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Seeing the light:

PECS appeal
l l l U N l N A T l N G P R A T l E
ISSN 1368-2105
vlNTER oo
http://www.speechmag.com
Early
intervention
Doing it
with EAZe
ICU-Talk
A can do attitude
to research
Unemployable
or
unemployed?
Working with
aphasia
In my
experience
A framework
by consensus
NEW SERIES!
Sociological
perspectives on
inequality
How I use
therapeutic
listening
My Top
Resources
Child speech
vn Scays
vord o Verbs
Do you struggle to find meaningful
material for working on verbs with
children? Then get in on the action
with Scally, a little alien who has
come to earth to learn English -
and been adopted by Topologika
Software and its special needs
consultant Bob Black.
Scallys World of Verbs can be
operated by a variety of input
devices - switches, touch screens, Intellikeys
- so that it is easily used by young children and those with
disabilities. Scally acts out more than 400 verbs, and there are
five activities to get children thinking about verbs in different
ways.
The normal retail price starts at 39.95+VAT, but Topologika has
copies to give away FREE to three lucky readers of Speech &
Language Therapy in Practice. To enter, send your name and
address to Topologika/Speech & Language Therapy in Practice
competition, 1 South Harbour, Harbour Village, Penryn,
Cornwall TR10 8LR. The closing date for receipt of entries is
25th January, and the winners will be notified by 31st January.
Scallys World of Verbs is available from Topologika Software,
tel. 01326 377771, www.topologika.com.
vn new narratve packs
Black Sheep Press continues its prolific output of photocopiable
resources with new narrative resources. So, whats the story?
Speech and language therapist Judith Carey, in partnership with
a local Early Years Centre, has devised a comprehensive pack of
session plans, games and activities to promote language skills in
young children using the principle of Becky Shanks Narrative
Therapy Programme (see review on p.7)
Language Through Listening is aimed at children entering
nursery with limited attention and listening skills. Nursery
Narrative introduces the narrative skills model to nursery aged
children, and Reception Narrative promotes further
development and enrichment of language skills at a higher
level for those of reception age.
Black Sheep Press is offering two readers a happy ending - a
complete FREE set of each of the three packs (normal price
100+). For your chance to win, send your name and address to
Speech & Language Therapy in Practice - LTL offer, Alan
Henson, Black Sheep Press, 67 Middleton, Cowling, Keighley, W.
Yorks BD22 0DQ by 25th January. The winners will be notified
by 31st January.
Available from Black Sheep Press, see www.blacksheep-
epress.com, or telephone 01535 631346 for a free catalogue.
Other new additions are the first set of materials in the Simple
Semantics series devised by Felicity Durham (Identifying &
Describing; Can You Get Home?) and Heavy and Light / Hot and
Cold for the Concepts in Pictures series.
In the Summer 02 issue, Anglian Pharma offered Infa-Dent Gum
Massager / Baby Soft Toothbrushes packs. They were won by
Patricia Broughton, Marion McCormick, Lisa Abba, Mary Cordle
and Mary Wickenden.
The two Speechmark titles offered in the Autumn 02 issue
proved highly popular with you. The lucky winners of The
Sourcebook of Practical Communication were Margaret Purcell,
Sarah M. Harris, Judith Hibberd, Elizabeth Reid and Emma
Gonoud. Feeding and Swallowing Disorders in Dementia goes to
Kay Guthrie, Shona Harvey, Elaine Stickland, Lynn Dangerfield
and Linda Armstrong.
Congratulations to all our winners.
Winter 02 speechmag
In need of inspiration?
Doing a literature review?
Or simply wanting to locate an
article you read recently?
Our cumulative index facility is
there to help.
The speechmag website enables you to:
View the contents pages of the last four
issues
Search the cumulative index for abstracts of
previous articles by author name and subject
Order a copy of a back article online.
New article
The speech and language therapy contingent in
the tiny Falkland Islands is looking to expand.
Pippa McHaffie extols the virtues of small classes,
a Flying Santa and sitting amongst hundreds of
penguins.
Plus
The editor has selected the previous articles you
might particularly want to look at if you liked the
articles in the Winter 02 issue of Speech &
Language Therapy in Practice. If you dont 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...
Kathleen Taylor & Claire Besser, try Change and
Involvement - Meeting the needs of carers
(Autumn 1997): Pound, C. & Clarke, M. (010) Mary
Law lecture - Less words, more respect: learning to
live with dysphasia and difference, and Denman,
A. (011) Carers - Investigating the needs.
Sally Poole, see (115) Moore, T. & Irwin, A.
(Summer 2000) Making an impact.
Lizzie Astin & colleagues, look at (134) Hurd, A. &
McQueen, D. (Winter 2000) The right things at the
right time.
Sarah Earle, what about (153) Earle, S. (Summer
2001) Sociology: a sure start.
Fiona MacAulay, try (144) Berrie, I. (Spring 2001)
Invigorating the wheel.
Caroline Bowens My Top Resources, see (020)
Ogilvie, M., Stanbury, R. & Williams, P. (Winter
1997) How I manage speech sound difficulties.
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
or renew online via a secure server!
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lnsde cover
vnter o speechmag
Reader oers
Win Scallys World of Verbs (Topologika Software)
and new narrative packs (Black Sheep Press)
News / omment
Revews
Multiple disabilities, phonological
awareness, anatomy & physiology,
aphasia, phonetics, play, epilepsy, music,
language development, narrative.
8lmprovng
communcaton wth EAZe
Classrooms look different. Symbols,
drawings and photos are being paired
with written text to assist children in
accessing the curriculum and their envi-
ronment. Some teachers have come to
believe that symbols are a bridge to liter-
acy which can positively impact on the
childrens confidence and self-esteem.
Lizzie Astin, Katie Roberts, Emma Withey
and Melanie Crawshawtake us on a journey into the class-
room through an Education Achievement Zone programme.
+ ommuncaton - an
naenabe rght
... working closely with the intensive care unit nurse has
taught me a great deal about these patients and the
effects that having a life threatening condition and a
prolonged stay in intensive care have on the patient. These
in turn affect the patients ability to use an AAC device.
When a person wakes up in the alien environment of
an intensive care unit, they may well feel they have
come from another world - but there is light in the
shape of the ICU-Talk device. Fiona MacAulay reports.
+ lurther readng
Phonology, Parkinsons disease, voice, community-
focused intervention, aphasia.
+ lN NY EXPERlENE: Great dea -
but how do we do t'
... we can work across Trusts, with limited evidence
bases, using the wealth of expertise that undoubtedly
exists within our profession - and reach a consensus. In
addition... a special interest group can be proactive in
developing practical tools and resources for therapists,
enabling us to address the government agenda within
their relatively tight timescale.
Della Money and special interest group colleagues
produce a consensus framework for developing
communication strategies to benefit people with
learning disabilities.
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2002 +
+8 Unempoyabe or unempoyed'
Respondents who had a better understanding of their
aphasia were more likely to be successful in returning
to employment. One ... provided prospective employers
with a summary of her aphasia and strategies that can
be implemented to overcome her difficulties.
As the interaction of many factors influences whether
or not an individual returns to employment, Kathleen
Taylor and Claire Besser
discover that the
profession needs to
show a bit more
imagination to be truly
working with aphasia.
+ Socoogca
perspectves on
nequaty
seres (+)
ass o oo: an
unequa uture
...children from poorer
backgrounds are seen to
lack the appropriate
environment that is
needed to foster educational success. For example,
children from less affluent backgrounds are the least
likely to have access to constructive forms of play, and
will have poorer access to books, newspapers and the
internet.
Sarah Earle argues that, while we do need to develop
an individualised, client-centred approach, we must
also be aware of how wider socio-economic and
cultural factors influence our practice.
( How l use therapeutc stenng
In the evaluation study the children were reassessed
at the end of the programme and then left for eight
weeks before being reassessed once more. The results
were beyond my expectations: all showed an
improvement greater than one would expect from
maturation. (Dilys Treharne)
Listen up and hear why our three contributors - Dilys
Treharne (The Listening Program), Dr Colin Lane
(A.R.R.O.W.) and Karen OConnor (Therapeutic
Listening) - wouldnt be without their CDs and
headphones.
Back cover Ny Top Resources
Its free, its phonological and its fun! ... the 700 plus
participants enjoy a growing collection of clinical
resources, a therapy ideas file, and a brilliant message
archive full of clinical insights and practical suggestions
(and a few fiery exchanges).
Australian speech-language pathologist and internet
icon Caroline Bowen romps through her top ten
resources for child speech.
WINTER 2002
(publication date 25th November)
ISSN 1368-2105
Published by:
Avril Nicoll
33 Kinnear Square
Laurencekirk
AB30 1UL
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e-mail: avrilnicoll@speechmag.com
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Editor:
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Avril Nicoll 2002
Contents of Speech & Language
Therapy in Practice reflect the views
of the individual authors and not
necessarily the views of the publisher.
Publication of advertisements is not
an endorsement of the advertiser
or product or service offered.
Any contributions may also appear
on the magazines internet site.
Cover picture by Paul Reid (posed by
model). See p.4
IN FUTURE ISSUES
USER INVOLVEMENT ETHICS BILINGUALISM NARRATIVE
ADULT LEARNING DISABILITY APHASIA DYSPHAGIA
CONTENTS WINTER 2002
J
www.speechmag.com
PES appea
David ...demonstrated that he
could transfer this skill to other set-
tings. For example, [he] walked into
his brothers room and said, I want
the light off.
Finding a lack of literature on the
use of the Picture Exchange
Communication System with adults
with a learning disability, Sally
Poole starts the ball rolling with a
study of 27 year old Davids
progress.
( OVER STORY
news
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2002
Autism campaign
targets GPs
GPs have been targeted in a campaign to raise awareness of autistic
spectrum disorders and to promote a helpline to parents.
The National Autistic Societys mailing to GPs includes a questionnaire
asking them about their experiences of the assessment, referral, diag-
nosis and support of clients with autistic spectrum disorders. The
results will be published next year.
www.nas.org.uk
NAS Autism Helpline, tel. 0870 600 8585 (Mon-Fri, 10am-4pm).
Supporting staff
Locum
shortage
As the professions staffing
difficulties push up demand
for speech and language
therapists to fill the gaps, a
locum agency is reporting a
shortage of new recruits.
Action Medicals Caroline
Evans says, Were speaking to
clients from all over the country
who are desperate for short-
term staff, but despite all our
efforts were finding it increas-
ingly difficult to help them.
Many clients need whole teams
of therapists and the situation
is such that they are willing to
be completely flexible about
the candidates skills.
Locum staff are generally
required for short-term
assignments such as maternity
and sickness cover and wait-
ing list initiatives, so are
expected to be highly adapt-
able and to enjoy a chal-
lenge. Agencies compete for
locums by offering benefits
such as accident and sickness
insurance, funding for contin-
uing professional develop-
ment and high rates of pay.
Action Medical, tel. 01225
447445.
Propeller move
Propeller Multimedia, supplier
of React and Speech Sounds
on Cue software, has moved
to PO Box 13791, PEEBLES,
Scotland EH45 9YR, tel/fax
01896 833528.
Get
chatting
The national educational charity for children with
speech and language difficulties is sending out a
chatterbox challenge.
I CAN is asking nursery workers, teachers, speech
and language therapists and other professionals
working with young children to take part in this
event and get children talking. Preschool children
will be sponsored to learn and recite a joke, song,
nursery rhyme, story, or anything they can, individ-
ually or as part of a group to raise money for I CANs
work.
The charity already runs seven Early Years Centres
in England, Wales and Northern Ireland, and is
setting up a further seven this year, including two
in Scotland. The centres provide preschool chil-
dren with integrated therapy and education plus
information and training for parents and profes-
sionals.
Fundraising packs, including a free tape with sing
along songs and a Tesco Baby & Toddler Club
Parent Pack - a step-by-step guide to encouraging
childrens language development, from the
Chatterbox Challenge hotline on 0845 130 3962.
www.ican.org.uk/chatterbox.
Just not good enough
A petition signed by 50,000 people has called on the government to
make stroke care a priority.
Only 27 per cent of people with a stroke are treated in stroke units,
although national standards state that everyone should have this service
by 2004. The Stroke Association quotes research showing that every day
30 stroke patients die or are left seriously disabled because they are not
getting this specialist care.
The National Audit of Stroke Services 2001/02 had news of progress, as
nearly 75 per cent of general hospitals have stroke units and 80 per cent
of Trusts now have a clinician with responsibility for stroke. But blasting
stroke care as moving forward at a snails pace, Margaret Goose of
the Stroke Association calls for the words of
the National Service Framework for Older
People to be put into action.
www.stroke.org.uk
Can you see me
at the back?
A campaign to ensure all television programmes are subtitled is seeing
steady progress.
The Royal National Institute for the Deaf reports that proposed
Communications legislation would enshrine legal minimum subtitling
standards for all forms of television, including digital, cable and satel-
lite. The organisation is continuing to press for assurances on the quality
of editing, colour contrasting and descriptions of noise effects, and is
backing research into the preferred speed of subtitles for deaf and hard
of hearing people. It also hopes to see an increase in subtitles on DVDs
and at film screenings, and is calling for improved access to arts and cul-
ture for deaf and hard of hearing people following a report which con-
demned the majority of the UKs top arts and tourist attractions for
effectively excluding them.
RNID Information Line tel. 0808 808 0123, text 0808 808 9000.
Cleft lip and palate gene
Scientists have identified the faulty gene which can cause Van der Woude, a syn-
drome accounting for two per cent of babies born with a cleft lip and palate.
About a third of all cases of cleft lip and palate are syndromic. In the case of Van
der Woude, the childrens other physical problems tend to be missing teeth and a
pit in the lip. Much of the DNA detective work in this research was based on twins
in Brazil, one born with Van der Woude syndrome
and one without.
The researchers hope there will be immediate benefit
to affected individuals and families, especially in
genetic counselling and postnatal diagnosis.
In the longer term they believe the dis-
covery could lead to antenatal treatment
and a better understanding of why and
how cleft lip and palate occurs.
The research, funded by Action Research
and the Wellcome Trust, has been pub-
lished in the journal Nature Genetics.
The NHS needs to prepare for increasing reliance on its non-professionally
qualified support staff.
According to research commissioned by the Institute for Policy Research,
there is a need for agreement on the future role, training and regula-
tion of this diverse group. Research Fellow Rachel Lissauer said, The
ippr wants to see the future structure of our health workforce based on
how best to meet patients needs. We anticipate a significant role for
support workers in providing elements of direct patient care. But if the
current neglect of their training needs and status continues, professional
staff will remain unwilling to let go of their responsibilities or tasks.
Support Staff in Health and Social Care: An Overview of Policy Issues by
John Rogers, see www.ippr.org.uk.
www.actionresearch.org.uk / www.wellcome.ac.uk
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2002
news 8 comment
lumnatng
practce
Dark mornings and evenings make us yearn for the blue skies of summer, when
motivation is easier to come by. But, never fear - Speech & Language Therapy in
Practice is here with the fairy lights to brighten your winter days!
Our How I section (p.24) turns the spotlight on therapeutic listening. We have all
dealt with clients who make slow or even no progress, and where we cannot see a
way forward. Proponents of The Listening Program, A.R.R.O.W. and Therapeutic
Listening find their approaches light the way sufficiently for their clients to be able
to benefit from other, more specific strategies.
Lack of motivation to communicate was the main barrier to progress for the young
man in Sally Pooles shining example of a case study (p.4). Through combined use of
the Picture Exchange Communication System and a widening of opportunities to use
the skills he has, his carers see flickers of true communication.
The 1995 Disability Discrimination Act was meant to break down barriers and herald a
new dawn for people with disabilities in the workplace, including those with aphasia.
Through in-depth interviews with clients, Kathleen Taylor and Claire Besser (p.18) shed
light on the reality, but also offer bright ideas for how things could be improved.
Fiona MacAulay and colleagues (p.12) also show a real flare for research that will
benefit clients. In the light of huge developments in computer hardware and software
they set out to develop a high tech device to assist intubated patients emerging from
unconsciousness into the harsh beams of an intensive care unit. While not the usual
subject matter for this magazine, the process involved a high degree of collaboration
and responsiveness which is relevant to all client groups and therapy.
Collaboration was the key to Della Money and colleagues (p.16) achieving their
glittering prize - a consensus framework for developing communication strategies to
benefit people with learning disabilities. Enthusiasm could have been dimmed by all the
challenges such as a short timescale and lack of an evidence base but the networking
opportunities of a special interest group ensured light at the end of the tunnel.
Phonology and internet icon Caroline Bowen (basking in the Australian sunshine) is a
networker extraordinaire. She sparkles in our back page top resources which includes
her take on Magic Lantern shows for consumers.
Lizzie Astin, Katie Roberts, Emma Withey and Melanie Crawshaw (p.8) have worked
their own magic in Bridgwater, coming out of the shade into the full glare of the
classroom through an Education Achievement Zone initiative. The benefits of health
and education working together can be clearly seen even in how different the
classrooms look. Unlike most therapists, these authors work with whole classes rather
than caseloads. In the first of our new sociological perspectives on inequality series
(p.21), Sarah Earle enlightens us on the influence of social class and suggests this kind
of approach allows us to tackle social exclusion more effectively.
Like a laser beam, Speech & Language Therapy in Practice authors get straight to the
point, illuminating practice and providing flashes of inspiration without leaving you
blinded by the light.
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Forum for children
A national network forum for providers of
childrens services aims to share and spread
good practice.
In particular it is focusing on involving young
people and education services, developing a
single assessment process, strengthening
child protection, clarifying accountability
and ensuring appropriate links with youth
justice. Through the Local Government
Association website the network will publish a
series of discussion papers and case studies.
www.lga.gov.uk
Neurologists needed
The Encephalitis Support Group has urged
members to contact MPs to raise awareness
of the need for more neurologists.
The Group is backing a report from the
Association of British Neurologists showing
inequality and a lack of specialist treatment
throughout the UK. They are calling for an
increase in the number of neurologists from
350 to 1400 over the next ten years to provide
a round the clock service across the country.
A member of the Neurological Alliance, the
Group is also one of the organisations
involved in the production of a report in
consultation with people who live with
neurological conditions and their carers.
Speedy access to high quality neurological,
rehabilitation and community services is called
for, along with a care plan, access to a key
worker and annual review to achieve a coordi-
nated, seamless, patient-orientated service.
Acute Neurological Emergencies in Adults,
free from the Association of British
Neurologists, tel. 020 7405 4060, e-mail
abn@theabn.org
Levelling Up, 5 (12 for organisations) from
the Neurological Alliance, tel. 020 7793 5907,
e-mail neurological-alliance@hotmail.com
www.esg.org.uk
Media Stars
Technology is opening up new possibilities
for communication and distance learning
for deaf students.
A UK television distribution and video
conferencing system, MediaStar, has been
installed in every classroom and computer
workstation at the Junior High School 47 -
School for the Deaf and Hard of Hearing in
New York. This allows deaf students to
communicate using American sign-language
with their colleagues and across the United
States and internationally with other deaf
students using similar facilities.
The schools director of technology said they
now plan to use the technology from
Berkshire company Cabletime to broaden
our students horizons, teaching them new
media skills which they might not otherwise
have the chance to develop.
www.cabletime.com
Opportunities in the community
Davids mother wanted immediate one-to-one
speech and language therapy input for him. I
explained that no input would be offered until
David could start accessing some day services. The
reasoning behind this was to ensure there would be
a key person to carry out work with David outside
his speech and language therapy appointments and
to give David opportunities in the community to
practise any skills learnt in the sessions.
Funding for specialist outreach support
was agreed and a one-to-one worker
from a specialist autism service joined
David for three days each week. The
aim of this support was to help David
access community services. Speech and
language therapy input was then
offered in the form of fortnightly ses-
sions with David and his support work-
er. Following her mothers wishes,
Davids sister accompanied him to all
sessions and therefore became involved
in the speech and language therapy input also. I
chose the PECS approach with the aim of develop-
ing Davids ability to initiate communication as well
as his spontaneous speech and eye contact.
STAGE 1 Identifying a reinforcer
The first step of PECS is to identify a reinforcer,
something that the person finds motivating such
as a biscuit or ball. A symbol (photograph, picture
or line drawing) of the reinforcer is obtained. The
person is asked to sit opposite a communication
partner and a physical prompter is seated behind
them. The reinforcer is put in front of the person,
just out of their reach. As the person reaches for
the reinforcer, the physical prompter puts the sym-
bol into their hand and supports them to put it
into the open palm of the communication partner.
As soon as the symbol is handed over, the commu-
nication partner rewards the person by giving
them the reinforcing item. They also give verbal
reinforcement and praise by saying for example,
Oh, you want a biscuit. Good! or by verbalising
what the person would have said: I want a bis-
cuit. Good! (If the person imitates what you say,
then verbalising what they would have said can
help with problems related to pronoun reversal at
this stage.) Some communication partners also
respond by labelling the item, as in Biscuit.
Good! The person must be given the reinforcer
immediately after they hand over the symbol.
Once the reinforcer is received they can then eat
the item if it is food, or hold it if it is an object such
as a ball. If biscuit is being used as a reinforcer
then small pieces can be given rather than whole
biscuits. The prompts are gradually reduced so
that eventually no physical prompter
or open hand prompt by the commu-
nication partner is needed.
David was introduced to stage 1. At
the beginning symbols were used as
recommended by PECS and the writ-
ten word was printed underneath as
we knew David was able to read the
word. The first reinforcer used was a
food item. Initially a physical
prompter was needed to support
David to reach for the reinforcer but
this was gradually reduced until the
physical prompter was no longer needed. The ver-
bal reinforcement given was, I want a biscuit.
Good! This was chosen due to Davids echolalia
so that if he imitated the words then problems
related to pronoun reversal would be avoided.
David was very quick to learn what to do and after
a short time started to say the name of the rein-
forcer while he was exchanging the symbol for it.
STAGE 2 Spontaneity and range
Stage two involves increasing the spontaneity
and range. The distance between the person
and communication partner is gradually increased
by moving the communication partner away a lit-
tle at a time so eventually the person has to get
up out of their chair and walk over to the com-
munication partner to get their attention. Also
the symbol is gradually moved away so the person
has to move to get the symbol and give it to the
communication partner. The physical prompter
may be required initially and the amount of sup-
port needed reduced as before. PECS recommends
at least 30 opportunities for exchanges to take
place during functional activities each day. Ideally
cover story
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2002 (
your cents
ack motvaton and
opportuntes to
communcate
need structured but
exbe support
rarey ntate nteracton
Read ths
PECS
appeal
avid is a 27 year old man with a learning
disability and autism. When I first start-
ed working with him, he was living with
his mother and three siblings who were
providing all his care. He was not access-
ing any services and had few opportuni-
ties to make choices in his life or to interact with peo-
ple outside his family network. Davids mother
appeared to have a strong influence over the whole
family and was very much of the opinion that David
would one day overcome his autism and learn to
speak.
I had just attended a two day Picture Exchange
Communication System (PECS) course following a
recommendation from a colleague. Psychologist
Andrew Bondi and speech and language therapist
Lori Frost developed PECS over 10 years ago. It is a
structured behavioural programme first used with
children with autism but now used with adults and
people with other functional communication diffi-
culties. PECS acknowledges that a person may not
be motivated to communicate by social rewards
alone, and teaches them to communicate by
exchanging a symbol for a tangible reward that is
motivating for them. I decided to find out if this six
stage programme could help David.
Assessment found that David had an understanding
of three key words or more. He had difficulty
understanding complex sentences, some wh ques-
tions and emotions, but responded well to visual
information such as pictures/symbols and written
material. David was verbal but at the time of
assessment only used single words or two word
utterances. His speech was mumbled and he used
little eye contact or gesture. David had an under-
standing of turn taking and would answer ques-
tions, usually with yes or by saying single words. He
was frequently echolalic. David had good numeracy
and literacy skills and was able to read and write. He
would spend time copying and writing out large
pieces of text without necessarily understanding the
meaning of what he was writing. David initiated
very little communication, but would occasionally
write a single word on a piece of paper and give it
to someone to look at. He appeared to have little
motivation to communicate; one reason may have
been that all his basic needs were being met and he
had little opportunity to make choices.
D
PECS
acknowledges
that a person
may not be
motivated to
communicate
by social
rewards alone
the exchanges should be carried out by different
communication partners. David completed stage
2 without any difficulty.
STAGE 3 Introducing the
concept of choice
Stage three involves introducing the concept of
choice. Two items are offered, a reinforcer and non-
preferred item with the correspond-
ing symbols. If the person picks up
the correct symbol for the reinforcer,
then they get the item. If they
choose the wrong symbol, they get
the non-preferred one. An error cor-
rection process is then carried out
where the correct symbol for the
reinforcer is shown and the person is given another
opportunity to choose the right symbol and obtain
the reinforcer.
Initially there were some difficulties introducing
stage 3 with David. He was shown two types of
food, one he liked and one we knew he didnt.
When offered the symbols representing these, David
chose the symbol of the reinforcer first and received
the food that he liked - but then chose the symbol
of the non-preferred item and proceeded to eat
that food too. He continued to choose alternate
symbols. David did not seem to understand that he
was being offered a choice and was confused about
which symbol he should go for, not necessarily tak-
ing the one that he preferred. At this point we
decided to deviate from the programme slightly and
create a more natural environment to practise in.
We devised a group activity making sandwiches.
This involved getting all the items needed to
make a sandwich - bread, butter, knife, plate, fill-
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2002
cover story

The six stage Picture Exchange


Communication System
recognises that a person may
need more than social rewards to
motivate them to communicate.
Finding a lack of literature on the
use of PECS with adults with a
learning disability,
Sally Poole starts the ball rolling
with a study of 27 year old
Davids progress.
ings and so on - and symbols for each item. The
symbols were put in front of David and there were
three other people in the room. Everyone took
turns to pick up a symbol and pass it to one per-
son who acted as the shopkeeper and was in
charge of giving out the food. Each person gave
the symbol of the item they wanted to the shop-
keeper and were immediately rewarded by being
given the item and verbal reinforcement as
before. David was quick to learn
what to do and picked up only the
symbols of the items he wanted and
handed them to the shopkeeper,
clearly indicating his choice from the
items available.
This activity proved to be successful.
Having practised this several times, we
decided to try using just the word rather than the
symbol and the word - and David did not have any
difficulty with this.
STAGE 4 Introducing sentences
When a person is able to exchange about 20 dif-
ferent symbols, the idea of using a whole sen-
tence is introduced. The person is taught to make
a request using a whole sentence. A sentence
strip is created. At the beginning are symbols rep-
resenting I want..... and a space is left at the
end where another symbol can be added to com-
plete the sentence. As the person reaches for the
reinforcer, the physical prompter supports them
to attach the symbol of the reinforcer to the end
of the strip to complete the sentence and hand
over the complete sentence strip to the communi-
cation partner. The communication partner says I
want..... a biscuit because they are reinforcing
what the sentence says to the person.
Stage 4 was introduced to David. A sentence strip
was created using written words rather than sym-
bols. The sandwich making activity was repeated
but this time using whole sentences. David was
able to say the whole sentence when exchanging
for each item and demonstrated that he could
transfer this skill to other settings. For example, in
McDonalds he spontaneously said, I want apple
pie and on another occasion walked into his
brothers room and said, I want the light off.
STAGE 5 Responding to questions
In Stage 5, the person is taught to respond to a ques-
tion such as What do you want?. They are taught
to respond using a whole sentence as before: I
want...... The same technique is used as in stage 4
and the person is supported to complete the sen-
tence strip and hand it to the communication part-
ner. We carried out this stage with David using the
sandwich making activity and he was able to
respond to a question using a whole sentence.
STAGE 6 More sentences
Stage 6 involves introducing a different sentence,
I can see.... For most people this is less motivat-
ing than I want... as there is no reward at the
end. We practised this as a group activity, looking
at magazines and taking it in turns to point to
something and say, I see.... adding the name of
the item to the end of the sentence (for example,
I see...... a blue sock.) David was able to do this
during the session but was not observed to use
the sentence spontaneously.
At the end of stage 6 we agreed the key worker
would take responsibility for continuing to use PECS
with David and supporting him to use the sentences
he had learnt in the sessions. We made some minia-
ture sentences for David including I want..... and I
see...... These were put on a key ring that he could
keep in his pocket and refer to as a visual aid
.
Communicating spontaneously
At the end of the programme, David was using more
eye contact than he had done before starting, and
seemed more aware that he needed to direct a
request to another person to communicate success-
fully. He started communicating spontaneously
using more than a one-word utterance, for example
in McDonalds he
spontaneously
said I want
apple pie
David ...demonstrated that
he could transfer this skill
to other settings. For
example, [he] walked into
his brothers room and said,
I want the light off.
cover story
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2002

saying, I want the light off. David started using


more speech and initiating communication through
speech rather than writing things down on paper.
He also began to answer questions with an appro-
priate answer rather than being echolalic or saying
yes. His sister reported that David seemed more
aware of other people - for example, he would offer
his food to share with her - and that he appeared to
have developed confidence in communicating with
new people. It is likely that this was due to a com-
bination of using PECS and the increase in opportu-
nities available to him. David seemed more moti-
vated to communicate than previously. As well as
this he seemed pleased when he received praise
from his family following his attempts to use speech.
One of the benefits of using PECS is that it is a
structured programme with discrete goals at each
stage. This is helpful for families and carers, as they
are able to see progress as the person moves
through the stages. The stages can, however, be
adapted for individuals, as we did for David at stage
3 to make it more like a real life situation.
David is one of the more able clients that I have
worked with. Despite this, this programme took over
a year to complete. It is likely that someone with a
greater degree of learning disability will take longer
to reach each stage and may never be able to move
beyond the first or second stage. In addition success
with this programme, as with many others, is highly
dependent on it being carried out regularly. The pro-
gramme resulted in some positive effects in terms of
Davids communication, however maintenance and
development of skills is dependent on someone taking
responsibility for continuing the work once speech
and language therapy is no longer involved.
One year since closing my involvement, Davids sis-
ter is still encouraging him to use PECS, David has
started receiving one-to-one input from a different
organisation and we are
awaiting a new referral
from them around how
to support David to
develop his use of PECS.
It would be interesting
to hear from other peo-
ple who have used PECS
with adults with learn-
ing disabilities and for
more information to be
published in this area.
Sally Poole is a speech and
language therapist work-
ing in a community
healthcare team for adults
with learning disabilities.
Resources
For further information about PECS (including courses)
please contact:
Office: 17 Prince Albert Street, Brighton, BN1 1HF
Telephone: (01273) 609555
Website: www.pecs-uk.com
E-mail: sbaker@pecs-uk.com
Do l ensure that
cents are recevng
sucent backup
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beore oerng them
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Do l oow tred and
tested ormats n a
way whch responds
to ndvdua need'
Do l consder wrtng
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Reectons
MUSIC
GO WITH THE FLOW
Approaches to Communication
Through Music
Ed Margaret Corke
David Fulton Publishers
ISBN 1 85346 843 6 15.00
This book suggests using music in imagina-
tive ways to go with the flow of clients
with severe and profound learning difficul-
ties and is inspired by the Intensive
Interaction approach.
The text clearly describes a framework to
develop social communication skills with
good guidelines for facilitators and a help-
ful trouble-shooting section. There are few
case examples although there are suggest-
ed songs to start you off. The emphasis is to
use these activities flexibly.
Some therapists could be inspired to use
this approach in groups but may need con-
fidence and musical knowledge to use it
most effectively.
Suzanne Thurling is a speech and language
therapist at Galtres school, a secondary
school for pupils with severe and profound
learning difficulties in York.
REVlEvS
MULTIPLE DISABILITIES
EASY TO FOLLOW
Basic Abilities - A Whole Approach; A
Developmental Guide for Children
with Multiple Disabilities
Sophie Levitt
Souvenir Press Ltd
ISBN 0285631713 12.99
This book for carers of a young child with multiple
disabilities is written in a friendly manner and fre-
quently refers to working in partnership with
therapists and teachers.
Chapters on daily life activities include eating and
drinking, dressing and play. Carers select an activ-
ity and there are ideas for targeting abilities with-
in each activity. Abilities include using hands, lis-
tening and understanding. A developmental
framework is followed and carers can record their
childs progress.
I found the introductions lengthy and repetitive
but the practical chapters with illustrations are
easy to follow. I have looked at the book with col-
leagues from other therapies. We would share
bits of it with some families to complement what
we already give.
Hazel Anderson is a senior speech and language
therapist working in a Child Development Centre,
Sure Start and NAS EarlyBird Programme in
Doncaster.
ANATOMY & PHYSIOLOGY
LOSES ITS WAY
Basic Medical Science for Speech
and Language Therapy Students
M. Atkinson & S. McHanwell
Whurr
ISBN 1 86156 238 1 29.50
This book was written to fill a gap which
existed. The authors, after previous success
with a dentistry book, have attempted to
produce an anatomy and physiology book
aimed solely at speech and language thera-
pists. The result is well ordered and covers
each area in a depth according to its rele-
vance. The interspersion of topics such as
the aphasias and agnosias give an added
dimension.
This book is, however, not without prob-
lems. The text often loses its way during
lengthy and complicated descriptions of
anatomical structures which could have
been easily illustrated using a diagram. If
read in conjunction with an anatomical
atlas and a glossary of terms, this is a useful
addition to any collection of anatomy and
physiology books. It is not, however, the
definitive guide that the authors may have
set out to produce.
Linda Morrison is studying for a BSc in
Speech Pathology and Therapy at Queen
Margaret University College, Edinburgh.
LANGUAGE DEVELOPMENT
ACTIVITIES PROVED POPULAR
Helping children to build self-esteem -
a photocopiable activities book
Deborah Plummer
Jessica Kingsley Publishers
ISBN 1 85302 927 0 15.95
This book offers a combination of imagework and
social use of language exercises to build self-
esteem. It mainly targets children at key stages 1
and 2 who stutter, have mild language impair-
ments, underachieve or have poor social skills.
Through photocopiable activities with instruc-
tions, groups or individuals join a treasure hunt to
fill their chests with precious things such as self-
knowledge, awareness of others, conversational
and problem solving skills.
The activities are nicely sequenced and progress in
small, logical steps. Helen selected the most
appropriate activities with a range of dysfluent
children but sees the advantages of covering all
the material.
The tasks require a well developed imagination
and would be most successful in groups.
Sometimes the printed pictures seemed a little
simple for the challenging, imaginative tasks but
generally the activities proved popular and pro-
voked interesting thoughts and ideas.
Judy King and Helen Lennox are speech and lan-
guage therapists with Selby and York Primary Care
Trust.
PHONETICS
REASONABLY PRICED AND
RELEVANT
Methods in Clinical Phonetics
Martin Ball & Orla Lowry
Whurr
ISBN 1 86156 184 9
19.50
Well written and easy to read, a great resource
and reference book for any student studying
phonetics.
The book introduces a wide variety of topics
relevant to those who work in the speech and
language therapy field. It would be difficult
for non-specialist readers to understand as
some sections tended to be technical - such as
the acoustic instrumentation and articulatory
instrumentation chapters which I have not yet
come across in my study or in my role as an
assistant. However this was no problem as the
authors present the range of instruments and
techniques with clarity and illustrate them
with relevant data and examples.
It is reasonably priced for students and rele-
vant to everyday work in the clinic.
Jaspal Kaur is studying for a BA Linguistics and
Psychology, and working as a speech and lan-
guage therapy assistant in special schools for
the South Birmingham NHS Primary Care Trust.
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2002 ;
revews
PHONOLOGICAL
AWARENESS
USEFUL BACKGROUND
RESOURCE
Sound Practice: Phonological
Awareness in the Classroom
(second edition)
Lyn Layton and Karen Deeny
David Fulton Publishers
ISBN 1 85346 801 0
15.00
A clearly written, comprehensive introduc-
tion to phonological awareness for teachers
and other education staff, this provides
good practical activities for both identifica-
tion of difficulties (covering attention,
memory, syllabification and rhyme aware-
ness and production) and for intervention
at all levels. It also includes coping strate-
gies for children with persisting difficulties.
The book advocates early intervention and
collaborative working with speech and lan-
guage therapists.
Best recommended for teachers due to its
focus on literacy development, it would be
useful as a background resource for thera-
pists working in schools, or as an in-service
training resource. The photocopiable activi-
ty sheets would be useful to include in indi-
vidual education plans for schools.
Andrea Arnold and Sally Kirk are paediatric
speech and language therapists working in
Leeds.
APHASIA
NOT FOR THE FAINT-
HEARTED
Grammatical Disorders in Aphasia
Ed. R.Bastiaanse & Y.Grodzinsky
Whurr
ISBN 1 86156 135 0
35.00
This collection of 11 papers by different
researchers in the field of neurolinguistics is
not for the faint-hearted clinician. Nonetheless
it presents the clinician with up to date investi-
gations into the nature of agrammatic Brocas
aphasia and deals with linguistic processes in,
among others, English, Hebrew, Dutch and
Hungarian.
A helpful chapter on Chomskys theoretical
model of Universal Grammar is included and
can provide a good refresher on the theoreti-
cal part of neuro-linguistic processing for the
less confident clinician or student.
An extensive bibliography is included.
Although the collection of papers is based on
primary research and may not always be easy
to digest, the book will provide sufficient food
for thought and may help the clinician experi-
enced in neuro-linguistic processing to make
more informed treatment decisions.
Elsje Prins is a speech and language therapist
(Clinical Lead Neurology) at Harrogate District
Hospital.
PLAY
A LOT OF INFORMATION
Play For Children With Special
Needs - Including Children
Aged 3-8
Christine Macintyre
David Fulton Publishers
ISBN 1 85346 935 1 14.00
The author is a lecturer in education and
has written this book to explain how includ-
ing play in the curriculum for children with
special needs can help to develop their
learning, language, self-esteem and social
communication skills.
There is a lot of information on the stages
of play and different types of special needs.
The later chapters have some practical ideas
on incorporating play into everyday activi-
ties within the mainstream setting.
At 14, this book is a useful resource for
therapists starting out in the field of special
needs or involved in the training of
preschool or educational staff.
Linda Smullen is chief paediatric speech and
language therapist with East Surrey PCT.
EPILEPSY
RATHER THEORETICAL
Language & Epilepsy
Yvan Lebrun & Franco Fabbro
Whurr
ISBN 1 86156 312 4 22.50
This book explores the link between language
and epilepsy from every angle - some have a
practical application within therapy and some
are interesting but irrelevant to most thera-
pists, for example ictal verbal behaviour. I was
disappointed by the two page chapter on
Remediation of verbal disorders associated
with epilepsy which basically said that clients
should receive verbal therapy!
The first two chapters provided some good
basic information including a thorough descrip-
tion of epilepsy, treatments, names used and
attitudes. The most useful chapters to thera-
pists describe the effect of epilepsy and drugs
and of surgical treatments on language.
Overall I found it was rather theoretical and only
provided brief practical information. It may be
of interest to therapists specialising in epilepsy.
Ruth Corkett is a speech and language therapist
with Enfield Primary Care Trust.
NARRATIVE
IDEAL FOR COLLABORATIVE
WORKING
Speaking & Listening Through
Narrative (A pack of activities and
ideas)
Becky Shanks in collaboration with
Helen Rippon
Black Sheep Press 40.00
This structured yet versatile pack will delight
therapists and teachers.
Developed for spoken language skills it has
great application for improving the structure
of written language. Intended to be used over
six weeks with a small group of Key Stage 1
pupils, the sessions cover Introduction to
Narrative; Who; Where; When; What happened;
The End, with accompanying suggested lesson
plans and activities. Clear interesting pictures
provide essential visual support that appeals to
pupils, yet are within their experience.
This pack has great scope for adaptation to older
pupils with learning difficulties and those with
specific language impairment. Excellent for struc-
tured teaching in the Literacy Hour with pupils
working at different levels, as it can be used from
the development of simple sentences to that of
the complex narrative plot. Additionally it pro-
vides resources for the structured teaching of syn-
tax, morphology and vocabulary.
Ideal for collaborative working in the school setting.
Virginia Martin is an advisory teacher - lan-
guage impairment in Surrey.
eary nterventon
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2002 8
ducation Achievement Zones (EAZs)
were established in areas across the
country where attainment levels were
low. They are funded in part by the
Department for Education and Skills
and by the private sector. We were appointed to
speech and language therapy posts as part of the
Bridgwater Education Achievement Zone
Programme. Critically, our brief is to work along-
side teachers so that we understand the chal-
lenges of teaching and they have the opportunity
to develop greater insight into language develop-
ment. In turn, this influences their practice and
the classroom environment, helps them recognise
the childrens preferred learning styles, and raises
attainment levels. What makes our posts so dif-
ferent is that we work with teachers in whole
class situations. This means we dont have case-
loads of specific children, see children on an indi-
vidual basis, write case notes, or draw up individ-
ual education plans.
Bridgwater EAZs aims are to:
1) raise standards of achievement in the 3-19 year
age group;
2) create new opportunities for learners of all
ages; and
3) work in partnership with business, industry and
the community.
These aims will be achieved through pro-
grammes that support families and learners, raise
the quality of teaching and learning, work in
partnership with business and other organisations
and join up services to tackle social exclusion.
Bridgwater EAZs long-term aims are to ensure
that the young people leaving school and further
/ higher education are:
well adjusted young people able to take control
of their lives
not frustrated and angry because they cannot
be understood or understand
more likely to be able to secure work/training
able to communicate well with family and
friends.
We were employed from 1 September 2000.
Our initial brief was open-ended and broad. We
were asked to begin working in Reception and
Year 1 classes in eight mainstream primary and
infant schools. This gave us a clear target group
and the opportunity to work with teachers and
establish ways of working which would help chil-
dren gain access to the curriculum and prevent
behavioural problems developing due to children
becoming frustrated through a lack of being able
to understand tasks set or simple instructions.
After seeking advice from a speech and language
therapist who worked for an EAZ in Salford, we
devised a brief (figure 1a).
Before going into the classrooms, we met with
groups of teachers and discussed the teachers
understanding of communication and their spe-
cific planning for language in the curriculum. This
discussion stemmed from the brief in figure 1a
and a questionnaire (figure 2), which we devised
with the support of a research psychologist. We
spent time in the classrooms observing and build-
ing a rapport with the children, teachers and non-
teaching assistants. A random sample was taken
for pupil assessment in the form of the British
E
you
are pannng to change
the way you work
need to strengthen
partnershps
want to encourage
mutsensory technques
Read ths
In common with other areas of the country, too
many children in Bridgwater enter school with poor
communication and literacy levels. Could the
inclusion of speech and language therapists in their
general education make a difference? Lizzie Astin,
Katie Roberts, Emma Withey and Melanie Crawshaw
take us on a journey into the classroom through an
Education Achievement Zone programme.
Improving
communication
with EAZe
Little girl
showing a
visual
dictionary
that the
teacher has
made with all
Year 2 sight
words.
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2002 ,
eary nterventon

Figure 1b EAZ speech and language therapy


brief 2001-2002
To work in partnership with teachers in the
classroom to effect change in teacher practice in
order that the curriculum is accessible to all children
irrespective of preferred learning style.
To achieve this objective we will:
provide Total Communication language training to
whole school communities. This training includes
simplifying language and increasing use of Visual,
Auditory and Kinaesthetic (VAK) teaching that
interlinks with the principles of Teaching for
Effective Learning.
continue to jointly plan the curriculum with teachers
at regularly scheduled intervals throughout the year.
model appropriate language and use of visual,
auditory and kinaesthetic approaches in the
classroom.
work in the classroom without withdrawing any
groups of children.
evaluate the effectiveness of the project through
assessment of children, teacher observation and
self evaluation.
liaise with teachers, special educational needs
coordinators and learning support assistants at a
mutually agreed time for technical and linguistic
support for the use of Total Communication
(symbols, signs, etc).
continue to link and liaise with the advisory
service for Somerset Total Communication,
Teaching for Effective Learning, Physical Disability
Service, community therapists within Somerset
Coast Primary Care Trust.
Figure 1a EAZ speech and language therapy
brief 2000-2001
to work alongside Reception and Year 1 teachers.
to identify possible blocks to childrens
learning/accessing the curriculum.
to think about and identify possible training needs
of staff in schools.
to ensure that teachers and others in schools
develop a better understanding of language
development, and an understanding of childrens
preferred learning styles and how this needs to be
taken into consideration in teachers planning.
Bridgwater E.A.Z. Project
Speech and Language Therapist Questionnaire
The EAZ aims to support the acquisition and development of language skills
of children in Bridgwater. Your views and comments regarding communica-
tion in the classroom would help us greatly. Please could you complete this
short questionnaire? Your replies are confidential. Please place the question-
naire in the envelope provided and return to one of the speech and lan-
guage therapists or the EAZ office.
About the project:
1. Are you aware of the aims of the EAZ?
Please tick YES NO
If you answered yes, please can you state one of the aims?
2. Were you aware that speech and language therapists were part of the pro-
ject?
Please tick YES NO
3. What do you think the role of the speech and language therapist in the
school setting is? Please tick all that apply
Working with: whole class
small group
individuals
children with speech and language problems
Enhancing communication:
within the classroom
skills of teachers
of children with speech and language problems
To: provide extra assistance in the classroom
joint plan with teachers
work alongside teachers
liaise with teachers and classroom assistants
About Communication:
4. Please can you rate the importance of language in the following areas of
the curriculum?
[Please rate from 0-5, 0 = not important at all, 5 = very important]
Maths
History
Information Technology
Geography
English

Please can you briefly say why you feel some are more important than others
5. How would you recognise the following in your classroom?
A child with poor attention
A child with language delay
Low self-esteem
6. What strategies do you use with a child who has poor comprehension
skills?
Please tick all that apply
Gestures
Symbols
Slowing down rate of speech
Signing
Raising voice

Please state any other strategies that you use:


About Planning:
7. Which areas of the curriculum if any do you formally plan for the
following social skills? Please write in the box next to each social skill.
Listening
Eye contact
Turn taking
Conversation skills
Initiation and maintenance
of communication
Picture Vocabulary Scales II, The Bus Story Test,
and the school-age Boehm Test of Basic Concepts.
This enabled us to ascertain the childrens average
language levels. General weaknesses were found
in both receptive and expressive lan-
guage skills but in most cases they
would not be severe enough to war-
rant being referred for speech and
language therapy.
Good listening
With the agreement of individual
teachers, narrative skills and listening
skills were addressed initially by
working with groups of children. A common com-
plaint from teachers was that the children just
werent listening and so this provided a good
starting point for us in the schools. Our objective
was to increase teachers understanding that lis-
tening is an active process that involves a number
of skills. We took groups of children out of the
classroom and devised sessions that enabled the
children to develop an understanding of the rules
of good listening and to practise those skills. We
started by encouraging the children to look and
make eye contact with a speaker. We ensured that
there were no particular linguistic or conceptual
demands entrenched in the activities. This gave us
the opportunity to provide positive feedback to
the children in the form of verbal praise, signing
and symbols. Once the children had developed
good eye contact with the speaker, we used this
skill to encourage the children to actively listen
and to think about the words they hear. We pro-
vided the teachers with session plans and dis-
cussed our approach and the children progress
with them. It was then that we encouraged the
teachers to help the children generalise these
skills in the classroom by using the same signs,
symbols and vocabulary. This also enabled us to
work in the classroom alongside the teacher and
gave us an opportunity to reinforce and model the
use of positive praise as a vehicle for enhancing
self-esteem, confidence and behaviour.
We also began to analyse the childrens Bus Story
Test scores to discover that the expressive language
scores were significantly lower than the receptive
results achieved and this also provided a discussion
point with teachers. We helped develop childrens
narrative skills using big books or topic books. We
spent several sessions focusing on the target book:
reading, making predictions, clarifying and defin-
ing vocabulary, role play, picture description, story
sequencing, extending and changing the ending,
setting and location of the story. This enabled us to
develop our rapport with teachers. We now plan
on a regular basis with teachers and work exclu-
sively in the classrooms alongside them, reinforc-
ing, modelling and co-teaching.
We also work with teachers to develop materials
which support and acknowledge the childrens
different learning styles, the goal being to influ-
ence teachers practice so all children can access
the curriculum. In particular we are encouraging
them to use all the principles of Somerset Total
Communication which include using signs, sym-
bols, body language, gestures, photos, real
objects, drawing and facial expression; this way
Literacy
Science
Physical education
Art
Drama
Music
Simplifying language
Placing them near a teacher
Calling their name to gain attention
Restricting language to short,
unambiguous sentences
Using shortened instructions
What makes our posts so
different is that we work
with teachers in whole class
situations.
Figure 2 Text of questionnaire
teacher. Since we are not just consulting or with-
drawing children we have the opportunity to
demonstrate different approaches and provide
materials to enhance communication. We are
training staff and are able to support and follow
up on the training. We have had the opportunity
to develop strong professional relationships with
staff and have unplanned, spontaneous conversa-
tions (teachable moments) during class and
break times.
Initially the time spent in each class was dependent
on reading score results and other deprivation
factors. Recognising the importance of early
intervention, we spent all our time in the
Reception and year one classes working alongside
teachers and encouraging them to use principles
of Somerset Total Communication in their daily
classroom practice. This enabled us to introduce
the principles to the school and to allow teachers
to talk to each other to promote the practice. We
have been moving up the schools and are begin-
ning to work in years 2 and 3. Where we work in
the school - and what our focus is - is agreed fol-
lowing discussions with the headteacher and their
senior management team, and the
EAZ project director.
It has been very beneficial for us
to work together as a team of
speech and language therapists on
the same project. We have been
able to share ideas, learn from each
other, provide support, and devel-
op and deliver joint training pack-
ages. Between us we have also
been able to liaise with speech and
language therapy colleagues and
others working with a range of chil-
dren with additional needs and
share and develop good practice.
We have learnt a lot. Demands faced by schools
to deliver curriculum content are considerable
and way beyond what we had anticipated. There
is a significant difference in the amount of knowl-
edge and expertise in language development
teachers have as opposed to speech and language
therapists due to the very different training pro-
grammes. Many teachers have minimal language
training and have little understanding that lan-
guage acquisition is developmental. Schools have
eary nterventon
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2002 +o
to model Somerset Total Communication practice
for the teachers and allows them to observe their
pupils and another style of teaching. Our brief at
the end of the first year was rewritten in the light
of what we and staff in schools had learnt and has
become more sharply focused (figure 1b, p.9).
We hope this will result in changes for the chil-
dren so they will
know what they are expected to do and when,
as this will be communicated in a variety of ways.
be able to recognise and learn more words
because pictures / symbols are there next to the
words.
know which areas of the room should be used for
different activities, therefore avoiding confusion.
be able to explain to the teacher what they have
just been asked to do, and act on it.
be able to learn more because they are allowed
to experience more.
be praised and encouraged frequently for
efforts with communication.
know what they have learnt and feel good
about this.
In some schools work, we have been undertak-
ing has been discussed and sup-
ported by the senior management
team and/or we have been working
closely with the literacy coordina-
tor or special educational needs
coordinator. Where this approach
has been taken, certain practices
have been established across the
school. These include visual timeta-
bles, importance of using symbols
as well as word labels, develop-
ment of resources and the role of
classroom assistants. Teachers are
using more visual and kinaesthetic
modes of teaching. Classrooms look different.
Symbols, drawings and photos are being paired
with written text to assist children in accessing the
curriculum and their environment. Some teachers
have come to believe that symbols are a bridge to
literacy which can positively impact on the chil-
drens confidence and self-esteem.
We believe we are being successful because we
are spending scheduled time each week in specific
classrooms. This has allowed us to understand the
challenges of teaching and work alongside the
We qualified as
Somerset Total
Communication
trainers and this
led to a systematic
training
programme for
staff in school.

1. Office Role play


Area - labelled with
symbols
2. Display: Seaside
vocabulary. Symbols
used to encourage
the children to use it
as an interactive
board (eg How
many buckets are
there?)
3. Visual timetable:
Placed at childrens
eye level.
1
2
3
the needs of the visual and kinaesthetic learners
will be addressed.
Somerset Total Communication was already being
used successfully in early years and some school
environments and in day centres in Somerset for
adults with learning difficulties. We qualified as
Somerset Total Communication trainers and this led
to a systematic training programme for staff in
school. This training has tried to address the lack of
understanding of the importance of multi-sensory
communication techniques which need to be used
when a childs vocabulary and understanding of
words and concepts is limited. This is in the main
due to a lack of language and communication train-
ing for teachers. The understanding and knowl-
edge we have gained by working alongside teach-
ers has given us the opportunity to take examples
of a breakdown in communication between the
teacher and child and provide practical ways such
problems can be overcome or, more importantly,
prevented in the future.
Time to plan
Through training and discussion with teachers
and staff we are increasing their knowledge of
communication and the necessity for adults to
provide children with the appropriate language
to access the curriculum. Supply teachers are paid
for by the EAZ so there is time for the teachers
and speech and language therapists to address the
National Curriculum and plan together during the
school day. Co-teaching is an excellent opportunity
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2002 ++
eary nterventon
a lot of people popping in and out to offer advice,
so this advice needs to be coordinated. All this
can explain why school speech and language ther-
apy programmes do not work optimally unless
they are well supported, very specific and ideally
linked into the curriculum with a one-to-one sup-
port for the child.
Opportunity
This project has provided an opportunity for pro-
fessionals to work together in a way which is not
normally possible for the majority of speech and
language therapists or teachers. This has led to
good communication becoming recognised as
the key to encouraging effective learning. The
way we work with colleagues in schools will con-
tinue to change and develop. Our plans include
working with parents and developing parent/child
interaction as children enter school, working with
teachers on language development in particular
curriculum areas including science and maths, and
working with a number of teachers in the sec-
ondary sector.
Our two professional groups have to work
together to address the ever growing complex
needs of many children in mainstream education.
We need to ensure that what we have learnt is not
lost and that health and education work together
to provide services in a holistic way which meets
the needs of the child/young person rather than
the service providers.
Lizzie Astin, Katie Roberts, Emma Withey and
Melanie Crawshaw are speech and language ther-
apists with Bridgwater Education Achievement
Zone which has links with Somerset Coast PCT
speech and language therapy service.
Resources
Contact the Somerset Total Communication
Project team at Resources for Learning, Parkway,
Bridgwater, Somerset TA6 4RL.
Boehm Test of Basic Concepts 3rd ed (Boehm-3)
is available from The Psychological Corporation,
www.tpc-international.com.
British Picture Vocabulary Scales 2nd ed from
NFER-Nelson, www.nfer-nelson.co.uk.
Bus Story Test by Catherine Renfrew from
Speechmark, www.speechmark.net.
Stroke - good practice
The Stroke Association has produced a
resource pack for those working in social care
with responsibility for planning, commissioning
and delivering services for those affected by
stroke. The third in a series of guides, it iden-
tifies good practice and includes case studies
and other sources of information.
Stroke - good practice in social care (ref SCP)
Stroke - good practice resource pack (ref R1)
Stroke - good practice in primary care (ref PCO)
All from The Stroke Association, tel. 01604
231000.
Take the bus
A subscription service for nurseries, schools
and parents includes interactive learning
software for children aged 3-11 linking into
the national curriculum. The Big Bus aims to
bridge a perceived
gap between
computer games
and curriculum
content.
For prices and a free
taster, see
www.thebigbus.com
ADHD information
A drug company has produced a patient
education pack for those affected by
attention deficit hyperactivity disorder.
Janssen-Cilag Ltd has included information on
psychological, educational and social
measures as well as drug treatment, along
with suggestions for books, support groups
and internet sites.
The booklet is available from prescribing
consultants and the company, tel. 01494
567567, www.concertaXL.co.uk.
Fragile X
The Fragile X Society has published a report
of the talks given at its National Family
Conference in May 2001. The genetics of
Fragile X and their impact and implications
for families was discussed by Dr Angela
Barnicoat, while Dr Jeremy Turks
presentation was Fragile X behaviour -
reducing the undesirable and enhancing the
desirable.
Three booklets - Fragile X Syndrome: An
introduction / An introduction to educational
needs / Education and severe learning
difficulties - are available free.
Details tel. 01245 231941,
e-mail lynne@fragilex2.k-web.co.uk.
Sex after stroke
A new leaflet from the Stroke Association
discusses sex after stroke. The importance
of communication is emphasised, and
readers experiencing language difficulties
following a stroke are advised that a
speech and language therapist will help
them and their partners find suitable ways
of communicating their feelings and
emotions for each other.
Sex after stroke From The Stroke
Association, tel. 01604 623933.
Software from Crick
ClozePro software, from the makers of
Clicker, provides a range of cloze activities
customisable for all ages and abilities. Users
can for example use it to work on word
finding or spelling, both on-screen and as
printed worksheets.
Single user 90, additional user licence 12.
From Crick Software, tel. 0845 1211691,
www.cricksoft.com.
Incentive Plus
A speech and language therapy catalogue
of resources for promoting effective
communication skills in adults and children.
Tel 01908 526120, www.incentiveplus.co.uk
Downs syndrome
answers
The Downs Syndrome Association answers
common questions with an
updated version of its most
popular publication. The
Association hopes this
format, along with
increasing use of audio
tape and video, will
improve accessibility of its
material for people with
learning disabilities.
People with Downs
Syndrome - Your
Questions Answered
is 2.50 from the DSA, tel. 020 8682
4001, www.downs-syndrome.org.uk.
..resources...resources...
Do we pan new servces n a
phased way, gvng a nvoved
a chance to deveop ther bre
together'
Do we do our research rst to
nd out what peope aready
know and where there are gaps'
Do we ase at management
and at ground eve to ensure
deveopments get estabshed'
Reectons
Voice on the web
Voice experts Gillyanne Kayes and Jeremy
Fisher have launched Vocal Process on the
web, including a page dedicated to speech
and language therapists.
www.vocalprocess.net
My experience of AAC with patients in intensive
care before our study was limited. I found that
the high-tech devices we had available in the cup-
board were only occasionally useful in ICU. The
buttons on the Parrot were too small for patients
to press, and the old-fashioned scanning Possums
which were 4, 16 or 128 location were too bulky,
slow to use and required a high degree of con-
centration and coordination. The E-Tran eye-
pointing frame was flexible but required a high
degree of concentration and cooperation from
the patient. Nursing staff within intensive care
encourage patients to use alphabet charts and
writing to communicate but feel these methods
have severe limitations as they require high levels
of concentration. Patients trying to use these
methods may produce words or phrases which are
meaningless, bizarre, inappropriate or difficult to
interpret. This is supported by literature which
reports that these methods are time-consuming
and frustrating (Albarron, 1991; Ashworth, 1984).
Patients have also stated difficulties with these
communication techniques (Hafsteindottir, 1996).
Over the last ten years the little that has been
published for speech and language therapists
about communication aiding or augmentation for
patients in intensive care has come mainly from
the United States (Costello, 2000; Beukelman &
Mirenda, 1998; Dikeman & Kazandjian, 1995). The
American intensive care unit populations
described differ from those here. The UK units are
more general so they see a greater range of
patient types with few planned admissions. Many
US patients tend to be in highly specialised units
(Mitsuda et al, 1992). In, say, a neurosurgical ICU
there may be very few patients who could use
AAC due to their cognitive problems, while in a
surgical ICU with planned admissions, patients
can be taught a technique prior to admission or
learn it while in the unit.
Exceptional skills
Nursing staff who work within the ICU setting
have exceptional skills in questioning to elicit
information on pain or discomfort levels but,
because of the patients situation, engaging in
conversation beyond the level of basic needs or
understanding and replying to unique questions
is not possible. Low morale and depression are
commonly documented in patients experiencing a
prolonged stay in ICU, and having an effective
means of communication is a recognised way of
reducing this. Most articles advocate the use of
low-tech AAC systems for ICU patients, stating
that high tech solutions are not suitable for the
intensive care environment. However, the last 20
years has seen many advances in terms of com-
research
hen patients recovered conscious-
ness after anaesthesia or sedation,
they reported that they experienced
complete emptiness - devoid of any
thought or feelings; and their language did not
function normally. They could not make themselves
understood and therefore were unable to communi-
cate and share experiences and feelings with others.
They became aliens, strangers, when they woke up,
connected to peculiar machines and apparatus, and
tied in their beds. They had no expressions or con-
cepts for the situation, and were unable to conduct
a dialogue, and therefore unable to share their
experiences. (Granberg et al, 1999).
Communication failure has been identified as one
of the most frustrating and stressful aspects of car-
ing for the temporarily non-speaking, ventilated
person in an intensive care unit (Costello, 2000).
Difficulty in communicating with ventilated
patients has been well documented in the nursing
and intensive care literature (Ashworth, 1984) but
tends to be glossed over by alternative and aug-
mentative communication literature. This is unfor-
tunate as the ICU patient population as a whole is
challenging and thought-provoking in terms of
AAC, as our three year collaborative research pro-
ject developing the ICU-Talk device has shown.
Although many patients are sedated during their
stay in intensive care, as they recover they are
weaned off the ventilator, sedation is reduced, they
waken up and, at this point, most attempt to com-
municate. There is also a group of patients within
ICU who have conditions like Guillain Barre
Syndrome, complications post meningitis, respira-
tory failure, severe chest injuries and high spinal
cord damage. Although receiving ventilatory sup-
port, they are conscious and attempting to commu-
nicate for part of their more prolonged ICU stay.
These are the patients who tend to be referred to
speech and language therapy for AAC intervention.
When a person wakes
up to find themselves in
the alien environment
of an intensive care
unit, they may well feel
they have come from
another world. While
vital contact made
through current
alternative and
augmentative
communication
methods is limited,
there is light in the
shape of the
ICU-Talk device. Fiona
MacAulay reports.
v
Communication -
an inalienable right
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2002 +

you want to
deveop a research dea
transer knowedge to a
derent cent group
mprove your
coaboratve workng
Read ths
Figure 1 The ICU-Talk communication aid.
puter hardware and the limits
of what computers can do.
The department of applied
computing at Dundee
University along with the
Dundee speech and language
therapy service has been devel-
oping AAC systems for 15
years. While working on a sys-
tem for adults with aphasia we
felt that some of the principles
of reduced cognitive load, min-
imal training, and transparent
interface could be used to
develop a system specifically
for intubated patients in inten-
sive care. A three year funded
collaborative research project,
ICU-Talk, was set up to develop
and test an AAC device for
intubated patients in intensive
care. My partners in the
research were a software engi-
neer and an ICU nurse.
There were two steps in the
development of the ICU-Talk
device. The first involved iden-
tifying a suitable hardware
platform to run the software
and then mount the hardware.
The second was to develop the ICU-Talk software
that would control how the device worked.
Many restrictions apply when developing an aid
for use in the intensive care environment. Risk of
infection to and between patients is a major con-
cern, so equipment must be able to withstand rig-
orous cleaning with chemical solutions. Staff must
be able to move the device out of the way quick-
ly in an emergency and the patient must be able
to use it when lying or sitting in bed, or from a
chair. It must be able to be accessed using a range
of input devices to compensate for a patients
physical weakness.
The multidisciplinary project team addressed
these factors and a solution was found which was
limited by the available hardware at that time. A
rugged, waterproof, flat panel screen was
obtained from Dolch. This screen weighed approx-
imately seven kilograms and so required a special
heavy-duty mounting solution to allow it to be
suspended safely above a patient (see figure 1).
Specific needs
Software was developed with the specific needs
of the ICU patient in mind. It had to be simple to
use and easy to learn with minimal training. Two
interfaces were developed which each supported
use of the touch screen, mouse or single switch
scanning (see figure 2). The interfaces were
designed to be visually stimulating but not distract-
ing, and advice was sought from a computer games
company as to how best to achieve this. They told
us how we could keep the animation working from
the same direction all the time so that the user
remains focused on the important central part of
the screen. The software includes a database of
phrases organised under eight topic headings. To
ensure the phrases were relevant for their intubat-
ed patients, nursing staff from ICU were asked for
examples of phrases patients frequently use, and
researchers also observed and noted the communi-
cation attempts made by patients. Communication
partners during observations were usually relatives,
so about half of the phrases were very personal,
everyday things such as a query about a family
member, or who was walking the dog. A computer
based interview was designed for relatives. There
were thirteen questions which asked for informa-
tion like names and ages of children, and hobbies.
The answers were turned directly into personal
phrases in the ICU-Talk device, and were available
immediately for the patient to use.
The first prototype ICU-Talk device was finished in
May 2001 and introduced to the intensive care unit
at Ninewells Hospital, Dundee for trials with patients.
Using the ICU-Talk device and working closely
with the intensive care unit nurse has taught me
a great deal about these patients and the effects
that having a life threatening condition and a
prolonged stay in intensive care have on the
patient. These in turn affect the patients ability
to use an AAC device (figure 3).
Despite all the complications described, 21
patients over a 12 month period have used the
ICU-Talk device. Preliminary results show that
patients are able to use the system with only min-
imal training to communicate. Most patients only
use it for a short period of time, as the window of
opportunity is small - perhaps only 24 to 48 hours
- between having their sedation reduced so they
are awake and extubated. There have been no
admissions of people with Guillain Barre
Syndrome or of other long-term alert and com-
municating patients during the evaluation period,
the initial target group for the ICU-Talk device.
Surprised
One of the features that most surprised me was the
patients inability to remember anything about
using the ICU-Talk device or about their stay in ICU.
This phenomenon is documented in the literature
(Russell, 1999; Stovsky et al, 1988) and is commonly
seen in patients who have been ventilated.
However, it meant that we were unable to ask the
patient how they felt about using ICU-Talk or for
feedback about what it was like communicating
with it. A questionnaire we put together was only
completed by three relatives. We had difficulty
accessing relatives and patients once they were dis-
charged from the unit, and no relative returned
the questionnaire if it was posted to them. Many of
our results are therefore anecdotal - from nursing
staff, our own observations of patients using the
device and from the data recorded automatically
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2002 +
research
Figure 2.1 Boxes Interface showing topics
Figure 2.2 Boxes Interface showing questions
Figure 2.3 Bubbles Interface showing
topics
Figure 2.4 Bubbles Interface showing
phrases
Many restrictions
apply when
developing an
aid for use
in the
intensive care
environment.
Figure 3 Effect on AAC use
Presenting Possible Cause Effect on AAC use
feature
Fatigue
Generalised
weakness
Reduced
cognitive
abilities
Fear/anxiety/
denial of
problems
Low mood
poor concentration
poor ability to retain information
hallucinations
difficulty using touch screen, mouse, joystick,
trackball
tire quickly
tremor in hand or arm
reduces cooperation
short-term memory loss (unable to retain
instructions)
long-term memory loss (do not remember their
stay in ICU)
difficulty following instructions
unwilling to try something new
reduced concentration
only want to use speech to communicate
poor motivation to participate
unwilling to try something new
social withdrawal therefore dont want to
communicate
medication
general medical condition
withdrawal of sedation
being bed bound
effect of medical condition
medication
general medical condition
waking up in the alien
environment of ICU
realisation of what has happened
difficulty coming to terms with
physical problems
feeling they are not getting better
severity of medical condition
feelings of isolation

research
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2002 +(
References
Albarran, J.W. (1991) A review of
communication with intubated
patients and those with tra-
cheostomies within an intensive
care setting. Intensive Care
Nursing 7; 179-186.
Ashworth, P. (1984). Staff-patient
communication in coronary care
units. Journal of Advanced
Nursing 9; 35-42.
Beukelman, D.R. & Mirenda, P.
(1999) AAC in intensive care set-
tings. In: Augmentative and alterna-
tive communication: Management
of severe communication disorders
in children and adults, Ed.2; 515-
530. Baltimore: Paul H. Brookes
Publishing Company.
Costello, J. (2000) AAC interven-
tion in the Intensive Care Unit:
The Childrens Hospital Boston
Model. Augmentative and Alternative
Communication 16; 137-153.
Dikeman, K.J., & Kazandjian, M.S. (1995)
Communication and Swallowing Management of
Tracheostomised and Ventilator Dependent
Adults. Singular Publishing Group; San Diego.
Granberg, A., Bergbom Engberg, I. & Lundberg,
D. (1999) Acute confusion and unreal experiences
in intensive care patients in relation to the ICU
syndrome. Part 2. Intensive and Critical Care
Nursing 15; 19-33.
Hafsteindottir, T.B. (1996) Patients experiences of
communication during the respirator treatment peri-
od. Intensive and Critical Care Nursing 12; 261-271.
Mitsuda, P.M., Baarslag-Benson, R., Hazel, K. &
Therriault, T.M. (1992) Augmentative communica-
tion in intensive and acute care unit settings. In:
Yorkston, K.M. (ed.) Augmentative
Communication in the Medical Setting.
Communication Skill Builders:Tucson.
Russell, S. (1999) An exploratory study of patients
perceptions, memories and experiences of an
intensive care unit. Journal of Advanced Nursing
29 (4); 783-791.
Stovsky, B., Rudy, E. & Dragonette, P. (1988) Caring
for mechanically ventilated patients. Comparison
of two types of communication methods after car-
diac surgery with patients with endotracheal
tubes. Heart and Lung 17; 281-289.
by the ICU-Talk device, which logs all
the button presses and selections
made by the patient.
Patients often had difficulty in fol-
lowing instructions. They were unable
to take on board that their attempts
at communicating using mouthing
were unsuccessful and that, to com-
municate more effectively, they need-
ed to slow down their speech rate,
use single words and use ICU-Talk to
augment their communication.
Patients tired very quickly so sessions
tended to be short and patients
would give up unless they found what
they wanted to say very quickly.
The number of patients in ICU who
are able to use an AAC system is rela-
tively small but giving them the facili-
ty to communicate allows them to
express their needs and wants and
reduces their feelings of isolation (see
case examples in figure 4). Feedback from nursing
staff in ICU suggests they feel ICU-Talk is a good
idea but that, in practice, the device was too big
and its physical size put patients and staff off
using it.
Use of the ICU-Talk system depended a lot on
the cooperation of the nursing staff. Although
the ICU-Talk team tried to be present in the unit
as much as possible, they could not provide week-
end or evening cover. Some members of the nurs-
ing staff reported that, although they felt com-
munication was important, they would rather
that the patient was washed and all the days pro-
cedures completed before the ICU-Talk device
was made available to the patient. This limited
the patients ability to use communication to par-
ticipate in aspects of their care.
Many of the feelings and perceptions of the
nursing staff were to do with the overall size of
the device. We have since sourced and trialled
much smaller hardware, a fujitsu pentablet (figure
5), with two patients. Staff feel the smaller device
is much better although it is not waterproof so has
to be put in a plastic bag to be used, and has a
smaller and less sensitive screen and poor quality
built-in speakers. At the point of writing it has
been ruggedised to make it suitable for use as an
AAC device, and we are keeping an eye on the
constant stream of new hardware coming on the
market. The patients ability to locate what they
want to say from the large database remains a dif-
ficult area and requires some further work to
develop easy to use navigation methods.
We have written a funding proposal for a multi-
centre randomised control trial to see if using this
smaller version of ICU-Talk is more effective than
the low-tech AAC methods traditionally used in
ICU. This would be based on 160 patients in 8 ICUs
across the UK and will also allow changes in the
software and database reorganisation to be tested
by a much larger number of patients.
Fiona MacAulay is a senior speech and language
therapist at Ninewells Hospital, Dundee. See
www.computing.dundee.ac.uk/acprojects/icutalk
for more information.
Do l have a can do atttude
to my work'
Do l ask or expert or
specased advce when
necessary'
Do l adapt recommendatons
and resources unt they
meet the needs o those
usng them'
Reectons
Figure 5 The new ICU-Talk prototype
Note: All photos posed by author.

Figure 4 Case examples


Irene was a 44 year old lady admitted to
ICU with septicaemia. She was ventilated
via a tracheostomy for 15 days prior to
using ICU-Talk. By the time ICU-Talk was
introduced she was recovering from
serious infection and was extremely
weak. She was unable to use the touch
screen due to weakness and tremor in
her upper limbs and was attempting to
use the trackball. She was keen to
communicate and was using non-verbal
methods of communication such as
mouthing, which was very difficult to
interpret, basic non-specific gesture,
facial expression, and was nodding and
shaking her head in response to questions.
When using ICU-Talk Irene was able to
use a range of utterance types including
requests such as Put the bed back,
statements like I want to die, My
throat feels sore, and questions including,
What did the doctor say?, What day
is it? Irene used ICU-Talk with nurses
who were looking after her but feedback
from the nurses was that they did not
feel it assisted with patient care. The
nurses also felt that Irene tired quickly
and that using ICU-Talk was a great effort.
Davie was a 53 year old man admitted to
ICU with an aspiration pneumonia. He
was ventilated orally for one day prior
to using ICU-Talk over a period of three
days before being extubated. Although
Davie had some generalised weakness of
his upper limbs he was able to use the
touch screen. A lot of time was spent
scrolling though the pages of phrases as
if looking for specific items. Most of
what he said using ICU-Talk were
questions asking for reassurance about
what had happened to him. Nurses felt
it did assist with aspects of his care and
that Davie was able to use ICU-Talk to
initiate conversations.
One of the
features that
most surprised
me was the
patients
inability to
remember
anything about
using the ICU-
Talk device or
about their
stay in ICU.
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2002 +
urther readng
ONNUNlTY-lOUSED
lNTERVENTlON
Pickstone, C., Hannon, P. & Fox, L. (2002)
Surveying and screening preschool language
development in community-focused interven-
tion programmes: a review of instruments.
Child Care Health Dev 28 (3) 251-64.
Preschool language intervention has come increasing-
ly to the fore with the development of community-
focused interventions including Sure Start in the UK.
Successful intervention methods may well be incorpo-
rated into mainstream service delivery, especially in
areas of disadvantage. The question of whether such
interventions will work and of their impact on chil-
drens language development has focused attention
on measures of language. This paper distinguishes
two reasons for measuring language development: (1)
surveying language; and (2) screening language. It
goes on to suggest a set of criteria for selecting instru-
ments for these applications. The review includes a
wide range of language assessment instruments for
preschool children and examines those most likely to
be suitable. It suggests a role for paraprofessionals in
survey and screening and argues that this may be
advantageous in terms of reaching families and there-
by achieving high levels of coverage of a population
group. Finally, there is a discussion of the implications
of such measures in community-focused preschool
interventions. (50 References)
PHONOlOGY
McLeod, S., van Doom, J. & Reed, V.A. (2001)
Normal acquisition of consonant clusters
[review]. Am J Speech Lang Pathol 10 (2) 99-110.
Childrens acquisition of adult-like speech production
has fascinated speech-language pathologists for over
a century, and data gained from associated research
have informed every aspect of speech-language
pathology practice. The acquisition of the consonant
cluster has received little attention during this time,
even though the consonant cluster is a common fea-
ture of speech, its acquisition is one of the most pro-
tracted of all aspects of childrens speech develop-
ment, and the production of consonant clusters is one
of the most common difficulties for children with
speech impairment. This paper reviews the literature
from the past 70 years to describe childrens normal
acquisition of consonant clusters. Articulatory, phono-
logical, linguistic, and acoustic approaches to the
development of consonant clusters are reviewed.
Data from English are supplemented with examples
from other languages. Consideration of the informa-
tion on consonant cluster development revealed ten
aspects of normal development that can be used in
speech-language pathologists assessment and analy-
sis of childrens speech. [127 References].
lURTHER
READlNG
Ths reguar eature
ams to provde
normaton about
artces n other
journas whch
may be o nterest
to readers.
The Edtor has
seected these
summares rom a
Speech 8 language
Database comped
by Bomedca
Research lndexng.
Every artce n
over thrty journas
s abstracted or
ths database,
suppemented by a
monthy scan o
Medline to pck
out reevant
artces rom others.
To subscrbe to the
Index to Recent
Literature on
Speech & Language
contact
hrstopher Norrs,
Downe, Badersby,
Thrsk, North
Yorkshre YO; (PP,
te. o+; (o8,
ax o+; (o.
Annua rates are
Ds (or vndows
,):
lnsttuton L,o
lndvdua L;o
Prnted verson:
lnsttuton L;
lndvdua Lo.
heques are
payabe to
Biomedical
Research
Indexing.

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VOlE
Pannbacker, M. (2001) Half-swallow boom: does
it really happen? [review]. Am J Speech Lang
Pathol 10 (1) 17-8.
The half-swallow boom is a voice facilitating tech-
nique used for clients with low loudness and air
wastage from unilateral vocal fold paralysis, severe
bowing of the vocal folds, or falsetto voice. This arti-
cle provides a summary of the technique. Although
the technique may be useful it induces vocal hyper-
function and can damage the vocal folds causing an
iatrogenic voice problem. Clinical trials of the tech-
nique did not show benefits and resulted in an
increase of vocal symptoms. There is a need for data
about its effectiveness.
PARKlNSONS DlSEASE
Haneishi, E. (2001) Effects of a music therapy
voice protocol on speech intelligibility, vocal
acoustic measures, and mood of individuals
with Parkinsons disease. J Music Ther 38 (4)
273-90.
This study examined the effects of a Music Therapy
Voice Protocol (MTVP) on speech intelligibility, vocal
intensity, maximum vocal range, maximum duration
of sustained vowel phonation, vocal fundamental fre-
quency, vocal fundamental frequency variability, and
mood of individuals with Parkinsons disease. Four
female patients, who demonstrated voice and speech
problems, served as their own controls and participat-
ed in baseline assessment (study pretest), a series of
MTVP sessions involving vocal and singing exercises,
and final evaluation (study posttest). In study pre and
posttests, data for speech intelligibility and all
acoustic variables were collected. Statistically signifi-
cant increases were found in speech intelligibility, as
rated by caregivers, and in vocal intensity from study
pretest to posttest as the results of paired samples t-
tests. In addition, before and after each MTVP session
(session pre and posttests), self-rated mood scores and
selected acoustic variables were collected. No signifi-
cant differences were found in any of the variables
from the session pretests to posttests, across the
entire treatment period, or their interactions as the
results of two-way ANOVAs with repeated measures.
Although not significant, the mean of mood scores in
session posttests (M = 8.69) was higher than that in
session pretests (M = 7.93).
APHASlA
Murray, L.L. (2002) Attention deficits in aphasia:
presence, nature, assessment, and treatment.
Semin Speech Lang 23 (2) 107-16.
Recently, there has been growing interest in under-
standing how nonlinguistic cognitive problems such
as impaired attention might negatively affect the lin-
guistic abilities of adults with aphasia. This article
begins with a summary of research focused on the
relationship between attention and language impair-
ments in aphasia and a discussion of why it might be
important for clinicians to address the attention abili-
ties of their aphasic patients. Also discussed are for-
mal and informal measures for quantifying and qual-
ifying attention problems, treatment strategies for
directly or indirectly remediating attention problems
in patients with aphasia, and empirical support for
such treatment.
n my experence
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2002 +
First stop was the vast evidence base that under-
pins our practice. Oh well... However, there was
light at the end of the tunnel. Agencies in
Somerset pioneered work on a collaborative com-
munication strategy that identified the key ele-
ments for success (Somerset Total
Communication: Jones, 2000). We invited Jane
Jones to our Trent Region special interest group
for speech and language therapists working with
people with learning disabilities. She gave a short
presentation then facilitated discussion around
key questions such as What is a strategy?,
What is total or inclusive communication? and
What are the key elements for a successful strat-
egy? After these seemingly straightforward
questions were posed and debated, we left sever-
al hours later realising we still had a long way to
go.
Reached by consensus
Through the next two special interest group
meetings we continued to allocate time for
Communication Strategies. We worked our way
through the key elements of management,
training and resources. For each element we
identified the principles that would have to be
in place to achieve success, then identified possi-
ble suggestions or processes that might be used
to achieve the principles. The principles and
processes were all reached by consensus - in itself
an achievement.
We formed a small working party, which met
twice, to pull all the special interest group work
together. We decided we needed a framework
developed by and for speech and language thera-
pists working with adults with learning disabilities
in Trent. The framework could then be used in
partnership with other agencies and stakeholders
to develop local communication strategies that
meet local organisational needs.
One major task was to define what a
communication strategy actually is. We
agreed the following definition - which
at 73 words clearly wont be found in a
dictionary - but we feel it sums up all
the elements and adequately describes
communication. As the framework is
designed to be a working tool, this def-
inition could provide a starting point
for further discussion and negotiation:
A communication strategy is a multi-
agency plan to develop a consistent
and coherent approach to meeting the
communication needs of people with
learning disabilities, within both their
daily environments and wider contexts. This
includes facilitating the use and understanding of
a range of different means, reasons and opportu-
nities for communication. A successful strategy
has to involve the key elements of management
support, training, and networks, and be under-
pinned by agreed and adequate resources.
This collaborative approach has been a great
success. It has demonstrated that we can work
Great government ideas can be quite a challenge to put
into practice - particularly when accompanied by a short
timescale. Undaunted, a special interest group worked
on a consensus framework for developing communication
strategies to benefit people with learning disabilities.
Della Money and colleagues take us through the
process and share the end result.
n March 2001 the Government launched the
first white paper for over 30 years for people
with learning disabilities. Valuing People: a
new strategy for learning disability for the
21st Century made some bold proposals,
within even bolder timescales, and outlined four
main principles of choice, independence, civil
rights and inclusion. It stated
that, there was not enough
effort to communicate with peo-
ple with learning disabilities in
accessible ways, and that, the
challenge was improving infor-
mation and communication with
people with learning disabili-
ties. It referred to both commu-
nication training and communi-
cation plans as well as individuals
who may require communication
techniques and the effective use
of new technology.
It quickly became obvious to us
that communication was central to these princi-
ples and underpinned the whole document. The
paper even stated: The Government expects
organisations working with learning disabled
people to develop communication policies... This
of course was great news for speech and lan-
guage therapists across England and Wales,
although there remained one small niggling
question - how do we do this?
l
you
ee speca nterest groups are
underdeveoped
know we need to up our evdence
base
are workng on Vaung Peope
Read ths
Great idea-
but how do
we do it?
the principles
and processes
were all
reached by
consensus - in
itself an
achievement.
across Trusts, with
limited evidence
bases, using the
wealth of expertise
that undoubtedly
exists within our
profession - and
reach a consensus. In
addition, it shows
how a special interest group can be proactive in
developing practical tools and resources for ther-
apists, enabling us to address the government
agenda within their relatively tight timescale.
Initial feedback has been very positive, and sever-
al teams within Trent Region are using the frame-
work. There has also been much interest from out-
side the region, and from other professions and
non-NHS organisations. So, just in case you are
feeling you never want to see another strategy,
take a look at this one - and let us know what you
think.
Della Money and Sue Thurman (Nottinghamshire),
Jane Parr (Leicestershire), Hilary Berry (Sheffield),
Kath Stewart (Lincolnshire), Liz James (S.
Derbyshire) and Judy Stephens (N. Derbyshire) are
members of the Trent Region special interest
group for speech and language therapists work-
ing with people with learning disabilities. They
formed the working group to pull together the
framework for developing communication strate-
gies. Address for correspondence: Della Money,
CLDT, Byron House, Newark Hospital, Boundary
Road, Newark, Nottinghamshire NG24 4UW, tel.:
01636 685927, e-mail: della.money@hq.cnhc-
tr.trent.nhs.uk.
Acknowledgements
We would like to thank Jane Jones for setting us off
and all the therapists who belong to Trent Region
SIG and have contributed to the framework.
Reference
Jones, J. (2000) The total communication
approach: towards meeting the communication
needs of people with learning disabilities. Tizard
Learning Disability Review 5 (1) 20-26.
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2002 +;
n my experence
Do l gve sucent tme to
thnkng through my
strategy beore tryng to
put an dea nto practce'
Do l get nvoved n the
work o speca nterest
groups'
Do l see the bgger pcture
and how l can pay a part'
Reectons
1. Management
Principles
1. Commissioners and Managers of key agencies
(such as health, social services, further education
and the voluntary and independent sectors) are
involved in communication strategies. This
includes partnership boards and planning groups
2. Service Users and carers are the major
stakeholders in developing communication
strategies
3. Communication strategies are jointly owned
4. Managers recognise the integral role that
communication plays in relation to key
legislation and guidance (such as Valuing People/
Disability Discrimination Act)
5. Speech and Language Therapy services are a key
part of communication strategies. Their role and
service designs are fully negotiated
6. There is an agreed protocol for responsibilities
and accountability for communication strategies
7. Communication strategies are documented with
agreed definitions of terminology
2. Training
Principles
1. Training promotes awareness of communication,
develops communication skills and/or supports
implementation of new initiatives
2. Training is based on identified needs of
individuals, environments or communities
3. Differing learning styles and needs of
individuals, and the cultures of organisations, are
taken into account when designing and
delivering training
4. There is a clear statement and agreement for the
purpose of all training. Training is planned with
defined and agreed outcomes, negotiated with
relevant people
5. Ongoing support and supervision is necessary to
achieve the outcome. Outcomes are measured
and evaluated as part of a performance
management cycle
6. There are recognised levels of competence for
trainers
7. Training is delivered within an agreed
inter-agency training framework (eg. LDAF-
Learning Disabilities Awards Framework)
3. Networks & Resources
Principles
1. Formalised Networks are established across
services, agencies and appropriate localities in
order to support all the elements of the
communication strategy
2. Each Network has a defined purpose, scope and
support mechanism. This includes clear channels
of communication and information exchange
3. Communication tools used to support the
strategy are evidence based and agreed
4. Multi-modal resources are widely and easily
accessible, using a co-ordinated process of
selection, training and dissemination
5. Management, technical and financial support is
essential for the development of accessible
resources
Framework for developing communication strategies
Processes may include:
Identifying other peoples agendas
Identifying your local management structures
(across all key agencies)
Developing the role of the lead Speech and
Language Therapist at a strategic level
Being consistent and repetitive in the messages
given to key managers and commissioners about
communication, in order to create a shared vision
Liasing with Partnership Boards/Planning Groups
Presentations to and feedback from key people
Involvement in relevant working groups or other
appropriate development activities
Agreement to time, personnel and financial
commitments from stakeholders at a strategic
level
Agreement to a protocol
Multi agency steering group
Linking with JIP (Joint Investment Plan), HIMP
(Health Improvement Plan) and other business
planning processes
Mechanism for meaningful service user
involvement
Assessing readiness for Partnership
Processes may include:
Identifying the stakeholders who need to be
involved
Identifying the named people within each of the
stakeholder groups
Developing ways of sharing information -
newsletters, meetings, publications, IT
Developing selection and design criteria for signs
and symbols and other communication tools
Identifying business planning processes
Identifying and defining networks (user groups,
statutory agencies, advocacy) and purpose
(communication, information, professional)
Developing guidelines on accessible information
Auditing current availability of IT support and
resources and identifying shortfalls
Identifying skill mix required to support strategy
Agreeing a protocol for sharing resources and
points of access
Developing an evidence base
Processes may include:
Agreeing and evaluating a training strategy with
all agencies, including service users
Providing different models of training to meet
different needs for individuals, environments and
communities
Identification of trainers and their training needs
Analysis of training needs of participants and
their environments
Developing a training plan, including resources
required
Delivering, evaluating and feeding back to
stakeholders
Establishing supervisors
Framework for ongoing support and supervision
Agreeing levels of competence of trainers
Cascading of training
One major task
was to define
what a
communication
strategy
actually is
proessona roe
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2002 +8
ell me what you do and Ill tell you
who you are.
Gaarders statement (1995, p.329)
sums up the importance of work and
how our individual occupations are closely related
to how we define ourselves as people. But if work
plays such an important part in our lives, what
happens when external factors interrupt our life
plans?
As fourth year students at City University we
were required to design and carry out a research
project. Although this was daunting, we realised
the importance of choosing a field that not only
interested us but that answered questions we as
students had asked. We had the opportunity to
work at the City Dysphasic Group where we met a
wide range of individuals with aphasia. It became
apparent that they had a variety of unresolved
issues around their employment status. This left us
with the questions:- What factors influence the
ability of people with aphasia post-stroke to
return to work? And how can we as speech and
language therapists enable them to do so?
We aimed to establish factors that influence the
ability to return to work and identify barriers that
prevent people with aphasia from doing so. We
wanted to compare and contrast the differing
barriers that may allow some individuals to return
to work successfully while preventing others, and
establish recommendations made by people with
aphasia on any aspect of returning to work.
Interviewed in-depth
The project involved nine respondents interviewed
in-depth using a method recommended by Parr et
al (1997). We used the social and community poli-
cy research framework method as described in
Ritchie & Spencer (1994) to analyse the data. All
respondents were of working age and in full-time
employment at the time of their stroke.
They had come from a wide range of working
backgrounds, and included a lawyer, sous-chef,
T
The 1995 Disability Discrimination Act was meant to herald
a new dawn for people with disabilities in the workplace,
including those with aphasia. In reality the interaction of
many factors influences whether or not an individual
returns to work. Kathleen Taylor and Claire Besser discover
that the profession needs to show a bit more imagination
to be truly working with aphasia.
Unemployable
or unemployed?
you
are nterested n
quatatve research
have cents o workng
age
want to enabe (and not
dsabe)
Read ths

Figure 1 Pie chart comparing changes in working patterns


Kathleen Taylor Claire Besser
benefits can mean individuals are unable to pur-
sue their interests. This in turn can lead to social
withdrawal and subsequent depression, which
reduces an individuals likelihood of returning to
work. The difficulty the person with aphasia had
in dealing with the complexity of information pre-
sented to them on available benefits had an
impact on returning to work.
E. Informational factors concern
peoples knowledge and under-
standing of aphasia and its associ-
ated difficulties. As found by Parr
et al (1997), many respondents
had difficulties understanding the
true nature of their aphasia. If
the person with aphasia is unsure
of their own difficulties, this will
affect what assistance and strate-
gies can be used within the work-
place. The respondents also felt
their employers had little or no understanding of
their aphasia. On his return to work, one respon-
dent was given a computer with voice recognition
software to reduce his difficulty with writing due
to hemiplegia. However, he has an expressive dys-
phasia characterised by perseveration and word
finding difficulties, which rendered the voice
recognition software useless. Respondents who
had a better understanding of their aphasia were
more likely to be successful in returning to
employment. One who found new employment
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2002 +,
proessona roe
teacher, freelance camera
operator and a surveyor.
Following their stroke, all
respondents had to adapt their
work (see figure 1). Some were
unable to return to work,
whilst others returned in a dif-
ferent capacity, often part-
time and on a consultancy
basis. Those respondents who
spoke more positively about their post-stroke
employment were those who took the opportuni-
ty to retrain in a completely different field of
employment (for example, from
public relations manager to
counsellor.)
Figure 2 shows the main and
diverse enabling and disabling
themes that influence whether
an individual may or may not
return to work. Each theme is
accompanied by an illustrative
quote from the respondents.
A. Attitudinal themes can be
both external and internal to the
individual. The data showed
that attitudes from medical pro-
fessionals, colleagues and
employers and those internal to
the person with aphasia affected
whether they returned to work
or not. This is supported in Parr
et al (1997). These attitudes
could also be classified as positive or negative
influences on a return to work.
B. Communication factors were not a major
theme within the findings. Rather, it is the com-
munication impairment interacting with other
factors such as the environment, which has the
biggest impact on enabling people to return to
work. Only one respondent cited their communi-
cation impairment as the overriding barrier pre-
venting them going back. Garcia et al (2000) sug-
gest it is not the communication dis-
order itself but the associated diffi-
culties such as fatigue and physical
impairment which cause more prob-
lems with returning to employment.
C. Emotional factors were raised on
numerous occasions reflecting Parr
et als reference to the coping
process as complex and long-
drawn-out (1997, p.111). The
respondents supported their advice
of taking time to deal with the
impact of aphasia, and recommend-
ed counselling.
Motivation is cited frequently in the
findings and the literature. Many
respondents reported they were
keen to return to employment but,
as one pointed out, employers do
not give you a job just because you
are motivated. It appears that people with apha-
sia must be motivated to overcome the barriers
within the workplace; however, it has little influ-
ence on their employment status.
D. Financial factors mainly concerned issues
around benefits. Parr et al (1997) report that the
drop in income and increased dependence on
Those respondents
who spoke more
positively about
their post-stroke
employment were
those who took
the opportunity to
retrain in a
completely
different field of
employment

Figure 2 Themes
THEME DEFINITION INFLUENCING FACTOR BARRIER
A. Attitudinal
B. Communication
C. Emotional
D. Financial
E. Informational
F. Other
G. Physical
Personal opinions and views from
colleagues, employers, medical
professionals and the individual
respondents.
Management of the individuals
aphasia within the workplace.
These are internal to the individual.
They include comments on confi-
dence, encouragement, motivation
and self-esteem.
Changes in financial status that the
respondents were confronted with as
a result of their aphasia.
Issues relating to gaining information
about aphasia, benefits and other
options open to all parties.
This includes anything that did not fit
comfortably under the headings
above, such as previous experiences,
familial support and job role
modification.
Any difficulties resulting from
hemiplegia and loss of cognitive skills
such as fatigue and shortened
attention span.
You know I wish I hadnt had the stroke,
but the reality is that I did....10 years on, I
think I have to say that, I think Ive gained
more than I have lost out of the whole
deal....Ive gained quite a lot, coz I felt like
Id lost so much.
They tried. Everything they gave me. I
said I wanted a computer.
I thought I want to look forward and at
the present.
I automatically got invalidity benefits.
Counselling...gives you the opportunity
to explore options you might have.
My wife is really good and my kids are
fantastic.
One respondent received a left-handed
keyboard to compensate for their
hemiplegia.
I thought about being a chef but
the doctor said to me, you cant
be a chef.
Usually my speech let me down.
In a way Ive got no confidence
in me.
If I could work one or two days
out of the year, why not? But the
benefits would make a
difference.
I look forward to getting a job,
but what job should I do? I dont
have a clue.
I didnt want to re-train and go to
a lesser position.
Some days Im so tired I cant get
up.
employers
do not give
you a job
just
because
you are
motivated
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2002 o
proessona roe
following her stroke provided prospective employers
with a summary of her aphasia and strategies that can
be implemented to overcome her difficulties (figure 3).
F. Other factors cited were support from others
and job role modification. Many said their family
and friends were supportive; however, this had no
bearing on their return to work. The respondents
experiences support the finding of Garcia et al
(2000) that employers frequently offer support
through the provision of specialist equipment.
One reported that by having their job modified
they were made to feel less able and incapable of
doing their job as well as they had prior to their
stroke. As Parr et al (1997) state, aphasia does not
affect intelligence. The respondents recommend-
ed that, rather than modify the job role, it may be
better to reduce the number of hours worked.
G. Physical factors reported include epilepsy,
fatigue, hemiplegia and memory. The respondents
cited these as direct barriers to returning to work
and also as barriers that interacted with other fac-
tors such as information.
Through using a qualitative approach to finding out
about the implications of returning to work with
acquired aphasia we have gained a broad perspective
of some of the factors and barriers people with apha-
sia encounter when considering return to employ-
ment. As a profession, however, we have a lot to do.
Speech and language therapists have a strong
influence on individual perceptions of recovery.
The opinion of the medical team can have a last-
ing effect on how the individual with aphasia
views their skills and chance of returning to work.
It would be useful to investigate further the
impact of our professional opinion and the therapy
we provide on whether an individual with aphasia
returns to work or not. It may also be beneficial to
raise the profile of the true nature of aphasia with
other professionals such as the medical team to
change their attitudes, with the aim of making the
information the individual with aphasia is given
more of an enabling than disabling factor.
Full awareness
The more aware the individual with aphasia is of
their strengths and weaknesses the more likely
they are to return to work successfully. If we want
to get better at enabling people with aphasia to
return to employment, we need to focus on
developing full awareness of the true nature and
characteristics of their aphasia.
Occupational therapists play an important role
in working with and encouraging individuals with
an acquired disability in returning to work. It
would be useful to investigate their therapeutic
ethos and how they encourage and support suc-
cessful reintegration into the workplace.
In Open Hole, the Stony Wall (1998), the impact
of the 1995 Disability Discrimination Act on peo-
ple with aphasia is discussed. The authors raise
concerns regarding possible loopholes and the
lack of provision there is for adults with aphasia in
the Act. A longitudinal study would enable us to
measure over time the changes in practice and
attitudes to people with aphasia brought about
by the legislation.
It has become apparent through this study that
many factors are significant, and no one single fac-
tor stands alone. More importantly, there are a
number of interacting factors occurring. As speech
and language therapists it is our brief to enable
individuals with communication impairments to
maximise on their choices and opportunities in all
aspects of their life including work, personal and
social capacities. Traditionally speech and language
therapy has been limited by time, resources and
research; this means that skills learnt within thera-
py sessions are not only difficult to generalise but
can also be irrelevant to the working environment.
It is essential that we consider our role with regard
to current legislation, research, clinical competencies
and guidelines so we can help those individuals
wishing to return to employment.
Kathleen Taylor is now a speech and language
therapist at Whipps Cross University NHS Hospital
and Claire Besser is a speech and language thera-
pist for Newham PCT and Sure Start. The City
Dysphasic Group has been superseded by Connect.
For further information about Connect and their
programme of education and training events,
phone 020 7367 0846 or see www.ukconnect.org.
References
Action for Dysphasic Adults Working Party (1998)
Open Hole The Stony Wall. Unpublished report.
Parr, S., Byng, S. & Gilpin, S. (1997) Talking About
Aphasia: Living with loss of language after stroke.
Open University Press; Buckingham.
Gaarder, J. (1995) Sophies World. Phoenix
House; London.
Garcia, L.J., Barrette, J. & Laroche, C. (2000)
Perceptions of the Obstacles to Work Reintegration
for Persons with Aphasia. Aphasiology 14 (3); 269-290.
Ritchie, J. & Spencer, L. (1994) Qualitative Data
Analysis for Applied Policy Research. In Bryman,
A. & Burgess, R. (Eds.) Analysing Qualitative Data.
Routledge; London.
5 steps to better practice: working with aphasia
1. help clients understand their aphasia better
2. work with clients to list possible solutions for prospective employers
3. make therapy relevant to a work environment
4. discuss the possible advantages of retraining
5. share skills and planning with occupational therapists.
Figure 3 Return to work solutions
Emma (not her real name) was twenty-one
years old when she suffered a stroke. Prior
to this, she worked for a company in an
administrative capacity. Her stroke left her
with a residual right-sided hemi-paresis and
an expressive dysphasia. This was
characterised by word finding and
syntactical difficulties and acquired dyslexia,
all of which worsen under increased stress:
I cant handle pressure, it goes terrible.
Following several years of seeking work
unsuccessfully, Emma found another job.
Emma suggests that being able to describe
your residual difficulties and giving practical
solutions will show an employer how these
difficulties can be overcome. Emma
recognised and reflected the need for
employers to be sympathetic and aware of
her needs with solutions such as:
working part-time to overcome the high
level of fatigue most people with aphasia
experience.
using checklists as prompts to remind the
individual what they are meant to ask, do
or say when performing tasks.
having a voice activated computer with
grammar and spellcheckers, to overcome
writing difficulties.
asking your manager to check
letters/reports before they are sent out.
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2002 +
nequaty seres (+)
nequality is considered to be one of the uni-
versal features of all human societies. However, it
is not equally distributed. Some theorists would
argue that inequality is an integral, and even
desirable, aspect of society whereas others would
suggest that it is produced by the socio-economic
organisation of society which unfairly advantages
one group over another.
Sociologists commonly use the term social strat-
ification to describe the stable structures of
inequality between groups that persist across dif-
ferent generations within any given society. The
term social class is used to describe the type of
stratification that exists
within a modern indus-
trialised society, such as
Britain. Although sociol-
ogists disagree on how,
exactly, social class
should be measured and
defined, in general
terms social class refers
both to material circum-
stances - a persons
income and wealth - as
well as social status - a
persons social wealth
and prestige.
Since 1991, social class
has been measured using the National Statistics
Socio-economic Classification (NS-SEC). In the
most commonly used version, there are eight
classes, the first of which is sub-divided (see table
1). The NS-SEC considers an individuals occupa-
tion, as well as their employment status.
In 1946 the NHS was established to eradicate
inequalities in health in Britain. However, the exis-
tence of class inequalities soon became clear.
l
you
want to reach out beyond the cnc
beeve the NHS shoud eradcate
heath nequates
see a nk between communcaton
and estye
We all hope for a long,
healthy and fulfilling
life with the
opportunity to develop
our particular talents.
Yet our chances are
unequal, and vary
depending on our
social class. In the first
of four sociological
perspectives on
inequality, Sarah Earle
argues that, while we
do need to develop an
individualised, client-
centred approach, we
must also be aware of
how wider socio-
economic and cultural
factors influence our
practice.
Some of the most damning evidence was pub-
lished in 1980 in The Black Report (Townsend et
al, 1982), which showed that individuals in social
classes V and VI (equivalent to classes 5, 6 and 7 in
the NS-SEC) were more likely to have accidents,
become ill, and die prematurely compared with
those in classes I and II. The Acheson Report
(Acheson, 1998) confirmed these findings and
provided further evidence of a widening of class
inequalities in health.
The White Paper, Saving Lives: Our Healthier
Nation (DoH, 1999a), established targets for the
four priority areas of coronary heart disease and
stroke, cancer,
injury prevention
and suicide,
recognising the
c o n s i d e r a b l e
extent of inequal-
ity throughout
Britain. The risk
of heart disease
is, for example,
more than dou-
ble for individuals
in the lowest
employment sec-
tors (even after
controlling for
risk factors such as obesity and smoking) and rates
of depression are twice as high for those who are
unemployed, compared to those who are in paid
employment (DoH, 1999a).
Since the educational explosion of the 1950s
and 60s, education has been regarded as one of
the ways in which societies can become fairer and
more meritocratic. However, a meritocracy
describes a society in which social rewards are
a meritocracy
describes a society in
which social rewards
are allocated
according to talent
but evidence suggests
that social rewards
vary considerably
according to social
class.

Class of 2002:
an
unequal
future
Table 1 The National Statistics Socio-economic
Classification
1. Higher managerial & professional occupations
1.1 Large employers & higher managerial
occupations
1.2 Higher professional occupations
2. Lower managerial & professional occupations
3. Intermediate occupations
4. Small employers & own account workers
5. Lower supervisory & technical occupations
6. Semi routine occupations
7. Routine occupations
8. Never worked & long-term unemployed
Read ths
nequaty seres (+)
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2002
allocated according to talent but evidence suggests that social rewards vary consid-
erably according to social class.
A good predictor
Recently published government statistics (DfES, 2001) suggest that social class is a
good predictor of educational and occupational success. For example, statistics show
that academic attainment - at all levels - is strongly related to social class and that
young people whose parents are classified at Levels 1 and 2 are most likely to succeed
(see table 2). Statistics also show that the number of 16 year olds not in education,
training or employment varies considerably according to social class. For example, in
2000 only 2 per cent of 16 year olds with parents in NS-SEC 1 were not in education,
training or employment, compared with 11 per cent of those in NS-SEC 7.
There have been many competing explanations put forward to explain the persis-
tence of class inequalities in health and education and, although explanations based
on natural selection or innate intelligence have been popular in the past, materialist
and cultural explanations are currently two of the most influential.
Materialist and structural explanations focus on the material causes of inequality, such as
living and working conditions, which are often seen as arising from the social structure -
the way in which society is organised. The poorest in society are seen to lack the material
resources required to sustain health and achieve educational and occupational success.
For example, within the context of health it is widely
accepted that individuals with lower incomes tend to
pay more for their food because they cannot physically
access larger (usually out of town) retail outlets which
sell food more cheaply than local shops (DoH, 1999b).
The inverse care law also disadvantages those in lower
socio-economic groups as statistics suggest that those
living in the most deprived areas have the worst access
to good quality health care services (see table 3).
Within the context of education, children from poor-
er socio-economic backgrounds are seen to lack the
material resources they need to succeed. They are, for
example, more likely to live in overcrowded condi-
tions, more likely to have a poor diet and will have
higher rates of illness, accident and disease; all of
which impact upon childrens educational careers.
Children from poorer backgrounds are also more like-
ly to have paid employment and more domestic
responsibilities than children from more affluent backgrounds and are, therefore,
less likely to stay on at school (DoH, 1999b).
Cultural theories explain class inequalities in health and education by referring to the
social processes that create cultural differences in attitudes and behaviour. With respect
to health, the emphasis is often on lifestyle and risky health behaviours. Indeed, some
sociologists believe that lifestyle is now the most important predictor of inequalities in
health (see Crompton, 1993). Individuals from lower social classes are seen to engage
in health behaviours that are not conducive to health. For example, they are more like-
ly to smoke, and consume a diet that is high in fats and refined sugars (DoH, 1999a).
With respect to education, children from poorer backgrounds are seen to lack the
appropriate environment that is needed to foster educational success. For example,
children from less affluent backgrounds are the least likely to have access to con-
structive forms of play, and will have poorer access to books, newspapers and the
internet (see table 4).
Important role
Defining and measuring social class is a complex process and some of the key issues and
debates have been highlighted here. However, it is clear that there is a strong rela-
tionship between social class and inequality; this has been recognised by Government,
and strategies to combat inequalities in health and education have been implemented.
Speech and language therapists have an important role to play in tackling and reducing
inequalities in health and education and they are increasingly being expected to either
coordinate or participate in multi-professional initiatives such as Sure Start (see
www.surestart.gov.uk).
Two of the most common problems for therapists (and other health professionals)
are those of attendance and compliance, which often strongly correlate to class divi-
Speech and
language
therapists
have an
important role
to play in
tackling and
reducing
inequalities in
health and
education

Table 2 Academic attainment in Year 11 by Parents


Occupation in 2000
Higher professional 74 60 2
Lower professional 61 46 2
Intermediate 51 33 3
Lower Supervisory 36 22 4
Routine 29 17 7
Adapted from: (DfES, 2001).
5+
GCSE
grades
A*-C
8+
GCSE
grades
A*-C
None
reported
Table 3 Cancer survival rates in affluent and deprived areas
Likelihood of surviving for 5 years (%)
Affluent area Deprived area
Mouth cancer 55 44
Breast cancer 79 72
Rectal cancer 41 35
Skin cancer 81 75
Source: ONS (1999).
Table 5 Tackling inequality and social exclusion - some examples of good
practice
The HANEN programme
family-focused programmes for children and parents, for example
It Takes Two to Talk, an intervention programme for parents and
the You Make the Difference Parent-Child Interaction Programme.
These programmes are especially suitable for children and families
who are socially, geographically and economically disadvantaged
(see www.hanen.org).
Self-help and support groups such as those provided by Headway
(www.headway.org.uk);
Speakability (www.speakability.org.uk);
and Sense (www.sense.org.uk).
Sure Start programme in Keighley, Yorkshire
a one-stop shop, including speech and language therapy, is being
established to provide local support to a deprived community.
Sure Start programme at Leigh Park, Havant
toy libraries, reading schemes, play schemes and an outreach
speech and language therapy service are planned.
Table 4 Access to the internet by household
Social class % of household with access
Professional 78
Intermediate 65
Skilled non-manual 52
Skilled manual 37
Partly skilled 33
Unskilled 27
Source: ONS (2001).
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2002
nequaty seres (+)
Does our caseoad management
stye perpetuate or reduce heath
nequaty'
Do we actate access to
servces and resources'
Do we recognse our roe n
tackng soca excuson'
Reectons
sions. In response to this, some areas are address-
ing waiting list problems by refusing to accept
clients after one missed appointment, regardless
that this serves to perpetuate inequality and social
exclusion. Under such circumstances, other meth-
ods of service provision may be more effective, for
example, drop-in sessions, outreach services or
comprehensive home programmes. Some of the
ways in which therapists, and others, are working
to tackle inequality can be found in table 5.
There is no easy solution to reducing class
inequalities in health and education and,
although it is important for therapists to develop
an individualised and client-centred approach to
care, it is also important for the therapist to be
aware of the wider socio-economic and cultural
factors that affect practice.
Dr Sarah Earle is Lecturer in Health Studies at University
College Northampton. Address for Correspondence:
Centre for Healthcare Education, Boughton Green
Road, Northampton, NN2 7AL, e-mail:
sarah.earle@northampton.ac.uk, tel. 01604 735 500.
References
Acheson, D. (1998) Independent Inquiry into
Inequalities in Health: A Report. London:
Stationery Office.
Crompton, R. (1993) Class and Stratification: An
Introduction to Current Debates. Cambridge:
Polity Press.
Department for Education and Skills (2001) Youth
Cohort Study: The Activities and Experiences of 16
year olds: England and Wales 2000.
http: / / www. dfes. gov. uk/ stati sti cs/ DB/ SFR/
[Accessed 26 April 02].
Department of Health (1999a) Saving Lives: Our
Healthier Nation. [Cmnd 4386]. London: The
Stationery Office.
Department of Health (1999b) Reducing Health
Inequalities: An Action Report. London: The
Stationery Office.
Office for National Statistics (1999) Cancer
Survival Trends in England & Wales 1971-1995.
Deprivation and NHS Region. London: The
Stationery Office.
Office for National Statistics (2001) National Statistics
Omnibus Survey. London: The Stationery Office.
Townsend, P., Davidson, N. & Whitehead, M.
(1988) Inequalities in Health. The Black
Report/The Health Divide. London: Penguin.
Back to pen and
paper
Do you need to record statistical information
as you go? Developed for teachers, the
AsPen may have applications for speech
and language therapists. A traditional
ballpoint pen, it also incorporates a bar-
code reader in the cap storing information
for later transfer onto a computer.
www.aspenonline.co.uk
Bilingual resources
Urdu and Punjabi versions of the Afasic
Glossary sheets and the Afasic leaflet Lost
for Words have been developed as part of
a Scottish Executive funded project to
support bilingual children with speech
and language impairments. The new year
will see the launch of Punjabi and Urdu
Fireman Sam and Dennis the Menace
videos as a resource for speech and
language therapists and teachers working
with parents to support first language
development.
Details: Afasicscot@aol.com, tel. 01382
666560.
Speech not babel
Text-to-speech software continues to
improve in quality. The new Windows
based Babel-Infovox Desktop offers full
control of voice parameters such as
volume, pitch and intonation, has a vari-
able reading speed, and allows users to
change the pronunciation of a word. Text
can be read sentence by sentence or
spelled out character by character.
www.infovox.se
Be alert
A system to protect people who have hidden
medical conditions and allergies in the event of
an emergency is reaching out to a wider audience.
MedicAlerts body-worn bracelets or necklets,
now available in different styles, are supported
by a 24 hour emergency telephone service.
Freephone 0800 581 420, www.medicalert.org.uk.
Deaf awareness
Bright new posters with BSL
greetings signs and finger-
spelling provide a focal
point for BSL and Deaf
Awareness. In addition,
four wipe-clean mats cover
greetings, questions, family
and feelings respectively.
A2 poster, 9.99 inc p+p
Set of A4 Poster/Mats
with separate guidance
notes 8.99 inc p+p
From The Forest
Bookshop
Warehouse, fax
01594 833446,
www.ForestBooks.com
Deaf Awareness and Sign Language Resources,
see www.deafsign.com.
The Grid
Sensory software has released The Grid, a pro-
gram that can be used as a predictive on-screen
keyboard or as a communication aid with syn-
thetic and pre-recorded speech, symbols and
pictures and text.
Autumn 2002 catalogue, tel. 01684 578868,
www.sensorysoftware.com.
Small sips
People with dysphagia who need to take small
swallows to reduce their aspiration risk may
benefit from a new type of cup. The PROVALE
cup offers liquid, including some thickened drinks,
by the teaspoon (5cc), has ample nose clearance to
minimise head tilt and a broad base to reduce
tipping and spilling.
www.ReliantMedicalProducts.com
..resources...resources...
Source database
A resource centre to meet the information
needs of those working in health, disability and
development worldwide has opened in
London. The majority of materials on the
on-line Source database are relevant to
developing countries and not recorded elsewhere.
Tel. 020 7242 9789 (ext. 8698),
www.asksource.info.
Therapy for deaf
children
Three different versions of the parent
booklet Speech and language therapy for
deaf children are available to cover
Scotland, Northern Ireland and England
and Wales.
Copies
from the
NDCS
Freephone
helpline,
tel/text
0808 800
8880,
open
Mon-Fri,
10am-5pm.
1. Be an objective sceptic - give things a try.
2. Attend a structured and comprehensive training programme.
3. Prime the system by activating repressed or undeveloped listening abilities.
4. Use the self-voice as a platform for improving other learning skills.
5. Enhance outcomes by working closely with other professionals.
6. Do not underestimate the power of therapeutic listening!
Practical points: therapeutic listening
l use
therapeutc
stenng
vhat do we do when cents are
makng sow or no progress'
vhen they have a varety o
dcutes whch nterere wth ther
earnng, communcaton and soca
sks' vhen t can be hard to put
your nger on where thngs are
gong wrong'
There s unortunatey no magc
wand n speech and anguage
therapy, but s our understandabe
suspcon o therapeutc stenng
programmes - whch do thngs very
derenty - makng us dea to ther
potenta benets'
So sten up, and hear why our three
contrbutors woudnt be wthout
ther Ds and headphones.
Dilys Treharne is a speech and
language therapist at the
Department of Human
Communication, University of
Sheffield. She is a trainer for
The Listening Program,
www.advancedbrain.com.
Dr Colin Lane, the founder of
A.R.R.O.W., is based at The
A.R.R.O.W. Centre, Bridgwater
College Campus, College Way,
Bridgwater, Somerset TA6 4PZ,
e-mail
arrowcentre@bridgwater.ac.uk,
tel / fax 01278 441249.
Karen OConnor is a speech and
language therapist who runs
her own private practice in
Galway, Ireland. Karen also
co-trains with Sheila Frick
internationally in Therapeutic
Listening, www.vitallinks.net.
you
beeve stenng has a
major mpact on anguage
and earnng
ee some cents are
underachevng
want evdence or therapy
approaches
Read ths
how l...
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2002 (
the programme). Nature sounds are added and the whole is presented
dichotically. This has the effect of the sound appearing to move around
the room and to be near or distant.
I purchased the CDs but ask parents to provide the CD player and high
quality headphones if possible. The childrens pleased expressions at
being expected to sit down and listen to CDs twice a day fade a little
when told it is based on classical music. Some have grown to like it
while others still only like the duck bits.
I discuss the listening diary by telephone and the parents collect and
return CDs to the clinic each week, so several children can work with a
single set. I am also able to lend a full or half set for eight or four weeks
to children who live further away.
Beyond expectations
In the evaluation study the children were reassessed at the end of the
programme and then left for eight weeks before being reassessed once
more. The results were beyond my expectations: all showed an
improvement greater than one would expect from maturation.
The pattern of change was interesting. Parents noticed an improve-
ment in general attention and attention to sounds within three weeks.
All reported a greater responsiveness to conversation. One child who
did not initiate conversation even at home began offering opinions and
became quite a chatterbox; another noticed the church bells for the first
time in his eight years. Awareness of sound and attention span had not
been assessed in the pre-trial period so I was unable to objectively mea-
sure the amount of improvement in these areas. In the sixth or seventh
week of the programme many children exhibited a deterioration in
behaviour, becoming disagreeable or aggressive. Fortunately this lasted
only a few days to a week, and settled as they moved on to the next CD.
This occurred at a point where the gating (acoustic modification) is
markedly increased and I believe this, together with the childs increased
sensitivity to sounds in the environment, was the cause and a sign that
the programme was being effective.
The greatest change was in selective attention (auditory figure-
ground). All made an appreciable improvement and the overall change
for the group was significant. Those with the severest difficulties made
the greatest improvement. In some this change was dramatic moving
from below the first centile to the 7th, 9th and in one case 16th centile
in just eight weeks. Remember, these childrens scores had remained sta-
tic for the previous eight weeks.
Many also showed change in auditory memory but perhaps this was
due to their improved attention levels. The measured changes were
small immediately after the programme and in many cases the greatest
change occurred within two months after completion.
These improvements were good in themselves but more importantly
they were maintained and opened the door for other activities such as
Earobics to become effective. Progress did not stop after two months,
and even those without direct intervention continued to make gains.
The length of this extended progress period varied. When progress
stopped or a slight regression was noticed the child took another course
of The Listening Program. Progress was also evident in fields not direct-
ly targeted. Joe, who had been very slow to make any progress in
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2002
how l
work with children and young people
with auditory processing difficulties.
Usually between 6 and 17 years of age
when referred, they are underachieving
or complain of not being able to hear prop-
erly in school but on pure tone testing have
no significant hearing loss. Some have had a
dyslexia assessment but only show a borderline pattern. Others have
had a significant amount of speech and language therapy focusing pri-
marily on phonology and comprehension with some expressive work,
and have made limited progress. Many have a history of poor attention
and in some cases have had a diagnosis of attention deficit disorder or
mild autism. Referrals come from audiology departments, speech and
language therapists, teachers and parents.
After an in-depth assessment a pattern of difficulty emerges with
selective attention or auditory figure-ground tasks (hearing speech in
background noise which most people are not aware of, such as the hiss
of a gas fire or a clock ticking), maintaining attention, auditory sequen-
tial memory, sequencing, dichotic listening tasks, temporal pattern pro-
cessing, pitch perception, processing language at normal speed, motor
coordination, and motor coordination with speaking. Not all the chil-
dren have all the problems. Some have a clear auditory processing dis-
order and some will be borderline or at the lower end of the normal
range. However, if they are having problems functioning in the class-
room they are offered a programme of therapy.
Initially I used Earobics to improve listening skills, together with tasks
tailored to the individual to teach tolerance of background noise, audi-
tory memory, and phonological awareness. I used the relative visual
strength to support comprehension of read and spoken sequences
through visualising and verbalising. Brain Gym style activities (see
Dennison & Dennison, 1989) were used to improve coordination and
concentration. Progress was slow and used a great deal of clinical time.
Worth a try
I was then introduced to The Listening Program (Advanced Brain, 1999),
a type of sound therapy programme based on the work of Tomatis and
Samonas (Leeds, 2001). It was different in that it was home-based and
required the relatively short two fifteen minute periods each day for
five days a week over eight weeks. I was objectively sceptical, but any-
thing was worth a try, and it came with good reports.
I evaluated it with a limited number of children, selecting the prime
problem areas for assessment (Treharne, 2001). In this first cohort were
10 children between the ages of 8 and 16 years with non-verbal intelli-
gence scores ranging from the 3rd to the 95th centile. They all had
problems with auditory figure-ground and most with auditory sequen-
tial memory and attention. Temporal pattern perception, phonological
awareness, reading and spelling were also common problems but at a
higher stage of processing. Baseline assessments were repeated on the
prime areas of auditory figure-ground using the Goldman Fristoe
Woodcock (1976) Auditory Skills Selective Attention test, and auditory
sequential memory using Gardners (1996) Test of Auditory Perceptual
Skills (TAPS-R). Temporal pattern perception was tested using my own
TraCoL (in preparation). Children who had made no progress over the
previous eight weeks were selected.
The Listening Program is contained on eight CDs, one for each week.
Each contains 12 tracks, three to be used at a 15-minute listening peri-
od of which there are two each day. The music is classical, specially
recorded and then acoustically treated by filtering out certain frequen-
cies (this varies from track to track and increases as you move through
l

lrom sceptc to convert,


the objectve way
Resuts rom her research were so
encouragng that Dys Treharne now uses
The lstenng Program as the rst step or
young peope wth audtory processng
dcutes , prmng the system or more
specc therapy programmes.
ing skills. Students aiming to improve their
reading/spelling skills are averaging eight months
improvement in reading and seven months improve-
ment in spelling after an eight hour A.R.R.O.W. pro-
gramme. Whilst the improvement of listening, speech
and cognitive skills is a central feature of the system,
many tutors also report an improvement in a learners self-esteem after under-
taking it.
Initially I developed A.R.R.O.W. as a listen read copy compare model for hear-
ing impaired children to improve their speech and listening skills. They were
expected to improve by comparing the original teacher recording with their
own recorded version played back to them on specially developed equipment.
Conventional modelling techniques were used for speech or language
improvements before self-voice replay. Tutor and child listened to the master
track recording, the child repeated the phrase and had both voices played back
as confirmation of progress. It quickly became apparent that severely hearing
impaired students could operate the recorders themselves. Students of all ages
and abilities maintain attention for up to 30 minutes when working alone on
A.R.R.O.W. During practice sessions I noticed many of the original group of stu-
dents preferred to turn down the tutor voice and only listen to their own
replayed voices. I observed them smiling when listening to the self-voice and,
in some cases, silently mouthing the replayed speech material. These effects
have since been noted elsewhere by other tutors. My later Ph.D. research into
the self-voice showed that children preferred their own voices far more than
any other voice delivering either a sentence, list of words or single vowel.
An early effect of A.R.R.O.W. was a marked improvement in listening skills of
the hearing impaired students at my unit. Parents and mainstream teachers
commented upon the improvements, including Shirley Manley, the parent of
a nine-year-old severely hearing impaired student: ...his speech has improved
enormously but also his listening. Before I would call him from upstairs and he
couldnt hear me, now I call him from upstairs and he responds.
Marked and sustained
I undertook higher degree research with children in special schools for
those with moderate or severe learning difficulty and in hearing impaired
units in Somerset. The research showed that 15 minutes daily A.R.R.O.W.
speech and language and at eight years was still almost unintelligible
with really low self-esteem, became much more relaxed and confident
and, two thirds of the way through the second course, his phonological
system had improved dramatically without further intervention.
We have also tried The Listening Program with students who were
finding lectures difficult to follow and some have noticed a change. The
results are being analysed.
Originally designed as a home programme, it can also be used in
school. Four children have completed it at two schools with a special
needs classroom assistant. The children listen in a group while the assis-
tant does paperwork. They discuss what they have heard and the lis-
tening record is written up. The schools are amazed at the results and
consider it time well spent.
The effect of The Listening Program has prompted me to explore other
sound therapy techniques - such as the sound health CDs, also from
Advanced Brain - to support and maintain attention and concentration
levels after the programme at home and in schools.
The Listening Program is now my first step in auditory training as it
seems to activate listening skills that have been repressed or never
developed, thus priming the system for more specifically targeted
therapy programmes.
References
Dennison, P.E. & Dennison, G.E. (1989) Brain Gym. Edu-Kinesthetics Inc.
Leeds, J. (2001) The power of sound. Healing Arts Press.
Treharne, D. (2001) Efficacy of TLP with children with auditory process-
ing problems. Paper presented at TLP conference November 2001 (full
version to be posted on www.advancedbrain.com).
Resources
Earobics: Cognitive Concepts www.cogcon.com.
Gardner, M.F. (1996) Test of Auditory perceptual Skills - Revised. Ann
Arbour Publishers Ltd.
Goldman, R., Fristoe, M. & Woodcock, R.W (1976) Auditory Skills
Battery Selective Attention Test. American Guidance Service.
Treharne, D. (in preparation) Test of Rhythm and Comprehension of Language.
The Listening Program (1999) Advanced Brain www.advancedbrain.com.
UK contact: F. Mitchell-Roberts, e-mail: twi@pobox.com.
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2002
how l

A.R.R.O.v. hts the


bus-ear
Dr on lane stresses the mportance o the se-voce
to the A.R.R.O.v. technque or mprovng stenng,
speech and teracy sks. Orgnay deveoped or
chdren wth hearng mparment, ts use has extended
across the communty to ncude aduts wth aphasa,
bran njury and earnng dsabty.
A.R.R.O.W. is a multisensory learning programme I first developed in 1975.
It is based on the use of the students own recorded voice which I termed
the self-voice. A.R.R.O.W. has since been under continuous refinement
with students of all ages and abilities including those with reading and
spelling problems, dyslexia, hearing impairment, speech and language dis-
orders, communication difficulties and visual impairment. Some 800 tutors
have been trained and an estimated 30,000 children and adults have been
helped. A.R.R.O.W. requires the use of special high fidelity two-track
recording equipment either in CD-ROM or audiocassette formats in which
tutor and students wear appropriate headsets.
A.R.R.O.W. is an acronym for:
Aural - The student listens to speech through headsets (either a tutors
spontaneous speech or pre-recorded speech through CD-ROM or audio
cassette facility).
Read - The student reads associated text whilst listening to speech.
Respond - The student is required to make a response.
Oral - The student repeats the text.
Write - The student writes down or types the text while
listening to the self-voice recording.
Whilst any or all of the above components may be stressed during training,
the role of the self-voice is essential to A.R.R.O.W.s effectiveness. Many stu-
dents, particularly those of preschool age or those with severe learning/com-
munication problems, may not be able to undertake the reading or writing
components. However, virtually all students can benefit enormously from the
use of the self-voice as a platform for improving other learning skills includ-
ing those of listening, cognitive processing and speech.
Since its inception, research and practical application of the programme has
taken place in schools, colleges and the community. It has been demonstrably
proved by A.R.R.O.W. trained tutors that it is possible to make rapid and sus-
tained improvements in reading, spelling, short term memory, speech and listen-
initial test averaged 60.6 words correct from 20 sentences containing 100
words. Re-test scores averaged 65.2, an improvement of 9 per cent. A sixth
student was tested but was then given A.R.R.O.W. listening training. On
re-test his score rose from a pre-training 51 to 81 correct after A.R.R.O.W.
- an improvement of 58.8 per cent. He comments, After completing the
A.R.R.O.W. Listening Enhancement Programme that took approximately
25 minutes I experienced a mental clarity, I had a feeling of heightened
awareness, found it easier to focus on the voice and differentiate and
exclude background noise... (Gallagher, 2002).
A.R.R.O.W. self-voice methods hold considerable application for children
and adults within the community. Through the auspices of Bridgwater
College, a community-based initiative featuring the self-voice has been
most successfully implemented. Members on the A.R.R.O.W. community
course include adults with aphasia as a result of stroke, adults with brain
injury as a result of accidents or surgery, and adults with learning problems
for whom Further Education at Colleges is not a realistic option.
Note
It is essential that practitioners receive a structured training programme to
competently assess and deliver A.R.R.O.W. Costs are currently set at 426.00
plus VAT for a four day Advanced BTEC Award for A.R.R.O.W. Tutors. These
courses cover both the CD-ROM and audio cassette format - equipment
costs p.o.a. and are organised on a regional basis according to demand.
References
Bellamy, H. & Long, L. (1994) In: Lane, C.H. A.R.R.O.W. Links 2, 1 (3); 5-9.
Crewdson, D. (1996) The Sound of Ones Voice. Bulletin, Royal College of
Speech and Language Therapists 533; 8-9.
Gallagher, J. (2002) Personal Comunication.
Harvey, B.M. (1995) An Arrow Experience. Dyslexia Contact 14; 2.
Lane, C.H. (1997) With One Voice. Special Children, May; 17-20.
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2002 ;
how l
s a speech and language
therapist with a keen
interest and growing
knowledge in the area of
sensory integration, I was fascinated
to hear of a three day course
Listening with the whole body,
given by Sheila Frick. This well-known American occupational therapist lec-
tures worldwide in the area of sensory integration, on topics such as clini-
cal neurology, respiration, the vestibular-auditory system and auditory
intervention techniques such as therapeutic listening. Occupational thera-
pists, physiotherapists, speech and language therapists, audiologists, psy-
chologists and other educators were there.
I returned with a new found enthusiasm in my heart, knowledge in my
head and a set of headphones in each hand! Parents also hoped this
technique could help their children where more traditional therapy had
not succeeded. Those same parents, having seen some very encouraging
results, urged me to write this article so others can benefit. From my per-
spective, it has opened up a new world where clients can now achieve
their potential in a more functional and effective way.
Therapeutic Listening uses sound stimulation in combination with
sensory integrative techniques to stimulate brain processing. It combines
a variety of electronically altered compact discs based on the ideas and
technology created by Alfred Tomatis, Guy Berard and Ingo Steinbach,
within a sensory integrative framework, (Frick, 2001.) This approach
highlights the importance of close collaboration and joint work
between therapists, as activities are often based on postural activation,
organisation, oral motor and respiratory strategies (Frick, 1991).
CDs vary in level of musical complexity and enhancement.
Individualised programme
Each client is assessed with the view to developing an individualised
therapeutic listening programme, which can be school and/or home
rather than clinic-based. Each programme should be supported by a
strong sensory-diet of activities (Wilbarger & Wilbarger, 1991). Sensory-
diet is a concept which proposes that each individual requires a certain
amount of activity and sensation to be at their most alert, adaptable
and skilful. These activities are tailored to the individuals needs and
scheduled throughout their day.
The development of listening techniques began with the work of
Alfred Tomatis - a French Ear, Nose and Throat Consultant - in the 1940s.
He researched the role of the ear and its profound effect on listening,
language and learning... he seeks to explain how humans function
through the focal point of the auditory system, (Madaule, 1994.)
Tomatis is renowned for developing the first auditory training device,
using progressively filtered sounds - Mozarts music, Gregorian chant
and mothers voice - to cause change.

A
Enthusasm, knowedge -
and a set o headphones
vth oo satsed cents, Karen Oonnor needs no urther
convncng o the benets o occupatona therapst Shea
lrcks Therapeutc lstenng n hepng chdren acheve
ther potenta.
training for five weeks caused marked and sustained improvements in lis-
tening and speech tasks. These improvements were statistically superior to
those being achieved from non-A.R.R.O.W. work being undertaken at each
site. The improvements covered identifying sounds of the environment,
sentence understanding, working short term memory for digits and words,
consonant discrimination and vocalisation skills.
After extensive use in Somerset schools, the A.R.R.O.W. programme was
tried with adults. A teacher of lip-reading, herself severely hearing impaired,
agreed to undertake A.R.R.O.W. training at home. She practised using the
special recorder linked to a neck loop attachment. Material was based on
various pre-recorded poems. After two weeks practice for a maximum of
15 minutes each day, she reported a considerable improvement in her abili-
ty to distinguish sounds of the environment and to hold conversation in less
than ideal acoustic conditions.
We have since developed an A.R.R.O.W. Accelerated Concentration
Programme. I had the idea of asking students to listen to their voice against
varying levels of background noise using the two-track facility available on
the A.R.R.O.W. recorder. Using carefully graded stages of listening, including
easily attainable and extremely difficult tasks, I found it was possible to min-
imise the time taken to train listening skills to a period of 40 minutes or in
some cases even less. I initially used the system with hearing impaired adults
and found marked improvements on pre-post test measures. Adults also
reported improvements in environmental listening and ability to hold con-
versations. Work with children followed and we showed it is possible to
improve listening skills with hearing impaired children inside a total of one
hours training. We have since found that the training is appropriate for
both normally hearing and hearing-impaired children / adults whilst the CD-
ROM format offers exciting new possibilities for self-help attention training.
In late August 2002 a small group of normally hearing students (n=6) were
given a background noise listening test. Five of the students were re-tested
without receiving any A.R.R.O.W. listening training. Mean scores on the
A French doctor, Guy Berard, felt the Tomatis method was too lengthy
and developed his own method of filtering sound. This Auditory
Integration Training (modulating sound frequencies at random intervals
for random periods of time) was developed to treat people with audi-
tory processing problems.
Ingo Steinbach, a German sound engineer, developed the Samonas
method. He found that by heightening his attention to the structural
elements contained in all natural sounds, and capturing them in his
recordings, immediate listening was achieved, even in unfiltered music.
He developed special technology to capture music as sound in space and
combined his spectral activation process with Tomatis method of filter-
ing (Frick et al, 1997).
The benefits of a therapeutic listening programme are extensive and
varied. When I introduce the areas in which families should expect to
see change, they are understandably surprised. Having used therapeutic
listening programmes with approximately three hundred children, I
have witnessed and recorded change in all the areas in figure 1.
The case studies in figure 2 give some indication as to how therapeu-
tic listening can be used with quite different client groups. I now use
this technique with most of my clients, in combination with other
approaches, and I endeavour to work closely with occupational thera-
pists and physiotherapists to
enhance the benefits.
Listening with the
Whole Body - courses
Karen OConnor (Ireland) e-mail
speechtherapyservices1@eircom.net.
Sandra deWet (UK), tel. 01892
513659 (also supplies the
Listening with the whole body
book in the UK for 37 inc p+p).
Further information
www.vitallinks.net - includes
case studies
www.samonas.com - Samonas
CDs, developed by Ingo
Steinbach.
References
Ayres, A.J. (1979) Sensory
Integration and the Child. Los
Angeles: Western Psychological
Services.
Ayres, A.J., & Mailloux, Z. (1981)
Influences of sensory integration
procedures on language develop-
ment. American Journal of
Occupational Therapy 35 (6); 383-
390.
Frick, S. & Hacker, C. (2001)
Listening with the Whole Body.
Vital Links, Madison, WI.
Madaule, P. (1994) When listening
comes alive. Norval, ONT., Canada:
Moulin Publishing.
Semel, E., Wiig, E.H. & Secord, W.
(2000) Clinical Evaluation of
Language Fundamentals - Third
Edition (UK). The Psychological
Corporation.
Tomatis, A.A. (1996) The Ear and
Language. Norval, ONT., Canada; Moulin Publishing.
Stark, R.E. & Tallal, P. (1981) Selection of children with specific language
deficits. Journal of Speech and Hearing Disorders 46 (2); 114 -122.
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2002 8
how l

Figure 2 Case studies


Eoin has Aspergers Syndrome. I worked with his family three years ago when the primary concerns were
concentration, auditory processing and pragmatics, in particular topic maintenance. We had utilised many
approaches with limited generalisation.
Mum was eager for me to reassess Eoin as she felt his auditory processing difficulties were directly related to his
auditory distractibility. He became my first client to use Therapeutic Listening - and he loved it!
We started Eoin on EASE 1 and blended in a Samonas CD within a fortnight. Mum reported he would lie down
on a chair and listen attentively to the music. She noticed improvements in his ability to concentrate within the
first three weeks. Over the past year we have focused on his ability to filter out important auditory information
from background noise, auditory processing skills, sentence formulation and pragmatic language.
Eoins standard scores on the Clinical Evaluation of Language Fundamentals (Semel et al, 2000) have increased by
approximately three standard deviations in both receptive and expressive language. More importantly, Eoin is
doing better at school and making more friends.
Peter, a twin whose general milestones were achieved as expected, was referred aged 3;4 years by his local GP.
Mum became worried when Peter was much slower than his twin to put words together. He had a significant
history of ear infections and grommets were inserted following his initial assessment.
Peter was constantly moving from one activity to another and generally did not respond to questions, but
chatted away to himself. He tended not to look at you when asked a question.
Peter attended regularly for eight months with the focus on:
* attention and listening skills
* auditory processing skills
* auditory memory
* sentence formulation skills
* vocabulary-building
* phonological development.
Limited improvements were noted and mum agreed to try Therapeutic Listening.
We started Peter on Disc EASE and gradually introduced Carulli (Classic Quality Version) on week 3. Within the
first three weeks mum noticed Peter was much calmer, less active and generally listening more attentively.
Improvements continue to be seen in the areas of expressive language and vocabulary building. Peter is also
following a language programme, which consolidates and enhances development of the emerging linguistic
skills. His skills are approaching age appropriate in all targeted areas.
Nigel (10), who has spina bifida, had been attending regularly for eighteen months. Formal and informal
assessments indicated attention and listening difficulties, auditory processing and sentence formulation deficits.
His teacher reported he was quite distracted in class, finding it difficult to concentrate and he was functioning
approximately three years behind the rest of his class. Rigorous direct and indirect work showed limited
improvement so we introduced Therapeutic Listening.
After three weeks, Mum reported Nigel seemed much more tuned-in, able to become involved in
conversations and beginning to follow and talk about story-lines from television programmes, which he hadnt
done previously. Nigel continues on a listening programme and is responding more effectively to other
language programmes to further develop and consolidate his skills.
Figure 1 Areas potentially affected by therapeutic listening
Arousal, attention and focus
Receptive and expressive language
Increased speed of motor and language processing
Balance and coordination
Praxic skill - ideation, planning and execution
Affect; facial expression and responsiveness
Motivation
Awareness of the environment
Gravitational security
Modulation of ability to stay calm while receiving sensations
Organisation
Self-initiation of play and work behaviors, and verbal instruction
Social and emotional development
Eye contact and tracking
Decrease in self-stimulating behaviours
Independence
Feeding skills
Eating and sleeping patterns
Improved awareness and regulation of hunger and thirst patterns
(Frick et al, 1997)
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EVENTS
8-11 JANUARY 2003
BETT 2003
London
www.bettshow.com
13-15 MARCH 2003
THE EDUCATION SHOW
NEC Birmingham
Includes an Early Years Centre and Special
Needs Village
Register for free entry, tel. 0870 429 4580,
www.education-show.com
4-8 MAY 2003
NATURE NURTURE KNOWLEDGE: SPEECH
PATHOLOGY AUSTRALIA NATIONAL
CONFERENCE
Tasmania, Australia
www.speechpathologyaustralia.org.au/
e-mail enquiries
gmcinnis@speechpathologyaustralia.org.au
14-15 MAY 2003 (1
1
/2 DAYS)
CONNECT TEAM INCLUDING CAROLE POUND
Working with people with severe aphasia
Working with groups
Aberdeen
130
e-mail Nan.McBeath@arh.grampian.scot.nhs.uk
29 JUNE - 3 JULY 2003
3RD WORLD VOICE CONGRESS
Antalya, Turkey
Deadline for abstracts 1 April 2003
www.voice2003.org
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Austraan speech-
anguage pathoogst
arone Bowen has
practsed prvatey n the
same ocaton snce +,;,
servng a oca Sydney
communty. By contrast,
ths nternet con has an
actve, and very pubc,
nternatona presence n
cyberspace, mantanng
www.slpsite.com, and
umprng the
phonoogcatherapy
stserv. arones nterests,
as cncan, researcher
and teacher, are argey
to do wth chdrens
anguage and speech
sound dsorders, amy
centred practce, contnung
proessona deveopment,
and technoogy asssted
teachng. vth trusty
aptop n hand, and an
eye on the web as usua,
she shares ten o her top
resources: h-tech and
ow key, od and new,
and comng soon, or
chd speech.
lnd the onne verson o ths
artce and oow nks to the
resources at
http://members.tripod.com/Caroline_
Bowen/topten.htm.
9. Something new
This is about not becoming burnt out. New goodies help
stave off the not-so-positive feelings that might accom-
pany having been at it (therapy) for over thirty years.
Producing something new yourself: an article, conference
paper, workshop or a piece of research, say, is good for a
clinicians morale. Participating in the give and take of
continuing education activities, as presenter or audience
member, can provide a welcome boost. The latest unex-
pected thing came through the post from an American
colleague (we met on the net) in the form of a pre-publi-
cation copy of Lynn Williams new child speech disorders
resource guide. Great stuff, and highly recommended.
Williams, A.L. (2003) Speech disorders resource guide
for preschool children. Singular Resource Guide Series.
Thomson: Delmar Learning.
MY TOP RESOURCES
1. ASHA (American Speech-Language-Hearing
Association) International Affiliate Membership
Bargain spotters - LOOK! For $125USD annually, I receive three
major publications: Journal of Speech Language and Hearing
Research (six issues a year), Language Speech and Hearing
Services in Schools (four), and the ASHA Leader (twenty three),
and have unrestricted access to electronic copies of all the
ASHA journals (such as the American Journal of Speech-
Language Pathology) as a member benefit. My membership
also allows entre to the restricted area of the ASHA web site
with its excellent online forums, discussions and events, and a
member directory which allows me to keep track of colleagues
movements, and vice versa. Definitely my number-one pick as a
professional, clinical, teaching and research resource.
http://professional.asha.org/
http://professional.asha.org/certification/
3. Phonological therapy group
Its free, its phonological and its fun! This online group pro-
vides opportunities to explore theoretical and research issues
related to childrens speech sound disorders. The emphasis is
on evidence based practice in clinical assessment and inter-
vention. Excitingly, clinicians and researchers, students and
consumer advocates are being exposed to each others points
of view. Representing thirty to forty countries, the 700 plus
participants enjoy a growing collection of clinical resources, a
therapy ideas file, and a brilliant message archive full of clini-
cal insights and practical suggestions (and a few fiery
exchanges). Joining is as simple as sending a blank email to
phonologicaltherapy-subscribe@yahoogroups.com. Be there!
http://groups.yahoo.com/group/phonologicaltherapy/
http://members.tripod.com/Caroline_Bowen/group.htm
5. Photocopier fodder
Dont you just love feeding good things to your photocopi-
er? Top picks for child articulation and phonology are these
versatile products from LinguiSystems: SPARCRevised by
Susan Thomsen, 1994; SPARCArtic Junior by Beverly Plass
1996; SPARCfor Phonology by Susan Thomsen and Kathy
Donnelly 2000; and Take Home Phonology by Martha
Drake 2000; and from Black Sheep Press, talented Helen
Rippons endlessly useful pictures and worksheets.
http://www.linguisystems.com/
http://www.blacksheep-epress.com/
7. Snap!
In 1980 I bought a carton of 500 packs of 100 blank
plastic-coated playing cards. They slip like proper casino
cards, even with pictures pasted onto the blank side. I
use them constantly for minimal contrast therapy,
sound-sorting activities, sound lotto and snap, production
practice, and so on. Face down they look like grown-up
playing cards - and children love them, and want more,
more, more. When approached, the manufacturer was
a little surprised, but happy to oblige. Look on the web
for card manufacturers and distributors who will do
custom decks. All those years ago they cost next to
nothing. (Doubt if they still do.)
http://playingcardsindia.com/playingcards.html
http://www.cartamundi.com/
10. Thats right - SCIP
Not the famed but moth-eaten bush kangaroo, but a
CD-ROM containing a 2000-word database of mono-
chrome illustrations to use as treatment stimuli.
Professor Lynn (multiple oppositions) Williams and
Thinking Publications are creating Sound Contrasts in
Phonology (SCIP). It will create treatment sets that
include the childs error production contrasted with one
to four target sounds that have been selected for inter-
vention, with pictures. SCIP will be broad-based (not tied
to processes) for use with different contrastive models
(minimal pairs, maximal oppositions, multiple opposi-
tions). Phase 1 development should be complete by July
2003. Im really hanging out for this exciting resource.
http://www.thinkingpublications.com/
http://www.etsu.edu/cpah/commdis/williams.htm
2. Special Interest Division 1 (SID1)
Special Interest Divisions are entities of ASHA established to
promote the exchange of professional, clinical and scientific
information among ASHA members and International
Affiliates who share an interest in a particular area. For an
additional $35USD per year, each, I can join as many of the
ASHAs sixteen Special Interest Divisions as I like. As a mem-
ber of SID1: Language Learning and Education, I receive
three newsletters a year, full of clinical nuggets, and am
able to participate in the divisions journal discussion groups
and highly informative listserv.
http://www.wslha.org/div1/home.htm
http://professional.asha.org/resources/divs/div_1.cfm
http://professional.asha.org/resources/divs/index.cfm
4. Magic lantern shows
Not a new idea! Magic lanterns, the first projectors, were
invented in the 1650s, and 17th century, wandering
lanternists were soon wowing audiences in inns and castles,
using candle-powered lanterns. Unlike the earliest shows,
which featured goblins and devils (hence magic lantern)
my consumer slideshows, made with PowerPoint and run
on my laptop, provide easy to digest information about
speech and language disorders for families and interest-
ed others. They can be shown to individuals, couples and
groups, and can be quickly customised. Try them out, put
your stamp on them, and make them your own (with
due acknowledgment, of course).
http://members.tripod.com/Caroline_Bowen/devphondis.ppt
http://members.tripod.com/Caroline_Bowen/mod.ppt
6. Print Artist and Clip Art dot com
More pictures. My Print Artist Gold Edition 2002 from
Sierra has been superseded but not eclipsed by the 2003
edition. Modestly priced at $54AUD it came with a free
one-year subscription to Clip Art dot com (formerly Art
Today), reputed to be the largest subscription-based
graphics resource on the web. Members have unlimited
access to more than 2,500,000 clipart images, anima-
tions, photos, fonts and sounds. You can combine and
print pictures for clinical use, photocopy free.
http://clipart.com/
http://www.sierrahome.com/products.html
8. Something old: lists, handouts, notes
Its so ordinary, but my most frequently used and oldest
resource started as a student project and continues to
grow. It is a ring binder of word lists, norms tables,
parent handouts, articles and (personalised) notes to be
included in childrens speech books. Many of these
materials later evolved into resources and documents
that I share with all-comers to my web site.
http://members.tripod.com/Caroline_Bowen/adobe.htm
http://members.tripod.com/Caroline_Bowen/wordlists.html