed to myself that worry really doesnt do any good. As it became obvious that Marys liver was in failure the consultant pulled me to one side and used the words rapid decline more often than I cared to hear. The last week of her life was spent observing how she almost imperceptibly detached herself from all the things and people she was most attached to. This was not callous - this was vital. I dont even know if Mary was aware that she was doing it.

What is this for?


Over Christmas and New Year a very natural gap appeared in my work pattern. Long-term clients finished working with me at absolutely the right time for them and me. However the diary wasnt filling up as I would have liked. Previously this gap would have filled me with a spot of panic, but this time I thought What is this for? Unfortunately I didnt trust my intuition quite enough and immediately set about networking for new clients, taking on speaking engagements and organising courses. Busy busy busy. No sooner had I done this than the phone call came in. What I could unpick I did, but it was

Time and distance are illusions


My time was spent masterminding family visits and farewells; screening phone calls but making sure that the people who needed a final word got it. I will never forget the last conversation of a mother to her eldest son. He was in Australia with no chance of getting back in time: Neither time nor distance can make any differ-

18

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2006

KEYS TO WINNIING WAYS (7)

ence to our love for each other. After the call she said It is really true, time and distance are illusions, I never believed it before. She wanted no more treatment and none was offered. From that momentous decision her fear disappeared. Palliative care was the route for the last twenty four hours. Two of my brothers, two of her children and I accompanied her to her death. We promised we would never leave her and we didnt. It was a bit like being in the departure lounge at an airport except that she was going on a journey from which there was no return. Normally Im hopeless at airports and can cry just watching other people saying good bye to each other! This was very different for there was laughter as well as tears. There were moments of farce and nonsense and there were moments of love so powerful that you realised it was a force stronger than anything else on earth. The precise moment of passing was when she was alone with her children. (My brothers and I had withdrawn to the chapel for an early morning prayer.) Nothing has ever felt so right. The next few days are a bit of a blur. The Irish way of death is nothing if not funny and I felt as if I was on the set of Father Ted and Ballykissangel. The undertaker really did work out of a pub and he lured my brothers into a business deal with a huge pint of Guiness and a pile of white bread sandwiches - just the job after the all night vigil (you can go off brothers pretty quickly!) But there was no point in stressing and it all worked beautifully. Marys body returned to the house. I stayed with her remains although I knew she wasnt there. There was something incredibly comforting about seeing the task through to the end. The funeral was joyous. I did not want to cry my way through, which is my usual style. I wanted to sing, read a lesson and speak to people who had taken the trouble to travel long distances. The creative key came into practice as we all swallowed copious quantities of Virtual Valium. (I had read that if you ask for tranquillity and calm, the body will produce a kind of natural valium for you. On an early morning walk with tears streaming down my face I cried out to the heavens for tranquillity and the idea popped into my head. I put out my hand and imagined taking a pill. I could take a couple of these. I could overdose on these with no harm done. The tears turned to laughter. I couldnt wait to tell my nieces and it had the same effect.) We floated through the next few hours gaining strength from each other and all the supporters who came from far and wide. It was a real traditional Irish wake.

All of us experience loss throughout our lives and it is important that we acknowledge its impact and award ourselves the time and space it requires. In applying my keys in a time of great loss, the Appreciation Key stands out; gratitude for the life of my sister, gratitude for the joy and wisdom and love of my sister and most sincere gratitude for the opportunity to share her final days with her without the need for any kind of excess. I long to see her again but what I gained from our shared Lent has far outweighed the hole in my world. To give you some idea of my sister I leave you with the appreciation paid to her by her daughter Eileen: Mum If we know what Love is, its because of Mum. It was in her eyes every time we walked through the door. It was shown in the way she protected us, but let us go our own path. If we know what Joy is, its because of Mum. Her never ending enthusiasm towards every part of life, from her grandchildren to a chocolate biscuit! Mum overflowed with life. If we know what Strength is, its because of Mum. Mum had the courage and strength to overcome the difficulties that faced her, and to blossom in her independence. If we know what Compassion is, its because of Mum. Mum gave herself to everyone. Her time, her skills and her acceptance helped so many people, not only through her St Vincent De Paul work, but also through her everyday life. If we know what Happiness is, its because of Mum. The laughs, the fun, the sharing cocktails and champagne at every given opportunity! If we know what Family is, its because of Mum. Mum fostered in us the importance of brothers and sisters and children. She created an unbreakable bond between all of us, making the future look bright and full of hope. She was our beautiful, fun and loving Mum. We are so privileged And thankful that we got to call her Mum.

resources
Special Source
The charity BDF Newlife has introduced Special Source, a free online web resource designed to complement its Nurse service. It provides answers to the commonest questions asked by parents, patients and support professionals about inborn conditions. The child health and research charity seeks to improve the lives of people affected by inborn conditions and to reduce the chance of children being affected. It says around 45,000 babies are born each year with an inborn condition in the UK and 20 per cent do not live to see their 7th birthday. www.specialsource.org www.bdfcharity.co.uk

Insight magazine
The Royal National Institute for the Blind has a new magazine for children and young people with sight problems. www.rnib.org.uk/insightmagazine

SEN

The May / June issue of SEN magazine includes a feature on speech and language development. www.senmagazine.co.uk

Oral health

National Smile month (ending 13 June) encourages everyone to consider how they can improve their oral health. Information, puzzles and games are available on www.nationalsmileweek.org.

Eating and drinking


Exhibitors at CareExpo 2006 included Medoris who make the Catchkin which is designed to look and drape like a napkin but perform the functions of a bib. www.medoris.co.uk

SLTP

CASP on the web

Travelled together
When its over its over, and one is left with the most extraordinary lethargy and exhaustion. All the things that have been written about the process of grief are true, to different degrees depending on the situation. My every waking moment was not concerned with my sister as we lived separate and different lives - but for six precious weeks we travelled together. We were supposed to be going to Canada in the summer for the trip of a lifetime. Although the journey we took was very different altogether, I will always remember it as one of the most important I have ever undertaken. Only in retrospect did I realise that it was almost exactly the period of Lent. On Easter Sunday I thought for the first time that I understood exactly what it meant to be living Lent rather than doing something for Lent. Jo Middlemiss is a qualified Life Coach with a background in education and relationship counselling, tel. 01356 648329, www.dreamzwork.co.uk. Jo offers readers a complimentary halfhour telephone coaching session (for the cost only of your call).

The second edition of the Communication Assessment Profile (CASP) and inserts are now available on the web, or from Speech Profiles, The Old Post Office, 4 The Street, Slinfold, Sussex RH13 0RP. The CASP costs 85.00 plus p&p. www.speechprofiles.co.uk

Reminiscence and Recall

This revised and updated guide includes intergeneration work, and working with minority ethnic elders and people with sensory and learning disabilities or with dementia. Reminiscence and Recall: 3rd edition A practical guide to reminiscence work by Faith Gibson is available from Age Concern Books on 0870 44 22 120.
SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2006

19

ACCESSIBILITY

As demand for accessible information grows, Alison Matthews and Rachel Samuels report on a multi-agency event that kick-started a north west of England forum for sharing good practice.
THE SHOW AND TELL PERSON CENTRED INFORMATION IN PRACTICE CONFERENCE ON 1 MARCH 2005 WAS ORGANISED BY THE ROYAL COLLEGE OF SPEECH & LANGUAGE THERAPISTS NORTH WEST ADULT LEARNING DISABILITY FORUM. A NOT FOR PROFIT EVENT SUBSIDISED BY AN RCSLT BT BURSARY, ALL SPEAKERS GAVE THEIR TIME FREE.

Conference calls:
1. The need
Discussions within the Royal College of Speech & Language Therapists North West Adult Learning Disability Forum highlighted a need to share good practice in the production of accessible information. As a result we set up a sub-group of speech and language therapists, assistants and an information worker from a variety of agencies to organise an event to kick-start the process.

2. The context
Over the years, many documents have emphasised the need for accessible information. Core NHS principles include The NHS will provide open access to information about services, treatment and performance (http://www. nhs.uk/England/AboutTheNhs/CorePrinciples.cmsx). Given that a large percentage of people with learning disabilities have difficulty in accessing written information, this presents its own unique challenge to services. Valuing People, the White Paper launched in April 2001, identifies that there is Not enough effort to communicate with people with learning disabilities in accessible ways (4.1, p.44). It adds that the challenge for public services is to begin Improving information and communication with people with learning disabilities (4.2, p.45). Signposts for Success (1998) indicated that people with learning disabilities and their families have the following information needs: Appropriate language in terms of gender and cultural awareness. Text in short clear sentences without jargon. Clear, life-like pictures that are presented in a simple and enjoyable way. Pictures, writing and the spoken word used together. Video tapes and audio tapes. Materials appropriate for people with impairments of hearing and vision. Computer programmes, models, large simple print, pictures, photographs, slides, posters, symbols, sign and Braille. Opportunities for practice and rehearsal. Involvement of carers, relatives and advocates to reinforce important messages. Allowing plenty of time. The risk in not addressing the need for accessible information is that we go on producing written information for people who are unable to read, denying them access to information about health and social activities and ultimately excluding them. As a service we have a responsibility to alter our communication to enable people to participate in planning and implementing changes and developments to their lives, health, and aspirations, whether that is their review, person centred plan, proposed house move or advice about diet. We need to remember that user led means user said and

signed, or symbolled, or drawn, or photographed, or gestured, or videoed. However, we have a decision to make in how we meet the demands for person-centred and service-centred accessible information as there is a tension here. Information can be required by a person for an event in his or her life. In producing person centred information, best practice involves individualised assessment by a speech and language therapist of a persons information needs, taking into account the persons symbolic understanding, then producing information in a format which enables them to understand. It may not necessarily involve pictures. Although it is time and personnel intensive, information can only be considered accessible and be easily measured in terms of its success - when it is person centred.

Alison and Rachel

ALISON MATTHEWS IS SPEECH AND LANGUAGE THERAPY TEAM LEADER WITH THE OLDHAM COMMUNICATION THERAPY TEAM, E-MAIL ALISON.MATTHEWS@ OLDHAM.GOV.UK. RACHEL SAMUELS IS A SPEECH AND LANGUAGE THERAPIST WITH CITY CARE IN MANCHESTER E-MAIL RACHEL@CITYCARE. ORG. OR RACHEL.SAMUELS@ MANCHESTER.GOV.UK.

we have a decision to make in how we meet the demands for personcentred and servicecentred accessible information as there is a tension
More recently political pressure has been placed on services to produce accessible information to wider groups of people with learning disability. The initial push began as early as 1995, with the Disability Discrimination Act. Under this, from October 1999 service providers have had a statutory obligation to ensure their services are accessible to everyone. More recently, Valuing People (DH, 2001) highlights the need for services to produce accessible information so people can make choices. This need is raised in sections on housing, mental health services, and people from ethnic minority communities. Information needs to be improved for carers (5.2, p.53), direct payment schemes must be accessible and there needs to be accessible sex education. Producing good service centred information is resource intensive. It needs to be produced in a variety of formats leaflets, tapes, video, and possibly in different languages, including sign. It is not simply a matter of illustrating a document with some pictures from the computer. Analysis of the language content and structure is necessary to maintain the meaning of the original document or source. It is important to remember that service centred information will always be an attempt to reach a middle ground and is therefore not truly accessible information.

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SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2006

ACCESSIBILITY

Show and tell


Both requirements have inevitably led to a real increase in the demands on therapists time. One solution of the Adult Learning Disability Team in Oldham was to second Chris Marsland, a support worker from the local day centre, into the role of information worker. A secondary benefit was that Chris undertook a great deal of the organisation of the conference.

3. The state of play


Workshops and presentations ran throughout the day. However, the opportunity to gather the thoughts of such a broad range of people working with people with

Table 1. What information are we making accessible? Area identified Number a) Service required materials for an individual: Person centred plans Tenancies Personal reviews Health action plans Staff interviews and selection Employment: contracts, conditions, application forms b) Bespoke information Timetables Staff rotas Choices Accessible environment eg. using objects Reports Menu choices Medication information Personal diaries and calendars Shopping lists Feelings barometers Consequences of actions How to do information Consent About me books Moving house books c) Service level information not personalised Minutes Leaflets about services Health information, eg. videofluoroscopy, epilepsy, diabetes Policies Service reports Agendas Complaints and compliments Newsletters Information leaflets eg. sexuality, money Rights Consultation documents Referral forms Appointment letters Care plans Statement of purpose Consent Anti bullying d) Information outside of learning disability services Police information Hospital information booklets 5 4 3 3 2 1

learning disabilities was not to be missed. All participants were invited into small groups to discuss fundamental questions posed by the conference working group: 1. What information is being made accessible? (Table 1) 2. Why is information being made accessible? (Table 2) 3. What are the risks / pitfalls of making information accessible? (Table 3) 4. What is being done to reduce these risks / pitfalls? (Table 4) The collated group responses showed a high level of consensus, with a plethora of accessible information in production, and more and more being shared via adult learning disability networks. There was an almost equal split in the information that was being produced for individuals and for services. Common types of person centred information included person centred plans, timetables and staff rotas. The most frequently produced service information included agendas / minutes and leaflets around health and other community services. The drive to make information accessible functions at three levels: society, policy and individual. Within these categories the human right to information, legal requirements and enhancing quality of life for the individual

were the most frequently cited drivers. Because it is about time and its good fun also struck a chord. Risks and pitfalls divided into those identified at a service level (such as lack of coordination, ownership issues and time), issues around the purpose of making the information accessible (overloading people with in-

Table 3. What are the risks of making information accessible? Highlighted area Number a) Service 8 Lack of support, eg. funding 5 Whos in charge 4 Time 3 Reluctance to sign up / passing the buck 2 Lack of review 1 Lack of coordination 1 Lack of collaboration 1 Lack of discussion b) Common pitfalls Who is the target audience / risk of one size fits all. Not a translation service Overuse of symbols / ignoring the written content Risk of lip service Overload of information Lack of how to knowledge Fails to make information more understandable Lack of training Cause offence Preaching to the converted c) Individual Accessible to the producer and not the person / pretty not accessible / style over content Over / under estimation of receptive language levels Confidentiality issues 9 8 8 7 6 3 2 1 1 7 6 3

6 4 4 4 2 2 2 1 1 1 1 1 1 1 1 6 4 4 3 3 3 3 2 2 2 1 1 1 1 1 1 1

Table 2. Why are we making information accessible? Area highlighted a) Society level Inclusion Human rights Increase participation Gain access to services Citizenship Respect Because its about time!! Equity b) Political / policy level The law Valuing People say so To comply with local policies Political agenda Because we are told to To meet demands For person centred planning Enable user involvement Multidisciplinary team requests Increase health and safety c) Individual level Increase understanding Promote choice Give power / control and empower Quality of life Maximise communication Increase independence Increase self esteem To increase knowledge Central to support Its good fun To explain change Number 7 6 5 2 1 1 1 1 6 5 4 3 3 2 2 2 1 1 8 7 6 3 3 3 2 1 1 1 1

Table 4. What are we doing to reduce the risks of making information accessible? Highlighted area Number a) National Sharing practice Multi agency working / partnership Speech and language therapists dont hold all the knowledge of how to produce accessible information Consistency across services b) Local Training Everyone needs to agree to it and there needs to be a locally based plan Support the people doing Critical analysis Service developed information Communication strategy Know your audience c) Individual Road testing / keeping the person at the centre Variety of formats Picture dictionaries to show people what there is available Be clear who owns the information Adapt meetings and allow time Keep it simple 4 4 2 2 9 7 2 2 2 2 1 7 5 3 2 1 1

1 1

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2006

21

ACCESSIBILITY

formation, overuse of symbols, lack of attention to the language used in information and a lack of clarity as who the target audience of the materials is) and those at the level of the individual, where content may be overlooked in favour of style and presentation. Finally, reduction of risks and pitfalls was largely being addressed at a national level through sharing practice and multi-agency working, and at a local level through training, encouraging a range of agencies to sign up to the process and locally drawn up communication strategies. On an individual level people attending the sessions were adamant on the need to keep the person at the centre, use a variety of formats and be sure whose information it is.

it accessible. Wendy Walker and Nevin Gouda, specialist speech and language therapists with Southwark Primary Care Trust, outlined the role of speech and language therapy in a project to use symbols in the community. The Lewisham Council Disability Discrimination Act Working Group has found interactive games useful in addressing the information needs of service users. Win, lose or draw, Lost in Translation, and Supermarket Sweep can be used at any level of training. wendy.walker@soutwarkpct.nhs.uk / nevin.gouda@wht.nhs.uk d) Making things easier to understand project Melanie Gray and Andrew Comer of the Birmingham Learning Disability Partnership Board described a multiagency approach to making things easier to understand. They gave a useful overview of the process, from developing a highlighted need into a city-wide training and advice resource. The group advise people on service centred information, with a strong message of the need to understand the requirements of the audience as far as possible. Andrew, who is a gentleman with a learning disability, added a poignant users perspective on the process. As the Lead Person for making things easier to understand employed by Birminghams Learning Disability Partnership Board, Melanie is working across organisations in Birmingham to raise awareness, and set up training and support groups. People with learning disabilities are involved in planning, delivering training and supporting organisations on a paid basis. http://uservoice.cswebsites.org/section4.aspx?page=7333 e) Multimedia and Person Centred Planning David Brown and Jill Eddlestone ran this incredibly popular workshop so people could increase their technical expertise in using multimedia and lots of different ways to make information for person centred planning easier to understand. They included examples of: easy words and pictures signs objects sound and video. See article at http://www.mencap.org.uk/download/viewpoint_janfeb03.pdf (p.20), or contact liz.stone@mencap.org f) Inclusive Technology Imogen Wedgewood ran two workshops on: 1) Using digital media for recording, sequencing and choice making activities. 2) Accessible symbols, photos software and Internet sites. www.inclusive.co.uk g) Ethnic Minority Communities and Accessible Information Naz Khan and George Dean raised awareness of considerations to take into account when making information accessible for people from black and ethnic minority communities. Very little work has been undertaken in this area. naz.khan@oldham.gov.uk h) Worth 1000 words Pete Le Grys has developed this photographic resource. He led a workshop about some things to remember when using peoples photographs in accessible infor-

mation. He explained how he went about using people with learning disabilities as models, developed consent forms and made sure people looked good. www.photosymbols.com i) The Rainbow Group at Change Three people with learning disabilities from Change used interactive exercises to engage participants in thinking about how we present and interpret information. www.changepeople.co.uk

4. Show and tell


Participants had the benefit of a number of workshops demonstrating useful resources and approaches. a) Talking Mats Joan Murphy and Lois Cameron are research speech and language therapists based in the AAC Research Unit Stirling University and speech and language therapists in Forth Valley NHS, Lois leading the learning disability team and Joan working in the area rehabilitation team in Stirling Royal. As developers of the low tech Talking Mats communication resource, their keynote speech sent a clear message of the need to evaluate the impact of any accessible system for the person / group using it. Talking Mats has been used with a wide variety of client groups and by a range of workers. Visual symbols are used to express emotions and opinions. Lois and Joan presented the results of their recent research which explored the efficacy of picture material to enable people with learning disabilities to understand. A subsequent workshop gave delegates the opportunity to hear more about their research and to try out Talking Mats for themselves. www.talkingmats.com

As developers of the low tech Talking Mats communication resource, their keynote speech sent a clear message of the need to evaluate the impact of any accessible system for the person / group using it.
j) Mencap Liz Stone, the MENCAP Accessible Communication Manager, kicked off this lively discussion on the roles and responsibilities of the range of workers with people with learning disabilities in implementing and developing accessible information. The workshop considered how to make paper based information accessible and any shortfalls this may have when the audience has a wide range of communication needs. www.mencap.org.uk The workshop also provided an opportunity to launch MENCAPs National Communication Network, which will help to develop the robust debate required to gain some level of consensus nationally. www.valuingpeople.gov.uk/documents/EventsCommNetwork.pdf k) Widgit Software / Rebus Symbols This group looked at: The new Widget Rebus Symbol set in colour The Communicate Series including Communicate In Print 2, a symbol based desk top publisher. WebWide a web browser that allows users to view pages in normal, plain text and symbol supported formats. www.widgit.com

On an individual level people were adamant on the need to keep the person at the centre
b) Visual Impairment and Accessible Information This practical workshop explored accessible information for people with learning disabilities who have poor or limited eyesight. Gill Levy from the Royal National Institute for the Blind outlined good practice in use of clear print and information on audio tape. www.rnib.org.uk c) The myth of Reasonable Adjustments Is it enough just to put signs on toilets in order to make a building accessible? Does simply putting symbols on things make them accessible? This workshop shared training resources which get across the need to think about the content of information and ways of making

References
Department of Health (2001) Valuing people: A new strategy for learning disability for the 21st century. London: Department of Health. Lindsey, M. (1998) Signposts for success in commissioning and providing health services for people with learning disabilities. NHS Executive: Crown copyright.

Acknowledgements
Thanks to all the speakers and to the conference working group of Chris Marsland, Kim Williams, Andrea Worrell, SLTP Vincent McDonnell, Scilla Reid and Jane Shelley.

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SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2006

RESOURCES

resources
Play ideas
Lesley Burton consulted speech and language therapists and Montessori teachers when developing this website selling toys for children with special needs so she could include play ideas and guidance on their use. www.sensetoys.com

Inclusion

Propeller software

Propeller Multimedia is working with speech and language therapists on React2, a re-write of its software for people with aphasia. The number of exercises in it will go up from 1700 to over 8000, and content will be included that is suitable for young adults with learning disabilities. The company is also distributing LEXION, a computer-based system from Sweden for stimulating and training people with language related disorders, dyslexia or aphasia. A free product demonstration CD containing 17 rehabilitation products is available from Gordon Russell, Propeller Multimedia Ltd., P.O. Box 13791 PEEBLES, EH45 9YR, Scotland. Tel. 01896 833528 E-mail gordon@propeller.net

A guide for parents, teachers, health providers and local authorities aims to give practical advice on providing support to children with complex health needs in schools and early years settings so they may attend regularly and take part in all activities. Including Me: managing complex heath needs in schools and early years settings from www.teachernet.gov.uk / The Council for Disabled Children, tel. 020 7843 1900 (12.50).

User involvement

The Department of Health has released best practice guidance on reimbursement and payment to health and social care service users for their involvement. It includes advice on the implications for service users who are in receipt of benefits. Reward and recognition: The principles and practice of service user payment and reimbursement in health and social care (A guide for service providers, service users and carers) is available on www.dh.gov.uk.

Saddle seat

Conventional wheelchairs are designed primarily for transport and mobility. A saddle seated chair has been designed with people with cerebral palsy specifically to provide a more comfortable but stable sitting position. The Association for Rehabilitation of Communication and Oral Skills says that it also promotes greater independence and ease with functional activities such as breathing, eating and communicating. www.arcos.co.uk

Parkinson s grants

The Parkinsons Disease Society is offering fast track project grants up to a maximum value of 10,000 to professionals including speech and language therapists who would like to conduct research that may lead to a better quality of life for people with Parkinsons. The Society can provide advice and partner recipients with more experienced buddy researchers. www.parkinsons.org.uk or e-mail research@parkinsons. org.uk

Communication and literacy

Spelling help

Letters and sounds

I CAN Talk Communication Disability and Literacy Difficulties is the first in a series of papers from the charity on contemporary issues in communication and language. www.ican.org.uk

The 2006 edition of Medical and Pharmaceutical spelling software for the UK includes more than 380,000 specialty words. From 43 for single users. Free evaluation copy available, see www.spellex.co.uk

The Calfone CardMaster Card Reader aims to enable pupils of all ages and abilities to link letters and sounds. Supplied with re-recordable blank cards. www.bretfordonline.co.uk

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2006

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CLIENT-CENTRED GOAL NEGOTIATION, OUTCOMES THAT REALLY MAKE A DIFFERENCE, EFFECTIVE USE OF LIMITED THERAPY TIME ALL OUR IDEALS CAN BE CHALLENGED WHEN WE ARE WORKING WITH CLIENTS WITH CHRONIC SEVERE APHASIA. FOR LINDA ARMSTRONG AND JACLYN DALLAS, THE TIME CAME TO ACT WITH ONE SUCH CLIENT WHEN HE INDICATED HE WANTED TO TRY SOMETHING DIFFERENT. HERE, THEY DISCUSS THE BENEFITS AND LIMITATIONS OF INTRODUCING MR MCDONALD TO BEESONS ANAGRAM AND COPY TREATMENT (ACT) AND COPY AND RECALL TREATMENT (CART) PROTOCOLS. The fact that the written word can be constructed one letter at a time, with ample time to examine, reject and revise, provides a flexibility that is unavailable for speech production. This difference may be a critical element in allowing individuals with multiple processing deficits to re-establish written communication, when spoken communication fails (Beeson, 1999)

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peech and language therapy intervention for the person with chronic severe aphasia is problematic for many reasons. With only limited spontaneous recovery and compensation the person will continue to have restricted means of expressing their thoughts, feelLinda Armstrong ings and needs and may have ongoing significant difficulty in understanding both what people say to them and the written word. While these problems clearly impact on everyday communication and social integration, they will also reduce therapeutic options, for example through difficulty in understanding task requirements. The person may already have had a significant amount of speech and language therapy input, with little or no perceived positive benefit in terms especially of spoken language expression (often the outcome measure for people Jaclyn Dallas with aphasia and their families). They may become dependent on the speech and language therapy service as one of the remaining health services provided on discharge from hospital and so resist discharge. Alternatively the person and their family may feel disappointed by the lack of progress. In our experience the speech and language therapist should be very clear about the aim and outcome of continued professional input so that there is evidence of met goals to support the ongoing efforts of the therapist, the client and the clients family. There may be rehabilitative as well as supportive episodes of care. A move towards discharge from speech and language therapy is sometimes accompanied by onward referral to a social group, such as those run by Chest, Heart and Stroke Scotland or the Volunteer Stroke Scheme. Discharge may be the eventual outcome of weaning the client from therapy by one or more of a range of means, including wait and see, negotiation, preparation, separation and replacement (Hersch, 2003).

Positive experience
This single case study demonstrates that at 2 years and 5 months post-onset, a simple therapy paradigm effected significant improvement in the written language ability of a person with chronic severe aphasia. Through sharing it, we hope to show how this made the move towards discharge a more positive experience for the client, his family and the therapist, provided a therapy paradigm that could easily be continued and developed by the client and his family, and demonstrated an ability which has the potential to improve his functional communication ability. Mr McDonald is a previously literate right-handed gentleman in his early 70s, who in 2002 suffered an extensive left middle cerebral artery territory infarct, with resultant right

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HOW I

hemiplegia, dysphagia, severe aphasia and later seizures. He also has other medical conditions that affect his general health. Speech and language therapy input began immediately post stroke, while he was an in-patient, and continued after this on a domiciliary basis, initially twice a week and latterly once a week. Re-administrations of the Aphasia Screening Test (Whurr, 1996) at intervals (table 1) showed improvements in auditory comprehension, reading comprehension, spoken language expression and written language expression but functionally, in 2005, he continued to exhibit severe expressive and receptive aphasia, exacerbated by articulatory dyspraxia. On the three-picture version of Pyramids and Palm Trees, he scored 42/52 in August 2003 and again in July 2004.
Table 1 Aphasia Screening Test results Date Comprehension (possible maximum 100) November 2002 44 January 2003 70 July 2003 76 July 2004 76 Expression (possible maximum 150) 0 15 27 35

At the beginning of 2005 Mr McDonalds speech output consisted of a few intelligible words and a recurrent unintelligible utterance, very occasional spontaneous use of appropriate single words as well as intelligible use of a four letter swear word. Speech attempts were increasingly accompanied by meaningful gesture and intonational variety. Auditory comprehension and reading comprehension were adequate for his everyday needs. He had a very socially and emotionally supportive family network and he and his wife were highly motivated to carry out therapy tasks. He was most able to get his message across in conversation with his wife and his daughter but found it very difficult to express his ideas to others and tended to sit quietly in company. There were still many occasions when the family gave up and tried again later. Mr McDonald was referred to the Volunteer Stroke Scheme in 2003 in retrospect too early and attended once. He declined to try again. Formal review sessions at regular but infrequent intervals throughout his domiciliary therapy provided opportunities for reflection on the past block of therapy and progress made, and for discussion about the next block. These reviews took place in April 2003, July 2003, December 2003, June 2004 and December 2004. They consisted of planned meetings including the client, his wife and daughter and the speech and language therapist. The speech and language therapist explained a simple written report and left a copy with Mr McDonald. This report included progress towards goals, assessment results and observations of any qualitative improvements in tasks or functional communication. Time was spent in evaluating the effectiveness of the past block of therapy, deciding whether speech and language therapy input should continue and what aspect of communication would be the forthcoming focus in therapy. Mr McDonalds wife had increasingly taken over the tasks and activities initiated by the speech and language therapist, thus ensuring regular practice. Mr McDonald had never wished to support his speech attempts through a low-tech communication aid based on words and pictures, despite several speech and language therapist attempts to demonstrate the usefulness of such an aid (for example a family tree, gardening words). Written expression received attention in therapy from time to time but again was not his chosen focus. By January 2005 he could consistently write basic biographical information. Previous therapy had, according to his wishes, focused mainly on speech production, using cueing methods such as articulograms for single sound and word production drills. Metrical therapy focused at word-level rhythm to try to reduce the use of his recurrent utterance.

expression of biographical information had improved in a previous block through copy and practice, we agreed that his written language expression would be the focus of the next block of therapy. An informal baseline assessment of his writing skills was carried out in early February 2005 to determine current strengths and weaknesses. This assessment consisted of basic shape copying, letter copying and word copying, then delayed copying of five words which were not to be targeted in therapy (and five which were), writing familiar words to dictation, written picture naming and written picture description. He scored 0 on all subtests of the assessment, except the copying and delayed copying subtests. This suggested that copying and delayed copying skills were relatively intact and therefore we decided that these abilities would be targeted in therapy as a means of making writing ability more functional and as a possible means of communicative support. The intervention used with Mr McDonald was based on Beesons (1999) Anagram and Copy Treatment (ACT) protocol and Copy and Recall Treatment (CART) protocol. These protocols were carried out once weekly over the course of Jaclyns final clinical placement. They are based on repeated exposure and practice of target words. The rationale is that particular orthographic representations will thus be relearned and strengthened. Mrs McDonald and one of their daughters produced a list of 23 target words (see figure 1), which were divided into four sets, with most of the verbs in the final set. These consisted of common nouns, verbs and adjectives of varying length and included yes and no. Each of the four word sets was targeted for one therapy session only and was revisited briefly during the following session.

Formal review sessions provided opportunities for reflection on the past block of therapy and progress made, and for discussion about the next block.
Figure 1 Target word lists

Ownership
The block of therapy to be described here derived from the review at the end of 2004. At that time the speech and language therapy view was that regular therapy input was beginning to be less integral to Mr McDonalds ongoing slow communication recovery as he and his wife had taken ownership of his speech practice, were observed to be adjusting to his aphasic status and the goals of the previous block of therapy had been met (in relation to word meaning and use of money). After reflecting on the review, Mr McDonald expressed through his wife that he now wished to explore new possible communicative means as an alternative to his impaired speech production. As written

We used the ACT protocol (see figure 2) during the 10 sessions (two of these were for assessment and some lists took two sessions to cover). It is a cueing hierarchy used to elicit the correct spellings of specific target words. We presented a Boardmaker symbol (or picture) of the target to the client along with related semantic information (for example, MONEY. You buy things with money in a shop). This optimises the likelihood that the graphemic representation is linked to the appropriate semantic information. In Mr McDonalds case, we only provided gestural semantic information (gesturing what is done with an object) as too much verbal information proved confusing. Initially, the client is asked to spell the word without any cues. If this is successful, the next item is targeted. If not, the letters of the target are presented randomly as an anagram to arrange. Following successful arrangement of the letters, the target is copied three times. The component letters are presented again, with the addition of two foil letters. After these have been arranged and discarded respectively, the word is again copied three times. The final step in the protocol is for the word to be written three times with all previous instances covered up. Throughout the protocol there is repeated copying of the target word to strengthen the Figure 2 ACT protocol words internal rep(Beeson et al., 2002) resentation.
SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2006

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HOW I

The ACT protocol was complemented by the use of the CART protocol (see figure 3), which was used between therapy sessions on a daily basis by Mr and Mrs McDonald to direct writing practice. Again, the client was presented with a Boardmaker symbol and a written model for each target word. He was then asked to copy each word 15-20 times daily. This copying task was followed by a self-test recall task for practice with no reference to a written model. We reviewed these tasks at the beginning of the following session to ensure completion and, although it was impossible to ascertain whether the self-test recall was completed without reference to a written model, the sheets left provided proof of the repeated copying of the target words.

Multiple repetitions...would not be suitable for clients who require variety in task and stimulus to maintain their interest.
Figure 3 CART protocol (Beeson et al., 2003)
Typically sessions began with asking Mr McDonald to write the target words for the session given only the word and a semantic cue (for example, cupyou drink from a cup). He was unable to write any of the 23 target words given only these and required the extra semantic (gestural cue) and visual information (written word to copy) to attempt the task. However, each time we re-visited the previous sessions targets at the outset of the following session, having implemented the ACT and the home based CART protocols, he was able to write on average 60-70 per cent of the words given the verbal and symbolic cues.

This single case study provides some evidence for an effective speech and language therapy intervention for a person with chronic severe aphasia through a relatively simple therapeutic paradigm. Delayed copying provides a therapeutic approach for people whose degree of spelling deficit is so severe that a cognitive neuropsychological approach to assessment and therapy has little to offer. As Mr McDonald was unable to write any words spontaneously before the delayed copy therapy was tried, we were not able to assess with any degree of certainty the source of his problem with writing words or whether any characteristics of the words themselves were significant (including length, grammaticality, frequency, regularity). The combination of ACT and CART worked for Mr McDonald. However, the nature of the protocols is multiple repetitions (parallel to the articulatory drilling used to try to improve speech production). This suited this client well but would not be suitable for clients who require variety in task and stimulus to maintain their interest. While there was significant improvement noted in this clients ability to spell the target words, there can be no automatic claim made that the therapy will generalise to other words. Rapp and Kane (2002) provide some evidence from two case studies that there can be benefits of this therapy for the spelling of trained words that are long-lasting. Both of their participants had less severe language deficit than the person reported here. Their participant with graphemic buffer problems was able to generalise to untrained words but the other, with orthographic output lexicon problems, was not. Therefore, increasing the number of words that can be correctly spelled may require the protocol to be repeated for each word, depending on the nature of the clients spelling deficits. This implicates a very high degree of motivation on the part of the client, therapist and / or significant others, over a lengthy period of time. Delayed copy therapy was successful towards the end of a very long episode of care for this client, at least partly because of a change in interest and motivation by him and his wife in exploring the potential of improving his writing ability. It could of course be employed with other clients much earlier in the therapy process. Linda Armstrong is based at the speech and language therapy department in Perth Royal Infirmary and Jaclyn Dallas is now working in the speech and language therapy department, Centre for Child Health, Dundee. This single case study was carried out during Jaclyns final student clinical placement.

References
Beeson, P.M. (1999) Treating acquired writing impairment: Strengthening graphemic representations, Aphasiology 13, pp. 367-386. Beeson, P.M., Hirsch, F.M. & Rewega, M.A. (2002) Successful single-word writing treatment: experimental analyses of four cases, Aphasiology 16, pp. 473-491. Beeson, P.M., Rising, K. & Volk, K. (2003) Writing treatment for severe aphasia Who Benefits? Journal of Speech, Language and Hearing Research 46, pp. 1038-1060. Hersch, D. (2003) Weaning clients from aphasia therapy: speech pathologists strategies for discharge, Aphasiology 17, pp. 1007-1029. Rapp, B. & Kane, A. (2002) Remediation of deficits affecting different components of the spelling process, Aphasiology 16, pp. 439-454. Whurr, R. (1996) Aphasia Screening Test. London: Whurr.

Figure 4 Summary of client response during final session

Considerable improvement
At the end of the block of therapy described here, Mr McDonald was able to spell correctly 14 of the 23 target words given only the symbolic cue (figure 4). The results show considerable improvement for Mr McDonald in his ability to write the target words, with little direct therapeutic time. After the end of the block, Mr McDonald received no regular therapy for six weeks but we provided him and his wife with materials and instructions for continuing with the delayed copy therapy. At the six-week review it was clear that, without the motivation of regular therapist visits, less practice was being undertaken, but improvement though slower was still ongoing. There was some positive anecdotal evidence though from his wife that during a conversation Mr McDonald had written the word football (one of the trained words) appropriately and in context. The McDonalds plan to build up gradually and over a lengthy period of time the number of words targeted using delayed copying. Training in their functional use will include practice of direct questioning to elicit the targets already practised, overt training during role-played conversation then opportunistic encouragement during conversations by his wife to use practised words functionally.

REFLECTIONS
DO I AVOID REINVENTING THE WHEEL BY CHECKING FOR TRIED AND TESTED TECHNIQUES TO SUIT A PARTICULAR SITUATION? DO I FIND A WAY TO RESPECT A CLIENTS WISHES AND RESPOND TO HOW THESE MAY CHANGE OVER TIME, EVEN IF I THINK I KNOW BETTER? DO I REGULARLY PLAN TIME WITH CLIENTS AND FAMILIES TO REFLECT ON THE THERAPY PROCESS AND AGREE THE NEXT STEPS?

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HOW I

NEVER TOO SOON TO START


READ THIS TO FIND OUT MORE ABOUT INDEPENDENT/ NHS / TERTIARY LIAISON BALANCING PRESCRIPTION AND FLEXIBILITY RESPONDING TO CHANGE IN A CLIENT
When a client makes progress, it is difficult to know if our therapy made a difference and if so, what aspect(s) of it were crucial. Heather Saunders explains why she believes the new edition of the Nuffield Dyspraxia Programme was the key to improvement made by Caelan, a preschool child with autism and verbal dyspraxia.

HOW I (2): PHONOLOGY

he Nuffield Dyspraxia Programme is well-known in the UK as a resource for treating children with dyspraxia. The new 3rd edition (NDP3) has been further developed. This article is an account of how I used it with Caelan, a preschool child with autism and verbal dyspraxia. The NDP3 comes in five ring binders. The first is a therapy manual that includes research-based information on how the psycholinguistic model can be applied to indicate where breakdown occurs in speech processing. The second binder contains the assessment materials. The final three binders house the master sheets of therapy materials, which are photocopiable. Some of the pictures for the vowels have been changed in a continued effort to make them more appropriate to the sounds they represent. For example, /I/ is now an angel instead of Mr. A. and /^/ is now an umbrella instead of a rocket. Two boxes of therapy cards accompany the ring binders. I like the way the new programme incorporates the psycholinguistic research. I also like the fact that the picture pages are laid out in grid boxes that are the same size, rather than odd-sized dividing lines. Previously, I had dipped into the programme with children with phonological delay and disorder / dyspraxia, even those with very little expressive language. I had never considered using it with an autistic child, but Caelans autistic features were reducing. He was becoming an unusually compliant child, and it seemed as though it was likely to meet his needs. Caelans parents asked me to see him for private speech and language therapy when he was just turned two. The family had returned to live in England from the United States, where Caelan was born. Caelan had already been diagnosed with autistic spectrum disorder. At the time of writing, he is aged 4;5. His sessions with me have been once a week for 45 minutes to an hour. Soon after the start of my involvement, Caelan was assessed by Maggie, one of the local NHS specialist speech and language therapists. We have liaised regularly, she working with Caelan initially at his home and then at his nursery, whilst I have always seen him at home. We have usually agreed to each work on a different aspect of Caelans needs at any one time. Maggie introduced the Picture Exchange Communication System (PECS) to Caelan at nursery. Phase one deals with how to communicate by exchanging pictures for a desired object. Caelan quickly progressed through Phases I to III, where the concept of choice is introduced. Like Maggie I am Hanen trained, and my input initially focused on joint attention, turn-taking, eye contact, following Caelans lead, and other principles of the Hanen More Than Words Programme (Sussman & Lewis, 1999). These sessions were sometimes not very productive, as Caelans social communication disorder resulted in him using many avoidance strategies! He would throw tantrums, for example, or become obsessed with a favourite toy or go to the corner of the room and face the wall.

was at a 2-year level, as assessed using the Reynell Developmental Language Scales III (Edwards et al., 1997). He was beginning to have some success at responding to requests containing three information-carrying words. However, his expressive language remained restricted to babble and a handful of unclear words. Interestingly, Caelan was a prolific babbler, using a wide range of phonemes, and I felt it was surprising that his expressive language had not developed more quickly. I had suspected for some time that Caelan might have verbal dyspraxia. He had a very restricted repertoire of consonants in spontaneous speech and many consonants were omitted. His vowels were distorted, his oromotor skills were poor and he had rather flat intonation. His attempts to speak were slow and laboured. I have never adhered to the traditional premise that it is too soon to begin work on speech sounds with a child with limited expressive language. If a child has reasonable verbal comprehension and is trying hard to communicate but is unintelligible or only partially intelligible, I have always felt that it is worthwhile helping him to say what he can say clearly. I therefore began to introduce a few of the NDP pictures (from a previous edition) when Caelan was 3;2. I always find that children benefit hugely from having an action and a verbal descriptor assigned to the picture / sound card. For example, with the picture of a lolly for /l/, I also make an action with my finger to imitate licking a lolly, and describe it to the child as the licking lolly sound. Firstly, I set out three to five pictures, make the action for each picture and tell the child the sound that goes with each picture. My first aim is for the child to be able to identify a picture when I make its sound and action. Next, I aim for the child to identify a picture when I only make its sound. Then I find out which sounds the child can imitate in isolation. Later, it is possible to prompt the child to produce the sound using a variety of modalities that is, by showing the picture, making the action or describing the required sound, or a combination of these. I work on vowels in exactly the same way and then CV, VC, and CVC strings can be tackled. This process is similar to Cued Articulation (Passy, 1993) and the Lindamood Programme (Lindamood & Lindamood, 1998). In my experience, Cued Articulation is probably most useful for delayed speech or less severe disorder, whilst the Lindamood Programme lends itself particularly to helping children whose literacy difficulties are linked with their poor phonological awareness. I would choose to use the NDP3 with children with severe phonological disorder or dyspraxia, as I feel it offers sufficiently graded steps for even the most severe of cases. As Caelan had no interest in the Nuffield pictures, I discontinued them shortly after my initial attempts. I had mentioned to Caelans father that I suspected a phonological disorder, and that we would eventually need to work on speech sounds. He had seen me introduce the Nuffield pictures previously, and knew the name of the programme. From that, he took the initiative and researched this further. A keen parent, the next thing I knew he had made an assessment appointment for Caelan at the Nuffield Hearing and Speech Centre in London. I had previously treated another child with dyspraxia who had subsequently been assessed at the Nuffield Centre, and I knew their reports to be very helpful. Following Caelans appointment, a diagnosis of oromotor and verbal dyspraxia was confirmed. Caelan was by then 3;5. Two months later, I began using the new NDP3 with Caelan, following the advice and recommendations of the Nuffield Centres specialist speech and language therapist. I liaised with Maggie, his NHS speech and language therapist, and we agreed that she would focus on language and communication whilst I focused on speech. She continued to see Caelan weekly at nursery and developed his use of PECS on to Phase IV which uses the sentence strip I want. .. She also worked on greetings and pretend play, and had a student on clinical placement for some of the time, who undertook some of this work under supervision.

As Caelans interaction skills developed, I began focusing more on his verbal comprehension. I used the Derbyshire Language Scheme (Knowles & Masidlover, 1982), and supported Caelan with Makaton signing. At 3;0, Caelans verbal comprehension

Expressive language restricted

The Nuffield report contained some detailed recommended aims of therapy to target oromotor skills, single sounds, single sound sequences and CV words. I had liaised with a Nuffield therapist on the telephone and found her to be very generous with her time and advice. In addition, the NDP3 Therapy Manual contains detailed steps of how to work through the programme. I would like to point out here that with the NDP3, as with any programme, there is still room for being innovative and creative according to the needs of the child. I dont ever want to lose my ability to think on my feet if a programme doesnt seem to be working as prescribed! I have followed the programme fairly faithfully, building up the recommended stages from single sound imitation to repetitions of the same sound to alternating pairs
SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2006

Room for being innovative

27

HOW I

and triplets of sounds. I started with consonants and then the vowels. I also included therapy material from the NDP3 to target Caelans oromotor and prosodic difficulties. The inclusion of these therapy materials in the programme is a welcome addition. Caelan took to the programme like the proverbial duck to water. Although features of social communication disorder were less obvious than previously, Caelan still liked routine and predictability. The routines of practice and therapy therefore worked well for him. A typical session might begin with revision of auditory identification of the individual consonant, and next we would go over the homework from the previous week. This might be Caelan saying alternating consonants as he tracked his finger along an NDP3 work sheet with a caterpillar, one sound per caterpillar segment. Next I would introduce new work, which might incorporate a lotto game or a pairs game, perhaps to work on VC words. At the end of the session, Caelan was allowed the bag of his favourite character toys that he knew I always carried with me in my case. Caelan was then free to escape into fairly ritualistic pretend play as a time of relaxation. He was surprisingly compliant in joining in the activities, in anticipation of the reward of the toys. At the suggestion of the Nuffield Centre specialist speech and language therapist, I had tried to find toys to use instead of the NDP3 pictures. This proved to be impossible, and so it was important to make the materials visually pleasing. I would invest time in mounting the materials on coloured card, making them into games and laminating them. This also made them durable. Perhaps future editions of the Nuffield Development Programme might include a set of toys to represent the individual consonants and vowels. I am sure this would provide an invaluable attraction for children.

expressive standard score 79. A recent reassessment using the Pre-School CELF at age 4;5 gave Caelan a receptive standard score of 92 and an expressive standard score of 87. Now, some 11 months after beginning the NDP3, I have been able to use a variety of other therapy resources to target Caelans needs in phonological development, for example Black Sheep Press phonology resources and Webbers Jumbo Articulation Drill Book on CD-ROM. Webbers resource contains some American vocabulary that often has to be omitted, but I like it because I can print materials directly from my computer in colour. We have worked through the consonant clusters and Caelan is beginning to adopt these into his spontaneous speech. He continues to distort some vowels. Caelan needs continued work on multisyllabic words, and I am using the NDP3 materials for this. He speaks slowly and deliberately, and this helps intelligibility. Caelan has made remarkable and unexpected progress with speech sound development. His expressive language skills have progressed so well now that he relies less and less on PECS. I would not hesitate to use the NDP3 with children as young as two, even if they have almost no expressive language, provided that they have reasonable verbal comprehension and are actively trying to communicate. The systematic way that consonants and vowels are built up gradually to be incorporated into words through graded exercises makes success almost inevitable. I have had other success stories since and would encourage others to have a go! Heather Saunders is an independent paediatric speech and language therapist, 61 Disraeli Crescent, High Wycombe, Bucks, HP13 5EW, tel. (01494) 447604, e-mail heather_m_saunders@hotmail.com.

Within just three months of using the NDP3, Caelans expressive language had surged ahead. He went from using an occasional two word phrase to regularly expressing himself in three word phrases. His vocabulary grew at an enormous rate. Within a further three months, he was using five and six words phrases, albeit with immature syntactical structure. Quite significantly, his speech sound system developed rapidly (see table 1 for transcription of some single word samples). It is this progress with his speech sound system that makes me think the phonological therapy unlocked his expressive language. Caelans father was initially the one to carry out the daily home practice activities. After five months of implementing the programme, I liaised with two members of the nursery staff, and arranged for them to come and observe one of my sessions with Caelan at his home. I explained the NDP3 to them and showed them some of the materials. They were very enthusiastic, and have continued implementing practice activities daily with him during the week, with his parents practising with him at other times. Five months after starting the programme, I was able to administer the Pre-School CELF (Wiig et al., 2000) with Caelan, aged 3;11. His receptive standard score was 67, his Table 1 Single word transcription

Sound system developed rapidly

Edwards, S., Fletcher, P., Garman, M., Hughes, A., Letts, C. & Sinka, I. (1997) Reynell Developmental Language Scales III. London: nfer-Nelson. Knowles, W. & Masidlover, M. (1982) The Derbyshire Language Scheme. Derbyshire County Council, www.derbyshire-language-scheme.co.uk. Lindamood, P.C. & Lindamood, P.D. (1998) Lindamood Phoneme Sequencing Programme (LiPS). Austin, Tx: Pro-Ed. Passy, J. (1993) Cued Articulation. Ponteland: Stass Publications, www.stasspublications. co.uk. Sussman, F. & Lewis, R.B. (illus.) (1999) More than Words: Helping Parents Promote Communication and Social Skills in Children with Autism Spectrum Disorder. Toronto: The Hanen Centre. Wiig, E.H., Secord, W. & Semel, E. (2000) CELF-PreschoolUK. London: Harcourt Assessment.

References

Resources

Black Sheep Press Phonology resources, see www.blacksheep-epress.com Makaton Core Vocabulary, see http://www.makaton.org/resources/resources.htm Nuffield Dyspraxia Programme 3, Nuffield Hearing and Speech Centre available from http://www.ndp2004.org/ Webbers Jumbo Articulation Drill Book on CD-ROM is available from companies such as Taskmaster, www.taskmasteronline.co.uk. SLTP

REFLECTIONS

DO I SELECT THERAPY PROGRAMMES THAT WILL SUIT BOTH A CLIENTS CLINICAL NEED AND LEARNING STYLE? DO I INVESTIGATE THE POTENTIAL OF NEW ASSESSMENTS AND THERAPY MATERIALS? DO I TAKE ADVANTAGE OF THE SUPPORT AVAILABLE FROM EXPERT TERTIARY SERVICES?

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SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2006

events
I CAN School Talk Cascades 16 June 2006 Halifax 19 June 2006 Islington 30 June 2006 Woking School Talk is designed to enable education and health professionals to pass on information to as wide an audience as possible. The morning is for practitioners of all levels of knowledge and experience; the afternoon continue in more depth for those new to issues and terminology. Details / brochure for I CAN training starting August 2006 tel. 0845 225 4073 or e-mail training@ican.org.uk The Listening Program Conference - Developing and Integrating the Senses 24-25 June 2006 York 229.13 Tel. 01274 777250 or e-mail info@learning-solutions.co.uk Quest Training Dysphagia courses 10 July / 16 October Introduction to working with dysphagia 12 July / 17 October Paediatric dysphagia assessment 14 July Adult learning disability dysphagia assessment 18 October Management of motor feeding disorders 19 October Management of sensory feeding disorders These one day courses are accompanied by a detailed self directed learning program. Birmingham From 115 www.quest-training.com, e-mail jfrost@ukgateway.net, tel. 0121 628 2813. Singposium 2006 11 July 2006 Birmingham 45.00 A singing, conducting and choral day for all who work with young singers. Music for Youth, e-mail singposium@mfy.org.uk / www.mfy.org.uk British Aphasiology Society Therapy Symposium 4-5 September 2006 The College of St Mark & St John, Plymouth www.ncore.org.uk / tel. 01332 254679

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1. AN OPEN AND FLEXIBLE APPROACH Parkinsons affects people in very different ways. So, one of the most important things is to treat each person as an individual, by ascertaining their personal symptomology at that time. There is no catchall speech and language solution for Parkinsons and therapy should be tailored to each persons specific difficulties, functional needs and progression through the condition. Importantly, these needs are likely to change over time, as Parkinsons is a progressive condition that we cannot put a timescale on. Individuals will progress at different rates. PARKINSONS DISEASE IS A PROGRESSIVE NEUROLOGICAL CONDITION, AFFECTING APPROXIMATELY 120,000 PEOPLE IN THE UK. ACCORDING TO SPEECH AND SWALLOWING PROBLEMS IN PARKINSONS DISEASE (DR NICK MILLER, UNIVERSITY OF NEWCASTLE, 2005), UP TO 70 PER CENT OF PEOPLE WITH PARKINSONS DEVELOP PROBLEMS WITH THEIR SPEECH, COMMUNICATION OR SWALLOWING. HOWEVER, SPEECH, WRITING AND SWALLOWING PROBLEMS DO NOT ALWAYS ACCOMPANY EACH OTHER. SPEECH AND LANGUAGE THERAPY IS VERY IMPORTANT FOR PEOPLE WITH PARKINSONS AND CAN MAKE A HUGE DIFFERENCE BOTH TO THE QUALITY OF THEIR LIVES AND THE LIVES OF THEIR FAMILIES. OFTEN PEOPLE ARE UNAWARE OF THE BENEFITS AND AVAILABILITY OF SPEECH AND LANGUAGE THERAPY. WHEN PEOPLE DO ACCESS THERAPY, HOW DO WE MEASURE UP? THE PARKINSONS DISEASE SOCIETY ASKED PEOPLE WITH PARKINSONS DISEASE TO THINK ABOUT THE RESOURCES THEY VALUE MOST IN A SPEECH AND LANGUAGE THERAPIST 2. AN ACCEPTANCE OF GOOD AND BAD DAYS The way a person is affected by Parkinsons disease can change from day to day, or indeed hour to hour, and the individual may be less able to do things during an appointment when all may have seemed fine on a previous occasion. This is due to the fluctuating nature of Parkinsons and not the person being obstructive or difficult. They may simply be more tired, or be having more difficulties with moving and focusing that day. 3. AN AWARENESS OF MEDICATION EFFECTS For people with Parkinsons the times when medication is taken is crucial, and each individual has their own regimen. The individual may experience periods when the effect of the most recent dose wears off before the next one is due or has begun to work, and a persons abilities will fluctuate in relation to this. There may be sudden switches from being on and able to move, to being off and immobile. It is important to consider times of appointments in connection with medication so that therapy can be scheduled when the person with Parkinsons disease is best able to gain benefit from it. 4. AN ABILITY TO SEE BEYOND THE MASK Being able to communicate is an integral part of managing and enjoying life. The loss of communication skills can have a profound effect on the quality of life of the person with Parkinsons as well as that of their family. Indeed, the effect of difficulties on the persons life may not be directly related to the extent of voice-speech changes, nor the level of intelligibility, but rather how they compromise the persons specific lifestyle. The need for therapy is very much an individual matter and it is important that therapy be directed at outcomes that are discussed with the individual in relation to their lifestyle. Communication difficulties can also create a misleading impression of the person, so that they are incorrectly perceived by other people as being difficult, deaf, drunk or unintelligent. Reduced facial expression when listening and during speech, plus problems with smiling, may result in the person appearing to be bored, unresponsive and humourless. Again this can also fluctuate. Impaired ability to communicate can lead to withdrawal from social events and activities so, when interacting with somebody with Parkinsons, be aware of their possible feelings of social isolation and avoid trying to guess or assume what theyre thinking. Decreased ease of communication can have a considerable effect on relationships, which makes it very important to involve family members in the therapy process. 5. A WILLINGNESS TO GIVE EXTRA TIME An appointment with somebody with Parkinsons may take longer than with other clients. Movement difficulties, unwanted involuntary movements (dyskinesias) and possible episodes of freezing may mean that it takes several minutes for the individual to get into the room and sit down. Make sure that the appointment room is easily accessible and check with the person that the seating provided is suitable for their use. Also, slowed response times may mean that the actual therapy process requires more time. An unhurried atmosphere is more relaxing for the person and creates a better therapy environment. The voice of somebody living with Parkinsons can be affected in a number of ways. For example, it may be soft or lack volume, fade in volume, lack variation and expression, be hoarse or tremulous. Also, the person may speak too quickly, hesitate or have difficulty when starting to speak. Any of these aspects may be targeted in therapy as appropriate to the individual. As with all clients, its important not to rush people with Parkinsons or interrupt them. Give them extra time to respond to questions and dont pretend to understand something if you havent. Watch as well as listen to them when theyre speaking, remembering that there will almost certainly be a decrease in the non-verbal aspects of their communication. 6. KNOWLEDGE OF EATING AND SWALLOWING DIFFICULTIES Some people with Parkinsons have difficulty with eating and drinking due to decreased musculature ability affecting both mastication and swallowing. This can be a cause of great anxiety, concern and embarrassment for both the person and others and can lead to avoidance of eating with others and indeed to malnutrition. It is worth noting that people often do not seek help until the problems have progressed. Managing saliva can be a further source of embarrassment through escape of saliva due to impaired lip closure. Its important that speech and language therapists identify and assess difficulties in this area. Advice and exercises can be helpful as can working with other specialists such as occupational therapists and physiotherapists to consider other options. It is also important to ensure the person with Parkinsons disease understands the need for continual practice of any exercises given, and to review the situation regularly. 7. A DESIRE TO INVOLVE AND HELP THE FAMILY An individuals family may not realise why some day-to-day activities are more challenging than others, for example why theyre having difficulty communicating, swallowing or eating. Wherever possible, advise and work with the family of a person with Parkinsons. If you help them to understand whats going on and give advice about what they can do to help, youll alleviate anxiety, improve communication within the family and make things easier to deal with. Explanation about the fluctuating nature of Parkinsons and indeed everything else mentioned here is helpful to family members and to the person with the condition. 8. A POSITIVE APPROACH For somebody living with Parkinsons, speech and language difficulties can be stressful and isolating. The individual can find him or herself in a world of ever-decreasing communication situations and opportunities. Therapists should adopt and maintain a positive and dynamic approach to rehabilitation at all times, for example by noticing and giving feedback on strengths and successes and helping the client identify and make the most of situations where they do feel more confident. 9. ACCESS TO COMMUNICATION AID SUPPORT In addition to exercises, its worth considering communication aids such as amplifiers. But people cant just be given a piece of equipment and left to their own devices. Instead, they should be given appropriate support to use the aid and their needs should be reviewed regularly. Whilst aids can help, consideration of the communication environment is also very important so that areas in the normal environment whether at home or in a work area can be addressed to be made more helpful. 10. A WISH TO FIND OUT MORE Parkinsons is a very individual condition, and many people living with it tell us they feel that health professionals do not know enough about it. The Parkinsons Disease Society has a range of information resources for professionals working with people with Parkinsons. In addition, it offers flexible, professional and financially accessible training programmes for all staff working with or providing care for people with Parkinsons and their carers. To find out more, visit www. parkinsons.org.uk or contact the PDS on 020 7931 8080 for details of the Education and Training Manager in your region.