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Autumn 03 speechmag
In need of inspiration?
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read recently?
Our cumulative index facility is there to
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The speechmag website enables you to:
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The editor has selected the previous articles you might
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the Autumn 03 issue of Speech 8r Language Therapy
in Practice. If you don't have previous issues of the
magazine, check out the abstracts on this website and
take advantage of our new article ordering service.
If you liked ...
see (198) Wri9ht, L.: Getting to know
you, (199) McNeil, c.: TIpping the scales, (200)
Blight, A.: Fighting fire with fire. All from
Summer 2002, How I manage stammering in
adults.
look at (090)
Code, C. (Winter 1999) Meeting expectations.
what about (183) Irvine, C. (Spring
2002) Preliminary findings of an informal
longitudinal study into the research I practice
interlace: noting the influence of extra trees in
the wood rather than throwing the baby out with
the bath-water.
you might
be interested in (065) Park, K. (Summer 1999)
Whose needs come first? (Reprinted in full at:
www.speechmag.com/archiveslkeithpark.html.)
see (111) Law, J.:
Good questions, good answers, (112) Valentine,
c.: No assumptions, (113) Langhorne, P., Legg, L.,
Pollock, A. 8r Sellars, C.: The burning questions.
All from Spring 2000, How I put practice into
research.
consider (123) Stow, C. 8r Pert, S.
(Summer 2000) My top resources.
Also on the site news about future issues, reprinted
articles from previous issues, links to other sites of
practical value and information about writing for the
magazine. Pay us a visit soon.
Remember you can also subscribe
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ISSN (online) 2045-6174 www.speechmag.com
AUTUMN 2003
(publication date 25th August)
ISSN 1368-2105
Published by:
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e Avril Nicoll 2003
Contents of Speech & Language
Therapy in Practice reflect the
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the publisher. Publication of
advertisements is not an
endorsement of the advertiser
or product or service offered.
Any contributions may also
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Cover picture by Paul Reid (posed by
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Inside cover
Aut umn 03 speechmag
Reader offers
Win Pip the puppet and Basic
Verbs in Simple Settings.
2 News / Comment
4 Taking the long view
"We ... have to just go with the
flow of all that happens in the
day opportunity service.
Personally I am taking a very
long view. I hope that over the
next year or so some of the
hiccups will be ironed out so
that this programme will run
smoothly and an increased
number of service users will
become involved. "
Yasmin Shah reports on the
16 COVER STORY
Sociological perspectives on
inequality series (4)
Ethnicit y and culture: an
unequal power
"It is widely acknowledged that speech and
language therapists (and all other health
professionals) should be sensitive to the
cultural needs of various minority ethnic
groups. However, Holland & Hogg (2001)
have rightly identified that, whilst health
professionals are encouraged to do this,
there is a definite lack of leadership within
the health care services on such cultural
issues. "
People in minority ethnic groups and
cultures face complex and wide-ranging
discrimination. Sarah Earle examines
how we can help reverse th is trend.
introduction of a Focused Interaction programme to a
Day Opportunity Service for people with severe
learning disabilities.
7 " Here's one I made earli er.. . "
Speech and language therapists will forever be in need of
low-cost ideas for flexible therapy activities and materials.
Alison Roberts, who suggested this new column, kicks
off with some gems of her own: Question dice, Spin the
bottle and Spidergram
8 A bright SPPARC
"Although the final number of carer participants
numbered only four, for them it was a new and
extremely worthwhile experience as reported in their
written evaluations throughout the programme. "
'Supporting Partners of People with Aphasia in
Relationships and Conversation' (SPPARC) was
developed in London. Can its positive findings be
replicated in a rural area? Linda Armstrong and
Helen McGrane investigate.
11 Further reading
Ageing, bilingualism, communication, epilepsy I
dysphonia, dysphagia.
12 Functional communi cation: the
impact of PECS
"Generally, the study showed that there was an overall
increase in the number of communicative attempts made
and that Group 1 (who had been using PECSTM for four
months longer than Group 2) showed an increase in the
range and quality of their Functions of Communication."
The Picture Exchange Communication System (PECSTM)
aims to teach individual users to initiate communication.
Sarah Heneker and lisa Maclaren Page investigate
the effectiveness of introducing the approach to whole
classes within a school.
Sadly, since this was written, Lisa died as a result of a
road traffic accident. This article is in her memory.
18 Revi ews
Neurodisability, AAC, inclusion,
conversational practice,
dysphag ia, semantics, assessment
and phonological awareness.
20 Letter to t he editor
Fundamental questions from
Patricia Sims
21 Altered perception
"The concept of contrasting
perceptions with reality is an
interesting one. If anything else,
when perceptions are not in tune
with reality, this challenges and
encourages previous attitudes to
be altered or modified. "
How do people who stammer
think others perceive them, and
are they right? Do people who
don't stammer find everyday speaking situations as
easy as people who stammer seem to think? Guet
lee finds some answers.
24 How I put research int o pract ice
'''Evidence based practice' sounds good, but updating
our practice as new information becomes available is
not always easy. .. Our contributors present the case
you, the jury, must decide. "
Nina Soloff is research coordinator for her service in
Milton Keynes, Sue Roulstone and colleagues are
based at the Speech & Language Therapy Research
Unit in Bristol and Avril Nicoll reflects on how
Carole Pound and Susie Parr are putting their
research into practice at the London Connect Centre.
Back page My t op resourc s
"If you are the sort of person who can look at a
brick and think, 'Mmm, if I drilled a hole in that and
put it on a cord it would be a really unusual
necklace. Perhaps I can get another one, break it in
two, and make matching earrings.. .', research may
be for you."
Paula leslie and Pauline Meek are clinical research
speech and language therapists and practising
clinicians.
In future issues ...
AAC
DYSARTHRIA
DYSPHAGIA
SCHOOLS AND CLINICS
COLLABORATION
SURE START
... and introducing WINNING WAYS
(WORKING WITH A LIFE COACH)
SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2003
ISSN (online) 2045-6174 www.speechmag.com
new s
I CAN TALK! State of the
Aiming
Ten thousand early years settings across the UK are to
receive a free training pack to help staff increase their eNation
The UK's top airlines are effectively barring disabled
understanding of speech and language development.
High
people from booking flights online by failing to meet
professionals with ideas and inventive ways to promote
The I CAN TALK 1 initiative also aims to provide early years
minimum accessibility standards on their websites. Schools need to provide better support for
communication skills and help them to seek support for National computing and disability charity AbilityNet Gypsy Traveller children - the mi nority ethnic
children with difficulties. Tesco Baby & Toddler Club has
audited nine airline websites for accessibility to people group most at risk in the country's schools,
funded the training packs which include a video narrated with visual impairment, dyslexia or a physical disability according to new government guidance.
by Michael Buerk, a booklet and a wall chart. affecting mouse use. The charity points out that the Aiming High: Raising the Achievement of
companies are missing out on potential buying Gypsy Traveller Pupils sets out how schools can
the Royal College of Speech & Language Therapists,
Produced by national charity I CAN and endorsed by
power. It adds, "From October 2004, when extensions overcome difficulties arising from institutional
the pack includes a video based on the acronym TALK to the Disability Discrimination Act come into force, racism, low teacher expectations and inter
- Talking together, Attention and listening, Level of
websites will have to be accessible as a matter of law." rupted learning to raise achievement. It also
language and Keep on commenting. Road shows have Virgin Atlantic, which performed particularly poorly includes examples of current good practice.
been held around the UK to introduce the pack. in the survey, has since made a public commitment to A recent survey of England's local education
I CAN's Gill Edelman says, "What makes I CAN TALKI improve the accessibility of its website. authorities suggested there are about 42,000
unique is that it demonstrates how making use of The survey of airline sites is the first of a planned series of Gypsy Traveller children in England. An Ofsted
everyday routines and play activities in early years settings 'State of the eNation' reports designed as an awareness report in 1999 said, "Although some make a
can have a remarkable effect on speech and language campaign to draw attention to the issue of accessibility reasonably promising start in the primary
development in preschool children. I CAN is proud to and to help disabled people find the best websites for school, by the time they reach secondary level
be providing such an important resource to so many their needs. On-line newspapers, supermarkets and bank their generally low attainment is a matter of
nurseries across the UK."
ing services will also come under scrutiny. serious concern."
www.abilitynet.co.uk See www.standards.dfes.gov.ukJethnicminorities. www.ican.org.uk
SIGNALONG
On the move
Stroke in Parliament
strategy i-to-i UK (which runs voluntary health
The first All Parliamentary Group for Stroke has been launched to highlight
In a strategic move, two top placements overseas) is now at
issues affecting people with stroke and to encourage more investment in
retired speech and language Woodside House
stroke prevention, care and research.
therapists have joined the 261 Low Lane
The Stroke Association is providing practical help to the group which is call
Leeds LS18 5NY SIGNALONG Board of
ing for more public awareness campaigns highlighting the simple things
Tel 0113 205 4620 Trustees.
people can do to reduce their risk, especially getting their blood pressure
Fax 0113 205 4619
Commenting on the appoint
checked regularly. It also wants to see greater awareness that stroke affects
ments of Pat Ie Prevost and
young as well as elderly people, and to encourage more hospitals to open
The Scottish Council on Deafness has moved to
Chairman Thelma Grove,
stroke units in line with government targets.
Central Chambers
Chief Executive Mike Kennard
www.stroke.org.uk
Suite A 1 st Floor
said, "We are grateful to
93 Hope Street
these outstanding volunteers
A character in BBC One's sitcom Glasgow G2 6LD
who have committed to give
OynaVpx
All About Me will acquire a new Tel 0141 2482474
so freely of their time and
voice in the forthcoming series, Text 0141 2482477
skills in helping those less able on
Fax 0141 2482479. courtesy of a DynaVox commu
than themselves."
nication aid.
The appointments coincide
The Encephalitis Support Group is continuing
Starring Jasper Carrott, and
with a move to new premises,
its work under the banner of The Encephalitis
described as offering a fresh
'-' complete with training suite,
Society - action for support, awareness and
insight into 21st century life in
and with SIGNALONG becom
research.
Britain, this second series sees
ing members of the Open
For further information contact the Society at

the Craddock family reacti ng to
College Network, able to
The Encephalitis Resource Centre
, j.
the arrival of a new baby. While
offer courses which carry r-.. 7B Saville Street
the others are bound up with
recognised transferable credits.
. -
Malton
their own concerns, Raj sees the
The charity sees th is as opening " \',"-.
North Yorkshire
big picture and, with his long
the way to significant expansion Y017 7LL
C/oc/(wi5e from centre' front Jamil Dhillol1
awaited communication aid, he
of SIGNALONG training as (Rdj). Ryan (.1rmghr (Perer). Almd Iqbal "
Helpline 01653699599
(Kav.!a ). Na'alid Keery Fi.h., (5"1" and , can now have his say.
Admin Line 01653692583 they will be able to franchise
Roben G>rM (Leo).
DynaVox distributors Sunrise
Fax 01653 604369 the course to suitably qualified
Medical say their aid was chosen against strong competition because it was so
www.encephalitis.info tutors.
easy to programme and create new vocabulary. Jamil Dhillon, who plays Raj,
www.signalong.org.uk
commented, "I was surprised how easy I found the DynaVox to use. It's real
Atasic Scotland can be found at
ly simple, I only had to be shown how to use it once or twice and then I just
1, Prospect 3

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worked the rest out for myself." Sunrise Medical's David Morgan added, "I
Gemini Crescent
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am really pleased that the DynaVox communication aid will be seen on
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national TV in a normal family environment. For too long we have treated
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www.afasic.org.uk www.dynavox.co.uk
SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2003 2
ISSN (online) 2045-6174 www.speechmag.com
news & comment
Autism support gaps
People with autism spectrum disorders and their fami
lies are still falling between the gaps when it comes to
getting the support and benefits they are entitled to.
A report from the National Autistic Society found that
people with autism and Asperger Syndrome don't fit
current ways of thinking about disability or the eligi
bility used to measure support needs. The main
groups less able to access support are people
described as 'high functioning', those in the transition
age group (16-24 years), and people with the lowest
household incomes. Only 9 per cent of respondent
were receiving social skills training.
Autism: Rights in Reality, How people with autism
spectrum disorders and their families are still missing
out on their rights. From the NAS, wwwnas.org.uk.
Dementia tips
As part of Alzheimer's Awareness Week, the
Alzheimer's Society produced its top ten tips for simple
life changes that might protect against dementia:
1. Don't smoke
2. Reduce your intake of saturated fat and salt
3. Take regular exercise
4. Drink alcohol in moderation
5. Eat plenty of fruit and vegetables
6. Eat oily fish once a week
7. Have your GP check your blood and cholesterol levels
8. Avoid head injuries - wear a helmet for cycling and
don't box
9. Have an active social life with outside interests and
hobbies
10. Do a daily crossword puzzle
www.alzheimers.org.uk
Safety project
The National Patient Safety Agency has widened its
focus to include an allied health professionals project
with a former podiatrist at the helm.
Linda Thompson will look at reporting and better
research of patient safety among the allied health
professionals and will work with staff groups to develop
solutions.
The role of the National Patient Safety Agency is to
improve the safety of NHS clients by promoting a culture
of learning and reporting from adverse events, and to
manage the national reporting system to support this
function .
www.npsa.nhs.uk
Children'S Trust
pathfinders announced
Thirty five Cpildren's Trust pathfinders are being created
in England to bring together children's social, education
and health services into a single local structure.
The idea is that money and staff can be pooled and infor
mation shared to offer better support and protection.
The initial wave will be funded for three years and many
will also involve partners from other statutory agencies
and the independent and voluntary sector. They vary in
size and scope, with some focusing on particularly vul
nerable children such as those with disabilities.
www.dfes.gov.uk
Avril Nicoll ,
Editor
33 Kinnear Square
Laurencekirk
tel/ansa/ fax
0 1561 37741S
e-mail
avril ni coll@speechmag.com
... comment. ..
An e.nq u i ri ng
mlna
What makes a good evidence based practitioner?
Nina Soloff (p.25) would approve of the fact that I am already asking a
question. Patricia Sims (p.20) asks even more, and Paula Leslie & Pauline Meek
(back page) also believe that, "Curiosity or, to use a technical term, nosiness"
is a vital quality for research and practice.
There is a danger in an NHS world where protocols and risk management
predominate that we lose our sense of wonder, and become unable to see
the wood for the trees. Combining research with practice is an excellent way
to appreciate how we can bring about evidence based change in our way of
working, as staff at the Speech & Language Therapy Research Unit (p.26) and
the London Connect Centre (p.27) have found. Thinking out of the box is a
vital quality for research and practice.
In her final sociological perspectives on inequality article (p.16), Sarah Earle
continues to give us points to consider and act on from a wide range of
disciplines. Open-mindedness is a vital quality for research and practice.
When what starts off as a question leads on to an investigation - whatever its
scientific value - the way that the results affect your practice can take you by
surprise. Guet Lee (p.21) has picked holes in her survey of perceptions of
people who don't stammer compared with those who do. Nonetheless, the
process has proved to be a valuable therapeutic tool. Seeing the positives is a
vital quality for research and practice.
In reality, of course, research is never finished. Yasmin Shah (p.4) has a good
term for this - 'work in progress' - and she has had to keep going and adapt
according to the latest changes foisted upon her. In our new column, "Here's
one I made earlier" (p.?). Alison Roberts transforms simple, low-cost materials
and ideas into fun activities. Ongoing flexibility is a vital quality for research
and practice.
Linda Armstrong & Helen McGrane (p.8) wondered if an off-the-shelf package
developed in London was flexible enough to be effective in a rural area.
Although there were logistical problems and final numbers were small, the
benefits were clear, and they suggest ways of improving uptake in the future.
An ability to problem-solve is a vital quality for research and practice.
Family, friends and colleagues of Lisa MacLaren Page will still be asking the
question "why?" following her untimely death and unfortunately on this
occasion there are no answers. Lisa was a valued subscriber to this magazine
for five years since her student days, and the research she carried out with
Sarah Heneker (p.12) demonstrates to me that she was a sensitive, reflective
and methodical therapist - vital qualities for research and practice.
SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2003 3
ISSN (online) 2045-6174 www.speechmag.com
work in progress

a In

view
Even when enthusiasm, cooperation and support
from the top are available, changing a culture isn't
easy. Yasmin Shah reports on the successes and what
is still to be achieved following the introduction of a
Focused Interaction progralTlme to a Day Opportunity
SeNice for people with severe learning disabilities.
SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2003
if you are
offering training
managing change
.delivering amulti-
professional service
. ~ wo different but crucial needs are
often identified by speech and
language t erapiSTs:
1. the need fOf organisations to take
on board therapy programmes - to
'own' them -fOf successful outcomes.
2. the limited speech MId language
therapy services allocated to meet the needs of ser
vice users with speech and languag intervention
requirements.
Finding ourselves in this situatio , e developed
a Focused Interaction project wh-ch combines
Intensive Interaction and Ind- 'dualiied Sensory
Environment work.
Intensive Interaction as desaibed by Nind &
Hewett (2001, p.vi) is, 'A spe<i ic interactive
approach to facilitating the de ent of social
and communication abilities i pEG with severe
learning disabilities based on the model of caregiver
infant interaction.' The broad aim - 'or the service
user to discover the world outsi e of themselves
and to start to engage with others.
Individualised Sensory Environment therapy, as
developed by Karen Bunning (1 996), involves the
use of structured sensory stimulatio to develop
purposeful interactions with the en ironment by
the service user. In this context, environment
refers to the people, items, places a events that
motivate the service user. The ,!m -so provide
sensory stimulation that enco rages he service
user to make a target response_ rough the
course of intervention the se ice USEr learns to
make the target responses to get E desired sen
sory reinforcement. Even1ually he target
responses are generalised to SI a -om outside of
the Individualised Sensory Envir ment.
Focused Interaction refers to eve ing the abil
ity of people with severe lea - disabi lities and
severe social communicatioo d- -es to learn
about the world outside of th selves, from devel
oping engagement to lear iog spec- {communica
tion signals (signs, vocalisa -0 voros), through
using Intensive Interacti on or - - ualised Sensory
Environments. Focused Intera - is an umbrella
term that covers both Intens- ~ Interaction and
Individualised Sensory Environment work. So, for
those people who are engag- 9 - others in a dif
ficult to see, minimal, or u -onal way, an
Intensive Interaction approadl is used. When the
person is more interactive and engaged,
Individualised Sensory Environmen erapy is used.
The term Focused InteractJOn is used because the
overall goals of both In ensive
Individualised Sensory En -w - , ork are simi
lar, but differ in the degree 0 - posed structure .
This work has been dE\eIoped ' a large Day
Opportunity Service in Kent. proximately 140
servi ce users attend the service" ugh not every
day. The day opportu nity ~ has historically
had three-month blocks of speech and language
therapy support every 12-15 mo, Servi ce is now
provided one day a week.
Aware and commi tted
Ja.son Gerlack, the manager of the By opportunity
service, is very aware of the need speech and
4
ISSN (online) 2045-6174 www.speechmag.com
In progress
language therapy services and is committed to
developing and delivering a high quality pro
gramme for service users. In the day opportunity
service two sessions are run daily, led by Day
Centre Officers or Sen ior Day Centre Officers.
Care staff are generally assigned to those service
users who have more complex needs and have
one-to-one staff support. In this day opportunity
service, care staff generally work with one service
user in the morning, and another in the after
noon. Sometimes care staff are assigned to sup
port the running of sessions.
The Focused Interaction programme developed
following a referral for three service users who
had severely limited interaction and communica
tion skills. These service users, Larry, Nina and
Helen, attended the day opportunity service daily.
On assessing the three referred service users, it
was clear that they would benefit from an
Intensive Interaction approach to develop
engagement and connection with other people,
and that using an Individualised Sensory
Figure 1 Record f orm used in Focused Interacti on
Name of client
-
Name of staff
Date Location ._-_. ..
DID THE SERVICE USER ...
Give eye contact
Respond vocally
Initiate vocally
Reach I look towards you
Follow or move away from you
Use facial expressions
Use meaningful sounds
(This means sounds I words that can be translated,
for example "Oi" meaning "Come here!")
Show anticipation
Show they wanted more
Take turns with you in activity
What happened? (Describe the sequence)
What do you think was important about this
session?
How did it feel to you?
Environment approach later would be
an effective way of building up more
formal communication skills.
I was aware of the need for therapy to
be delivered as often as possible, and by
staff who were familiar to the service
user. Given that much time is spent
training carers to deliver a programme,
only for carers to leave or be re
assigned, and that as the speech and
language therapist it often is difficult to
ensure programme delivery, I proposed
a different model of service delivery to
the day opportunity service manager.
I discussed the therapy needs of these
people with the manager, and suggest
ed that, for effective intervention, a
number of staff needed to be trained
1998; Nind & Hewett, 2001) . We then developed
our skills through role-play with each other and
observed each other working with one of the des
ignated service users. Della later attended a train
ing day in Intensive Interaction but we did not
want to wait for the formal training before we
were able to launch this project.
We felt that both objective measures of the ser
vice users' responses and subjective impressions of
the staff needed to be recorded, so we designed
a form that we hoped would be easy and clear to
use. This combined elements of forms developed
by Nind & Hewett (2001) and Bunning (1996).
Della and I then delivered staff training. This
consisted of a formal training session,
presented three times to cover all partici
pating staff, as well as session leaders.
Including session leaders was part of
involving all levels of staff in the project
so that they would be able to support the
staff who were carrying out Focused
Interaction. Within the training sessions
My role
would be to
design the
programme,
train all staff,
and to
support staff
on a regular
basis
to deliver the programme at least daily, and that,
preferably, a day opportunity service staff person
should coordinate and support programme deliv
ery. My role would be to design the programme,
tra in all staff, and to support staff on a regular
basis as well as the day opportunity service pro
gramme coordinator. The manager was most sup
portive and freed up a staff person from another
commitment to work with me on this project.
Simple and user-friendly
We decided to keep things as simple and user-friendly
as possible. The idea was that the programme
would start using Intensive Interaction and then,
as the skills of the service users as well as those of
the staff developed, Individualised Sensory
would be introduced. Much time
was spent on Intensive Interaction, partly for staff
to feel comfortable working directly with Larry,
Nina and Helen without using any equipment. I
have found that people can easily focus on equip
ment rather than the service user.
First, much time was spent with the designated
coordinator, Della Heaton, to teach her what
Intensive Interaction is and why it works. This was
supplemented by readings (Bunning, 1996; Irvine,
both knowledge and experi
ential skills were developed
through listening, observation
and role-play.
Following the formal staff
training session, Della or I
supported the staff as they
worked with Larry, Helen and
Nina. Staff were asked to
spend at least ten minutes
morning and afternoon
doing Focused Interaction,
and to then fill out the record
form. We felt that stipulating
a minimum t ime would result
in more success than specify
ing a longer period . We also
hoped that, as staff became
more comfortable, they would naturally
spend more time doing Focused
Interaction, and that the style of their
general interactions with these three
people would shift. We also tried to
schedule a formal meeting with staff
every si x to eight weeks to discuss any
issues and to share our experiences.
Project has changed
Focused Interaction has now been running in the
day opportunity service for ten months. The form
of the project has changed quite considerably.
Initially, more than 10 staff were involved. We
found that some were more comfortable working
in the Focused Interaction style than others. We
also found that staff were reluctant to fill out
record sheets. The feedback from staff meetings
was positive overall . Staff felt that they were see
ing changes in Helen and Nina, and this was
encouraging. Some feedback was also critical - for
example, some staff expressed their view that
they felt it was childish to mirror behaviour.
Della and I responded to the feedback by
1. redesigning (with staff input) the record form to
make it simpler to understand and to use (figure 1).
SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2003 5
ISSN (online) 2045-6174 www.speechmag.com
work in progress
~ 2. asking staff to fill out a simple questionnaire
about their experience using Focused Interaction
and giving them the opportunity to withdraw
from the project. The five staff who returned
the questionnaire wanted to stay in the project.
So our staff group then stood at five, but all
five were comfortable delivering Focused
Interaction and felt that they could see the
benefits of it.
3. resolving to be more present with
this core group of staff. It became The support service I This means that the
clear that, without our regular trained core group of staff only
involvement, they felt they were
of the day
work with Helen and Nina
working in a vacuum, and perhaps when they relieve the contract
opportunity
this contributed to decreased motivation ed agency staff. Staff pointed
in delivering Focused Interaction. out in one of the group meet
service manager
They needed support and ings that this would really
encouragement. This meant that I impact on Focused Interaction.
has been a
would work with whoever was When staff worked all morning
delivering Focused Interaction when I
critical enabling
with Helen or Nina, they could
more confidence'. Helen is also signing 'want' to
request an object during Focused Interaction with
just a minimal prompt.
These are highly significant shihs for both Helen
and Nina, attributable to their participation in the
Focused Interaction.
Things have recently changed again. All individ
ual support workers are being supplied by an
agency. And Larry no longer
attends the day opportunity
was at the day opportunity service and
that Della would do so during the week. factor.
4. developing the skills of staff further.
We videotaped ourselves working
with Helen and Nina and later reviewed these
tapes with staff. The video camera was also
used to record staff as they delivered Focused
Interaction. The recordings were later reviewed
to identify areas of good practice as well as to
facilitate reflection by the staff on their skills.
So, now, five day opportunity service staff were
involved in delivering Focused Interaction. Della
and I continued to try to support staff regularly,
but were not able to do so as ohen as needed. We
also found that staff were not delivering Focused
I nteraction as ohen as we had asked and hoped
for. This was partly explained by staffing short
ages within the day opportunity service as staff
were ill or took summer annual leave.
Nina and Helen have continued to make slow
but subtle changes. Both young women have
been attending the day opportunity service for
several years. Nina used to become quite agitated,
and would butt her head against her chair and
scratch others. She would leave group areas fre
quently. She is now calmer, head butts and
scratches less and stays in group settings, tolerat
in.g being close to others far more. It is also clear
that she is engaging more with others both dur
ing the Focused Interaction sessions and outside
of them. This engagement is demonstrated by
smiling, staying close to staff and looking at, or in
the direction of, staff.
Helen has}lways been more responsive to oth
ers than Nina and at home would talk to her
mother, but her language was not reported to be
functional - that is, she did not use speech to
answer questions or to get her needs met. At the
day opportunity service Helen rarely used her
speech spontaneously, and never in a functionally
communicative manner. Now she occasionally says
the name of the staff member she is with when
engaged in Focused Interaction, sings Iines of
songs and is reported by her mother to, 'have
choose their time to do Focused
Interaction. Perhaps more sig
nificantly, the relationship that
had developed between Nina
and Helen and the staff would obviously be affect
ed now that they were only to spend ten-minute
periods together.
Back to the drawing board
So again it has been back to the drawing board.
We have also analysed the forms with respect to
frequency of delivery of Focused Interaction
expressed as a percentage of sessions in which
Focused Interaction was delivered per month.
The resul ts were disappointing. We have been
getting return rates of 13-51 per cent per month
for the nine months that the data has been
analysed, this in spite of the positive changes in
the skills of Nina and Helen. We have shared with
the day opportunity service manager the prob
lems of delivering Focused Interaction only in
break times, and also the poor rate of delivery.
The plan now is that all the agency staff will be
trained in Focused Interaction through two for
mal sessions and support to the individual agency
staff. The delivery of Focused Interaction will be
written into their contract and the manager will
discuss this with the agency manager. In addition,
all staff in the day opportunity service will be kept
appraised of Focused Interaction through updates
in weekly staff meetings. Della and I will also sup
port staff in delivering Focused Interaction. I will
do so weekly and Della one to three times per
week.
This project continues to be 'a work in progress'.
It is very exciting to see how two service users are
making clear gains as evidenced in increased t ol
erance of others, decreased challenging behav
iour, increased use of words, and the develop
ment of use of a single sign to communicate a
request. The quality of life experienced by both
Helen and Nina has been enhanced.
Unfortunately Larry, the other service user, is no
longer at the day opportunity service.
Critical enabling factor
The support of the day opportunity service man
ager has been a critical enabling factor. He has
freed up a staff person to coordi nate the day-to
day running of the programme and has made it
known to all staff in the day opportuni ty service
that this work is important a d needs to be car
ried out. He has also sent the coordinat or to be
trained in Intensive Interaction, an conti nues to
be supportive as evidenced by ping into place
measures to ensure that the programme of
Focused Interaction is delivere!L
Another key factor has been that both Della and
I have needed to be flexible and responsive to
staff and also to the needs of the day opportunity
service as changes happen. his has meant, and
cont inues to mean, considerable time on a constant
basis for the weekly support of staff, coll ection and
analysis of records, and regular staff meetings.
We also have to just go wi th the flow of all that
happens in the day opport nity service.
Personally I am taking a very long ie . I hope
that over the next year or so some of he hiccups
will be ironed out so that this programme will run
smoothly and an increased numbe of service
users will become involved.
Eventually I envisage that this programme will
become part of the fabric of service delivery at the day
opportunity service, without the intensi e involve
ment of speech and language therapy services.
Yasmin Shah is Senior Speech and Language
Therapist, Advisor in Challengi ng Be aviour, with
the Community Learning Disability Team, Speech
& Language Therapy Department, East Kent
Coastal Primary Care Trust.
References
Bunning, K. (1996) The rinci ples of an
'Individualised Sensory Environment'. Bulletin of
the Royal College of Speech & Language
Therapists 52, 9-10.
Irvine, C. (199B) Addressi 9 e Needs of Adults
with Profound and Multi ple earni ng Disabilities
in Social Services Provision. In: Hewett, D. & Nind,
M. (eds) Interaction in Action - Reflections on the
use of Intensive Interacti on. London: David
Fulton.
Nind, M. & Hewett, D. (2001 ) Practical Guide to
Intensive Interaction. Pl ymouth: BILD
Publications.
Reflections
Do I have a clear vision to work
towards?
Do I see changes that are
beyond my control as a barrier
or a cha lIenge?
Do I provide training in a
variety of ways to maximi se its
impact?
SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2003 6
ISSN (online) 2045-6174 www.speechmag.com

here' s one I made earlier...
DVDs/ PlayStation/ txt and chat-rooms may be all the rage/
but speech and language therapists will forever be in
need of low-cost ideas for flexible therapy activities
and materials. Alison Roberts/ who suggested this
column/ kicks off with some gems of ner own.
II II
Here's one I made earlier.
Question dice
USt,1 fo.r COditfSa!lO(, btAddrvrg in grOlAt'l5or
q()estor;
Materials
v 10cm deep foam (safer than wood)
v indelible ink pen
Brawn
Cut the foam into 10cm cubes (I
suggest you make several)
Artistry
On each face of one of the dice write a
question beginner - who, what, where,
when, why, how. (You could w rite other
word classes such as adverbs and
conjunctions on the other cubes, for use in
other games.)
In practice
1. Take turns to roll the dice
and ask another member of the
group a question beginning with the word
on the face of the dice.
2. You could develop this - as I do - by
presenti ng' alongside photo-cards of people
doing various occupations / activities, and
think up questions to ask them. I also have a
silver, inflatable 'a lien' who sometimes sits in
the group and is asked questions; the group
has to think what its response would be.
3. The question dice is also
useful for MAKATON practice
on staff training days.
Alison Roberts is a speech and language therapist at Ruskin Mill Further Education College in Naiiswort h, Gioucestershire.
SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2003
Spi n the bottle
ThiS ofaCfflli j rfiU$t he the best lJalue
ejlcr lIS Oll/U irmile hi U,O() f
! . J -" ...
ili1()9,(lonol1 ClV;!A 'I cos/) Ylext 10 1101Y1l r'g
Materials
v 1 empty plastic bottle
v sheets of sticky labels
va table with a
forgivi ng surface
Artistry
Write the labels appropriately for
what you are working on. It could
be categories, in which case you
wou ld need to write the different categories
on the labels, and stick them in a large circle
on the table .
In practice
1. Your clients sit around the table and take
turns to spin the bottle, naming things in
the nearest category pointed to by the
bottle when it stops.
2. You could write or illustrate words for
sign language practice. I ha ve used this
game for 're-bonding' a group after a
longi sh break. The labe ls I wrote were
"Since last time I've been to... "
"Since last time I've met..."
"Since last time I've learnt. .. "
"Since last time I've made ... "
"Since last time something that was on the
news... "
" Since last time something that changed for
me was... "
or
larel'ai-tYlitY<J1 J:} prorYrorer ,lOt YOI)r cite, /)
In practice
You will be familiar wit h the traditional
spidergram - a circle or oval 'body' drawn on
a page, with eight ' legs' radiating outwards.
You wri te a word in the
middle, such as 'hobbies' or
'clothes' and then, with your
help, your client thinks of
eight con nected words to
write at the ends of the 'legs'.
You ca n now make these word
into the centres of eight new spiders.
A version of this, which is deemed 'cool'
by chi ldren and teenagers, beefs
up the scary element by depicting a much
more realistic spider.
First, buy a plastic toy spider about Scm
across. Pl ace it on the photocopier platen,
then recopy the result with a blanked-out
space in the middle of the spider body.
In a group setting, we have used these as
a front page for scra pbooks focusing
on ou r interests, then finding
magazine pictures to illustrate each of
\
the hobbies - great for self/other
awareness .
7
ISSN (online) 2045-6174 www.speechmag.com
repli cati on
if you w ant t o
support carers further
use video as a therapy
tool
understand uptake of
your service
'Supporting Partners of People
with Aphasia in Relationships
and Conversation' (SPPARC)
was developed in London and
is a proven method of
improving interpersonal
communication. But can its
positive findings be
replicated in a rural area
where distance and population
figures are so different?
Linda Armstrong and Helen
McGrane investigate.
upporting Partners of People 'i Aphasia in
Relat ionships and Conversation (SPPARC) (Lock et ai,
2001 ) brings together very successfully two threads of
speech and language therapy for people with aphasia
carer support and conve rsational analysis, Carer support
has been an integral part of the rna agement of aphasia
for some t ime now. Conversational analysis is a relatively
new concept in aphasia therapy but has already ~ shown to be an
effective techni que for the assessment and anagement of acquired
language proble ms (Wilkinson et ai, 1998).
In SPPARC, he conversational part ners of pei>p e . h aphasia are
included in 0 separate group programmes, eoch ru ning once a week
for eight weeks. SPPARC can also be provided 0 a - ,,-to-one bas is.
Althou gh t e effectiveness of the progra mme IS proven, it cannot be
pres umed that ' will be easily implemented in a r -al area, particularl y
where there are small population centres, as rba a rural areas pro
vide many different challenges in servi ce pro isi n. r roject aimed to
investigate het her t his method of improving irrrerp..,dfSOnal communi
cation coul d be replicated in our rural area. We v e pleased to find
that it could, although the number of carers we rea( ~ as small and
we identified a number of logisti cal problems for co "de ation if the
programme ere to be repeated in our area.
Discussion of possible group participants with
speech and language therapy colleagues
Familiarisation with the programme
Decision re: location of proj ect group'S
Weeks 7-14 Eight-week support programme
Video recordings of person with aphasia and
partner
Analysis of videos
Weeks 15-22 Eightweek conversational t raining programme
Weeks 2328 Second video recording
Analysis of videos
Project report
Information and support
We allocated 28 once weekly sessi ons for prepara ' ni ng and
reporting of the project (table 1) . The first half o _ rogramme pro
vides the pal1icipants with information and suppo 'or example on
stroke and aphasia, and has been demonstrated by the programme's
authors to be a necessary precursor to the second ' .lD( and her col
leagues found that, following a stroke, the conversa:' al styl e of the
partner often changes in an attempt to adapt t communica
tion situation, for example they may adopt a more tea( e -t herapist'
style of con ersation and try to correct speech SO!) rors, even when
the message is clear. The second group programme is sp-e<ifically aimed
at increasi ng e participants' knowledge of con ersa: n (turn -taking,
topic and so on). Int egral to this second part of e _ amme are pre
and post-trai ning vi deo recordings of the person '.i h oil sia and their
conversational partner. Lock and her colleagues ve been able to
effect significant and lasting change to the conver;af al 'style' of the
non-aphasic conversational partner, thus all o 'l19 _ person wi th
aphas ia maximal opportunity to get their message aero, Changes
include, for example, conversational partners as iog ew- yes-no ques
ti ons and engaging in fewer ' repeat after me' exch- .g5.
SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2003 8
ISSN (online) 2045-6174 www.speechmag.com
IIII
A set of sequential selection exclusion criteria was established to help
ascertain which carers would be invited to part icipate in the pro
gramme. 'Carer' here means a family member or friend who regularly
participates in conversation with the person with aphasia (it does not
imply dependency on the part of the person with aphasia). The speech
and language therapists in our adult service evaluated each client on
their case load for the client's and their carer's suitability for inclusion.

At the time of this audit, the adult ser Changes include,
vice caseload totalled 174 clients. The
for example,
results of this exercise are shown in table 2,
conversational
which lists the criteria and the number of
partners asking fewer
clients and carers who did not meet each
of the criteria. Eleven per cent of the clients
yes-no questions and
and carers were suitable for inclusion. engaging in fewer
The ease of delivery of the pro
'repeat after me'
gramme, its excellent resources and
exchanges.
carer-perceived benefits outweigh any
difficulties encountered along the way. However, as with all groups,
problems did arise which we had to try to overcome.
Initially, 89 per cent of our caseload was not suitable (see table 2). In
total 19 carers were invited to participate in the programme. From table
2, the biggest number excluded were those with a range of medical
diagnoses apart from stroke (a). As our adult service also includes a ther
apist with a commitment to voice, this number may be disproportion
ately high in comparison to adult services that may be neurology-based.
The other main reasons for exclusion were those stroke clients who
were not dysphasic (mainly clients with dysphagia only) (b), followed by
a lack of carFr (c) or the carer not being fit for participating in the pro
gramme (d) . Other reasons for exclusion were that the person with
aphasia was very unwell (2); the carer was not motivated to participate
in speech and language therapy (2); the aphasia was so mild that it did
not affect conversational ability (1); the person with aphasia had multi
ple medical problems (2); and one person with aphasia was very new to
the service and had yet to be assessed.
Locating the programme
Initially we thought that two groups would run. We had envisaged
locating the programme away from the hospital environment. One was
Table 2 Participant selection
Criterion 10 Criterion description No. failing
criterion (%)
a Medical diagnosis of 110 (63.2%)
cerebrovascular accident (in the
absence of head injury, dementia
or other progressive illness)
b Has dysphasia (plus other 18 (10.3%)
communication or swallowing
diagnosis)
c Has a carer 8 (4.6%)
d Carer able to participate 8 (4.6%)
physically, cognitively and
emotionally
e Carer able to commit to 16 3 (1 .7%)
two-hour sessions
f Carer able to travel, if necessary 0
g Any other reason for unsuitability 8 (4.6%)
for SPPARC
Total 1SS(89%)
participate in SPPARC. Ten responded that they were interested and
able to attend. Tab le 3 shows their relationship to the people with aphasia.
Table 3 Initial parti cipants
Relationship Perth group Blairgowrie group
Husband 4 1
Wife 2 1
Partner 1
Daughter 1
TOTAL 6 4
Unfortunately, half of the Blairgowrie group carers had to withdraw
for family reasons before their group began and so it was cancelled . The
speech and language therapist whose geographical area includes
Blairgowrie tried to offer the programme on an individual basis to the
two remaining possible participants, who lived 30 miles apart, but
found it could not be done within her usual service delivery pattern.
Two of the Perth group participants had to withdraw during the pro
gramme because of personal or family illness.
repl c ~ ~ ( : > n
planned for the main population centre in our area (Perth) where an ini
tial group of six carers could participate. Being a city, it was not difficult
to identify suitable premises, and we arranged to locate the group in
the local Association of Voluntary Services building in the afternoon.
We planned to run the other group in a small rural town (Blairgowrie)
in the morning. Finding a suitable venue for this took some more inge
nuity but a local GP's surgery was the final choice. During this search, a
referral was made for a past client, so 20 carers received an invitation to
While a nine-to-five programme fits in nicely with a speech and lan
guage therapist's remit, it does not suit many carers who may be the
main 'bread-winners' or full-time carers of the family. This was high
lighted in criterion (e), where two carers were excluded as they were
known to be in full-time employment and a third was the main carer of
four young children. Again this cropped up as the main reason for the
five ' invited' carers who were interested but not able to participate, as
they worked or for other reasons could not commit to a daytime pro
gramme. Unfortunately, at the time of the project, this problem could
not be specifically addressed.
The wide geographical distribution of potential participants for our
mainly rural service is 2500 square miles. The possible distances to be
travelled to a speech and language therapy event are vast compared to
a city-based programme. In some households the person who survived
the stroke was the only driver, with the carer being left without private
transport. A rural bus service is obviously less frequent, may not be
direct to location and, with greater distances to be travelled, incurs
expense of time, energy and money (often by older people) . From our
own experience of SPPARC, this was a de-motivating factor for some
participants. There are several possible solutions to the problem of dis
tance and transport:
if group numbers were larger, we could position groups as near as
possible to the participants' homes - but it may be difficult to find
suitable premises and, practically, it is very difficult to get sustainable
group numbers in rural areas
prior to the programme beginning, we could find out if people with
private transport can give lifts to those who do not have transport
if we had funds, bus or taxi hire could be arranged or we could use a
volunteer driver scheme
in years to come, the greater availability of telemedicine could help.
The current solution is to locate the group in the largest urban area,
with best public transport links.
SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2003 9
ISSN (online) 2045-6174 www.speechmag.com
repl ication
Video recording
An integral part of the programme is a video
recording between the person with aphasia and
their carer, which is made before and after con
versational training. This is then used as person
alised examples of good conversational strategies and
highlights those that may be adapted to facilitate
more effective two-way conversation. Only two
of the carers (and their partners) were willing to
video themselves so, for us, this was the least
effective part of the programme delivery. A further
problem was with the actual recordings that were
made. For one dyad, for example, we felt that the
recording was not representative of the conversa
tional style of the couple. Instead of the usual
supported chat, the video recording showed a
series of test questions. To improvise we decided
to use the programme's many video clips of people
with aphasia and their carers, instead of person
alised clips. The participants found these very useful
in consolidating the materials with 'live' examples.
Although the recordings that were made were
not used as part of the individualised training, we
were able to use them as training for ourselves in
analysis. This analysis would also be used as a
measure of effectiveness. The checklists are very
user-friendly and we found that our individual
analyses were very similar, so we felt quite secure
about the reliability of our observations.
From the point of view of the del ivery of the pro
gramme, the detailed session plans and handouts
provided an excellent resource, which has not had
to be adapted. The materials are clear and well
explained. SPPARC really is an 'off-the-shelf' pro
gramme. It could probably be run in conjunction
with experienced speech and language therapy
assistants.
Although the final number of carer participants
numbered only four, for them it was a new and
extremely worthwhile experience as reported in
their written evaluations throughout the pro
gramme (half-way and final reviews of both
parts) . Not all carers were able to attend the Perth
group every week, as they also had unexpected
health and other family problems/commitments.
However, their return to the group following res
olution of these crises indicated the importance of
the programme to them. The evaluations were
unanimously very positive about the benefits of
SPPARC and about the concept of them being
together as carers to share experiences:
' .. even though we were learning we could also
laugh (very important).'
'I have found out lots of things I didn't know
about.'
' .. we all had similar experiences.'
'Yes I have really enjoyed it, as we have all been
able to discuss our partners' difficulties.'
Carers' group
As a result of this project, a monthly evening carers'
group has been piloted for the carers who attended
the Perth group as well as for those carers who
are unable to attend sessions during the day. A
speech and language therapist was responsible
for both the administration and facilitation of the
group. This group has been evaluated very positive
ly by the carers who attended (mainly two of the
Perth group carers and two younger carers who had
been unable to attend that group) and a proposal
has been made for funding so that it can continue.
As the numbers remain very small, the proposal is
for a group for carers of people with any acquired
neurological communication impairment, and for
staffing to include a speech and language therapy
assistant (to undertake the group's administration)
and a speech and language therapist.
Discussion 's taking place about the programme
with local speech and language therapy colleagues
who work wit h chi ldren with autism. Although the
programme materials are quite specific to stroke
and dysphasia, its framework has the potential to
be more widely applied in speech and language
therapy.
Linda Armstrong is employed by Tayside Primary
Care NHS Trust and is based at the Speech and
Language Therapy Department, Perth Royal
Infirmary. and Helen McGrane at the School of
Speech and Language Sciences, Queen Margaret
University College, Edinburgh.
Acknowledgement
The Speech and Language Therapy Department
of Perth and Kinross Local Heal and Social Care
Co-operative thanks the Chest Heart and Stroke
Scotland for funding th is project.
References
Lock, S., Wilkinson, R. & Bryan, K. (2001)
Supporting Partners of People with Aphasia with
Relationships and Conver sat i ons (SPPARC).
Speech mark Publishing: Bicester.
Wil kinson, R., Bryan, K. & Lock. S. e al (1998)
Therapy using conversation a alysi>: hel ping cou
pl es adapt to aphasia in conversation.
In ternational Journal of Language &
Communication Disorders 33 (Supplement).
Reflections
Do I offer a service that is flexi ble
enough to meet t he needs of
people with complex r5ponsibili ties?
Do I look at why people may not
be using my service and work
towards solut ions?
Do I adapt programmes to suit
t he nat ure of the location?
"
Training directory
If you are looking for counselling and psy
chotherapy related training in the UK, the
19th edition of the British Association for
Counselling and Psychotherapy's Directory
includes over 1200 courses .
Grandpa's had a stroke
The Stroke Association has produced a leaflet to help children
come to terms with f amily members who have had a stroke.
A spokesman said, ot only does it explain to chil dren what
a stroke is, in easy to understand terms, but it also t eac es
them that it is okay t o be scared."
people, the Foundat ion eople with
For a copy of Grandpa's had a stroke, tel. 01604623933. Training in Counselling and Psychotherapy
11-----------------------11 Learning Disabilities has shed two
Directory 2003, [19, tel. 0870443 5172 or
order online at www.bacp.co.uk. Proud Owner of a Speech
__ 1mped i ment
Mac' version
Topologika have released the early language
pack Speaking for Myself for Apple Macintosh.
An updated Windows version Speaking for
Myself 2 will be released early in 2004.
Prices from 34.95 + VAT for a single user.
Available for Apple Macintosh OS 8.5 and above
(including OSX in Classic mode) and Windows.
Author Tom Cribbin, ho has cerebral palsy, wants to inspi re
readers with this book by demonstrating that all peoplE have
ability despite their disabilities. Using humorous or emo ionaJ
anecdotes to emphasise his points, he says that the t itle of
the book is about an attitude which not only helps impro e
his speech fluency bu allows him to regard his speech in a
lighthearted way.
[8.94 inc. airmail posting from Canada, for details e-mail
See www.topologika.com.thomas.cribbin@sympatico.ca.
information booklets to sllJIport their
mental health and e ellbeing.
The booklets draw dire<tJy on e first
hand experiences of yo 9 peopl e with
learning disabilities ana
All About Feeling
Young People with le
Meeting the emotiona JtrEds of young
people with learni 9 disa . 1:5: A
booklet for parents an (ara>
See www.learningdisab-- OI9..tJ .
Meeting emotional
needs
As young people with lea . disabili
ties are four times as likely to experience
mental health problem as ot young
see p.1 e Resources
10 SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2003
ISSN (online) 2045-6174 www.speechmag.com
DYSPHAGIA
Setzen, M., Cohen, M.A., Perlman. P.W., Belafsky, P.c.,
Guss, J., Mattucci, K.F. & Ditkoff, M. (2003) The asso
ciation between laryngopharyngeal sensory deficits,
pharyngeal motor function, and the prevalence of
aspiration with thin liquids. Otolaryngol Head Neck
Surg 128 (1) 99102.
OBJECTIVE: The study goal was to evaluate the association
among laryngopharyngeal sensory deficits, pharyngeal
motor function, and the prevalence of aspiration with thin
liquids. STUDY DESIGN AND SETIlNG: We conducted a
prospective study of 204 consecutive patients undergoing
flexible endoscopic evaluation of swallowing with sensory
testing and an assessment of pharyngeal motor function
(pharyngeal squeeze). Patients were divided into 6 groups
depending on the results of sensory and motor testing in
the laryngopharynx. Subjects were given 5 ml of thin liquid,
and the prevalence of aspiration in each group was com
pared. RESULTS: The mean age of the entire cohort was 65
years (58% female). The prevalence of aspiration in patients
with intact laryngopharyngeal sensation was 2% (3 of 137)
in persons with intact pharyngeal motor function and 29%
(2 of 7) when pharyngeal motor function was impaired (P <
0.05). The prevalence of aspiration in patients with a mod
erate decrease in laryngopharyngeal sensation was 0% (0 of
9) in persons with intact pharyngeal motor function and
67% (2 of 3) when pharyngeal motor function was impaired
(P < 0.05). The prevalence of aspiration in patients with
severely diminished or absent laryngopharyngeal sensation
was 15% (5 of 33) in persons with intact pharyngeal motor
function and 100% (15 of 15) when pharyngeal motor
function was impaired (P < 0.05). CONCLUSION: Patients
with severely diminished laryngopharyngeal sensation and
pharyngeal motor function are at an extremely high risk of
aspirating thin liquids (100%). Moderate sensory deficits
only appear to influence the prevalence of thin liquid aspi
ration in the presence of pharyngeal motor dysfunction.
Severe laryngopharyngeal sensory deficits are associated
with the aspiration of thin liquids regardless of the integrity
of pharyngeal motor function. We assume that all persons
with an insensate laryngopharynx aspirate thin liquids until
proved otherwise. These results emphasize the relationship
between laryngopharyngeal sensation and pharyngeal
motor function in the evaluation of patients for suspected
aspiration.
AGEING
Williams, K., Holmes, F., Kemper, S. & Marquis, J.
(2003) Written language clues to cognitive changes of
aging: an analysis of the letters of King James VIII. J
Gerontol B Psychol Sci Soc Sci 58 (1) 424.
Reductions in language complexity normally occur in older
adults because of decreased working memory and rate of
language processing. Comparative measures can reveal
whether linguistic change is due to normal aging or dementia.
Linguistic an,alysis of a series of letters of King James, 1566
1625, investigate whether he exhibited a normative or atypical
pattern of change. Fifty-seven letters from the years 1604 to
1624 were analyzed. Data modeling reveals a quadratic pattern
of decline in written language complexity with increased
diversity of vocabulary corresponding to historical reports of
illness around 1618-1619. This investigation demonstrates how
language analysis can provide valuable insight to normal and
pathological cognitive changes of aging as well as to the
understanding of historical figures.
EPILEPSY / DYSPHONIA
Zalvan, c., Sulica, L., Wolf, S., Cohen, J., GonzalezYanes, O. &
Blitzer, A. (2003) Laryngopharyngeal dysfunction from the
implant vagal nerve stimulator. Laryngoscope 113 (2) 2215.
OBJ ECTIVES/HYPOTH ESIS: The objective of the study was to examine
the side-effect profile of the vagal nerve stimulator. Vagal nerve
stimulators have been used to treat intractable seizures in all age
groups. They provide relief to the patient with a seizure disorder by
decreasing the overall number and severity of seizure activities.
Although significant complications are rare, many patients have some
complaint, usually of their voice. STUDY DESIGN: A retrospective eval
uation of four patients with intractable epilepsy. METHODS:
Evaluation of charts and medical records and endoscopic examination
of the larynx. RESULTS: In this small series, all four patients had
implantation-related paresis. Three of the four appear to have side
effects from device activation. CONCLUSIONS: Patients in whom a
vagal nerve stimulator is placed can have adverse side effects. These
can be related to the surgical manipulation of the vagus nerve, result
ing in a temporary paresis of the vocal folds. A second set of side
effects is related to the actual electrical stimulation of the device, and
these side effects can directly affect the laryngeal musculature.
BILINGUALISM
Oh, J.S., Jun, SA., Knightly, L.M. & Au, T. KF. (2003) Holding
on to childhood language memory. Cognition 86 (3) B5364
While early language experience seems crucial for mastering
phonology, it remains unclear whether there are lasting benefits of
speaking a language regularly during childhood if the quantity and
quality of speaking drop dramatically after childhood. This study
explored the accessibility of early childhood language memory by
comparing the perception and production of Korean speech
sounds by childhood speakers who had spoken Korean regularly
during childhood to: (1) childhood hearers who had heard Korean
regularly during childhood but had spoken the language minimally,
and (2) novice learners. All three groups were enrolled in first-year
college Korean language classes. Childhood speakers were compared
to native speakers of Korean to see how native-like they were. The
results demonstrated long-term benefits of childhood speaking expe
rience, underlining the importance of early language experience even
when such exposure is dramatically reduced after childhood.
COMMUNICATION
Sundin, K. & Jansson, L. (2003) 'Understanding and being
understood' as a creative caring phenomenon in care of
patients with stroke and aphasia. J Clin Nurs 12 (1) 10716.
Five care providers particularly successful at communicating with
patients with communication difficulties were video-recorded
together with three patients with aphasia after stroke, during
morning care activities. The care providers were then interviewed
immediately after the video-recordings, about their experiences of
communicating with such patients. The interviews with the care
providers were interpreted by means of a phenomenological
hermeneutic method. Co-creating was the main theme found. Care
providers invite the patient to participate in the creative act of
communication. They have a communicative attitude and show
interest in the patients' personal desires. The care providers
encounter the patient as a presence in a caring communion. In
part, care providers communicate by continuously conveying their
presence to the patient and even creating availability in a close and
open intersubjective relationship. A relaxed and supportive atmos
phere facilitates reciprocity between care provider and patient. The
communication is not technical or strategic; instead care providers
share the patients' experiences in a silent dialogue. This silent dia
logue involves sharing the patients' feelings and thus receiving
messages from the patient.
FURTHER
READING
This regular feature
aims to provide
information about
articles in other
journals which
may be of interest
to readers.
The Ed itor has
selected these
summaries from a
Speech &Language
Database compiled
by Biomedical
Research Indexing.
Every article in
over thirty journals
is abstracted for
this database,
supplemented by a
monthly scan of
Medline to pick
out relevant
articles from others.
To subscribe to the
Index to Recent
Literature on
Speech & Language
contact
Christopher Norris,
Downe, Baldersby,
Thirsk, North
Yorkshire Y07 4PP,
tel. 01765 640283,
fax 01765 640556.
Annual rates are
CDs (for Windows
95):
Institution 90
Individual 70
Printed version:
Institution 72
Individual 50.
Cheques are
payable to
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Research
Indexing.
SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2003 11
ISSN (online) 2045-6174 www.speechmag.com
on line observ ati o ns
IS
if you want to
improve functional
communication
help staff identify and
ma ximise all
communication
opportu n ities
clarify your role
The Picture Exchange
Communication System
(PECSTM) aims to teach
individual users to initiate
communication.
Sarah Heneker and
Lisa MacLaren Page
investigate the
effectiveness of introducing
the approach to whole
classes within a school.
Sarah writes, "Sadly, since
this article was written, Lisa
died as a result of a road
traffic accident. Lisa was a
talented and dedicated
speech and language
therapist and friend to the
whole team. She will be
greatly missed. This al'ticle
is in her memory. /I
unctiona
communication:
PECSTM is a system that aims to teach spontaneous
communication (Frost & Bondy, 1994). The ability
to initiate communicative exchanges is paramount
from the outset and this is achieved by the student
exchanging a symbol of a desired item in order to
obtain it. This system has been rapidly introduced
into a number of locations in which we work.
A local school for children on the autistic spec
trum undertook an extensive programme of staff
training in PECSTM and set out to integrate the sys
tem into their school day. They decided that, in
addition to individual PECSTM programmes, they
would offer two groups of children an entire
PECSTM environment.
'Group l' began in September 2000 and
involved all the children in a specified class. The
entire environment was set up to facilitate the
ideas of PECSTM. Parents received support and
advice from class staff around the use of the sys
tem at home. 'Group 2' began in January 2001
and involved a smaller group within another class.
Just prior to this, class staff and parents of the
children within the group attended a formal
PECSTM training course.
We wanted to evaluate the impact that intro
ducing PECSTM had on:
1. the amount that the children were
communi cating,
2. the functions of the communication,
3. the methods of communication,
4. the level of adult support needed to achieve this.
Figure 1 Communicative parameters observed
We wanted to be as non-intrusive as possible
whilst encompassing the whole communicative
environment in our evaluation . We therefore
chose on line observations, watching the children
in their everyday environments. The data was col
lected through interval recording which involved
the use of a dictaphone to prompt the therapist
when to begin and cease observat ion periods.
The four different contexts in which the children
were observed - 'free play', 'snack', 'swimming'
and 'structured teaching' - were adapted from
Wood et ai 's study (1998) . 'Freeplay' and 'swi m
ming' were defined as 'unstructured', where the
adult's attention on the children was variable,
thus providing opportunities for attention gain
ing. 'Snack' and 'structured teaching ' were
defined as 'structured' . Within 'snack' the com
munication opportunities were highly predictable
(for example, choice making), whilst within 'struc
tured teaching' communication opportunities
were less predictable as the nature of the sessions
make them more variable.
We designed an observation schedule and all
observing therapists were trained to ensure con
sistency. There were two observation phases:
baseline
follow-up.
Each child was observed for a total of one
hour and four minutes over all contexts. The
communicative parameters we observed are in
figure 1.
Level of cueing t Function of
communication
Method of
communication
Manner in
which adult's
attention
was gained
Adult's
response
Level of
prompting
needed to
exchange
symbol
Physical Prompt Requesting Physical Not None None
Model
Question
Presence of
Object I Event
Presence of
Listener
Contextual and
Interoceptive
Greeting
Rejecting
Commenting
Labelling
Responding
Anticipating
Object
Gestural
Symbol
Vocal
Gesture and
Vocal
Symbol and
Vocal
Symbol and
Signing
Physical
Prompt
Environmental
Spontaneous
Already
Gained
Explained
'Not
Possible'
Actioned
Physical
Prompt
Gestural
Prompt
Spontaneous
tThe continuum used to observe the 'level of cueing' was based on that devised by Halle (1987) in his
research on spontaneous language.
12 SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2003
ISSN (online) 2045-6174 www.speechmag.com
the imgact of PECSTM
Group 1
Group 1 were in years 1 to 3 (age range 6;08 to
8;04 at follow-up), Baseline was carried out in
September 2000 when PECSTM had been recently
introduced, At baseline the group's communica
tion skills varied - few used any clear words and
the main method of communication was physical
(such as leading the adult to the item or trying to
take the item themselves) or gestural (for example,
pointing to a required item),
Follow-up was carried out 10 months later, We
have highlighted the key findings for each part of
our evaluation:
1. Amount of Communication (Total Number
of Communicative Acts)
This changed by the following amounts:
BASELINE FOLLOW-UP
-
Freeplay 12 21
- - - , - - - - ~ - - - - - - -
Snack 9 20
Swimming 26 22
- - - - - ~ - ---;--
Structured teaching: 15 29
Although the Total Number of Communicative
Acts during swimming decreased at follow-up,
the children were using more sophisticated forms
of communication and needed less prompting to
do so,
2. Function of Communication
'Requesting' was the main function at both
baseline and follow-up,
Additionally, at baseline, 'commenting', 'greeting'
and 'rejecting' were observed during some activi
ties, namely 'swimming' and 'structured teach
ing'. At follow-up, the use of these functions had
increased and use of them across situations
appeared to have generalised,
3. Method, of Communication
At baseline this was generally symbols, At
follow-up the main methods of communication
were 'symbols' ('snack' and 'structured teaching')
and 'physical' ('freeplay' and 'swimming').
We felt the high occurrence of the use of symbols
at baseline (with the exception of no symbols
being available during swimming) was due to the
intensive teaching of the use of PECSTM,
In all but one context ('freeplay'), symbol use
increased, Children's spontaneous use of symbols
varied at follow-up - some would seek out their
PECSTM folder spontaneously, whereas others
tended to need prompting, The children were
often using their most effective form of commu
nication within the given situation (for example,
if they were playing a joint attention game with
staff, then using physical, gestural or vocal means
appeared to be most appropriate), and this is
something that we strongly advocate,
4. Level of support needed
The 'Presence of an Object or Event' remained
the main level of stimulus to which the children
were responding for all activities,
The children did not show an increase in sponta
neously gaining the adult's attention, and this
remains a key area to focus on, However, they did
appear to have learnt the importance of needing
somebody's attention before communicating with
them, The children showed a striking increase in
the number of attempts they made to communi
cate following the adult giving the child their
attention (from 48 per cent to 88 per cent),
The children learnt the process of exchanging
symbols over the period of observation, At base
line, the children generally either did not
exchange the symbol, or required a physical
prompt to do so, At follow-up, the children were
spontaneously attempting to exchange the sym
bols in 95 per cent of cases, This, however, did not
always result in a successful communicative
exchange, as the adult's attention had not always
been gained first.
Group 2
Group 2 consisted of children in years 4 and 5 (age
range 9;04 to 10;10 at follow-up), Baseline was
carried out in January 2001, Prior to this, PECSTM
had been used solely within snack with no gener
alisation observed, Children were receiving struc
tured PECSTM teaching sessions at phases 1 to 3
(see figure 2) during the baseline observation
week, At baseline the group had a stock of spo
ken words or phrases, but their functional use was
limited,
Follow-up was carried out six months later, As
with group 1, we have highlighted the key find
ings for each part of our evaluation:
1. Amount of Communication (Total Number
of Communicative Acts)
This changed by the following amounts:
-
BASELINE FOLLOW-UP
Freeplay 1
- - - ~ - -
5
Snack
Swimming
8
I
16
3 11
--,
Structured teaching i 16
I
10
Although the Total Number of Communicative
Acts was observed to decrease in 'structured teach
ing' at follow-up, the students were being taught
the more independent skills of commenting for
the first time, and this may have had an impact on
the amount of communication observed,
2. Function of Communication
'Requesting' was the main function at both
baseline and follow-up,
(In addition, at follow-up, 'commenting' was evi
dent in 'structured teaching' as it was being taught.)
3. Method of Communication
Over the period of observation, the children were
observed to move towards using more formal
methods of communication across all contexts,
The children were also increasingly using a combi
nation of methods at follow-up (such as 'physical
and vocal' or 'physical and gestural') even if they
were not always using symbols, Symbols were not
always readily accessible during all activities for
this group,
Symbol use increased in 'snack' and in 'struc
tured teaching', During 'swimming' no symbols
were available during either baseline or follow
up, In 'freeplay' use of symbols remained the
same, The children's spontaneous use of symbols
varied at follow-up - some would seek out their
PECSTM folder spontaneously, whereas others
tended to need prompting,
Figure 2 Phases of PECSTM
Phase 1 Identifying a reinforcer and
teaching picture exchange
Phase 2 Increasing spontaneity and range
Phase 3 Introducing the concept of choice
Phase 4 Introducing sentences
Phase 5 Responding to the question,
'What do you want?'
Phase 6 Commenting in response to a
question
SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2003 13
ISSN (online) 2045-6174 www.speechmag.com
o n line observations
~ 4. Level of support needed
The 'Presence of an Object / Event' remained
the main stimulus that the children were
responding to during 'snack' and 'swimming '.
However, for 'freeplay', responses became
more 'independent', with the children moving
towards 'Presence of a Listener' as the level of
cueing required to initiate communication.
In 'structured teaching', responses became less
'spontaneous', moving from 'Presence of an
Object / Event' to a 'Question'. This appears to be
because the children were being taught the com
municative function of 'commenting' at this t ime.
The data showed an increase in spontaneously
gaining the adult's attention during 'snack' and
'swimming'. No major
change was observed
during 'teaching', but the chl'ldren
the adult's attention
appeared to show less frustrati on and were able
to accept that they could not always have what
they had asked for. When using symbols, we often
saw them waiting patiently if the adult was not
able to give them their attention immediately.
Group 1 communi cated more at baseline than
group 2 and made more progress in relat ion to
Number of Communicative Acts, but we must
acknowledge that the time between baseline and
f ollow-up was longer. We also need to be sensi
tive to the fact that group 1 were younger chil
dren who had had less experience of communica
tion breakdowns than group 2. This supports the
need for early intervention.
This study gave us the opportunity to observe
PECSTM being used with a whole class group and
in all situations versus a sub group. For us, this has
clarified the importance of the
whole environment being con-
Sarah Heneker and Lisa Ma cLaren Page are
speech and language therapists working for
North Surrey Primary Care Trust.
For further information, please contact Sarah at:
Speech and Language Therapy Department,
Bournewood Resource Centre, North Surrey
Primary Care Trust, North West Surrey Therapy
Services, Guildford Road, Chertsey, Surrey, KT1 6
OQA. Tel: 01932 722866 E-mail :
sarah. heneker@nsurreypct.nhs.uk.
Acknowledgements
We would like to express our thanks to staff and stu
dents and Freemantles School in Chertsey, Surrey.
References
Halle, J. (1987) Teaching
Language in the Natural
Environment
was already gained not, the use of such an approach
were uSing more in the study
for the entirety of the facilitates staff to identify and Handicaps 12.
ducive to PECSTM Irrespective of An Analysis of
whether children use PECSTM or
children involved
Spontaneity. The Association
for Persons with Severe
activity observed at
follow -
soph isticated
up.
Significantly with this
group, ' free play'
forms of
appeared to be a less
motivating activity
communication
and, consequently, the
context in which the
and needed
children were less like
ly to be communica
less prompti ng
t ive.
As for Group 1, the
to do so
children in this group
had learnt the process
of exchanging symbols. At baseline, there was
limited occurrence of symbol exchange. At fol
low-up, spontaneous exchange occurred on aver
age 96 per cent of the time for all interact ions
that involved a symbol.
Changes in communication
Generally, the study showed that there was an
overall increase in the number of communicative
attempts made and that Group 1 (who had been
using PECSTM for four months longer than Group
2) showed an increase in the range and quality of
their Functions of Communication. Symbol use
and more formalised methods of communication
increased and children showed a greater aware
ness of the importance of having somebody's
attention b,efore communicating with them. The
children were only observed to use PECSTM with
adults and not with their peers.
The fact that The Presence of Object / Event
remained the main level of stimulus in order to
communicate is an interesting observation. A fur
ther follow-up study could identify whether this is
still the case 18 months on, and for whi ch
communicative functions.
Although not formally observed we noted that,
at follow-up, children involved in the study
maximise all communi cative Frost, L.A. & Bondy, A.S.
appeared to
opportunities. (1994) PECSTM The Picture
Exchange Communication
Challenges for the
show less
System Training Manual .
future Wood, P., Clarke, M. &
We have many challenges for the
frustration and
McConachie, H.R. (1998) The
future. Communication is a CASTLE Project
process that is dynamic in nature.
were able to
Communication Aids and
It is therefore important that Speech and Language
opportunities continue to be Therapy in the Learn ing
accept that they
identified and set up to provide Environment. School
could not always communicative environments in Observation Procedure.
which the children are able to Copyright P. Wood, Institute
consolidate, general ise and of Child Health.
have what they
expand the skills that they have
learnt. To achieve this, staff need to
had asked for
Resources
continue to constantly think ahead
and plan for future communicative
opportunities and ensure that sufficient symbols
are always readily available.
Speech and language therapists have an ongoing
role wit h the introduction and implementation of
PECSTM. Thi s should include:
1. Advising on the communicative environment
and monitoring vocabulary and language
levels.
2. Stressing the importance of the developmental
symbolic hierarchy to ensure that children are
working at a level where they are successful,
moving towards a higher symbolic level as
appropriate. This may mean working at an
object level before moving onto the higher
level of symbolism.
3. Ensuring that communication is multi-moda l.
PECSTM should be considered alongside, and
not to the detriment of, other communicat ion
systems.
4. Ensuring that care is taken to move
methodically through the PECSTM phases, at an
appropriate pace for the child, general ising
skills at each level before moving onto the next.
Further information about
PECSTM (including courses)
from Pyramid Educational Consultants UK Ltd,
Pavilion House, 6 Old Steine, Brighton BN11EJ, tel.
01273609555, www.pecs.org.uk.
Re ections
Do I have an organised
approach to observing clients?
Do I evaluate therapy in terms
of the amount, functions and
methods of communication and
the level of support needed to
achieve this?
Do I give clients the
opportunity to practise using
the most effective form of
communication for a given
situation?
14 SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2003
ISSN (online) 2045-6174 www.speechmag.com
Area
to
services.
new s extra
disabled person."
Parkinson's and also how the person affected can be supported to inter-
The report also highlighted a drastic shortage of care
act with the world around them.
homes, meaning that families are being split apart as
advisory
The MS Trust believes the survey findings also have J2J
individuals are forced to move out of their area to
Pa rkin'i(l n"s
implications for people with other chronic medical
groups
take up the only available options.
conditions.
John Grooms is using the information to
The Parkinson's Disease Society has established
There are 85,000 people with multiple sclerosis
shape its future services and to calion oth
Advisory Groups throughout England in an effort
in the UK. The MS Trust is celebrating its 10th
ers to take up the challenge.
improve services for people with Parkinson's and their carers.
birthday this year.
A summary and full copy of the report is avail
Each of the eleven groups will have representatives with spe
The Information Needs of People with Multiple
able from the John Grooms National Office
cialist skills and experience from health and social services, as
Sclerosis is available from the MS Trust, tel.
ring supporter services on 020 7452 2121,
well as service users. The groups will aim to champion the
01462476700, e-mail info@mstrust.org.uk.
wwwjohngrooms.org.uk.
cause of Parkinson's across their area and to ensure the
development and improvement of local
Student slams
Meeting four times a year, each advisory group will
be led by the Society's Community Services
aphasia service
Support
Manager for that area.
www.parkinsons.org.uk cutbacks from the start
A speech and language therapy student who is also a vol Three sets of linked guidelines for professionals aim to cre
unteer for the Dysphasia Support Service in Stockport is calling ate stronger partnerships between parents and education,
for cutbacks in the service to be reversed. health and social services providers.
Louise Walters, a student at Manchester Metropolitan University, says that the The guidelines, published by the government in England in
region's NHS Primary Care Trust is refusing to fully fund the shortfall of the Dysphasia Support association with voluntary bodies, advise professionals on
Services work which in recent years had been met by the Stroke Association. As a result, the ser how to provide family centred services with access to the lat
vice's organiser has had her hours cut by half, reducing the number of times groups can meet and est advances in health technology. The authors hope they
making a merger of two centres likely. Regular group meetings at a stroke rehabilitation unit will break down the barriers to early identification and
have also been stopped. Louise says that the cutbacks are also affecting the number of home ensure that children receive effective support.
visits and the total number of clients receiving services, leading to lengthy waits and a growing Together From the Start, from the Department for Education
backlog. and Skills and the Department of Health, promotes a more
The Stroke Association commented, "Stroke patients are losing out yet again and it will have a coordinated, family-centred approach to multi-agency working.
knock on effect on other services. We are disappointed that the primary care trust could not Developing Early Intervention I Support Services for Deaf
find the money in this instance to continue funding the dysphasia support work, especially as Children and their Families is from the Department for
purchasers and stroke patients generally value the service so highly." Education and Skills in conjunction with the Royal National
They continued, "We are encouraging PCTs to invest more in stroke services, not less, because Institute for the Deaf, and is designed to assist local education
people affected by stroke deserve a better deal. Decisions like this will make it even more of a authorities dealing with the ramifications of Newborn
postcode lottery for people affected by stroke. There are 300,000 people at anyone time cop Hearing Screening.
ing with disabilities as a result of stroke and it is well-established that less would have had to Right From the Start Template comes from SCOPE and a number
cope with disability if more patients had access to specialised stroke services. of other voluntary bodies and professional organisations
"We are committed however, despite the financial difficulties, to continue working with the with the backing of the Department of Health. It covers
PCT to develop a comprehensive stroke service." breaking news of disability and promotes a culture of
Louise Walters would like to hear from anyone experiencing similar cutbacks in other areas, respect for children and parents.
e-maillouisejanewalters@hotmail.com. tel. 0161 442 7460. The guidance is at www.dfes.gov.uklsenl.
Empowering parents
Are you a speech and language therapist with experience of working with children who are on the autistic spectrum?
The National Autistic Society's Advocacy for Education Service is compiling a database of speech and language therapists with an interest in autistic spec
trum disorders. Information on this database will be made available to people with autistic spectrum disorders 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. We aim to empower parents and enable them to make informed choices and decisions about their child's education.
If you would like your details to be included on this list please email advocacy@nas.org.uk Please title your email 'Speech and Language Therapist'.
Alternatively write to Advocacy for Education Service, 393 City Road, Islington, London, EClV 1 NG.
MS information
could be improved
Information provision at the time of diagnosis of mUltiple sclerosis is better than it
used to be but there is considerable scope for improvement according to recent
research.
A comprehensive survey funded by the MS Trust used qualitative and quantitative
methods, with 11 focus groups involving 103 people and a questionnaire complet
ed by 2030 people with multiple sclerosis. Specific recommendations have been
made as a result of the findings. Firstly, information should be developed for three
distinct communities - people with multiple sclerosis, the general public (including
family and friends of those affected) and service providers. Secondly, information
should be provided in an appropriate and positive way that takes account of the
individual's needs and motivates them to take action. Finally, appropriate
information needs to be created and provided both for the time of
diagnosis and beyond, when it must address the disease itself
Where.do G\.,",ohn Grooms
you think W Olkll''J WI1I1 clisabl flri people
you're going?
A comprehensive review of the current and future needs of disabled people
has been described by the John Grooms charity as a damning indictment of
Britain in 2003.
Funded by the Lloyds TSB Foundations for John Grooms, Where do you think
you're going? concluded that a number of factors are leading to increases in the
numbers of disabled people and yet services are not being provided at a speed
to match this. One example is long-term support for premature babies as they
reach adulthood. The charity said, "It is only in the last 20 years that we have
seen hope given to those babies; but adulthood for them and their families pre
sents the reality of unsuitable housing, inflexible care and a lack of
facilities to support the need for independence of that young
SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2003 15
ISSN (online) 2045-6174 www.speechmag.com
and cui r.
an unequal
power
M
odern Britain is culturally diverse
and most recent figures suggest
that the minority ethnic population
includes 4.6 million people, or 7.9
per cent of the population (ONS,
2002) (see table 1). It is widel y acknowledged that
speech and language therapists (and all other
health professionals) should be sensitive to the cul
tural needs of various minority ethnic groups.
However, Holland & Hogg (2001) have rightly
identified that, whilst health professionals are
encouraged to do this, there is a definite lack of
leadership within the health care services on such
cultural issues.
Table 1: The UK Popul at ion by ethnic group, April 2001
Percentages
Percentage Percentage
of total of minority
population ethnic
population
White 92.2 nfa
Mixed 0.8 11 .0
Asian or Asian British
Indian 1.7 21.7
Pakistani 1.3 16.7
Bangladeshi 0.5 6.1
Other Asian 0.4 5.7
Black or Black British
Black Caribbean 1.0 13.6
Black African o.g 12.0
Black Other 0.1 1.5
Chinese 0.3 4.2
Other 0.6 7.4
Not stated 0.2 nfa
All minority ethnic 7.6 100.0
population
All population 100 nfa
Source: ONS (2002)
It is useful to begin by defining what we mean
by the terms 'race' and 'ethnicity'. The term 'race'
is commonly used and usually refers to genetic or
physical variations between groups of people
skin colour is a good example of this. However,
sociologists prefer to use the term 'ethnicity' as this
recognises the socially constructed nature of 'dif
ference'. Sociologists usually agree that ethnicity
refers to a common ancestry, a particular geo
graphical territory, and those who share a lan
guage, religion and social customs (Fenton, 1999).
Other indicators of ethnicity might include diet,
name and nationality.
Heterogeneity
It is important to recognise that minority ethnic
groups are not homogenous, and that there is a
great deal of heterogeneity, including differences
of socio-economic status, gender and age,
amongst others. More recently, sociologists have
highlighted how the term ' ethnic' usually refers
to those in minority ethnic groups, rather than
the 'White' majority. However, Pfeffer (1998)
argues that the term 'White' is unhelpful as it can
include people of Irish origin and Jews, amongst
others, reflecting a rather diverse range of needs
and experiences. Defining ethnicity is complex
and there is no universally agreed classification.
However, the most recently recommended classifica
tion for ethnic identification can be seen in figure 1.
Figure 1 Classification of Ethnic Groups in Britain
White
British
Irish
Other White
Mixed
White and Black Caribbean
White and Black African
White and Asian
Other Mixed
Asian or Asian British
Indian
Pakistani
Bangladeshi
Other Asian
Black or Black British
Black Caribbean
Black African
Other Black
Chinese or Other ethnic group
Chinese
Other ethnic group
Source: ONS (2002)
In spite of the difficulty of defining ethnicity
and measuring differences between ethnic
groups, research studies time and again demon
strate wide-ranging inequalities.
Surveys have consistently shown that the health
of most minority ethnic groups is significantly
AUTUMN 2003
ISSN (online) 2045-6174 www.speechmag.com
cov er story : inequality series ( 4)
worse than that of the general population. The research with Black and White stu However, it is important to be
It should be
most recent Health Survey for England (DoH, 1999) dents in the United States, they cautious when considering cul
recognised that the
reveals that Pakistani and Bangladeshi men are argue that White people are more tural differences. Ahmad (1994)
three to four times more likely to describe their likely to perceive Black people's therapist is always argues that minority ethnic cultures
own health as 'bad' or 'very bad'; Black Caribbean speech negatively: as loud, ostenta are often demonised as 'wrong'
in a position of
women are almost twice as likely. The same survey tious, aggressive, active and argu or 'bad' in comparison to those
power relative to
reveals that Pakistani and Bangladeshi men and mentative. This is relevant to thera of the so-called 'White' majority.
women, and Black Caribbean women, are most pists because, as they argue, speech their client. Studies also demonstrate that,
likely to report suffering from cardiovascular dis style stereotypes exist' not on Iy to within education, children from
ease conditions (for example, heart attack, stroke, describe "what is" but to prescribe "what should minority ethnic groups feel devalued, and assump
angina) . Indeed, Bangladeshi men report rates of be'" (Popp et ai, 2003: 317). Figure 2 lists points to tions are often incorrectly made by teachers, based
cardiovascular disease that are 70 per cent higher consider in relation to ethnicity and language. on perceived cultural 'differences' (for example, see
than those of the general population. Rates of dia Brah & Minhas, 1983).
Figure 2 Ethni city and languag e: points to consider
betes are also significant with Bangladeshi men Other theorists suggest that it is impossible to
why children from minority ethnic groups
understand the experiences of minority ethnic and women being nearly six times more likely to
may be either over or under-represented
report this condition (DoH, 1999). groups without considering structural factors and
within your caseload;
Given these figures, it is relevant to ask if speech that an analysis of culture alone is inappropriate
and language therapy services for adults plan for (Smaje, 1996; Karlsen & Nazroo, 2002) . In general
the higher incidence of stroke in people from some
whether you expect English to be the
dominant language;
terms, people in minority ethnic groups are more
minority ethic groups. There is some evidence to likely to be socially excluded; that is, they are
whether you perpetuate racist speech
more likely to be living in poverty, to be unem suggest that people from minority ethnic groups
style stereotypes.
receive an inferior service from the NHS compared ployed or in low-paid employment and are more
to the service received by others. Torkington (1991), Understanding ethnic inequalities is complex likely to have a lower standard of living than the
for example, argues that there is a lack of knowl and there are several perspectives. One explanation general population (ONS, 2002). Indeed, Nazroo
edge amongst NHS staff of the conditions that suggests a genetic component. Traditionally, this (1997) argues that material deprivation probably
most affect people from minority ethnic groups. explanation has been used to explain differences in accounts for most of the inequalities between
Many empirical studies also show evidence of levels of IQ, although this has been widely discredited. ethnic groups and Karlsen & Nazroo (2002) argue
racism and racist discrimination, leading to poorer More recently, theories of genetic variation have that experiences of racism and perceptions of
quality care (for example, see Bowler, 1993). been used to explain differences in the prevalence racist discrimination are also strongly related to
Power and privilege can be mediated and perpet of some health conditions, for example, diabetes, inequality. In other words, many sociologists suggest
uated through language (Crawford 2001). Indeed, hypertension and sickle cell disease. However, Braun that it is not ethnic culture and identity per se
Pugh & Jones (1999: 530) suggest that language has (2002) argues that our knowledge of the history of which leads to inequality, but the marginalisation
a powerful role 'in constructing social realities, populations and their identities and affiliations is of people in minority ethnic groups.
delivering discourses, and representing particular too vague and incomplete to make such an asser There is no single explanation that can account
ideologies' which should neither be overlooked, nor tion, and furthermore that, for ethnic inequalities and it is likely that there
underestimated. It is not surprising, therefore, that 'the current emphasis on genetic explanations rei are multiple factors. A recent study of language
children from minority ethnic groups are often over fies racial and ethnic classifications by reinforcing development in West African children (Law,
represented in referrals to speech and language the notion of biological difference rooted in 2000), for example, demonstrates that delays in
therapy (Law, 2000), although it is difficult to assess genetics. This reification leads to stigmatization of speech and language may be related to stress,
quite how widespread this is. There is also evidence racial and ethnic minorities and to research strate unemployment, financial worries, immigration
to suggest that, in some areas, minority gies that divert attention from status, as well as the influence of cultural beliefs
ethnic groups may be under-represent
It is important
confronting the multidimensional and expectations, which place high expectations
ed in relation to the overall population ways in which racism, not race, on children .
to recognise
(Winter, 1999). influences patterns of disease.' Speech and language therapists clearly need to
that minority
(Braun, 2002: 160). be aware of cultural differences that may affect
Assumptions ethnic groups This implies that other factors practice. Clients from some minority ethnic back
Although English is the language must contribute to the patterns of grounds may differ in relation to language, reli
are not
most commonly spoken in Britain, inequality that can be found with gious beliefs, and beliefs about health, illness and
homogenous,
minority language use is extensive in healthcare, education and else- disability; these may all influence compliance and
and that there is
and probably underestimated. Pugh where. adherence to treatment. Similarly, the therapist
& Jones (1999) argue that mistaken a great deal of needs to be wary of stereotyping clients according
assumptions are often made about Dynamic and changing to so-called ethnic categories, recognising both
heterogeneity
minority languages and that minority Cultural variations between ethnic homogeneity across ethnic groups and hetero
language issues may be oversimplified in practice. groups are often thought to account for a wide geneity within groups.
An e x a m p l ~ of this was noted by the Royal variety of inequalities. Sociologists regard culture as It should be recognised that the therapist is
College of Nursing (cited in Holland & Hogg, a set of beliefs and values which are shared by all always in a position of power relative to their
2001) who identify some of the difficulties members of a cultural group. However, culture is client. Speech and language therapy is a predomi
encountered when using translators: believed to be dynamic and changing, rather than nantly 'White' profession whose 'expert' status is
inaccurate translation of important concepts static. Culture is thought to influence the interpre derived from a predominantly Western biomedical
and ideas; tation of experiences and to guide behaviour. For model. It is, therefore, important for therapists to
bias and distortion; example, beliefs about food, diet and body image reflect on whether they operate within an ethno
lack of confidentiality. are thought to contribute to higher rates of cardio centric framework which serves to marginalise
Popp et al (2003) also highlight the prevalence vascular disease and diabetes amongst some minor and exclude those with different cultural beliefs
of racist speech style stereotypes. Drawing on ity ethnic groups (Holland & Hogg, 2001). and values, or whether they operate within a ~
SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2003 17
ISSN (online) 2045-6174 www.speechmag.com
co v er story: inequalit y series ( 4 )
~ model of openness and informed sensitivity to cultural needs (figure 3). To con
clude, as Henley and Schott (1999:76) suggest: 'The only person who can tell you
what will or will not be right for them is the patient. If we really want to find out,
we have to ask.'
Figure 3 Action points for speech and language therapi sts
improve your inter-cultural communication skills;
respond adequately to cultural and religious needs;
portray positive attitudes to minority ethnic clients and their families;
avoid stereotyping and listen to individual needs.
Dr Sarah Earle is Senior Lecturer in Health Studies at University College
Northampton. Address for correspondence: Centre for Healthcare Education,
Boughton Green Road, Northampton NN2 7AL, tel. 01604 735500, e-mail
sarah.earle@northampton.ac.uk.
References
Ahmad, W. (1994) Consanguinity and related demons: science and racism in
the debate on consanguinity and birth outcome. In: C. Samson & N. South
(Eds.) Conflict and Consensus in Social Policy. Basingstoke: Macmillan.
Brah, A. & Minhas, R. (1983) Structural racism or cultural difference: school
ing for Asian girls. In: G. Weiner (Ed.) Just a Bunch of Girls. Buckinghamshire:
Open University Press.
Braun, L. (2002) Race, Ethnicity, and Health: can genetics explain disparities?
Perspectives in Biology and Medicine, 45 (2), (Spring): 159 - 74.
Bowler, I. (1993) 'They're not the same as us': midwives' stereotypes of South Asian
maternity patients. Sociology of Health & Illness, 15 (2): 157 - 178.
Crawford, M. (2001) Gender and language. In: R. Unger (Ed.) Handbook of
the Psychology of Women and Gender. New York: Wiley, 228 - 244.
DoH (1999) The Health of Minority Ethnic Groups, Health Survey for England
1999. London: DoH.
Fenton, S. (1999) Ethnicity: Racism, Class and Culture. London, Macmillan.
Henley, A. & Schott, J. (1999) Culture, Religion and Patient Care in a Multi
Ethnic Society. London, Age Concern.
Holland, K. & Hogg, c. (2001) Cultural Awareness in Nursing and Health Care.
London: Arnold.
Karlsen, S. & Nazroo, J.Y. (2002) Agency and structure: the impact of ethnic
identity and racism on the health of ethnic minority people. Sociology of
Health & '"ness, 24 (1): 1 - 20.
Law, J. (2000) Factors affecting language development in West African chil
dren: a pilot study using a qualitative methodology. Child: Care, Health and
Development. 26 (4): 289 - 308.
Nazroo, J.Y. (1997) Health and health services. In: T. Modood, R. Berthoud, J.
Lakey, P. Smith, S. Virdee & S. Beishon (eds.) Ethnic Minorities in Britain:
Diversity and Disadvantage. London: Policy Studies Institute, 224 - 258.
ONS (2002) Social Focus in
Brief: Ethnicity. London: ONS.
Pfeffer, N. (1998) Theories of
Re ections
race, ethnicity and culture.
Do I ensure translators appreciate
British Medical Journal, 317 (14
the need for accuracy, impartiality
Nov) : 1381 - 1384.
and confidentiality?
Popp, D., Donovan, R.A.,
Do I recognise that heterogeneity
Crawford, M., Marsh, K.L. &
is a feature of all ethnic groups,
Peele, M. (2003) Gender, Race
including my own?
and Speech Style Stereotypes.
Do I seek (or provide) leadership Sex Roles, 48 (7/8): 317 - 325.
on cultural issues? Pugh, R. & Jones, E. (1999)
Language and Practice:
Minority Language provision with the Guardian ad litem Service. British
Journal of Social Work, 29: 529 - 545.
Smaje, C. (1996) The ethnic patterning of health: New directions for theory
and research. Sociology of Health & Illness, 18 (2): 139 - 171.
Torkington, P. (1991) Black Health: A Political Issue. London: Catholic
Association for Racial Justice.
Winter, K. (1999) Speech and language therapy provision for bilingual chil
dren: aspects of the current service. International Journal of Language &
Communication Disorders, Jan-Mar, 34 (1): 85 - 98.
18 SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2003
~ V I EVVS
CONVERSATIONAL PRACTICE
DOES HALF OF WHAT IT SAYS
The Sourcebook of Practical Communication
(A programme for conversational practice and functional
communication therapy)
Sue Addlestone
Speechmark
ISBN 0-86388-317-6 29.95
This photocopiable sourcebook will be useful for clients who wish to continue
working in a therapeutic way on their output. The 90 topics, with open questions,
are structured enough to be given directly to assistants or family members who
require ideas to continue with conversational practice.
Recording forms can be used to monitor which topics have been discussed,
success at conversation and amount of time spent on each topic.
It will not replace naturalistic interaction, the use of conversation ramps 0
truly functional communication. It does half of what it says on the cover and
is value for money if you need 'a programme for conversational practice'.
Ruth Williams is a specialist speech and language therapist with the Primary
Care Rehabilitation Team, Sa ndweII, West Midlands.
PHONOLOGICAL AWARENESS
RECOMMENDED FOR CONTENT AND VALUE
Soundaround
Andrew Burnett & Jackie Wylie
David Fulton
ISBN 184312001 1 14.00
I enjoyed using this photocopiable book of games to help children develop
early phonological awareness skills. It is fun and interactive, and designed to
be used either in a group or individual setting in mainstream classes for foun
dation through to Key Stage I.
It has a clearly understandable section on the developmental progression of
phonological awareness starting with the development of concepts (often
overlooked) right through to developing an understanding of letters/symbols.
It includes very simple games which are often overlooked in other books. The
layout is simple and easy to follow.
The developmental framework and record keeping forms allow the therapist or
teacher to plot programmes and chart progress easily. The photocopiable pictures
and vocabulary lists are good time savers. Although many practitioners will be
familiar with the games, Soundaround presents them in a new and fun way.
Children enjoy the games especially those such as 'worm sandwiches' and 'sylla
ble steps'. The games are easily adaptable to an individual child or group's need.
I would recommend this little book both in terms of content and value for
money. It is a very useful tool to develop collaborative working between
teachers and therapists.
Wendy Wellington is a senior specialist speech and language therapist for spe
cific language impairment with Sheffield Speech & Language Therapy Agency.
SEMANTICS
QUICKLY EXHAUSTED
Semantic Workbooks
Caroline Davidson, Kaye Beveridge & Carol Nelson
Speechmark
ISBN 0 86388 267 6 90.00
On first impressions this is a well-presented boxed set of basic training exer
cises. Patients find the worksheets easy to access, as the pictures are clear and
the text is a good size.
It is useful for supplementing therapy, but the volume of exercises is quickly
exhausted. As the pages are photocopiable they may be appropriate for take
home packs but there are few explanations within the workbooks, therefore
sometimes it is unclear what the therapist is expected to do. This promotes cre
ativity with the resources but, as there is nothing new that goes beyond other
well-established products, departments may find it of limited value. This resource
is probably most useful for those starting out in semantic therapy who need some
ideas and a guide to the breadth of basic exercises to try with their patients.
Mary Bailey is a speech and language therapist with Surrey and Sussex
Healthcare NHS Trust.
ISSN (online) 2045-6174 www.speechmag.com
~ V i e w s
INCLUSION AAC
INTERESTING, PRACTICAL DESERVES CAREFUL STUDY
AND RELEVANT Augmentative and Alternative
Augmentative Communication Communication (Developmental
and Inclusion: Children and Adults Issues)
Allan Wilson (Ed.) Stephen Von Tetzchner & Nicola Grove (Eds)
CALL Centre on behalf of Augmentative Whurr
Communication in Practice: Scotland ISBN 7867563370 35.00
ISBN 7 89804224 Although the field of AAC is about 30 years
7 0.20 inc. p&p from the CALL Centre old, the editors point out that little is known
(www.callcentrescotland.org.uk) about the natural course of alternative lan-
Augmentative Communication in Practice: guage acquisition, and therefore a critical
Scotland comprises users, their families, carers knowledge base to support our interventions is
and enablers and professionals. This collec- missing. This book is an attempt to redress this,
tion of papers presented at their 12th annual with chapters written by experienced practi
study day is of the usual high standard. tioners presenting case studies and small group
The papers are well-written, easy to read and data of children who develop communication
consider issues around inclusion across the using alternative modes - either sign or symbols.
whole age range, and in a variety of settings. The editors give an excellent overview of the
Examples of good practice are truly inspiring, issues. Later chapters discuss topics such as joint
from the full inclusion of a pupil with physical attention and lexical development; memory and
and communication impairments into a rural strategic demands of electronic speech output
primary school, to a group for adults with communication aids; the influence of different
learning disabilities who use high tech com- language environments and the interactive
munication aids. I found the notes on the dis- nature of alternative language development.
cussion of whether inclusion is the same or dif- There are several longitudinal studies of children
ferent for people with communication difficul- developing alternative language, describing the
ties particularly interesting, and the questions changes in their language use over time. Shirley
posed could be discussed profitably in many McNaughton's retrospective description of Kari's
work situations, including mine! communication development is fascinating, as it
Two small criticisms - the first two papers look also traces the development of AAC in Canada.
at inclusion in mainstream education gener- This is interesting and stimulating but certainly not
ally, but with no reference to children who an easy read. It requires and deserves careful study.
use augmentative communication, and some Each chapter contains a wealth of ideas and experi
papers did not give references. However, the ences which are considered and evaluated with
book is excellent value for money, and I regard to the literature and theories of language
would recommend it to all speech and lan- development. The authors also consider the impli
guage therapists, whatever their level of cations for intervention in a very practical way. It
experience, as interesting, practical and rele- should be required reading for any therapist who
vant to all clients with a communication specialises in MC, and should have a profound
impairment. effect on clinical practice and future research.
Sue Bell is a specialist speech and language therapist at Greenacre School, Barnsley and Chair of
the Trent AAC special interest group.
ASSESSMENT
AN ATTRACTIVE ALTERNATIVE
Diagnostic Evaluation of Articulation and Phonology (DEAP)
Barbara Dodd, Zhu Hua, Sharon Crosbie, Alison Holm and Anne Ozanne
The Psychological Corporation 204.67
Those of us who have used the DEAP feel that it would be a useful addition to our clinic
resources. We liked the bright, bold illustrations and thought that our children would like them
too. We thought the assessment would be especially helpful to newly qualified therapists as it
presents a clear and straightforward path towards diagnosis of specific speech disorders v delay.
However, speech and language therapists at all levels are likely to welcome it as an attractive
alternative to those already in use.
It could be made even better by:
Having a summary of how to work out what to do next on the actual record sheet (for
example, table 3.2 (p.29) could also be at the bottom of the record sheet)
Changing the order of the columns on the diagnostic screen to lay them out in the same order
as transcriptions are made (Target; Transcript; Transcript 2; Speech sounds)
Changing wording of 'Number of words produced twice' to 'Number of words produced the same'.
It is important to bear in mind that, due to the diagnostic nature of the test, there are four dif
ferent, colour coded, forms to choose from whilst carrying out this assessment. These are fairly
complex to use and careful reading of the manual before beginning the test is advised.
Karen Clarke and colleagues are speech and language therapists with Herts Partnership NHS Trust.
NEURODISABILITY
EXCELLENT AND COMPREHENSIVE
Sourcebooks for Neurodisability 1 & 2:
Adults with Profound Communication
Disabilities
Assessing and Maintaining Communication
Fiona Sugden-Best
Speechmark
ISBN 0 86388 269 2 / 0 86388 3052
35.95 each
These two books will be reviewed together, reflecting our
feeling that they could easily be combined to make one
comprehensive volume. The author provides us with an
excellent supplement to existing resources for speech and
language therapists working in the area of adult commu
nication disorders. The information is not new, but well
trial led by practising speech and language therapists
worldwide.
A series of handouts comprise information and exercises,
and record sheets monitor the frequency of practice. All
handouts are addressed directly to the user rather than the
carerlhelper, and all sheets are photocopiable. The layout is
easy to read, the print large and bold, and the diagrams
particularly good. The language is English, rather than
American English. Some of the dysarthria exercises may be
more detailed than is necessary for many patients. The
handouts are excellent for inclusion in treatment pro
grammes for assistants, and in training of other staff.
Aspects that are particularly good include: yes/no screen
ing, facial exercises, strategies for communicating with a
dysphasic partner, and AAC screening. Questionnaires
exploring how people feel about their communication dis
ability could be used effectively to measure outcomes of
therapy.
Anne Baggs, Kathryn Daniels, Karen Simmonds and Louise
Harris are with the adult neurology speech and language ther
apy service at East Cheshire NHS Trust.
DYSPHAGIA
CLEVER BUT FLAWED DESIGN
Provale Drinking Cup
Reliant Medical Products
(www.ReliantMedicaIProducts.com)
$47.90
The relevant feature of this cup is that it only dispenses Scc
of liquid with every drinking motion. It's a clever design
and an excellent concept. In practice I discovered a few
design flaws.
Aesthetically pleasing would not be a phrase that springs
to mind. It takes some time to get used to the look of this
cup. It's big, blue but not very beautiful. The two handles
are removable, however it remains very indiscreet. The
double lid is rather tight, making cleaning and re-filling
hard work for anyone without access to strong hands. That
said, it is made of plastic, making it lightweight and dish
washer safe. There is a vent hole at the back which,
although small, easily spills liquid should the cup be
tipped.
It claims to be suitable for all thin and most 'nectar thick'
liquids and I found it effective with any thickened but
pourable liquid. Those patients for whom bolus volume
makes a significant difference and who are willing to
accept the cup would no doubt find this a useful drinking
device.
Diane Sellstrom is a speech and language therapist at the
University Hospital of North Tees, Stockton-an-Tees.
SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2003 19
ISSN (online) 2045-6174 www.speechmag.com
letter to the editor
~ 1 : e r to the ed itor
Fundamental questions
(From Patricia Sims bye-mail)
Dear Avril,
My son has a twenty-five year old friend who
is dyslexic and who has just embarked on a
new job. On his first day, he found himself
being bombarded with information which
was personally addressed to him at a meet
ing. He had a switch-off panic reaction and
was unable to take a word in. A common
enough, perhaps normal, reaction? Yes, of
course. We all have our absorption limits and
each one of us can find ourselves unable to
attend in a situation where we desperately
want to. But isn't it often the case that a
dyslexic person has a greater degree of this
problem?
Patrick is a thirteen year old who is severely
dyslexic. His inability to take in information
is pervasive. It affects his everyday compre
hension of spoken and written information.
His conditioned reactions are not limited to
the panic one might experience in an impor
tant meeting or interview; they have
become his status quo, rather than a
discernible panic reaction.
Our training
Is it not time to look more closely at under
lying factors, along with the symptoms of
developmental difficulties' How often is
CONDITIONING considered in the training of
speech and language therapists? (Or, indeed,
in the training for many other related pro
fessions.) Yet conditioning appears to me to
be a very important factor in a variety of
developmental difficulties. It plays a funda
mental role in verbal dyspraxia, stammering
and mutism, for example.
We understand that a child has phonological
difficulties. We know when he has
too readily that developmental difficulties
are inherited per se, as kinds of defects'
Aren't we just as likely to have inherited
(probably in a complex way) the ways in
which we are likely to react? Might not our
tension levels feature here (hence a connec
tion between developmental difficulties and
boys with their greater tension levels; Sims,
2002)?
Respected tradition
The voice therapist is fortunate to inherit a
respected tradition of considering a client's
personality and tension levels. Why does the
paediatric therapist feel obliged to pussy
foot for fear of treading on the toes of other
disciplines? Are we going to progress other
wise?
What will be the advantage of spending a
lot of time, resources and energy in the field
of evidence based practice if our approaches
are based on limited understanding' Aren't
we always in danger of acknowledging what
the child can't do and trying to teach him to
do it without addressing the reason? Isn't
that the kind of experience his failure is
based on?
Enough questions! We need to consider how
the answers can affect treatment and out
come. I, personally, have found that one
intuitively takes an appropriate action when
one is properly in tune with a child and his
difficulties. I have already written at some
length about how understanding literacy
problems can influence treatment (No
Failure approach, Sims, 2002). Such methods
may fly in the face of phonological training,
but I have come to see the phonological dif
ficulties as a symptom, rather than a cause,
of overall problems. Since specific difficulties
clear up as the child becomes able to absorb
information, we need to facilitate the child's
very poor comprehension, perhaps in
Figure 1 Text for Patrick
spite of obvious intelligence. We
FLYING
know when he has a very poor audi
tory memory, semantic difficulties, is
verbally dyspraxic, mute, or stammer
At first people made wings and tried to fly like birds.
ing. We are good at diagnosing and But people are too heavy. They are not strong enough
quantifying all his problems and we
to flap big wings.
are expert at breaking them down in
our report writing. But could we be
The first plane to fly properly had a light petrol engine
better at looking at the mechanisms
behind the difficulties? Are we good in it. The pilot could bend the wings to control it.
at seeing when problems arise from
exaggerated reactions, from normal
1. Why can't we make wings and fly like birds?
behaviour?
Do we allow ourselves to become
2. What did the first plane which flew properly have?
brainwashed by simple cause-and
effect judgements? Do we assume (a) a steam engine
(b) a light petrol engine
3. Why did the pilot want to bend the wings?
ability to absorb information, rather than try
to teach him the skills in a direct way.
To give a more specific example, what do we
do with a child who has difficulty under
standing spoken and written information,
although he is, in theory, able to read? We
might custom-write a small piece of text for
him, taking into account his difficulties, age
and interests. A passage whi ch was designed
for Patrick is shown in figure 1. Initially, I
read the text to him two or three times.
Then I read the questions, re-reading the
text as often as was necessary to help him
give the answers. Once he was completely au
fait with the text, questions and answers, I
encouraged him to read it all on his own
silently - simply to lose his fear of print. The
aim is to keep giving the child manageable
pieces of texts in this way so that he becomes
desensitised to his problem. A simple
method? Yes. Impressive' Perhaps not - it
may not impress an observer - but it is the
psychology behind it which is the important
thing.
The texts can be designed to tie up with the
National Curriculum or might relate to any
specific topic or interest, such as basic astron
omy - most children seem to enjoy learning
all about our nearest star, the sun, and inci
dentally learn some biOlogy, chemistry and
physics. Afterwards, the topics can be used
to assist the child to form and sequence writ
ten information.
It is important that speech and language
therapists move forward as evidence based
clinicians. I believe that we can only achieve
this if we ask ourselves fundamental ques
tions about the way in which we practise.
Yours sincerely,
Patricia Sims
Speech and Language Therapist
References
Sims, P. (2002) Reasons &
Remedies (2nd Ed.) Barnstaple:
Mortimore Books.
20 SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2003
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surveys
IS
if you want to
test your instincts
work from a
cl ient's bel iefs
turn black and
white into shades
of grey
How do people who stammer think others
perceive them, and are they right?
Do people who don't stammer -Find everyday
speaking situations as easy as people who
stammer seem to think? Guet Lee set out to
find answers - and discovered that
comparing perception and reality can be a
useful therapeutic tool.
here seems to be an abundance of Against such a backdrop of studies, it is hardly
literature indicating that people surprising that the adults I have worked with
who don't stammer hold negative often tell me that they perceive people who don't
perceptions of those who do. For stammer to regard them as less confident, social
example, Ham (1990), who ran ly disabled, laughable, unprofessional, having
dom Iy contacted telephone incomprehensible speech and ignorant, amongst
respondents ranging from 11 to 85 years of age, other things. These negative perceptions are fur
found a general trend among his respondents, ther extended to perceptions that, unlike them
regardless of whether or not they stammered selves, people who don't stammer have no prob
themselves, to hold stereotypical views of peo lem whatsoever handling speaking situations like
ple who stammer - that is, they were often per telephoning, ordering meals, going for inter
ceived as less adequate and less well adjusted. views, speaking whilst in a queue, and interacting
In another 1990 study, Silverman & Paynter with the opposite sex.
found that their subjects who stammer were This led me to wonder whether people who
often regarded as less competent in their occu don't stammer do indeed perceive those who do
pations than those who don't. In Kalinowski & to have negative personality traits? My personal
Armson's study (1993), there was a tendency for feelings and those of various colleagues and cer
both speech clinicians and the general public, tain personal friends seem to indicate the con
for differing reasons, to perceive people who trary. Also, do people who don't stammer really
stammer as being "guarded, withdrawn, tense, have no problems coping with everyday speaking
shy, anxious, afraid, reticent and introverted". situations, as those who do stammer seem to
Such negative views were further reinforced by think? I have encountered many people who
Lass et al (1994), who reported perceptions held report problems being interviewed, talking on
by school administrators of negative personali the telephone or communicating with someone
ty traits in people who stammer. These percep in authority.
tions were similar to those held by teachers, To try to answer these two questions I carried
special educators and speech and language out a very small-scale survey in two parts: the first
pathologists. dealt with personality traits typically associated
SPEECH & LANGUAGE THERAPY IN PRAalCE AUTUMN 2003 21
ISSN (online) 2045-6174 www.speechmag.com
surveys
confi dence In handling
speaking situations
became something of a
motivating {actor - they
looked upon It as
something to aspire to.
~ with people who stammer and the second with
how easily people who don't stammer deal with
common speaking situations.
I asked a client, Alan, to list the typical negative
traits that he perceives people who don't stam
mer to have of people who do. He came up with
eight which I developed into the polarities of :
unconfident
easily embarrassed
socially disabled
have incomprehensible
speech
fearful
ignorant
confident
not easily
embarrassed
not socially disabled
have comprehensible
speech
not fearful
not ignorant
have restricted social lives do not have
restricted social lives
I then put these polarities on a rating scale of 1
(extreme negative) to 5 (extreme positive).
Alan also listed the speaking situations with
which he thought people who don't stammer
would have no problems:
making phone calls socially
making phone calls at work
answering phone calls socially
answering phone calls at work
ordering food/drinks
speaking in shops
speaking in queues
speaking in group situations
speaking to people in authority
talking to strangers.
Each of these situations was also given a rating scale
of 1to 5of various degrees of difficulty (1 - totally dif
ficult; 2 - significantly difficult; 3 - average difficulty; 4
- slightly difficult; and 5 - not at all difficult.)
Representative
The next step involved taking both sections of the
survey and discussing them with a self-support
group for people who stammer. Although Alan
provided me with the survey items, I wanted to
know if the same items were representative of
the way most people who stammer would view
other people's perceptions of them, and if the
speaking situations listed were typically the ones
that they thought people who don't stammer
would have no problems with. Almost all the
members of the self-support group agreed with
the items in the survey.
I then went back to Alan and asked him to pre
dict what number on the rating scales a person
who doesn't stammer would circle in both sections
Table 1 . Perceptions versus actual views (traill)
4.7o 1
2.60 I
3.90 1
2.301
4. ,5 I
2.901
3.381
2.20 I
3.80 1
2.10 1
3.50 I
2.20 I
2 7 0 ~
1.60
3 0 0 ~
1.70
5 4 3 2
extreme
extreme RATINGS
negative
positive
end
end
of the survey. He made his predictions by circling
the appropriate numbers. This was repeated with
nine other dysfluent clients, male and female. I
kept all the predictions / perceptions. The 10
clients then kindly took four copies of the survey
each to distribute among their colleagues, friends
and family members who don't stammer. In all, 10
clients made their predictions and 40 other people
- who had no idea what these predictions were
circled the appropriate number on the rating scales
according to how they actually felt.
The results for the first section of the survey
dealing with personality traits of the people who
stammer are in table 1 (the scores on the horizon
ta I axis of the table are averages). They show that
perceptions did not match the reality. They clearly
suggest that the person who stammers had a ten
dency to think that other people's view of them
was much more negative than it actually was.
The results for the second section of the survey
are in table 2 (again the scores on the horizontal
axis are averages). They indicate that, in this case,
perceptions appeared to match the reality. There
did not appear to be a significant difference
between the way in which a person who stam
mers thought someone who doesn't stammer
would cope with various speaking situations, and
the way they actually do.
The results in table 1 conflict with the literature
and allude to the possibility that, if anything, peo
laughable - not laughable
restricted lives - unrestricted lives
ignorant - not ignorant
V1
r
<t:
fearful- not fearful
cr:::
I-
incomprehensible speech - comprehensible speech
socially disabled - not socially disabled
easily embarrassed - not easily embarrassed
unconfident - confident
Mann-Whitney UTest Of Significance
=0.000 (Highly Significant)
CliENT,' PREDICTIONS 0 RfAllTY
pie who don't stammer have a much more posi
tive view of people who do stammer than these
people who stammer would think. However, a
direct comparison with the literature is not possi
ble as this is a small-scale survey and not a
research project. I did not eliminate variables nor
did I set up control groups. In addition, the sam
ple size is quite small and results may be vastly
different with a much larger sample size.
Positive and self-confident
Despite these drawbacks, I found that contrast
ing perceptions with the reality became a useful
therapeutic tool. On hearing the results of the
first half of the survey, the dysfluent clients were
very surprised, and even pleased, that their origi
nal negative perceptions were mostly not proven
right. The realisation, when I compared their
original predictions with the results, encouraged
them to change their perceptions and helped
them to develop a much more positive and self
confident attitude. Alan (26), who gave me the
idea for the survey in the first place, began ther
apy with many negative perceptions. The percep
tion that people who don't stammer think of him
as ignorant and foolish figured quite predomi
nantly. This did not help his then lack of self-con
fidence and sense of isolation. By carrying out the
survey and discovering the more positive trend
that people who don't stammer generally do not
22 SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2003
ISSN (online) 2045-6174 www.speechmag.com
Table 2 - Perceptions versus reality (speaking situations)
2.70 I
speaking to strangers
3.001
speaking to people
in authority
2.70 I
3.00 I
2.571
speaking in groups
3.50 I
3.30 I
speaking in queues
3.70 I
3.50 I
speaking in shops
3.701
3.871
ordering food/drink
3.801
3.651
answering phone
3.50 I calls at work
3.501
answering phone
3.90 I
calls socially
3.50 1
making phone calls
3.50 I
at work
3.95 1
making phone calls socially
3.70 I
I I I I
5 2
Mann-Whitney UTest Of Significance
notat all
offk1J1t dofftQjh diffic.ult =0.818 {Not Significant}
RATII\lGS CLI ENTS' PREDICTIONS D REALITY
hold the same degree of negative opinions of
people who do stammer as he had once thought
- helped to build more positive attitudes. It also
appeared to aid in reducing Alan's once hard-held
image of the world as a place that was constantly
against him.
However, the general pattern from the second
half of the survey was a tendency for perceptions
to match reality. Did this have a negative effect on
my clients? On the contrary, for most, this seemed
to reaffirm their perceptions that generally peo
ple who don't stammer cope better with typical
everyday speaking situations. This confidence in
handling speaking situations became something
of a motivating factor for some of my dysfluent
clients - they looked upon it as something to
aspire to. For the rest, the general trend was to
feel pleased that their predictions were proven
part were generally
The results.. . clearly suggest that
the person who stammers had
a tendency to think that other
people's view of them was
much more negative than it
actually was.
correct in most cases.
Michael (19) could not
resist saying, "There, I've
told you so!" when we
discussed the results of
the second half of the
survey. One of his princi
pal difficulties was in
telephone situations. He
came to therapy wanting
to reduce his fear of the
telephone as one of his
goals. The second part of
the survey did not actual
ly help him in achieving
this goal but merely reaf
firmed his conviction that
he wanted to handle the
telephone without any
qualms, just like the
majority of people who
don't stammer.
The survey was a useful
exercise in this respect
but I can see there were
flaws _ for example, some
---------------------------... of the people who took
known to my clients and
would perhaps be inclined to be more positive
than people who did not know them. The other
limitation is the possibility that, when faced with
filling in a survey form, someone who does not
stammer might give more positive answers than
they truly feel, to appear more sympathetic. In
this way, the question remains - can any sort of
surveyor research truly assess actual feelings?
I am sure that the work I have done can be
extended further or developed into another form
of study. In the meantime I would welcome any
comments.
Guet C. Lee is a speech and language therapist
with City Hospitals Sunderland NHS Trust.
Although she specialises in adult neurology she
also carries an adult dysfluency caseload. At the
time of completing the survey in this article, Guet
was working for Hull and East Riding Community
NHS Trust.
Acknowledgements
I wish to say thank you to the Hull and East
Yorkshire Self-Support Stammerers' Group for their
assistance with this survey, to former colleagues Liz
Buckles and Ruth Edwards for their helpful sugges
tions, and to Dr. Trudy Stewart for her comments
on the first draft of this article. Most of alii would
like to say thank you to all my clients without
whom this article would not have been possible.
References
Ham, R.E. (1990) What is Stuttering: Variations
and Stereotypes. Journal of Fluency Disorders 15,
259-273.
Kalinowski, J. & Armson, J. (1993) Clinicians' and
the General Public's Perceptions of Self and
Stutterers. Journal of Speech and Language
Pathology and Audiology, 17 (2): 61-67.
Lass, N.J., Ruscello, D.M., Pannbacker, M., Schmitt,
H., Kiser, A.M., Mussa, A.F. & Lockhart, P. (1994)
School Administrators' Perceptions of People Who
Stutter. Language, Speech and Hearing Services in
Schools 25, 90-93.
Silverman, F.H. & Paynter, K.K. (1990) Impact of
Stuttering on Perceptions of Occupational
Competence. Journal of Fluency Disorders 15,
87-91.
Re ections
Do I recognise that
perceptions are crucial to
progress?
Do I use surveys as a
therapeutic tool?
Do I access the expertise in
self-support groups?
.. resources ... resources ... resources ... resources ... resources ...
Talking Traffic
This game aims to give children practice in
developing key questioning skills. It is designed
for 1-6 players at reception or key stage 1 and 2,
and for older children with special needs.
Talking Traffic, 24.95, available on 30 days
approval from LOA, tel. 01945463441.
Building on strengths
This guide for dementia care services is intended
to enable care workers to achieve good quality
individual care through creating and using a simple,
structured care plan and risk assessment.
69 including one-off copyright fee from
Alzheimer'S Society Qct orders, tel 01736333333.
Better Vocal Functioning
Vocal Process has produced this CD audio
guide aimed specifically at women who
want to understand and improve their
voice. Narration is by Jeremy Fisher and
demonstrations by Gillyanne Kayes.
9.99, see www.vocalprocess.net.
SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2003 23
ISSN (online) 2045-6174 www.speechmag.com
how I
.l put research.
Into practice
based practice' sounds
good, but u pdati ng ou r practice as
new information becomes available is
not always easy. The unwieldiness
of public services, long waiting lists
and lack of time to research the
research can all conspire against us.
In the Spring 2000 issue, three
contributors discussed how they put
practice into research. Then we
observed that speech and language
therapists "want to know optinlunl
ti mes for intervention, tech n iq ues
that produce results and caseload
organisation that makes the best
use of limited time". So, once we
know, how do we change our
practice accord i ng Iy?
Our contributors present the case
for evidence based practice - l1li.:;)
you, the jury, must decide.
24 SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2003
ISSN (online) 2045-6174 www.speechmag.com
how I
, ResearCh is big.' 'Research means
statistics.' 'Research is time
consuming.' That's one perspective,
but what about another? 'I want
Research isn't confined to ivory towers or
weighty journals. Nina Soloff challenges us
to ask, investigate, discuss and share the
everyday questions that add to the evidence
base for our practice.
Gatheri ng the evidence
to do the best for my clients.' 'I want to be sure I' m making a difference.' Index to Recent Literature on Speech and Language. This is a database
'I know I'm making a difference and I want to share it with other people.' of abstracts from over thirty journals. (The only problem is you often
The problem with the word 'research' is that people have precon find there is too much that you want to follow up.)
ceived ideas about what it involves. Sometimes I think the word should b. Use your librarian. Most Trusts have a library with staff who have a great
be abolished completely, and I should have a different job tit le. many skills in searching for articles. Even if you just go in with a word or a
'Evidence-Based Practice Co-ordinator' is a bit of a mouthful, but phrase relating to what you want to look for, they will be able to help you
evidence-based practice is really what we're talking about as it is: identify relevant articles and books, order items from other libraries, and
'... an approach to decision-making in which the clinician uses the best may even train you in doing literature searches. If you don't have a Trust
evidence available, in consultation with the patient, to decide upon the library, try your local council library.
option which suits the patient best.'
(Muir Gray, 1997)
Evidence-based practice is a part of our everyday
working lives (see stages in figure 1). It happens when
you devise, execute and evaluate therapy plans; when
a discussion with a colleague helps you make a clinical
decision; when you read an article in this very maga
zine and apply it to your own situation.
So how can we put Muir Gray's definition into
operation?
1. Questions, questions, questions
I believe that for most research to be relevant to
clinical practice, it has to be borne out of clinical
practice. A practical way to start is to capture those
questions that pop into your head in your everyday
work (see figure 2) and then ask yourself what evi
dence you need in order to be able to answer them.
It would be great if every clinician had a notebook
to write those sorts of questions down in. That way,
if you're not able to think about the question there
and then, you can go back to it later. Th is can be a
really rewarding process because, when you're
bogged down with clinical work, you often forget
how creative you can be. It can rekindle your enthu
siasm when you look back through your notebook
and say to yourself, "Did I really think of that...?"
But what counts as evidence? Le May (1999) makes
the point that, while evidence from well-conducted
research is given greatest credibility, practice is, in fact,
informed by many sources of evidence, including:
Evidence based on experiences - this type of evidence
links with the habit of 'question-asking' described
above, and includes reflecting on practice, discussing
Figure 1The stages within evidence-based practice

Deciding what we want to
find evidence about
Accessing the evidence
Appraising the evidence
Using the best available
evidence

Evaluating the impact of the
evidence
(Ie May, 1999)
Figure 2 Sample questions
What effect does taste have
on swallowing;
What is the incidence! treatment
efficacy of cluttering in people
with Down's Syndrome;

How soon after adenoldectomy/
grommet insertion should we
expect changes in speech
perception/production; That is,
should I delay offering therapy
until the surgery has had time
to 'take effect'?
(Thanks 10 membersof Milton Keynes' Speech and
Language Therapy Service.)
c. Set up journal alerts. If you have internet
access, you can set up a messaging service that
tells you when the latest editions of journals
come out. You can choose which journals to
be told about, so you don't have to be
swamped bye-mails. The e-mail 'alert' links
you to a web-page showing the contents ofthe
journal, giving you further links to the abstracts
of the articles. I mainly use Arnold Publishers
(www.arnoldpublishers.com) and Taylor &
Francis (www.tandf.comjournals). The best way
to go about it is to find out who publishes the
journal(s) you're interested in, then search for
their website. They will probably have a link
telling you how to set up the alerting service.
Unfortunately, unless you subscribe to the
journal itself, you usually won't be able to get
the full article on-line, but at least you can see
whether it would interest you enough to ask
your friendly librarian to get it for you.
d. Get 'Athens' access. Your Trust library
may be able to give you a password allowing
you free access to a range of databases which
house journal abstracts. You can log in to the
Athens website (www.athens.nhs.uk) from
any computer, which means that if you have
internet access in your clinic or at home, you
don't even need to leave your desk to search
for articles. The databases available to Health
Service workers through Athens include
Medline, CINAHL, AMED, EMBAsE, Psyclnfo,
British Nursing Index and NeLH (see glossary).
You may need some training in literature
searching to get the best out of the databases.
cases with colleagues, and using information from articles in e. Read the Royal College of Speech & Language Therapists' publica
professional magazines. tions. Some of the leg-work has been done for you, with a new set of
Evidence ga,thered from clients and / or their carers - either in your own Clinical Guidelines about to be publ ished. Clinical guidelines should be
practice or from studies and articles published by other people. based on the best evidence available. The Royal College uses evidence
Evidence passed on by role models / experts This usually means panels from research as well as consensus from expert panels.
with expert opinions. The Royal College of Speech & Language Therapists'
Clinical Guidelines by Consensus fall into this category. 3. Appraising the evidence
A couple of brief tips on appraising research evidence:
2. Accessing the evidence Set up a journal club, or bring case-relevant articles to discuss at your
This depends on the type of evidence you want to access. Some of it will be supervision sessions if you have them; two or more heads are usually
readily available to you in your everyday work, but the research evidence better than one.
may need some more digging out. There are ways and means, however... All Trusts should now have an R&D (Research & Development) strategy,
a. Get your manager to take out an institutional subscription to the and many will have a research facilitator in post. This person should be ~
SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2003 25
ISSN (online) 2045-6174 www.speechmag.com
how I
~ able to guide you to courses such as CASP (Critical Appraisal Skills
Programme). Alternatively, your Trust should be part of a regional
Primary Care Research Network (PCRN), who may offer free courses.
http://drsdesk.sghms.ac.ukJ may be able to link you to your regional
Pr imary Care Research Network.
4. Core skills and attitudes
A questioning attitude to existing knowledge and accepted practices
A need to be aware that what we believe to be true mayor may not
reflect what the evidence is telling us
A recognition that we all have gaps in our knowledge
A realisation that there isn't an evidence base for much of what we do.
Lastly, a very useful thing to have is a manager who recognises the
value of evidence-based practice and allows you the time to find things
out. So start writing those questions down ...
References
Ie May, A. (1999) Evidence-based practice. Nursing Times Clinical
Monographs, 1. Emap Healthcare Ltd.
Muir Gray, J. (1997) Evidence-based healthcare: How to make health pol
icy and management decisions. Edinburgh: Churchill Livingstone.
Royal College of Speech & Language Therapists (1998) Clinical Guidelines
for Speech and Language Therapists by Consensus. RCSLT, London.
Royal College of Speech & Language Therapists (1996) Communicating Quality
2- Professional Standards for Speech and Language Therapists. RCSLT, London.
Resources
Biomedical Research Indexing, do Christopher Norris, Downe, Baldersby,
Thirsk, North Yorks, Y07 4PP, tel: 01765 640283, fax: 01765 640556.
Annual rates: CD - Institution 90, individual 70; Printed - Institution
72, individual 50.
Glossary
Abstract - a summary of the main points of the article
CINAHL - Cumulative Index to Nursing and Allied Health
AMED - Allied and Complementary Medicine
EMBASE - Excerpta Medica
NeLH - National Electronic Library for Health
Researchers at the Speech and Language Therapy
Research Unit pause amongst the protocols to
reflect on their research. All practising clinicians in
a previous or parallel life, what impact has their
resea rch had on thei r approach to practice?
M
: ~ ; ~ ; : ; ; ~ i ~ ~ : ; ; ~ ~ : ; Weighing the arguments
controlled trial of preschool children in the community and patient will gradually internalise the strategy, relying less on external
now leads the project to follow up those children. As part of her PhD she
carried out a series of in-depth interviews with parents:
What I learned from my qualitative interview study with the parents of
speech / language delayed children would profoundly affect my work
with this client group. I would aim to address three areas of major concern
for parents - the first appointment, their information needs and negotia
tion of treatment. Having your child referred to speech and language
therapy is a 'big deal' to parents. For that reason, the initial appointment
would be with parents alone. This would give them the chance to tell me
about their child and the difficulties and ask questions without worrying
about how their child is coping in an unfamiliar setting. Wherever possi
ble I would see the child at home. I would explain the child's difficulties to
the parents as far as these difficulties are explicable, guiding them
towards information resources available to them. If I would see the child
for therapy, I would find out what role parents could take on and clearly
spell out what I would ask them to do. I would discuss with parents the
form therapy could take, practicalities of the arrangement and difficulties
they might have. From what I heard in the interviews, I believe this
approach in the early stages could reassure, truly inform and motivate
parents as they embark on the therapy process with their children.
Corinne Dobinson is developing software for people with dysarthria
to support independent practice:
/t was important that the software provided maximum potential for
transfer and generalisation of the strategies to change speaking rate
and improve intelligibility. In my literature search I discovered motor
learning principles relating to short and long-term learning, transfer
and generalisation.
These prinCiples would influence my use of feedback in clinical practice.
While instrumentation and verbal feedback in the speech and language
therapy clinic provide useful information, there is a potential for feed
back overkill. Frequent feedback is likely to be more helpful in the early
stages of motor learning. By providing increasingly less feedback the
26 SPEECH & LANGUAGE THERAPY IN PRAOICE AUTUMN 2003
feedback from the therapist or instrumentation.
In speech and language therapy we appreciate the importance of self
monitoring in developing this internalisation, but the literature suggests
that the focus of self-monitoring should be different at earlier and later
stages. In the early stages of self-monitoring it is beneficial to focus on the
process of the strategy. This might be the method used to reduce speak
ing rate. When the process becomes more natural to the speaker, then the
focus should shift to an outcome goal. This might be a specified speaking
rate or level of intelligibility. These principles help us to clarify the appro
priate use of feedback and self-monitoring in motor speech therapy.
Yvonne Wren is investigating the use of computer software as a therapy
tool in the school context for children with phonological difficulties:
In a recent study, I worked in partnership with several primary schools.
The schools were approached because they had a pupil with a phono
logical impairment. All schools were initially keen to participate as they
were told they had a two in three chance of th is child receiving eight
weekly sessions of therapy in school. However, they were also told that in
order to participate they would need to provide someone (teacher, assis
tant or volunteer) who could work with the child for three 30 minute ses
sions per week. At this point, all schools took a sharp intake of breath'
In my previous role working as a speech and language therapist in a cluster
of mainstream primary schools, I endeavoured to get assistant support
to back up work I was carrying out with a child. Generally this was
agreed to but, in all too many instances, this support tailed off as the
weeks went by. The Christmas play, swimming trips and preparing dis
plays were all given priority over the speech and language therapy work.
In the research study however, after schools had regained their breath,
we discussed the ways in which they would benefit, such as assistants
and teachers gaining new ideas of how to work with children with
phonological impairments while waiting for speech and language ther
apy advice. We also highlighted the benefit to the child - that there
would be someone, possibly in their classroom, who could highlight
ISSN (online) 2045-6174 www.speechmag.com
how I
therapy targets throughout the school day. Provided we tried to fit with
their needs regarding days and times to visit and were flexible about
who worked with the child, almost all schools agreed to commit some
one to work on the project, Moreover, the assistants were committed to
the three sessions per week throughout the whole eight week period
and their comments at the end of the study were positive with regard to
the skills they had acquired and the importance of their role in helping
the child move on with their speech,
In my future practice, I would be more intent on requesting a commit
ment from schools to contribute to the child's speech and language ther
apy support. Heads and Special Educational Needs Coordinators may
consider this impossible at first but it can be done in most circumstances
and the benefits to the child are worth the effort,
Rosemarie Hayhow is studying the process and outcomes of the
Lidcombe program with children who stutter:
The evaluation of a specific therapy approach requires that the therapy
is used according to a protocol whether within a single site or across
sites, Similarly, if we are to refer to an evidence base to support our
choice of therapy then we must administer that therapy in the same way
as the researchers so that their results are applicable to our work, That
sounds straightforward but in practice it is hard to do, There are all sorts
of events that conspire to make it difficult to comply with pre-deter
mined time schedules, therapy progressions, record keeping and so on,
There is also being a speech and language therapist, We are a creative
bunch, we like to be flexible and able to respond to a client's expressed
needs, For some therapists, years of working with ill-conceived pro
grammes, poor equipment and minimal theoretical support have led to
the development of a pragmatic and eclectic approach, We are not tech
nicians but thinking, feeling and interacting practitioners, Researching a
specific therapy programme has highlighted for me the extent of the
conflict, for myself and others, between being a creative practitioner
and a systematic, protocol-directed administrator of a treatment. To
complicate things further, these are not mutually exclusive positions,
Therapy may work best when the essential components are rigorously
adhered to but presented in a manner that is adapted to best suit indi
vidual clients, Creative problem solving within the framework of the
therapy may be needed to deal with the inevitable difficulties that arise
when specific strategies or actions are integrated into diverse lives, And
so this brings us back full circle to the importance of knowing which
components of a treatment are essential,
Julia Wade is investigating the use of Automatic Speech Recognition
software with people with aphasia:
I recently had the task of carrying out in-depth interviews to determine
what recipients of computer-based therapy thought of the therapy
received, Training in conducting these interviews gave me the following
skills:
knowing how to ask genuinely open questions and avoid putting
words in people's mouths
being aware of my professional 'baggage' or framework and learning to put
this to one side in an attempt to encourage the person to communicate
what matters to them rather than what I believe matters to me,
I carried out 11 interviews, six with people with aphasia and five with
their carers, The experience was a revelation! Despite having been a
therapist for eight years, and having had people with aphasia on my
caseload throughout this time, I had never had (or never created?) the
opportunity to listen to a series of personal accounts of what it was to
live with aphasia and receive therapy. I suddenly wished this experience
had happened years ago, Ialso felt embarrassed at the thought that, by
failing to set aside enough time when first meeting a client to listen to
what they had to say (instead of frantically assessing their communication
skills), I had no doubt at times suggested inappropriate therapy goals,
The effect has been to change the way I go about taking a case history
entirely. I now go prepared with what I think of as my 'blank sheet'
mindset and ask the person to tell me about themselves and their apha
sia, and perhaps what they might be expecting or hoping for, from me
specifically or from therapy in general, This way, I get their story much
more efficiently than if I went through all the detail of a case history
form, More importantly, I get what matters to them.
Sue Roulstone is the Co-Director of the Research Unit:
Reading my colleagues' contributions, I was struck by the similarities and
how they parallel my own experience, The process of setting up research
projects has taught me to pay attention to detail and to be explicit
about my rationale, expectations, decisions and outcomes, I've seen the
benefits of that in my relationships with research participants, Listening
to participants (therapists, parents and patients) talk about their experiences
of therapy, I am also clear that their rationale, expectations, decisions
and outcomes are often miles away from mine, By surfacing and exploring
our different perspectives we stand much more chance of establishing a
working partnership and achieving goals together, D
Susie Parr and Carole Pound from the London Connect Centre
are at the forefront of aphasia research. Avril Nicoll caught up
with them at an Aberdeen study day on improving services for
people with severe aphasia. She contemplates the opportunities
we all have to put their research into practice, whatever our
client group.
W
hat is the reality of aphasia
in the UK? Students learn
Setti ng you rself free
that it is an acquired lan
guage impairment which
can t a k ~ different forms depending on the area of the brain that has that enables them to draw on their resilience and resourcefulness, to
been affected, Services focus scarce resources on the acute period and, have control, to take advantage of new opportunities and choices, and
occasionally, on short episodes of rehabilitation, usually based in a hos celebrate their successes?
pital. Whether informal or formal, assessment involves asking bewil Looking through the eyes of the person with aphasia is a useful place
dered people to do bizarre things with everyday objects, to start to redefine it in a meaningful way: long-term bewilderment, iso
Frustration, guilt, exasperation, panic and inadequacy are just some of lation, frustration, 1055 of confidence, self-respect, self-esteem and moti
the strong emotions experienced by therapists working with people vation, 1055 of roles and responsibilities, 1055 of the tools and opportuni
with severe aphasia, We have the best understanding among health pro ties for choices and 1055 of control - in short, social exclusion,
fessionals of what aphasia is and how it impacts on everyday life, 50 how
do we make the changes in our practice that will make us more effective 'Do you want soup, Brenda?' asks the nurse, 'NO' she says very firmly and
and fulfilled in our work? How do we begin to support people in a way places her hand over her mat. She makes her face express disgust. Her ~
SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2003 27
ISSN (online) 2045-6174 www.speechmag.com
everything this takes practice, writing a direct, user-friendly report to
clients or parents is a relatively simple way of modelling good practice,
putting the client in a position of control, ensuring that we understand
each other, and reducing jargonistic reports that are difficult for other
professionals to understand.
Recognising that not everyone can come to Connect, staff have been
exploring alternatives for isolated people with aphasia who no longer
want or need speech and language therapy. The Conversation Partner
Outreach Scheme volunteers are not there to be speech and language
therapists or friends, but to be a conversation partner. Disability, equali
ty, health and safety and communication partner training is provided.
Volunteers are encouraged to make use of The Aphasia Handbook to
help the person with aphasia find answers to their questions or sources
of further information and support. The volunteers have ongoing super
vision in the form of weekly feedback sheets, one-to-one meetings and
six-weekly support meetings or follow-up training. They are encouraged
to problem-solve: what other communication ramps could you make use
of? what could you do when you get stuck? They visit for six months
once a week for an hour and there is an option to negotiate a second six
month period either with the same or a different volunteer. Having had
variable success with volunteer schemes in the past I can see that, to be
successful, there has to be a very clear role and significant investment of
time in ongoing training and support.
You don't need a full-scale research project to look at change in your
own work environment. To set yourself free, Carole and Susie suggest
you ask yourselves:
What do I currently offer?
What options am I happy with?
What would I like to offer?
What two things could I do to extend opportunities for clients?
What challenges do I predict I might face')
What practical tasks will I need to undertake to carry the project
through?
Reference
Parr, S. (in press) What happens to people with severe aphasia? Joseph
Rowntree Foundation.
Practical points: putting
research into practice
1 . Listen to and work from the client's
perspective
2. Observe your client in different settings
3. Note down questions as they occur
to you
4. Ensure commitment before you start
5. Bounce ideas off a colleague
6. Re-think your initial interview
7. Improve your negotiation skills
8. Know where to find research evidence
9. Write reports for clients (or their
parents)
10. Consider volunteer schemes
~ purse and a glasses case are lying by her mat. The nurse gives some soup
to the woman on Brenda's left, who lifts it from her mat and places it in
the centre of the table. It is getting very hot. The windows are closed
and there is a smell of urine. Brenda looks at me then makes the same
disgusted face, then smiles. Today's menu is written on the white-board
by the door. This is chicken soup. I see a nurse at another table where
three women are sitting, pouring the soup from the plastic cups into
ceramic bowls for them. This doesn't happen for anyone else in the
room. The soup doesn't look or smell very appetising. It smells like a
packet mix. Its appearance is not helped by the plastic cups, pretty much
the same colour as the contents.
Artefact: The leaflet on the care home says: 'Comfort and service ... excellen t
catering and a wide menu choice provided by a qualified chef using
in-house facilities and fresh produce ... '
In research funded by the Joseph Rowntree foundation, Susie Parr doc
umented and tracked the social inclusion and exclusion of Brenda and 19
other people with severe aphasia. The ethnographic study included
three sessions with each person in different settings such as the pub,
swimming pool, a stroke club, therapy, home and shops. Susie made
detailed field and reflective notes, and told it like it was - sights, sounds
and smells. She says that ethnography has the potential to open your
eyes to what's around in everyday settings, to reveal the detail, subtlety
and dynamism of communication, and to suggest relevant interventions.
While we cannot all engage in full-scale research, we can use this kind
of observation with clients of all ages and communication difficulties to
think out of the box and identify possible changes.
Susie found that people with severe aphasia enter many different set
tings and encounter many different people for many years after the
stroke - and after rehabilitation. Exclusion happens everywhere, all the
time. Social exclusion - or inclusion - is evident in communication, access
to opportunity and choice, involvement, the environment, and respect
and acknowledgement, all interacting and influencing each other.
Therapy is not just about supporting change in communication skills, it
is about creating the conditions for participation and inclusion: attend
ing to context, listening to people's stories, reflecting on the social
dynamics of service delivery and developing new opportunities to par
ticipate in health care and life. At Connect, this approach has influenced
everything from the design of the building - free from pictures of the
brain, and with a cafe at its hub - to the way assessment, goal setting
and report writing is done.
Two hours is allowed for the initial interview with two members of
staff either at the Centre or at home, including one-to-one time with
both the client and their partner. This has been identified as both cost
and time effective and is a similar set-up to other specialist services, for
example for young people who stammer attending the Michael Palin
Centre. Although some participants felt they couldn't re-allocate their
time in this way, I was interested because of my experience when inter
viewing people with severe aphasia for the Winter 2001 issue. I had
expected them to last about an hour apiece but, taking my lead from the
interviewees, all four took two hours each.
Perspectives and lives
All Connect staff receive the same training in basic communication skills.
Interviewers need to try to understand the perspectives and lives of peo
ple they meet, and to listen carefully. They have to be skilful in eliciting
and probing ideas through drawing, key words and pictures. This record
of the discussion is kept as a reference and basis for negotiation of goal
setting - a useful tool for any client group. The two interviewers try to
hear what is important for the person with aphasia and their partner,
get an idea of the impact of stroke and aphasia and of their expectations
and aspirations, and start presenting service options. Tea I coffee is
offered, no formal assessment is used and the interview is conversation
based.
At the end, a letter is written to the person with aphasia covering the
content of the discussions and the decisions reached. This is copied with
permission to the GP and other interested parties. Although as with
28 SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2003
ISSN (online) 2045-6174 www.speechmag.com
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Theme: 'Eat a rainbow' to encourage every
one to eat at least five servings of varied fruit
and vegetables every day.
Information pack: tel 01604 623933.
Augmentative Communication in
Pradice: Scotland
13th Annual Study Day
Communicating with pictures and symbols
Details: SCTCI, tel. 0141 201 2619.
CALL Centre, Edinburgh
Courses include
12 November 200], Getting to Grips with
Boardmaker
12 December 2003, Pidure Exchange
Communication System
28 January 2004, Making Personal
Passports
10 February 2004, Making Symbol
Materials
Details: tel. 0131 651 6236,
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