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A no failure method
This is IT!
The potential
of computers
Should we follow?
Your firm and
flexible friend
ISSN 1368-2105
Clueing up for inclusion
How I manage
in adults
In my
Right for the job
My top
Early years
lna-Dent Gum
The Sprng o reader oer wnners are:
Miss C. Ward, Exeter and Anne Gosling, Colchester
(Talking Mats and Learning Disability)
Caroline Durso, Winchester (AlphaSmart 3000
- see review on p17)
Ciara Robertson, Aberdeen and Margaret
Purcell, S. Glos. (Speaking & Listening Through
Narrative from Black Sheep Press)
ongratuatons to you a!
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Summer 02 speechmag
Whether youre in need of
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recently, our new cumulative
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The speechmag website now
Contents pages of the last four
Cumulative index for previous
articles by author name and
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articles in this issue. If you dont have previous
issues of the magazine, check out the abstracts on
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new article ordering service.
If you liked...
Nibbhaya, try (103) Junor, B. (Spring 2000) In his
own style.
Myra Kersner & Ann Coxon, see (117) Gill, S. &
Ridley, J. (Summer 2000) Reshaping opportunities,
sharing good practice.
Tracy Robertson & Wendy McKenna, look at
(028) Adams, A. (Spring 1998) How I manage my
caseload. Community paediatric: a magic formula?
Julia Wade & Sarah Woodward, see (050)
Armstrong, L. & MacDonald, A. (Winter 1998)
Augmentation or extra effort? Using computers
with people who have aphasia, and (110) Lombard,
M. & Atkinson, Z. (Spring 2000) Assessments
assessed [Clicker 4].
Patricia Sims, try (118) Sims, P. (Summer 2000) A
change in direction.
How I manage stammering in adults, look at
(116) Sage, R.J. (Summer 2000) Reaching the parts
others dont.
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Inside cover
Spring 02 speechmag
Reader offer
Win Infa-Dent Gum Massagers
8 Removing the obstacles
Many a time a parent has approached me saying,
My child needs help with his speech. His teacher says
its holding him back with his reading.
I usually offer to tackle the problem
the other way round.
In a profession undecided about its role
and boundaries, Patricia Sims uses
her no failure method to argue we
should be saying YES to literacy therapy.
12 Further reading
Literacy, non-verbal, palliative care,
voice, language, deafness.
13 This is IT
We hope that
our explanation of
our evaluation
protocol will
enable readers to
apply evaluation
thus keeping
abreast of
innovation. In
reviewing non-specialist software, we want to
encourage readers to think broadly when it comes to
software resources.
Julia Wade and Sarah Woodward check out
software packages and, with the help of J (a 73 year
old lady with aphasia), show that its never too late
to learn.
16 Reviews
Voice, learning disabilities, AAC, inclusion, aphasia,
paediatrics, dysphagia.
18 On the right track?
Within our department, clinics are often managed by
newly qualified therapists. They may benefit from care
pathways being in existence to provide guidance in
following an accepted departmental procedure which
should lead to increased
confidence in decision making.
Do care pathways help departments
provide a more consistent service
for preschool children? Tracy
Robertson and Wendy McKenna
turn to the literature to find out.
20 In my experience
Those embarking on a training
course should be doing so with as
clear and realistic an idea as possible
about speech and language therapy,
and should be sure that it is the
right decision to suit their skills, interests and personality.
Through organising speech and language therapy as a
career courses, Lucy Wood was reminded of the
positive aspects of the profession.
22Clueing up for inclusion
We hope that there may be a
commitment for increased funding to
support recruitment as well as
reorganisation of therapists working in
an inclusive educational system so that
services may continue to develop.
Myra Kersner and Ann Coxon ask how
speech and language therapy services are
meeting the challenge of inclusive education.
25 How I manage
stammering in adults
My aim in all therapy is to empower
the client to manage their stammer
long-term, by helping them to acquire
the understanding, therapy tools and
confidence needed to react to their
changing needs and circumstances.
Stammering is a multifactorial and com-
plex phenomenon with no known cure.
Our three contributors - Louise
Wright, Claire McNeil and Anne Blight - appreciate
that a holistic and individualised approach is required.
Back cover My Top Resources
Our team has recently started a quarterly newsletter,
Lets Talk, to inform the public and a wide range of
professionals (including health visitors, school staff and
paediatricians) about our service and topical projects.
Tracey Marsh and Clair Brookes make time for
collaborative working to meet the needs of their
community paediatric caseload.
(publication date 27th May)
ISSN 1368-2105
Published by:
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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. See p4.
Thanks to Karma Jiga and Rokpa Dundee,
tel. 01 382 872020.
(Rokpa Dundee, 51 Reform St. Dundee,
DD1 1SL specialises in Healthy Living
through Meditation, Tai Chi, Yoga,
Complimentary Treatments, Therapies,
Counselling & Tibetan Medicine. Please
contact us for more information.)
Attention - your firm and flexible friend
Having observed qualities of attention control other than those
described in the literature, I decided to develop a descriptive model to
cover them, as more specific descriptions should lead to more
awareness about attention control and more specific treatment
Nibbhayas work in progress on attention control is inspired primarily
by his work with children with autism and his experience of meditation.
The model can, however, be applied to any client group - and to ourselves.
Patricia Sims
Common standards in
Conductive Education
Proponents of Conductive Education are welcoming funding for
a project to establish common standards in training across
The project is funded by the European Union under its Comenius
programme which encourages transnational projects for school-
ing of children and improving the skills of educational staff.
Conductive Education is taught by specially trained Conductors
who work with individuals with motor disorders. Underlying the
teaching is the philosophy that all children and adults, no matter
how brain-damaged, can learn.
Andrew Sutton, director of the Foundation for Conductive
Education, commented, Our Foundation has a broad-church
approach to sharing the benefits of Conductive Education, fun-
damental to which is the creation of a conductor profession with
initial training to degree level. We are also keen to explore the
potential of training in Conductive Education for existing thera-
pists and teachers and are delighted that the EU is funding a pro-
ject to create common EU standards for such training.
Pot of gold for I CAN
The national educational charity for children with speech and
language difficulties is hoping for a pot of gold at the end of the
Rainbow of Hope.
I CAN, an officially nominated charity on the occasion of the
Queens Golden Jubilee, is being supported by Marks & Spencer
fundraising efforts. Children are being invited to place their
hopes and dreams for the next 50 years onto a Rainbow of
Hope at their nearest store. For each of the first 50,000 wishes
received, Marks & Spencer will donate 1 to I CAN. The retailer
will also welcome donations from customers and encourage
school children to take part in a Rainbow day where they wear
the colours of the rainbow at school.
L-R, Helen Gowland of Tayside Speakeasy (and cover star
of the Winter 01 issue of Speech & Language Therapy in
Practice), John McAllion MSP, Convenor of the Public
Petitions Committee in the Scottish Parliament, and Alex
Frederick, Chairperson of Forth Valley Speakability.
The Scottish Parliament has heard loud and clear
the message that people with aphasia are a vul-
nerable group who need additional care and sup-
port to remain included in society.
Speakabilitys Forth Valley and Tayside groups
launched a petition on behalf of Scotlands 30,000
people with aphasia at the end of February at an
event attended by ten MSPs and fifty guests from
healthcare and the voluntary sector. The petitioners
received support from First Minister, Jack McConnell,
who said, I would like to assure you that a life dis-
abling condition such as aphasia will be given better
recognition, better support and better understand-
ing in order that the people who suffer from such
conditions can lead as full a life as possible.
Presenting the petition to the Public Petitions
Committee on 26 March, Alex Frederick and Claire
McArthur of Forth Valley Speakability were praised
by Convenor John McAllion MSP for the quality of
their opening statement. Committee members had
the opportunity to question the deputation which
led to discussion about the nature of aphasia, par-
ticularly the wider social implications and the value
of communication methods such as symbols.
Parliament petitioned on aphasia
Speak About Aphasia month aims
to raise awareness among health
and social care staff, service indus-
tries such as banks and transport
providers, and the general public.
Organisers Speakability want to get
as much publicity as possible so that
more people understand about
aphasia and can give the quarter of
a million people with aphasia in the
UK the support they need.
Speak About Aphasia month runs
from 18 May - 16 June, 2002.,
tel. (admin) 020 7261 9572.
Speech and language therapist Joyce Seaward
commented, It takes courage for people with
aphasia to come here and speak. For example, no
ramps have been provided for them and we have
not slowed down the meeting. We have not been
allowed to write things in advance. They have
done the hardest thing. It is like asking someone
with one leg to somehow get up the stairs to this
committee room. Aphasia is a largely invisible dis-
ability. Kim Hartley of the Royal College of Speech
& Language Therapists followed up with a plea for
more adequate and equitable provision of speech
and language therapy services in primary and sec-
ondary care.
The petition asks the Parliament to recognise that
aphasia is a life-disabling condition, to develop and
produce accurate measures of aphasia in Scotland,
improve the quality of service to people with apha-
sia, and support service development based on
accurate measures of need and performance. In
addition, it calls for adequate funding and guid-
ance to ensure that measures are put in place to
meet the needs of people with aphasia through
adequate training of health and social care
employees, improved access to speech and lan-
guage therapy and new treatment and support
packages at all stages, from acute treatment to
long term rehabilitation. The committee promised
to keep the petitioners up to date with action
Full text on
Apology for horrendous inconvenience
Speech & Language Therapy in Practice has received a full apology and compensation
for costs incurred through faulty surcharging of renewal letters by Royal Mail.
Over 20 per cent of subscribers sent renewal letters in March were incorrectly charged
64p, and many faced the inconvenience of having to travel to collect their letters at a cen-
tral depot. Those affected have hopefully all now been compensated by us, but should
note the following explanation in a letter from a Customer Service Advisor in Aberdeen:
...It would appear that the surcharging was done on a Saturday when there were no
Revenue Protection staff on duty. The surcharging was also done with scales that need-
ed re-calibrating. Revenue Protection were aware that they were inaccurate but regret-
tably the member of staff on duty when your items of mail were surcharged was not.
I can confirm that all scales in the building have been checked and the situation will not
arise again as all surcharging is now the sole responsibility of Revenue Protection.
I can only sincerely apologise for this horrendous inconvenience you have suffered.
news & comment
A sense o
An e-mail from a reader asks what has really happened to the profession in
the thirty years since the Quirk report. Are we going somewhere or have we
seen it all before?
My final year project was on using computers with people with aphasia. At
that time there was one textbook, a handful of small research projects and a
general dearth of hardware and software. Fourteen years on we are still not
anything like exploiting the potential of computers but, with therapists like
Julia Wade and Sarah Woodward (p13) plugging away, we will hopefully see
a lot of movement over the next few years. Much of this will be demand-led
by our clients with aphasia who are finding new ways of expressing their
dissatisfaction with services and ideas for improvements. The Scottish
Parliament petitioners (see news report on p2) demonstrate how users, the
voluntary sector and professionals are beginning to work together to make
their needs heard and understood.
Working in schools really did at one time mean withdrawing individual
children from their classroom at twenty minute intervals to sort out minor
speech sound problems in a broom cupboard. Myra Kersner and Ann Coxon
(p22) look into what is happening now, and find services trying to change to
live up to the ethos of inclusion in spite of coming across as many barriers to
new ways of working as there are to inclusion itself.
In Barnsley, collaborative working is being adopted with enthusiasm and direct
client contacts correspondingly reduced. Clair Brookes and Tracey Marsh (back
page) tell me they found the opportunity to reflect on what they do a very
positive experience. Similarly, Lucy Wood (p20) finds that helping potential
recruits make informed decisions about whether speech and language therapy
is the career for them reminds her why she joined the profession in the first place
and why it is still the place she wants to be. Tracy Robertson and Wendy McKennas
work on care protocols (p18) is particularly relevant for empowering new
graduates and giving them a sense of direction while leaving room for flexibility.
The How I manage stammering in adults contributors (p25) all have considerable,
long-term experience in their field, which has given them the opportunity to
learn from clients over time how their needs change. Stammering is one of
many areas where the profession is opening up more to accepting that not
only speech and language therapists can help people with communication
difficulties. Particularly with recruitment, retention and resourcing as they
are, we should consider working with non-NHS ventures to benefit our
clients. Nibbhaya (p4) has experienced the value of meditation both personally
and clinically and recommends we consider involving teachers of meditation
to help specific clients. Patricia Sims (p8) is now finding the theories she
developed through practical experience in the NHS are able to be fulfilled in
her independent work where she can offer realistic amounts of therapy to
motivated individuals and their parents and liaise with schools as necessary.
In an age of evidence based practice, the articles in this issue suggest things
on the ground are changing. So, if youre looking for a sense of direction,
take a trip down memory lane and see how far youve come.
Avr Nco,
Knnear Square
ABo +Ul
o++ ;;(+
Dyslexia competition
A national competition aims to give young people
with dyslexia the opportunity to demonstrate
their natural creative strengths through writing,
art, video and photography.
As I See It, with the themes of Communicating
through the ages or My hero, is organised by
the Dyslexia Institute (tel. 01784 463851) and the
British Dyslexia Association (tel. 0118 966 2677).
Open to people with dyslexia aged 18 and under,
the competition has a closing date of 31st July,
2002 and cash and camcorder prizes.
Early years
accreditation scheme
A new accreditation scheme sets the UK standard for
integrated therapy and education for children up to
five years with speech and language impairment.
I CAN, the national educational charity for children
with speech and language difficulties, has
launched the scheme for providers of early years
services for children who have difficulty commu-
nicating. It will build on the expertise of I CANs
expanding Early Years Network which has been
shown to greatly benefit preschool children with
persistent speech and language impairment.
Details from I CAN, tel. 0870 010 40 66.
Raising profile of MND
Motor Neurone Disease is getting a higher politi-
cal profile with the establishment of an All-Party
Parliamentary Group.
The group is expected to meet four times a year
with the aim of raising the profile of motor neurone
disease, providing a political forum for discussion
and debate and opening a channel of communica-
tion between those affected and the government.
Three people a day die from motor neurone dis-
ease in the UK and average life expectancy is just
14 months after diagnosis.
National helpline 08457 626262.
Computer research
A research project will look at the use of auto-
matic speech recognition software by people with
aphasia following a stroke.
The 46,000 grant from the Stroke Association to
Professor Pam Enderby will fund a study to investi-
gate whether clients will be able to use the software
to write using a computer or e-mail. In addition,
the Bristol research team will look at which clients
are likely to benefit the most and will make recom-
mendations to guide potential users in choosing
software appropriate to their needs.
The Stroke Association is also reporting that the
Step-by-Step program, the result of a project it fund-
ed at the Speech and Language Therapy Research
Unit in Bristol, should be available to speech and
language therapists by September 2002. The soft-
ware, to be used at home via the internet, needs an
average of one and a half hours a month input from
a speech and language therapist for an average of
15 hours of computer therapy for the client.; Steps Consulting Ltd, tel.
01249 783007, e-mail
cover story
erhaps the first thing you notice about
another person when you meet them is
whether they are with you or not. This
skill of engaging in your topic of thought
and conversation is known as joint or
shared attention (Ellis, 1990). An example of suc-
cessful joint attention is when a child looks at a
toy, then makes eye contact with an adult, smiles
then looks back at the toy as if to say, Look at this
great toy or hey you, I like this.
When a child enters education they are required
to have the skill of joint attention because they
need to attend to the topics chosen by teachers.
Some children do not have this listen and do skill
at school entry. Reynells developmental frame-
work of attention (1980, see figure 1) is frequent-
ly used by speech and language therapists when
deciding to treat delays in attention development
associated with a communication difficulty. Often
the attention of a child with a delay is single
channelled. Treatment including sound lotto,
sound matching, comprehension and memory
games is aimed at gaining and sustaining the
childs attention until they can follow instructions
of a certain length.
Children with autism have been described as
having tunnelled attention (Jordan, 1997).
Superficially, the presentation of children with
either single channelled or tunnelled attention is
the same. To use a Hanen term (Manolson, 1992),
they both have their own agenda. However, autis-
tic childrens attention sometimes appears to be
strongly influenced by their interest. Attention
span can be of very long duration and is therefore
disordered rather than delayed.
GN is a child with tunnelled attention. She has
a restricted range of interests, particularly liking
rabbits. In free play it is very difficult to share her
games because her attention is on one thing to
the exclusion of others. She is insistent about the
type of play and there is very little sharing of
I observed a quite different quality of attention in
DS, a child diagnosed with autism. (This was before
June 2001 when I was given a Buddhist name,
Nibbhaya, to replace my old name of James.)
When DS saw me in school he said, James,
James Bond, and went on to make connections
about the fictional character. He also said
hello, but could not sustain his attention to my
response long enough to take another turn. His
attention rested only briefly and lightly on me.
There was no joint attention, and he seemed
vague or not present, his attention drifting in
verbalised free association.
Descriptive model
Having observed qualities of attention control
other than those described in the literature, I
decided to develop a descriptive model to cover
them, as more specific descriptions should lead to
more awareness about attention control and
more specific treatment strategies.
The spiritual practices of meditation and reflection
are ways of cultivating and sustaining attention
and could give clues to finding suitable methods
of describing attention control. Sangharakshita
(1980), a Buddhist with fifty years of meditation
you want
a cnca too or
attenton contro
to engage wth your
to ke other peope
Read this
Sandwell speech and language therapist Nibbhaya
contemplates the skills involved in attention control
and shares his work in progress, a new model for
clinical use. Although his inspiration comes primarily
from children with autism, the model can be applied
to any client group - and to ourselves.
-your firm and
flexible friend
Picture posed by model (see p1)
cover story

experience, described the quality of attention

needed for the skill of reflecting on a topic.
Reflection, he said, requires attention that is both
directed and flexible: directed onto an object - for
example, a friend - yet flexible enough to move
onto other objects of thought - for example,
events in their lives. Reflection and joint atten-
tion share the same skill. In joint attention this
would be bearing of attention onto the object of
someone elses thoughts as expressed verbally or
non-verbally. The attention of DS was too flexible
for interaction and that of GN too rigid. As oppo-
sites a continuum can be drawn between two
extremes (figure 2).
There are other children whose attention is quite
rigid but moves quickly from one object to anoth-
er. For them to be described another dimension is
needed - the degree that attention is rested on an
object. That allows for DS having light attention
as well as flexible. GN has firmattention as well as
rigid. The model can now be completed using two
continua (figure 3). The rigid-flexible continuum
relates to the number of objects in awareness,
whilst the light-firm continuum relates to the
extent that one object is attended to.
Four possible qualities of attention can now be
described, one for each quadrant. Examples are
given of everyday uses of each quality to demon-
strate how attention control varies:
1. Light and rigid
This is similar to levels 2 and 3 in Reynells frame-
work. A production line worker would need this
quality of attention in order to inspect items as
they pass before them on a conveyer belt.
2. Light and flexible
Attention is freely associating from
one item to the next without control
as, for example, when day dreaming.
3. Firm and rigid
Attention is fixed onto one object for
long periods of time, the type of con-
trol used in ball sports.
4. Firm and flexible
The attention that would be used by a
chairperson in a meeting. They have
the aims of the meeting continually in
mind, but need to be flexible enough
to let discussion roam to related items. At this
level attention control is a very conscious act.
It is interesting to note that the first three examples
do not involve other people in communication so,
although the first may have developmental relevance
and all have their uses, clinically their absence is
not a problem. The problem for interaction
occurs when the client does not have the fourth
quality in their repertoire.
In going from the world of the clinician to the
world of the child, there seem to be two main
approaches in gaining joint attention. The first is
for the therapist/adult to undertake activities that
grab a childs interest in a certain way as
described. The second approach is to teach the
child the tools required to enable them to gain
the attention of another person, for example
through pointing behaviour:
SB appeared to have very little intention to
interact. He used a lot of jargon with varied into-
nation that did not seem at all communicative.
Whilst I was looking at his father, he suddenly
said, excuse me. I looked at him and he was mak-
ing strong eye contact. He then started using jar-
gon. Because he does not use pointing or gaze to
refer to something it appears as if he is talking
without communicative intent. He does not refer
to anything non-verbally. He may be using a
strategy, in jargon, for gaining joint attention but
it is idiosyncratic, incomplete or both.
The method of following the childs interest and
commenting on it as well as imitating their
behaviour is a sort of middle way, and is the basis
for Intensive Interaction (Hewett & Nind, 1998).
With children who appear to have very little inter-
est in others this would be the primary method:
BS and ST are in nurseries but do not initiate contact
with others, and respond only very briefly to high
interest activities like blowing bubbles or balloons.
When treating clients I often hear views from
adults such as teachers, therapists and parents.
One view is that children who have idiosyncratic
interests in things to the extent that joint attention
is not gained do so as a function of their personality
and, as such, they should not be treated. I dis-
agree. We are in a privileged position. One of
awareness. We are aware that people have different
interests and then make our choice as to what to
attend to. That is, we have an informed choice.
Children with such attention control may not be
making an informed choice. Therefore it is our
responsibility, where possible, to give them the tools
they need to make that choice.
I choose to define humans as
social creatures, so the lack of
development in attention and
therefore interaction is a breakdown
in activity*. One head teacher had
the view that evolutionary theory
would explain that there would
be people who are not sociable.
Again, if a person with austistic
spectrum disorder is aware of
their own social skills and is happy
to make a choice to avoid interac-
tion then I wouldnt want to
intervene. The degree of partici-
pation* would be a personal choice.
Reading the accounts of adults with autistic spec-
trum disorder could be the best way of deciding the
degree of distress* experienced by people with
autism in regard to interaction, and would therefore
aid the forming of a philosophy of intervention. For
individual children hypotheses about the causes of
distress can be made. Distress may be significantly
due to interaction difficulties, and teenage children
with Asperger Syndrome may become depressed as a
result of difficulties with social skills (Ellis, 1990).
Rigorous rationales
Having made an attempt to describe the different
attention skills of clients in terms of the model in
figure 3, I found myself considering these as an
outcome of the different theories of the underlying
Figure 1 Reynells levels of attention
Level 1
(0-1 year)
Level 2
(1-2 years)
Level 3
(2-3 years)
Level 4
(3-4 years)
Level 5
(4-5 years)
Level 6
(5-6 years)
(Based on Reynells levels of attention as
quoted in the Speechmark publication
Working with Childrens Language by Jackie
Cooke & Diana Williams.)
Figure 2 Early model of attention
Rigid/ associating
Figure 3 The latest model
When a child enters
education they are
required to have
the skill of joint
attention because
they need to attend
to the topics
chosen by teachers.
Extreme distractibility when
childs attention flits from one
object, person or event to
Child can concentrate on a task
of his own choosing. His atten-
tion is single-channelled and he
must ignore all extraneous
Child cannot listen to adults
directions while he is playing
but he can shift his whole
attention to the speaker and
back to the game with the
adults help.
Child must still alternate his full
visual and auditory attention
between the speaker and the
task but he now does this
Childs attention now two-
channelled, that is, he
understands verbal instructions
related to the task without
interrupting his activity to look
at the speaker. His concentration
span may still be short but he
can be taught in a group.
Auditory, visual and manipulatory
channels are fully integrated
and attention is well
established and sustained.
cover story

causes of autistic spectrum disorder. Such a con-

sideration is one of impairment*. It is similar to
asking what the level of breakdown is in speech
and language difficulties so that specific interventions
may be designed. Instead of only treating surface
behaviours - although this can be valid - treatments
for the underlying skills may be developed, ideally
leading to more rigorous rationales for intervention.
It may be that children with different attention
difficulties have different underlying aetiologies
1. weak central coherence
2. executive dysfunction
3. weak Theory of Mind
4. high anxiety.
1. weak central coherence
In the case of firm/rigid attention the
theory of weak central coherence
may be the primary or significant
impairment. Central coherence is the
ability to see the wood for the trees,
to be able to put information togeth-
er, to get the gist of communication
or the thread in a story. Weak central
coherence would result in attention
to bits of information. One item
would be attended to rather than
putting many together. This theory may fit for
the child who has good rote learning skills, or the
child who remembers small details on a journey.
PJ looked at a picture of someone being
mugged. He ignored the main event in favour of
examining a clock.
For me this does not explain why one item is
chosen over another. Why is the child interested,
say, in a hat as opposed to a face? The answer
may be in the childs perceptual preferences.
Sensory experience of one kind, for example
sight, may be more salient than experience
through the other senses. For PJ the movement of
a clocks second hand was alluring. Perhaps for
GN the touch of rabbits fur is attractive.
2. executive dysfunction
In the case of light/flexible attention the theory of
executive dysfunction may be applicable. Executive
functions are those skills that modulate behaviour
towards a goal. They therefore manage behaviour
over time. They are, amongst others, the skills used to
develop and carry out plans. The strategies used to
carry out those plans are monitored and altered as
necessary. If one has not got a goal in mind, or the goal
is held weakly, then the mind will wander, attaching to
anything that comes into consciousness whether from
outside the client (such as another person coming into
view) or internally (for example, memories). This
appeared to be the case with DS.
3. weak Theory of Mind
A weak Theory of Mind is also posited as a reason
for lack of interaction. This is where the client
does not appreciate that others have their own
perspective, views and feelings about experience.
There is therefore no
reason to share experi-
ence. Further assess-
ment would be
required - for example,
using the Sally Anne
Test (Baron-Cohen et
al, 1985) - to establish
the status of this skill,
although my col-
and I have found results from this
test inconsistent. There are levels
of the Theory of Mind skill, and the
Sally Anne Test evaluates one level:
that other people have beliefs of
their own about events or things.
In the test two dolls are used. In
front of them and the child, an
item is put into one of two boxes.
One doll, Sally, then leaves and
Anne puts the item into the other
box. Sally is brought back in. The
child is asked which box Sally will
look into for the item. If the child
understands that others have their
own beliefs (in this case based on
the experience of sight) then the
child will say that Sally will look in the first box
where she saw the item placed. Developmentally,
this skill is expected to develop by four years.
If a client has not got skills to infer what goes on
in the minds of others - a theory of mind - then an
approach based on the Metta Bhavna meditation
may help develop empathy. This meditation is
used to develop positive mental states such as
compassion and kindness. Simply put, you develop
the desire for the well-being of yourself and others.
People you feel neutral about, for example
strangers, and people you feel ill will towards are
brought to mind in order to develop kindness
unconditionally. Over time one result is that
when you meet people you tend to respond to
them more out of good will than previously.
After preparing yourself you bring others to mind.
In my experience thinking about others doing the
most basic human things, for example, washing
up, shopping, talking, as well as experiencing the
pain and joy that we all do, has helped develop a
growing appreciation that others are alive too,
not two-dimensional cardboard cut-outs. Therefore,
similar exercises could be developed in the guessing
of what people do when they are not in the pres-
ence of the client (see for example Wendy Rinaldis
self / other awareness material (1995; 2001)).
4. high anxiety
Another reason why attention control can be rigid
is high anxiety. This can be reduced with a structured
routine and strategies such as visual aids or ges-
ture to help comprehension of language and
events. Meditation can also be used to relax.
Probably those practices that involve observing the
process of breathing would be most appropriate.
These would be suitable
for older/able children
with good comprehen-
sion of the concepts
involved. I suggest gain-
ing parental consent
before undertaking
teaching of meditation.
Teaching should come
from someone who is
already a meditation
teacher, so outside agencies such as Buddhist centres
may need to be involved.
Intervention aims at gaining and establishing
joint attention through moving away from the
extremes of attention control to achieve more
balance. The following are some ideas for inter-
vention under the different qualities of attention.
1. Light and flexible
Therapy was devised for DS before the model
illustrated in figure 3 was developed. I observed
that he could not engage with a speakers inter-
action for more than a single turn. In group work
he was described by the teacher as being in a
world of his own. His therapy required him to
answer closed questions in tasks of increasing
length. To begin with he answered yes or no
when I labelled noun pictures correctly or incor-
rectly. With consistent correct responses the task
was extended to functions, simple sentences, and
so on. He was inconsistent at the level of nouns
initially. By the time he was able to respond to
sentences he was also able to take two to three
turns in conversation with his teacher.
Taking theories on executive dysfunction into
account, therapy could be aimed at a graded pro-
gramme with the aim of achieving goals. Tasks
would be made that control what is required to
achieve goals, for example choosing, sorting and
prioritising. They may simply be memory tasks to
begin with then, later, involve an obstacle where
a change of plan is required. For example: The
task is to get from A to B on a map but there are
natural barriers such as rivers and mountains.
Give a choice of items that could be used to
enable the journey to be continued.
2. Firm and rigid
Interestingly, the same method was used with GN as
with DS. She went through the same steps. By the
time she was able to respond to simple sentences
there was an observable difference in her quality of
attending to me. She appeared to be checking
what my attention was on. The method is likely to
have been successful with both extremes because
the task requires a balance between the two. The
game also involves the adult making mistakes and
this can delight children and grab their interest.
Increasing the awareness of the interests of others
through social activities may be appropriate here.
Also consider using a childs interests as a reward for
attending to an adults choice of activity. However,
children with rigid and firm attention may attend to
If a client has not
got skills to infer
what goes on in the
minds of others - a
theory of mind -
then an approach
based on the Metta
Bhavna meditation
may help develop
Could the odd interaction of any
of my clients be described with
reference to their attention control?
Do I consider the relative merits
of treating surface symptoms and /
or underlying causes?
I already use reflection to improve
my practice - could meditation
be my next step?
the reward to the exclusion of the activity. The teaching
staff of GN negotiated with her that she could have
her toy rabbits on Fridays but she was observed on a
Tuesday to ask for them frequently. Her under-
standing of words of time may not yet be established.
Lastly, to facilitate more flexible thinking try a
sorting activity where the items can be sorted by
different qualities, for example cards of different
shapes and colours. Begin by sorting into colours
then change task to sorting by shape. The same
task can be done with clothes, coins or books.
3. Light and rigid
The Manolson (1992) approach of following the
interests of the child and commenting on them as
well as imitating the child would be applicable
here as it may be with firm and rigid.
With DA, a nursery age child, I copied his physical
play such as kicking legs out whilst sitting on a chair,
and then began to initiate my own movements. DA
soon began to copy me. This was extended to fol-
lowing my commands verbally with an increasing
number of information carrying words.
Work in progress
Several of the children referred to are either diag-
nosed with autism or are in the process of multi-
agency assessment. The cases mentioned also have
a very wide range of ability. Although not peculiar
to autism, difficulty with joint attention is one of
the main features of children with autistic spec-
trum disorder. There is no reason not to use the
model with any client group or ourselves for that
matter (how difficult is it to keep a goal in mind
when leading a meeting?!) I hope this work in
progress will enable clinicians and researchers to
have a simple way of describing attention control,
design intervention and measure progress.
Baron-Cohen, S., Leslie, A.M. & Frith, U. (1985)
Does the autistic child have a theory of mind?
Cognition 21 (1), 37-46.
Ellis, K. (Ed) (1990) Autism. Professional perspec-
tives and practice. London: Chapman and Hall.
Frith, U. (1989) Autism. Explaining the Enigma.
Oxford: Blackwell.
Hewett, D. & Nind, M. (1998) Interaction in
Action. Reflections on the use of Intensive
Interaction. London: David Fulton Publishers.
Jordan, R. & Powell, S. (1997) Autism and
Learning. London: David Fulton Publishers.
Manolson, A. (1992) It Takes Two To Talk. Ontario:
Hanen Centre Publications.
Reynell, J. (1980) Language Development and
Assessment. Lancaster: MTP Press.
Rinaldi, W. (1995) SULP for Primary and Infants.
Guildford: Learn-Communicate.
Rinaldi, W. (2001) SULP-R. Windsor: NFER-Nelson.
Sangharakshita (1980) Publication in preparation
by Windhorse Publications, Birmingham.
Note: *Categories originally developed by the World
Health Organisation and modified in Sandwell.
cover story
Workplace conflict
Practical assistance with workplace conflict,
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Computers as
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Sensory Software offers one day training
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Two new education booklets are available
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An introduction
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The number of registered users of Clicker
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grammed and the status quo, arising without
signs of unease. Difficulties in absorption and
retrieval of words ensue.
Whilst reading problems can be caused or exac-
erbated by tension and anxiety, they naturally
cause additional anxiety. When confidence and a
sense of well-being is restored by sensitive atten-
tion to the literacy problems, there can be a
noticeable spin-off in the direction of speech and
language, since anxiety can also, and often for
the same reasons, be a major factor in slow, dis-
connected, confused, disjointed, and dyspraxic
speech, and in inattention to ones own speech or
that of others. On the other hand, working directly
on speech and language difficulties while self-
esteem is lowered by literacy difficulties is likely to
be less productive, because a literacy problem per-
vades almost all school work and affects ones con-
fidence with peer groups. It is generally perceived
by the child to be their greatest problem; they
may well be relatively unconcerned or unaware of
any speech and language problem.
Positive experiences
I have devised a No Failure Method to help children
with, or developing, literacy problems or dyslexia; it
can be adapted for older children and adults. A
fuller account of it and reasons for its particular for-
mat are given in Reasons and Remedies (Sims, 2000).
The method replaces programmed and conditioned
negative experiences with positive ones. It enables
the child to maintain concentration so that they can
better make connections, memorise, and reinforce
their memory and retrieval of words.
Children who truly lack motivation, such as
those with a pathological demand-avoidance
alternative approaches
ur profession remains undecided
about our role in the field of liter-
acy problems and dyslexia. But
should we say that it is not our
area, that there are other experts?
To turn ones back on literacy problems is to miss
a huge opportunity. When, equipped with full
understanding, we correct or prevent reading and
writing problems in school aged children, we fre-
quently remove obstacles to progress in speech
and language. Many a time a parent has
approached me saying, My child needs help with
his speech. His teacher says its holding him back
with his reading. I usually offer to tackle the
problem the other way round. I work on the literacy
difficulty and find that the speech and language
improve simultaneously. Many parents who are
anxious for speech and language therapy would
be much less concerned about their childs speech
if they did not fear that it would inhibit his or her
progress in reading and writing.
Why should rectifying literacy problems have
such an effect on speech and language? Attention
to letters and written words can help the spoken
form and comprehension, but another - and in my
opinion more important - factor to consider is tension
or anxiety. Many speech and language difficulties
are related to tension and anxiety, and so is
dyslexia. Common signs for dyslexia, as listed by
the British Dyslexia Association, can be related to
tension and anxiety (Sims, 2000), and the tension
or anxiety does not have to be out of the normal
range to create problems. Children learning to
read or write may become flustered, panic and
experience some shut-down. Problems with con-
nection (Paulesu et al, 1996) may become pro-
you have cents who
avod stuatons where
they w a
rush beore ther
memory ades
become ustered, then
panc and shut down
Read this
problem (Newson, 1989), are unlikely to benefit,
and care should be taken with autistic children to
ensure that reading skills are accompanied by full
comprehension. Generally, however, children with
a literacy difficulty really care about their inability
to read, and their anxiety over their failure exac-
erbates the problem. They may well avoid reading
and writing but, once given empathetic help, and
hope, they are keen to improve and are stimulat-
ed and motivated by the progress they make.
To avoid the problems it is necessary to avoid all
the things which trigger the negative reactions
which lead to shut-downs. Initially, the chief of
these triggers is being asked or
expected to read a word. This trigger
can be removed by following these
1. If the child is in the infant school
years, utilise a very basic reading
scheme which has a lot of carry-over
of words from one book to the next,
and a lot of repetition thereafter. It is
best to liaise with the school in this
matter. The One Two Three and Away!
scheme is excellent (McCullagh, 1978).
2. Read the book to the child, pointing
to the words. Help them to become a
little familiar with and take some
notice of individual words by encour-
aging them to point to a word you have just
pointed to while you were reading a sentence
aloud. Point to all the words as much as seems
necessary to help them, and encourage them to
ask you to point to a word they choose, too. Let
the child count how many times a particular word
occurs in the book.
3. Write the first word of one of the short (per-
haps three word) sentences, and tell them what it
says. Then ask them to look at it for as long as
they wish and tell you when they are ready to
write it. When they think they are ready to have a
go, remove the word, giving them a blank piece
of paper and pencil. Paper can be exchanged for
keyboards and computers for children with a
physical impairment.
4. As soon as the child begins to make a mistake
or hesitate for more than a second, show them
the word (and name it for them) again so they can
repeat the exercise in absorption. Repeat this as
often as necessary, keeping quiet and
relaxed yourself. Avoid any pressure or lav-
ish praise. Try not to give any message that
you are eager for them to succeed quickly,
and avoid additional instructions. Try to
make it seem like a game or little challenge,
but do not imply that it is easy. NEVER
writing a word; observe them carefully and
always be ready to jump in and show them
the word again as soon as they need help.
Do not allow them to correct a mistake;
always remove their effort and start the
absorption process again. When they
decide they are ready for it, present them
with blank paper again - their mistake can
be folded over.
5. Once the child has written the word successful-
ly, move on to the next word in the sentence.
When they are successful with this one too, name
and let them view the two words of the sentence
together and write them both when they feel
ready. Should they make a mistake on the second
alternative approaches

An independent speech and language therapist

specialising in the prevention and treatment of
literacy difficulties, Patricia Sims believes that
many speech and language difficulties and
dyslexia are related to tension and anxiety.
Using her no failure method, she works on
literacy difficulties and finds speech and
language improve simultaneously. In a
profession undecided about its role and
boundaries, she argues we should be saying
YES to literacy therapy.
learning to
read or
write may
panic and
word, they view both words again and begin once
again to write both words, starting with the first.
This gives extra, relaxed practice with the first
word and reinforces it.
6. When they have written both words together
correctly, introduce the third word of the sen-
tence, following the same procedure. When they
have written it correctly, give them all three words
to view together. Remember that as soon as the
child makes a mistake they must view the entire
sentence again and begin it again on more blank
7. NEVER TEST THE CHILD to see if they have
remembered the words. The aim is to change
habits by allowing them to relax, absorb words
and their sounds, and maintain concentration.
They will not be able to remember and retrieve
words instantly. Their confidence and belief in
their own ability has to be gradually built up.
8. Practice can be varied by mixing words from dif-
ferent sentences or encouraging the child to
rearrange words written individually on separate
pieces of paper (for example, here is Ben can
become Ben is here). A picture of Ben might be
drawn and labelled.
9. When the child has become really familiar with
the words, they can be written on individual
pieces of paper and hidden around the room, a
few at a time. Allow the child to choose which to
hide. Their task is to find each one and say what
they have found, if able. If they dont instantly
know the word, they are told it immediately; for
example, Good, youve found has. The child
may feel more relaxed, and hence be more suc-
cessful, if they play this game with an older sibling
who can read. Take turns to hide and find.
alternative approaches
10. Once the childs confidence and ability to
absorb, retain and retrieve information has
grown, some words might be casually sounded
during the practice. The adult should, however,
be wary of offering detailed instruction concern-
ing letters and their sound combinations too
Absorb and practise
For a child whose main difficulty is writing and
spelling, the chief trigger is being left to struggle
to retrieve the impression of words or their parts.
A variety of appropriate sentences can be given to
older children and adults, utilising this no strug-
gle and no failure approach. The same words may
be placed in different sentences for their rein-
forcement. Words from school spelling lists can be
included in suitable sentences for children to
absorb and practise. Should the person forget the
sentence itself as they are writing, it should be
repeated for them in its entirety, not word by
word as they write.
With this method we eliminate the possibility of
failure. The child is not encouraged to read a
word unless it becomes apparent that they can
recall or retrieve it with ease. They dictate their
own pace and do not experience the harmful neg-
ative feelings brought about when progress is
tested or monitored. They can therefore relax and
absorb the information, and new learning path-
ways are opened up.
You may be asking, How much of the progress
could be attributed to individual, focused atten-
tion? Most of the children I see have previously
had an enormous amount of individual attention,
often from enthusiastic and caring learning sup-
port classroom assistants. The children were only
too aware that everyone was making a huge
effort and that they were failing in spite of it. The
more practice they have had at failing, the worse
the problem. It is the nature of the intervention
that is critical.
The four case examples (figure 1) illustrate the
use of the basic method and its adaptation for
older clients with writing rather than reading dif-
Research needed
Research is needed to test the robustness of my
clinical experience and theory, and a challenge
goes out to any speech and language therapist
interested in research. There is a need to acknowl-
edge that high levels of tension and anxiety are
commonplace and natural in childhood and form
a positive component of the human race. But
even when within the normal range, tension or
anxiety can be responsible for, or a contributory
factor in, developmental difficulties of all kinds,
depending upon its mode of expression. While we
await appropriate research in this area, we will
find it illuminating to speak in some detail with
adults and older children who experience literacy
and speech and language difficulties, and to
make use of a personality checklist (Sims, 2001).
Alice came to me when she was six years
old and failing to read at school. Her
teacher had suggested that speech and
language therapy to correct some sounds
might help her to read. Alices speech was
found to be satisfactory apart from her
lack of affricates and some voicing of initial
voiceless phonemes. Administration of a
Personality Checklist (Sims, 2001) revealed
some early and current tension and
anxiety. She had always been restless and
excitable but her behaviour had recently
become more difficult, she was more
distractible, and she was sleeping more
fitfully. She had begun to hide her school
reading books as soon as she returned
home from school.
It transpired that she no longer followed a
reading scheme at school, often being
allowed to choose her own books from a
selection. She tended to learn sentences
by heart but the only word she could read
reliably was her own name. She was able
to sound letters competently.
A visit was paid to the school where Alices
difficulties were discussed, and it was
agreed that she should return to a basic
reading scheme while the No Failure
Method was implemented. Initially it was
to be implemented only by me and her
parents, since there was little opportunity
for Alice to receive individual attention in
the classroom. But her teacher was happy
to remove any pressure on her to read
aloud and she was willing to renew her
reading book only when it was entirely
finished with.
Within a few weeks Alices reading ability
had developed and her confidence had
grown. She was delighted to be awarded a
certificate for achievement during a school
assembly. After 14 weekly one hour visits,
regular therapy was discontinued; it was
sufficient that the method was maintained
each evening at home. I did give her some
incidental help with her speech during her
weekly visits but I have little doubt that
her increased confidence in reading and
writing and her enhanced self-esteem were
largely behind improvement in her speech.
Robbie came for help at six and a half. He
was highly sensitive and keen to succeed
but a basic problem with absorption and
retrieval of information was affecting his
comprehension, speech and self-expression,
and his progress in literacy. He had always
tended to switch off at times, and could
become panicky. He was clumsy and had
been late with milestones and slow to
develop his left-handedness. In spite of a
generous period of time allocated to him in the
classroom with a learning support assistant,
Robbie was unable to read and write
words, though he could sound any letter.
As with Alice, the No Failure Method was
implemented with the support of Robbies
school. His mother was taken aback by his
immediate new level of concentration dur-
ing the procedures, just as Alices mother
had been. As he relaxed, he gradually
became able to pay more attention to the
sounding of the words. His confidence,
enthusiasm and belief in his own ability
rose as his literacy, sequencing and speech
and language difficulties faded. One hour
sessions had been given weekly for the
first three months, fortnightly for the next
month, and then more sporadically as the
need diminished, home practice having
been well established.
At the age of thirteen, Rupert was receiving
extra support for dyslexia at his comprehensive
school. He displayed obvious anxiety and
some disturbed behaviour. The same trouble
with absorption and retrieval which lay
behind his spelling problems created
comprehension and self-expression difficulties.
Utilising vocabulary from the school curricu-
lumsubjects, appropriate whole sentences
were shown individually to Rupert for him
to absorb and write according to the No
Failure Method. Care was taken to ensure
that the challenge was enjoyable and never
excessive. Frequently occurring words which
Rupert misspelled were also targeted and
incorporated into various sentences, but
never tested. Each sentence was re-read for
him if he needed to be reminded of it whilst
he was writing, so that his auditory memory
was not taxed or tested. Rupert enjoyed the
procedures and the challenge, feeling
relaxed and in control. As his spelling ability
developed, he made fewer word repetitions
and omissions in his writing.
At the same time, Ruperts learning support
assistants broke down his work tasks into
small sections which did not appear
daunting to him. His goals were well-
defined and essay writing and organisation
was facilitated by this approach.
At the end of a year, after 24 one hour sessions
and additional weekly practice provided
by a learning support assistant, Ruperts
speech and language had noticeably
improved, along with his literacy skills.
He was absorbing more information and
initiating conversation in the classroom,
which he had failed to do hitherto.
Janine was a highly sensitive and self-critical
lady aged 30 years. Her undiagnosed
dyslexia, complicated by some depression,
caused her a great deal of distress at work,
and she was quite unable to express herself
well verbally at meetings.
Janines difficulties were explained to her
in terms of the disconnection she was
programmed to experience. She embraced
the No Failure Method of writing sen-
tences. Lists of appropriate sentences were
given to her. Generally, she successfully
carried out her routine nightly practice
alone. She had always relied heavily on
word shape and visual impressions and she
had tended to rush her writing before her
memory had the chance to fade. The new
method of absorbing an entire sentence in
her own time and writing it correctly in its
entirety without making corrections or
permitting any struggle encouraged and
enabled her to slow down and pay attention
to the word and sounds she was writing,
instead of rushing ahead and attempting
to correct mistakes afterwards.
Janine developed a new sense of purpose
and her literacy skills and powers of self-
expression went from strength to strength.





members of the department. Grasp any such

opportunity and brighten your days!
Patricia Sims has worked principally within the
NHS. She is now an independent speech and lan-
guage therapist specialising in the prevention and
treatment of literacy difficulties. She is willing to
demonstrate her No Failure Method to groups of
therapists (e-mail
McCullagh, S. (1978) One, Two, Three and Away!
London: Harper Collins.
Newson, E. (1989) Pathological Demand
Avoidance Syndrome: diagnostic criteria
and relationship to autism and other
developmental coding disorders.
University of Nottingham.
Paulesu, E., Frith, U., Snowling, M.,
Gallagher, A., Morton, J., Frackowiak,
R.S.J. & Frith, C.D. (1996) Is developmen-
tal dyslexia a disconnection syndrome?
Evidence from PET scanning. Brain, 119,
Sims, P. (2000) Reasons and Remedies.
Barnstaple: Mortimore Books.
Sims, P. (2001) Personality Checklist. An
A4 Reproducible version. Barnstaple:
Mortimore Books.
British Dyslexia Association,
98 London Road, Reading RG1 5AU,
National Helpline 0118 966 8271,
Patricia Sims A4 photocopiable Personality
Checklist, used in conjunction with Reasons and
Remedies, helps the professional and parent or
carer to see any relationship between a childs
difficulties and tension or anxiety. It may be
completed by the professional or an informant.
An additional set of questions for the child of
school age is included. 8 Available from
bookshops, STASS or direct from:
Mortimore Books,
PO Box 156,
EX33 1YN,
8, p&p free, ISBN 0953620913.
alternative approaches
The role of my Personality Checklist in the literacy
field is to highlight behaviour such as worrying,
panic, sensitivity to failure, and switching off.
When parents link their childs personality to his
or her problems, they are enthusiastic about the
No Failure Method, the reasoning behind it having
been explained to them. So the checklist has an
educative role and inspires enthusiasm in parents
who may have been feeling quite desperate. As
long as the therapist, parents and teachers are
aware of the programmed problems which cause
or aggravate the difficulties, the implementation
of the method becomes sensitive and
it is not in the least difficult to go at
the appropriate pace for the child.
A sample from the 30 groups of
questions in the Personality Checklist
is in figure 2. The thinking behind the
list is explained in Reasons and
Remedies (Sims, 2000). At first sight,
some questions may seem to address a
purely physical problem, but the
checklist is designed to help link
groups of traits and reveal heightened
tension and anxiety in fears, switched
off behaviour, emotional and physical
hyper- and hyposensitivity, attention
deficits, distractibility and excitability,
obsession and compulsion, and mani-
festation of tension and anxiety
through speech and language. Having fully con-
sidered the childs tension or anxiety, the parent
or carer may be able to take steps to remove,
where possible, any environmental influences
which may be contributing to it.
The checklist has a diagnostic purpose and helps
to pinpoint the main problem for a child
(although there is considerable overlap of symp-
toms); for example,
They may be a worrier and fearful, and this may
underlie literacy and speech/language problems,
or give rise to depression or obsessional
behaviour, stammering and tics.
They may be rather globally switched off, as in
Tension may take the form of attention deficit
hyperactivity disorder, possibly with additional
symptoms of dyspraxia.
Obsessional demand-avoidance may be the
main problem.
When we properly understand what young chil-
dren are experiencing with their early reading and
writing difficulties, a heavy burden is removed
from their shoulders and, with relaxed and confi-
dent adults helping them, they are able to move
forward with confidence and reassurance. Their
resultant success is manifest in their speech and
language, too.
This literacy therapy is straightforward, enjoyable,
successful and very rewarding. Perhaps forward-
looking speech and language therapy departments
might appoint a specialist therapist for literacy
problems - who will be simultaneously reducing
the speech and language problems for other
Do I recognise how anxiety
can influence progress?
Do I allow clients to dictate
the pace of therapy?
Do I give clients practice at
failing - or gradually build
confidence and self-belief?







The child is
to read a
word unless
it becomes
that they
can recall or
retrieve it
with ease.
2. Does he flit from one activity to
another and have difficulty sustaining his
interest in, for example, a toy?
Can he sit still and concentrate?
Can he concentrate when he is really
interested in something? If so, how well?
Is he impulsive?
Does he fiddle with ornaments, etc., in
peoples houses or with things in shops,
despite being told not to?
Does he always seem to be restless and
does he keep fidgeting?
Is he always in a hurry to do things?
Does he become bored easily?
Does he become very excited?
Is he easily distracted?
Is he very impatient?
Does he look where he is going - is he
properly aware of obstacles in his way?
3. Is he easily frightened?
Does he become terrified of anything?
Is he anxious in an unfamiliar place?
Does he worry?
Does he panic?
5. Is he sensitive and easily hurt by
Does he sulk?
Is he very shy?
Is he weepy?
23. Does he listen well?
Does he listen well when he is being
addressed in a group?
Does he switch off or seem switched off
from his surroundings - perhaps
appearing deaf without being deaf?
Does he remember nursery rhymes?
Kelman, C.A. (2001) Egocentric language in deaf children. Am Ann Deaf 146 (3), 276-9.
Egocentric language is a generalization of Piagets egocentric speech concept
(1926/1969) investigated by Vygotsky (1962). Behaviors of eight children ages 2
to 5 years with profound congenital deafness were analyzed using six classes of
egocentric language: motor reaction activity, silent lips articulation, murmur,
oral-facial mimics, body expression, and vocalization. No child had received oral
or sign language training. All attended videotaped play sessions. Events in which
children engaged in dialogue with themselves or a toy, while pursuing a specific
solution, were observed. Such extralinguistic behavior moves the thinking process
toward problem solving like that of hearing children. Consequently, teachers should
not interrupt when a deaf child is playing with or signing or vocalizing to a toy,
because this behavior may be the manifestation of a reflexive moment and the gen-
erator of a decision process fundamental for cognitive development.
Vocalization by a deaf child does not indicate willingness to speak; it merely
manifests symbolic reasoning. Silent lips articulation and oral-facial mimics have
the same effect and can also be interpreted.
Roy, N., Gray, S.D., Simon, M., Dove, H., Corbin-Lewis, K. & Stemple, J.C. (2001) An
evaluation of the effects of two treatment approaches for teachers with voice dis-
orders: a prospective randomized clinical trial. J Speech Lang Hear Res 44 (2), 286-96.
Teachers commonly report voice problems and often seek medical assistance for
voice-related complaints. Despite the prevalence of voice disorders within this
occupation, there are no studies evaluating the effectiveness of treatment pro-
grams designed to remedy the voice problems of teachers. To assess the func-
tional effects of two voice therapy approaches, 58 voice-disordered teachers
were randomly assigned to 1 of 3 groups: vocal hygiene (VH, n = 20), vocal func-
tion exercises (VFE, n = 19), and a nontreatment control group (CON, n = 19).
Subjects completed the Voice Handicap Index (VHI) - an instrument designed to
appraise the self-perceived psychosocial consequences of voice disorders -
before and following a 6-week treatment phase. The VFE and VH subjects also
completed a posttreatment questionnaire regarding the perceived benefits of
treatment. Only the group who adhered to the VFE regimen reported a signifi-
cant reduction in mean VHI scores (p <.0002). Furthermore, when compared to
the VH group, the exercise group reported more overall voice improvement (p
< .05) and greater ease (p < .02) and clarity (p < .01) in their speaking and
singing voice after treatment. These findings suggest that the VFE should be
considered as a useful alternative or adjunct to vocal hygiene programs in the
treatment of voice problems in teachers.
Register, D. (2001) The effects of an early intervention music curriculum on pre-
reading/writing. J Music Ther 38 (3), 239-48.
This study evaluated the effects of music sessions using a curriculum designed to
enhance the prereading and writing skills of 25 children aged 4 to 5 years who were
enrolled in Early Intervention and Exceptional Student Education programs. This
study was a replication of the work of Standley and Hughes (1997) and utilized a
larger sample size (n = 50) in order to evaluate the efficacy of a music curriculum
designed specifically to teach prereading and writing skills versus one that focus-
es on all developmental areas. Both the experimental (n = 25) and control (n = 25)
groups received two 30-minute sessions each week for an entire school year for a
minimum of 60 sessions per group. The differentiating factors between the two
groups were the structure and components of the musical activities. The fall sessions
for the experimental group were focused primarily on writing skills while the
spring sessions taught reading/book concepts. Music sessions for the control
group were based purely on the thematic material, as determined by the class-
room teacher with purposeful exclusion of all preliteracy concepts. All partici-
pants were pretested at the beginning of the school year and posttested before
the school year ended. Overall, results demonstrated that music sessions signifi-
cantly enhanced both groups abilities to learn prewriting and print concepts.
However, the experimental group showed significantly higher results on the
logo identification posttest and the word recognition test. Implications for cur-
riculum design and academic and social applications of music in Early
Intervention programs are discussed.
further reading
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
hrstopher Norrs,
Downe, Badersby,
Thrsk, North
Yorkshre YO; (PP,
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Ganschow, L., Philips, L. & Schneider, E.
(2001) Closing the gap: accommodating stu-
dents with language learning disabilities in
college. Topics Lang Disord 21 (2), 17-37.
This article describes language difficulties of
college students with language learning dis-
abilities (LLD) and the types of accommoda-
tions that are provided to these students.
First, it presents four language issues that
affect the provision of accommodations. It
points out that there are differences across
universities in the accommodations offered
and stresses the importance of matching
the student to the university that can provide
accommodations appropriate to the students
needs. It presents three case studies of stu-
dents who vary on a continuum of severity of
language problems, describes accommodations
provided for each, and presents two perspec-
tives on accommodationsthat of the LD ser-
vice provider and that of faculty who taught
the three students. The article suggests ways
for speech-language specialists to collaborate
on a high school transition team and with the
LD Coordinator at the university. (34
Stallard, P., Williams, L., Lenton, S. & Velleman, R.
(2001) Pain in cognitively impaired, non-commu-
nicating children. Arch Dis Child 85 (6), 460-2.
AIM: To detail the everyday occurrence of
pain in non-communicating children with
cognitive impairment. METHODS: Thirty four
parents of cognitively impaired verbally non-
communicating children completed pain
diaries over a two week period. Each day, for
five defined periods, parents rated whether
their child had been in pain, and if so, its
severity and duration. RESULTS: Twenty five
(73.5%) children experienced pain on at least
one day, with moderate or severe levels of
pain being experienced by 23 (67.6%). Four
children (11.7%) experienced moderate or
severe pain lasting longer than 30 minutes on
five or more days. No child was receiving
active pain management. CONCLUSIONS:
Everyday pain in children with severe cogni-
tive impairment is common, yet is rarely
actively treated.
Frost, M. (2001) The role of physical, occupa-
tional, and speech therapy in hospice:
patient empowerment. Am J Hosp Palliat
Care 18 (6), 397-402.
The use of physical, occupational, and speech
therapy is a growing trend in hospice. The
purpose of this paper is to define the role of
the physical, occupational, and speech thera-
pist as part of the hospice team in the context
of the various therapies objectives. A case
study is presented and clinical implications
are discussed. (19 References)
hatever we as therapists feel about them, computers are here
to stay. We are increasingly being asked about the possibili-
ties of using a computer in therapy. But how does a busy clin-
ician keep abreast of new software that becomes available so
as to be able to respond to this in an informed and informa-
tive way? And, given that software resources specific to individual client groups are
limited, could we be borrowing more from what is available to other client groups?
Software reviews which evaluate the potential for application in speech and lan-
guage therapy do exist. Wren (2001a; 2001b) provides a review of software for work-
ing with children which was carried out as part of the Hear IT, Sound IT project to
develop software appropriate for working on phonological difficulties in children.
The Software Evaluation Booklet produced by the Aphasia Computer Team (1999) at
the Speech and Language Therapy Research Unit at Frenchay Hospital reviews soft-
ware appropriate for people with aphasia. It covers some of the most widely known
software such as INTACT, REACT, Parrot and Bungalow (see resources) as well as some
recreational and word-processing software. The evaluation process involved people
with aphasia giving their views.
Therapists often report frustration at the limited choice and quality of specialist
aphasia software available, not to mention the cost. The number of software titles
designed specifically for aphasia therapy, though growing, is still limited and is small
compared to the number designed for the education sector in general. This article
therefore draws attention to the fact that software designed for other groups may
nonetheless by useful to people with aphasia. We review a limited selection of seven
titles (My House, Smart Start English, Speech Sounds on Cue, Jigsaw, Co:Writer, Clicker
4 and Out and About), none specifically designed for users with aphasia, and demon-
strate in what ways these may be useful to them.
There is a risk in any evaluation that the software reviewed is quickly superseded.
We hope that our explanation of our evaluation protocol will enable readers to apply
evaluation procedures independently, thus keeping abreast of innovation. In review-
ing non-specialist software, we want to encourage readers to think broadly when it
comes to software resources.
The task of systematically reviewing software taken from such diverse categories as
therapy software, word processing software and recreational software is a challeng-
ing one and inevitably results in distilling information to a summary. However, 10
questions were borne in mind when developing the evaluation protocol:
1. What language tasks are targeted?
Software may target auditory language comprehension, written language compre-
hension, speech sound production, word processing skills or visual skills. Just as with
conventional therapy programmes, it is likely that you will get most from the software
by picking and choosing aspects suitable for individual clients.
2. What is the intended client group and what other client groups
may benefit?
Some software (for example, My House) has been designed primarily for children and
uses cartoon type drawings, but may be useful with other client groups. If you have
reservations regarding the suitability of software for adult clients, demonstrate it,
explaining it was designed for use by children as well as adults, and let the user decide
whether it is acceptable or not. Even if aspects of the software are clearly appropri-
ate, you may need to select and leave out those that are not. Certain parts of Out and
About, which is designed for people with learning difficulties, are appropriate for
people with head injury but will not necessarily be appropriate for people with apha-
sia following a stroke.
you want to
keep abreast o
normaton technoogy
open up new
opportuntes or cents
oer therapy at both
mparment and
unctona eves
Read this
With the range of software for
people with aphasia limited,
Julia Wade and Sarah Woodward
use an evaluation protocol to
check out packages designed for
other markets. So, have you
embraced the age of
information technology?
Or is IT still just a pronoun in
capitals? Whatever your level of
experience and client group,
read on to wise up to the
potential of computers.

Julia Wade and Sarah Woodward

This is IT
strategy by the user. Trial and error is possible in
My House when the instruction is simply repeated
taking no account of the nature of the error. In
most software, a maximum of three incorrect
responses is allowed before the target is demon-
strated so, even where no informative feedback is
given, the user knows the correct response will be
revealed after three attempts.
In Jigsaw no information is given as to why any
attempt at placing a piece of the jigsaw might be incor-
rect and the piece is simply removed again. In Speech
Sounds on Cue the users attempts are not recorded
therefore no feedback on production is given.
This question does not apply to the adapted
word processing software because there is no pre-
determined correct answer.
7. How are the results recorded and
Ideally the number of correct responses will be
presented graphically in a form accessible to the
non reader, as in Out and About and Smart Start.
My House also gives the response time in seconds
but all feedback is in the written word which is a
far less use-friendly medium for people with com-
munication impairments. Out and About also
reports the time taken to complete the activity
and whether a prompt has been needed.
The recording and presentation of results does
not apply to the adaptive word processing software
as the purpose of this software is simply to facilitate
3. What are the hardware/software
requirements of the therapy software and
cost of the software/extra user licenses?
i) Hardware/software
If the software uses sound output, the computer will
need a sound card and speakers. Many recently pro-
duced software packages will only run on Windows
95 or later and may at some point become incom-
patible with future versions of Windows.
ii) Software costs
Costs vary tremendously. It is worth considering
whether you are likely to want to install the soft-
ware on a persons home computer or just use in
clinic - and examining the price structure for multi-
ple user licenses. For example, the cost of My
House is 129 for a single user license, 449 for the
5 user license, and 645 for a 35 user licence, a price
structure clearly favouring large scale use in schools
over home usage. By contrast, for the software
Out and About a single user licence costs 59, addi-
tional user licenses are available at 10 each and
the recently introduced single license home user of
20 has allowed cheaper access for use at home.
4. What level of ability does the user need?
This is a very gross categorisation to act as a gen-
eral guide. We have used a three point scale of
low-moderate-high. We felt some of the soft-
ware reviewed could be appropriate for a broad
range of ability depending on how it is used.
5. How clear is visual presentation?
In Co:Writer, an assistive word processing package,
several windows need to be open simultaneously
and users can be confused as to which window
they are working in. As a result they may need
support and facilitation for longer before being
able to use the software independently. However,
in Speech Sounds on Cue, information on screen is
limited to a visual demonstration of the lip shape
that corresponds to the target sound and the letter
that corresponds to this sound. Users therefore
need fewer demonstrations before they are able
to use the software independently. We used a
simple three star rating system to indicate clarity
of presentation with one star indicating poorest
and three stars greatest clarity.
6. Does the software provide intervention
and feedback for incorrect/correct
In Out and About the feedback given relates to
the nature of the error made. For example, the
response No, you need to find something to
wear when its hot is given when the user has
mistakenly selected an overcoat to wear in hot
weather. Smart Start also has some exercises
where the feedback relates to the error made,
such as, No thats the banana, you want the
apple. This encourages linguistic processing of
feedback rather than a repeat trial and error

Figure 1 Summary of evaluations

Package My House series Smart Start Speech Sounds Jigsaw Co:Writer Clicker 4 Out & About
English on Cue
Description of
client groups
(single licence)
Level targeted
Visual interface *** ** *** *** * ** ***
* *** 0 * N/A N/A ***
on error
*** * 0 N/A N/A N/A ***
of results
** 0 0 0 N/A N/A ***
0 0 0 *** N/A *** 0
Input device M K T S M M M K T S M K M K T S M K

Adapted word
software designed
for all ages with
limited literacy skills
Stroke, head injury,
learning difficulties
Crick software
W95, soundcard
Speech and language
therapy software
designed for the learning
disabled for work on all
areas of auditory
language and memory
Stroke, head injury,
learning difficulties
59 (20 home
W95, soundcard
Adapted word
software designed
for all ages who
need some help
with their writing
Stroke, head injury,
learning difficulties
Don Johnston
W95, soundcard
Software for doing
jigsaws on the
computer for all
Crick software
Speech and
language therapy
software designed
for work on
W95, soundcard
English as a foreign
language software
designed for any
learner to work on
English language
Stroke, head injury,
learning difficulties
W95, soundcard,
SVGA video card
Speech and
language therapy
software designed
for children to
work on auditory
Stroke, head injury,
learning difficulties,
Laureate Learning
W95, soundcard
Ratings key: 0 = none
* = poor
** = good
*** = excellent
Input device key: M = mouse
K = keyboard
T = touchscreen
S = switch
Figure 2 Case example
J, a 73 year old lady who had a left cerebrovascular
accident about 18 months ago, was referred to the second
author who provides a Computer Assessment and Training
service from Frenchay Hospital to support clients and
therapists in using computers in therapy. She has aphasia
and dyspraxia, which have severely affected her spoken and
written output. She is ambulant around the house, but
needs a wheelchair to get about for longer trips. She has
good functional use of both her hands.
Communication history
Js levels of comprehension are compromised in formal
assessment but rarely affect her social and functional
communication. Her speech is very limited and the few words
she has are often difficult to understand due to her dyspraxia.
Her writing is restricted to initial one to three letter spelling.
She reads well at sentence level. She is an active participant in
all communication settings.
Current communication
J is a very sociable, confident and effective total communicator.
She rates well in terms of communicative competence and uses
her various strategies to respond, ask questions, initiate new
topics and indulge in general banter. However she obviously
has frustrations. J uses a combination of spoken single words
augmented with lots of clear, functional gesture; pointing; use
of a communication book; use of a diary; use of a dictionary;
and writing (initial one to three letter spelling). She has excel-
lent levels of attention and concentration, and
demonstrates good potential for new learning.
Speech and language therapy input
When J was first referred, she was working on improving her
writing at a single word level, improving her reading at
paragraph level and increasing her speech output.
Previous computer knowledge
J had never used a computer before and indeed was extremely
nervous about doing so. Her husband felt similarly. Her speech
and language therapist had some limited experience of using
computers, but did not feel certain of how to introduce them
into Js therapy.
Reason for referral
J was referred to us by her speech and language therapist
because she appeared to have so much potential and was so
eager to try everything possible to increase her communication
Js aims:
to learn how to use a computer
to then use the computer to work on the same areas as in
speech and language therapy sessions, independently
to increase leisure opportunities
to improve written output.
Software we looked at
1. REACT (specific speech and language therapy language programme): We looked at
using this for work on reading comprehension, spelling and whole word sentence
2. Co:Writer (word prediction package): We examined this to see if J could use her
initial letter spelling and whole word reading to generate some of her own writing.
3. Clicker (supportive writing tool): We considered using this for work on sentence
building skills in a functional way (writing cards and letters).
4. WAPS (basic keyboard familiarisation): We looked at this to see if it would help J
practise finding her way around the keyboard.
With help from the local speech and language therapist, we put together a therapy
programme using a combination of three of these software packages (WAPS, REACT and
Clicker) which J would find motivating and of immediate functional use. The aim was
for her to improve skills on some packages while putting these new skills to functional use,
for example when writing cards and letters. Long-term, we will review progress with
spelling and sentence structure with a view to introducing the fourth package (Co:Writer).
We set up a loan computer at Js home and trained J and her husband in
operating the various packages. We left a folder with detailed, user-friendly, step by
step, picture supported instructions for them to follow.
J and her husband quickly became familiar with the operation of the computer and the
layout of the keyboard. J was able to find her way in and out of the software packages
and the various exercises we had set her with ease. J and her husband only needed
one session of two hours to be using the computer independently (bearing in mind NO
previous experience). This was followed by four home visits each lasting 1
/2 hours.
Within a month they were eager to purchase their own computer and three months
after they had first set foot in the computer assessment and training service they were
fully set up with their own PC (personal computer) and printer.
J now uses the computer daily for:
working on her spelling and sentence building skills
writing her Christmas (and now starting on her Easter) cards
writing to her family who live far away
carrying out new hobbies such as making cards and playing games on
the computer. (J and her husband have now purchased various
software packages themselves which they have figured out how to use
with minimal help.)
J and her husband have also attended free IT lessons at the local library to boost their
skills and confidence. J feels extremely proud of her achievement given her age, lack
of previous experience and language difficulties. She has mastered something
without difficulty that others, without any language impairment, are still challenged
by. She feels it has helped her work independently on certain skills thus giving her
more therapy. She also feels it has opened up new pastimes for which she is grateful
given that, like many people in her situation, a lot of her previous hobbies such as
gardening and cooking are now impossible to realise.
During a course run by the second author
and Alex Davies in June, many delegates
expressed an interest in forming a
Computer SIG. This could provide a useful
forum for the exchange and brainstorming
of ideas and equipment. If you would be
interested, contact us:
Sarah Woodward, tel. 0117 9701212 x
2241, e-mail
Alex Davies, tel. 0117 9754834, e-mail
Frenchay Hospital, Bristol, BS16 1LE or at
Wren. Y. (2001a) Software and Speech - a review
of software in phonology therapy. International
Journal of Language and Communication
Disorders 36 supplement, 487-492.
Wren, Y. (2001b) Childrens software evaluation
for Hear IT - Sound IT Research Project. Available
on request from the Speech and Language
Therapy Research Unit, Frenchay Hospital, Bristol,
BS16 1LE or at
Bungalow Software, see
Clicker 4 from Crick Software, 35 Charters Gate,
Quarry Park Close, Moulton Park, Northampton
NN3 6QB, tel. 01604 671691,
Co:Writer from Don Johnston Special Needs, 18/19
Clarendon Court, Calver Road, Winwick Quay,
Warrington WA2 8QP, tel. 01925 241642,
INTACT from Aphasia Computer Team, Frenchay
Hospital, Bristol BS16 1LE, tel. 0117 918 6529,
My House series by Laureate Learning Systems, Inc.
From Rompa, Goyt Side Rd, Chesterfield, Derbyshire,
tel. 0845 3000 899,
Parrot Software, see
REACT and Speech Sounds on Cue from Propeller
Multimedia Ltd, PO Box 27028, Edinburgh EH10
6WD, tel. 0131 4460820,
SEMERC, Granada Learning Ltd, Granada
Television, Quay Street, Manchester M60 9EA, tel.
0161 8272927,
Smart Start English from AVP, School Hill Centre,
Monmouthshire NP6 5PH, tel. 01291 625439,
Speech and Language Therapy
(The Decision-Making Process
when Working with Children)
Edited by Myra Kersner and
Jannet A.Wright
David Fulton Publishers Ltd.
ISBN 1-85346-668-9 25.00
This book addresses the everyday decision-
making processes that speech and language
therapists face when assessing and managing
children. It starts by describing a framework
for the processes involved, which is then
applied to different work settings and a vari-
ety of client groups. Working with other pro-
fessionals and parents is also included.
Each chapter covers a different specialism
and is by an expert in that field. They pro-
vide clear details with helpful key points.
Terminology is clearly defined and learning
outcomes highlighted.
It is especially relevant to and a useful refer-
ence point for students, newly qualified
therapists, plus returners (and anyone super-
vising them). A valuable addition to any
speech and language therapy department.
Philippa Fieldson is a returner working as a
speech and language therapist for
Worcestershire NHS Trust.
Phonology Resource Pack for
Adult Aphasia
Sarah Morrison
Speechmark ISBN 0 86388 228 5
This will be a welcome resource to all therapists
who like to offer psycholinguistically motivated
impairment therapy. The pack consists of five
ring bound A4 booklets providing a substantial
body of therapy exercises aimed at developing
the phonological skills of people with aphasia.
Most exercises are rhyme judgement tasks
based either on pictures or written words.
Others involve homophone judgement and a
degree of phonological segmentation. There
are no syllable number judgement exercises
(the sales blurb describes the pack as being
comprehensive, always a dangerous claim!)
The pictures are line drawings presented in a
gently humorous style and photocopying is per-
mitted. The generous appendix allows for pre-
exercise familiarisation and the consistency of
format between exercises makes it easy to use.
Therapists working in an outpatient or rehab
setting will certainly get their moneys worth.
Jon Hunt and Lauren Caris are speech and lan-
guage therapists with North Bristol NHS Trust.
word processing. No score representative of accu-
racy rate is given in the Jigsaw software.
8. Does the software allow the therapist
to customise the menu options available
to the user?
My House gives the option of an exploring or a
testing mode for the user and allows customisa-
tion of response time. Smart Start does not allow
any customisation so the full suite of exercises is
always available to the user. Out and About has a
totally customisable menu facility so that anything
from one to eight exercises can be made available.
9. Does the software have an authoring
component to allow the clinician to
create their own exercises?
This allows the flexibility of targeting material
that is personally relevant. Jigsaw lets the thera-
pist use scanned or digital photos. Clicker 4 allows
for personalised words, phrases and pictures to be
inserted into the users grid from which users then
select relevant items to build up sentences in a
separate word processing window.
10. Does the program allow for
different input devices to be used?
My House, Jigsaw and Clicker 4 can all be accessed
by people unable to use a keyboard or mouse
(that is, using a touchscreen or a switch). A lot of
people with any kind of upper limb weakness will
find a tracker ball easier to use than a mouse.
The summary of evaluations is in figure 1 (p. 14).
It shows that, as in conventional table-top thera-
py, no one therapy activity is sufficient to target
any individuals needs, and activities become most
effective when functional gains are the main goal.
The case example (figure 2, p.15) illustrates how
different software can be used concurrently by one
person with aphasia to target their language diffi-
culties at both impairment and functional level.
Both authors are speech and language therapists
working for North Bristol NHS Trust at Frenchay
Hospital. Julia Wade (tel. 0117 918 6529, e-mail works in the Speech
and Language Therapy Research Unit, investigat-
ing use of computers in aphasia therapy. Sarah
Woodward (tel. 0117 970 1212 ext 2241, e-mail provides a Computer
Assessment and Training service from Frenchay
Hospital to support clients and therapists in using
computers in therapy.
To Alex Davies and Jane Mortley for their contri-
butions to the Software Evaluation Booklet and
the evaluation protocol on which our evaluations
were based.
Aphasia Computer Team (1999) Software
Evaluation Booklet. Available on request from the
Speech and Language Therapy Research Unit,
Do I need to invest more time
and resources in computer
based therapy?
Do I consider how therapy
materials designed for one
client group can be adapted
for another?
Do I encourage clients to take
advantage of community
education opportunities?


EWS. . . . . . . . . . . . . . . . . . . . . . .
r e v e w s
Supporting Partners of People with
Aphasia in Relationships and
Conversations (SPPARC)
Sarah Lock, Ray Wilkinson & Karen Bryan
Speechmark 95.00
Developed following the two year Coping
with Communicating research project, this
pack contains three manuals and a videotape.
The manuals are easy to read and use. They
contain a sound theoretical background and
rationale for providing psychosocial support
and conversation training for carers of people
with aphasia. However, it goes beyond the the-
ory and provides ready to use group plans and
reproducible materials. Quotes from partici-
pants and practical tips from the lead clinician
make it very easy to adapt the materials to the
specific needs of various carer groups. The pack
also serves as a sound introduction to, or
refresher in, conversational analysis and its use
in group or individual therapy.
A useful addition to any department working
with people with aphasia and their communi-
cation partners.
Tracey McDevitt is senior speech and language
therapist in neurorehabilitation at St. Marys
NHS Hospital Trust, London.
Alpha Smart 3000 with Co:Writer
SmartApplet unit and software
AlphaSmart Inc. (SmartApplet from Don
Johnston Special Needs)
Around 190 per unit (230 if pre-loaded
with Co:Writer SmartApplet which is also
available separately at 89)
Kathleen I wrote my story on your little computer
and I got to the end!
Perhaps the best recommendation for this compact and
easy to use computer companion was nine-year-old
Davids reaction. It allowed him to sit with his peers at
a table in his mainstream class. He could concentrate
on the content and organisation of his piece of work,
rather than the painful process of spelling and letter
formation. His classmates were envious of him.
With the word prediction and topic dictionaries in
Co:Writer, this device can also aid sentence construc-
tion and vocabulary. It is not a traditional therapy
tool, but could be recommended to schools as part of
a package of resources to aid the inclusion of older
children with language and/or motor difficulties. It
may seem expensive but, as it supports eight separate
files, it lends itself to multiple users. (Using the built-
in calculator, I worked out that is under 30 per child.)
Its practical, portable, gives the child a sense of
achievement, and it looks good. Mine is already well
Kathleen Cavin is a specialist speech and language
therapist at Robert Blair Language and
Communication Resource in Islington.
InterAACtion: Strategies for
Intentional and Unintentional
Produced by SCIOP (Severe
Communication Impairment
Outreach Projects)
SCOPE (Vic) Ltd, PO Box 381, St
Kilda 3182 Australia
This Australian video is an excellent resource
for those working with people with severe
learning disabilities.
It covers the three stages of communication
used in the Triple-C checklist. These are
explained clearly and illustrated with real life
situations. Practical communication strategies
are suggested and an accompanying manual
will be ready in July.
There are major challenges in making a video
about interaction. Sometimes the structured sec-
tions which focused on teaching lacked the shared
closeness required for good interaction. The use of
short clips at either side give very positive exam-
ples which are well worth studying in themselves.
The video is professionally made and reflects
good practice with a client group for whom
there is a dearth of quality resources.
Lois Cameron and Joan Murphy are research
speech and language therapists at the AAC
Research Unit, University of Stirling, Scotland.
Annies Signalong CD Rom
The Signalong Group
Graydex Software Ltd 49.50 + 4 p&p
This CD contains the Signalong Core Vocabulary from
1A - 1D. There are two main sections - a dictionary and
a game/quiz.
The vocabulary can be set to the individuals require-
ments. The dictionary enables you to get a clear
description and a demonstration of each sign.
Handshapes and the finger spelling alphabet are also
described separately.
The game is very simple; Annie performs a sign and
you have a choice of three answers. A friendly little
boy informs you whether you are correct and you are
given a score out of ten.
The CD is extremely easy to use. Anyone with an interest in
signing correctly can check the database at their own pace.
A useful resource to supplement the teaching of signs.
Parents, teachers, carers, as well as the client them-
selves can spend time checking their signing ability or
increasing their vocabulary.
Dee Burgess is a speech and language therapist with
Plymouth Primary Care NHS Trust. She works with chil-
dren and adults with physical disabilities, with moderate
- severe learning difficulties. She is a Signalong tutor.
The Editor wishes to apologise to Lynn Busby
and readers for inadvertently missing out the
first paragraph of her review in the Spring 02
issue. The full version is below.
The Accent Method (A Rational Voice
Therapy in Theory & Practice)
Kirsten Thyme-Frokjaer & Borge
Speechmark ISBN 0 86388 272 2
Nicely presented, this will be of interest to those
trained on an Accent Method course who feel their
skills have become a little rusty. The accompanying
CD is particularly useful, with good quality voice
and drum recordings to clarify the written exercises.
The book covers four areas: history and principles;
anatomy, physiology and acoustics of phonation;
teaching the method; and acoustic and physiolog-
ical measurements. The section on teaching,
although short, is extremely practical and
describes fully the dynamic approach of the
method. However, I would have liked to see some
sample case presentations and felt the writing
style was rather wordy.
It represents good value for money but should
not be considered to be a substitute for the inten-
sive training courses run by the authors.
Lynn Busby is a specialist speech and language therapist
(voice) within the Ulster Hospitals and Community Trust.
Working with Dysphagia
Lizzie Marks & Deirdre Rainbow
Speechmark ISBN 0-86388-249-8
35 + VAT
This is a useful resource and reference book, giv-
ing a good basic introductory text with a wide
breadth of information for the less experienced
dysphagia therapist. It may not be detailed
enough for highly specialised areas in dysphagia
but, as a general handbook, it is appropriate for a
range of client groups in both acute and commu-
nity settings, with chapters covering issues from
practical assessment and comprehensive dyspha-
gia management, tracheostomies, ventilation,
nutrition and hydration, to legal, ethical and pro-
fessional issues, and health and safety.
It is clearly laid out, written in straightforward lan-
guage, easy to use, and has many useful diagrams. It
also contains photocopiable charts and forms, assess-
ments and programs, which are helpful in practice.
Generally, a good addition to the Working with series.
Julia Loughran is a speech and language therapist
working for Bath & North East Somerset PCT with
Adults with Learning Disabilities.
care pathways
n any one year, 50 per cent of new referrals
received by our department will be aged
between 3 and 4 years. An audit in 1999 exam-
ined referrals of children aged 3 to 3
/2 years
and identified the care pathway to current sta-
tus or discharge. One outcome was the identification
of variation in patterns of care within the diagnosis
of delayed speech and language development. Could
this be resulting in an imbalance in delivery of care to
individual clients? Are some being seen who would
respond spontaneously without professional input?
And are some not being seen who would benefit?
Would care pathways help us clarify and overcome
this as a department?
Care pathways are most commonly used to
describe a multidisciplinary team approach devel-
oped by all involved and not led by one discipline
(Hunt & Slater, 1999). They have tremendous
appeal because they accommodate inter-discipli-
nary teams of care, focus on process, reduce
unnecessary variation of care, and attend to qual-
ity and client outcomes (Olds, 1997). Within uni-
disciplinary teams the term could still be valuable
since it describes a route taken for an individual
client from the point of first contact to eventual
discharge, mapping the modes of intervention
provided along the way. A perceived advantage is
consistency of care. Within our
department, clinics are often man-
aged by newly qualified therapists.
They may benefit from care path-
ways being in existence to provide
guidance in following an accepted
departmental procedure which
should lead to increased confidence
in decision making. A possible dis-
advantage of a care pathway is if it
is perceived as prescriptive and
inflexible - and we know, when
viewing a client as a whole, it is
important to take into account vari-
ables such as parental anxiety and
We decided to investigate care pathways, firstly
through a comprehensive literature review on
their existence to support children presenting
with delayed speech and language development
within the 3-3
/2 year age range. It became apparent
that this was too narrow and thus too limiting so
we extended it to the preschool age range, 0-5
years. We wanted to determine the benefits for
clients and therapists and to see how they matched
up with what we do in our department (figure 1).
Following referral, we carry out initial assessment to:
1. make a diagnosis and describe the childs diffi-
culty by comparison to developmental norms in
terms of delay or disorder
2. inform others involved with the child
3. plan and prioritise the caseload.
Individual therapists are responsible for deciding
the next appropriate course of action which can
include getting a second opinion within the
department and onward referral to other agencies.
Objectivity and sensitivity
The literature suggests a number of variables
influence the therapists decision on proposed
management of the client. Highlighting current
practice in Wiltshire and Swindon, Owen et al
(2001) stress the need for combined objectivity and
sensitivity in decision making. They looked at deci-
sion making amongst therapists in their manage-
ment of children with phonological delay with a
view to devising a pathway protocol.
Case descriptions were given to the 14
therapists who were asked:
1. What would be your management
of this child?
2. What would be your criteria for
offering therapy to this child?
Responses to the first question fell into
four categories:
regular therapy
programme and review appointment
advice and/or review
The second question highlights the
range of factors therapists take into
account when deciding whether to provide treat-
ment: the childs speech, support and commitment,
general development, anxiety, intelligibility, case-
load pressures, and environmental factors.
The authors feel these factors highlight the sub-
jectivity in making clinical judgements. A protocol
in the form of a flow chart was designed by the
team to help therapists make a decision to pro-
vide treatment or discharge for children with
phonological delay or disorder. They hope that
less therapy will now be provided for children
who are likely to progress spontaneously.
The three main outcomes of the decision making
process in our department are:
1. Review with advice
2. Discharge with advice
3. Intervention.
Monitoring option
In general, therapists offer review with advice if they
feel the childs speech and language falls within
normal developmental patterns but may require
therapy at a later date. It may also be appropriate
if spontaneous progress seems likely. Reporting on the
Early Communication Audit Manual, Sheridan (1999)
discusses review as a recommendation following ini-
tial assessment and suggests this could be perceived
as a means of having a hidden waiting list. However,
the authors of the manual feel it is a viable monitor-
ing option for some kinds of difficulty, particularly
children under three years with expressive problems,
as these often resolve spontaneously.
In Newcastle, where initial assessment is by two
members of staff, review has been removed as a pos-
sible outcome of initial assessment for children
whose speech and language is delayed but might
develop spontaneously or with minimal input
(Stringer, 1999). Advice and the criteria for re-referral
is given to the parent/carer. If the child is re-referred
within 12 months of this type of discharge and needs
intervention, they are placed on the waiting list as of
their first assessment date. The author reported that
staff involved in the audit were concerned about the
number of children being re-referred. Information
on the database, however, indicated that therapists
were actually 94 per cent accurate in predicting the
children who would need therapy.
Removing review as an option and discharging
with advice is also favoured by Pickstone (1997) to
avoid the system becoming clogged up with
Are some clients
being seen who
would respond
professional input?
And are some not
being seen who
would benefit?
you want to
hep new graduates
encourage approprate
be more consstent
Read this
Some clients have a smooth journey through speech and language therapy -
others find there are leaves on the line. Tracy Robertson and Wendy McKenna
turn to the literature to find out if care pathways can help departments
provide a more reliable and consistent service for preschool children, while
leaving sufficient flexibility in the system to respond to clients as individuals.
Tracy Robertson Wendy McKenna
On the
right track?
Do we use team
discussion to discover
and address differences
in service delivery?
Do we recognise that
consistency and reliability
are important service
quality markers?
Is our decision making
process transparent?
Figure 1. Flow chart
care pathways
This would be concerning but, when examined
further, other factors may have influenced the out-
come. The therapy group did not always receive the
amount of therapy the individual therapist had
planned or thought was ideal due to variance fac-
tors such as caseload size, waiting list pressures,
general workloads and sickness and holidays on the
part of the therapist and child. To us, this suggests
care pathways to make our service consistent and
targeted would be the first step in preparing to
evaluate the effectiveness of the therapy we offer.
The final stage in a care pathway is discharge.
This decision is discussed with the parents/carers
with the understanding that future re-referral is
an option. In this instance, the care pathway
would be revisited. The criteria for discharge will
vary and can include:
1. Satisfactory, where original aims have
been achieved.
2. Limit of improvement.
3. Lack of cooperation, for example, consistent
fail to attend.
4. Deceased.
5. Left district.
So, what have we concluded from our literature
search for our department?
1. A care pathway/protocol may be a way for-
ward, specific to diagnostic category (for exam-
ple, phonological delay/disorder). This should lead
to consistency of care across the department and
provide all therapists, regardless of experience,
access to standard guidelines. It would still allow
flexibility in decision making if variance factors
are accounted for.
2. Therapists are relatively accurate in predicting
who to treat, and team discussion has a valuable
role in reaching clinical decisions. Although a team
approach to initial assessments involving more
experienced therapists can raise confidence in clin-
ical judgements, in practice this may work better
where a high number of staff are within easy
reach of each other - not the case in our service.
3. There appears to be no real agreement on the
value of review as a recommendation. For the
moment, we plan to keep it as a means of moni-
toring development.
unnecessarily high caseloads. She reports that origi-
nally all therapists in Sheffield carried out initial
assessments and it was often unclear if they were all
offering therapy to the same type of child - that is, if
a similar care pathway was in place. A new tripartite
system was introduced in 1992, the first component
of which was referred to as triage where the ser-
vices most experienced therapists carried out a
screening within three months of referral. The sec-
ond component meant children were followed up
within three months for a full assessment and a
rapid response intervention programme consisting
of four one hour slots with the family. The third com-
ponent meant that those requiring continued inter-
vention three months after rapid response would
receive intensive block treatments. The author
reports positive outcomes to both staff and clients
including a more equitable spread of workload
amongst therapists and a decrease in waiting lists.
The content of intervention offered is beyond the
scope of this review but, given that we are talking
about community clinic work, we did note the
findings of Speech and Language Therapy
Effectiveness with Pre-school Children (STEP)
(Glogowska et al, 1998), a randomised controlled
trial which aimed to establish effectiveness of
speech and language therapy with preschool chil-
dren and to track the natural history of early lan-
guage development. Children assessed as needing
therapy were, with the consent of parents, ran-
domised either to immediate treatment or
watching/waiting where parents were given
advice but their child did not receive therapy.
Sheridan (2000) reports that the impact on the
speech and language of the children in receipt of
therapy was minimal. At 6 and 12 month follow-
ups the researchers found that, although average
differences between the two groups nearly always
favoured the speech and language therapy group,
only one of three primary outcome measures
(auditory comprehension) and two of eleven sec-
ondary measures (improvements in phonology
and re-eligibility for the trial) showed statistically
significant differences in favour of the therapy group.
A fuller version of this article has been distrib-
uted to all speech and language therapy staff in
the Trust for their comments. Informal discussion
provides a favourable view towards implementing
care pathways / protocols. Newly qualified thera-
pists feel this framework would ensure that they
were adhering to a certain standard and help
them gain confidence in assessment and planning.
Benefits to clients and other members of the mul-
tidisciplinary team would include access to a well-
defined policy concerning appropriateness of
therapeutic intervention.
We would welcome an information exchange
with other departments where care pathways /
protocols have been devised and used.
Tracy Robertson and Wendy McKenna are speech
and language therapists with Ayrshire & Arran
Primary Care NHS Trust which provided the fund-
ing for this project.
Glogowska, M., Roulstoe, S., Enderby, I. & Peters,
T. (1998) A time of trial. Bulletin, Royal College of
Speech & Language Therapists October, 8-9.
Hunt, J. & Slater, A. (1999) From start to outcome
and beyond. Speech & Language Therapy in
Practice Autumn, 4-6.
Owen, R., de la Croix, H., Lewin, J., Lawer, E. &
Davies, S. (2001) A first class team. Speech &
Language Therapy in Practice Spring, 16-19.
Pickstone, C. (1997) Weighting not waiting.
Human Communication 6 (2).
Olds, S. (1997) Designing a care pathway for a
maternity support service program in a rural
health department. Public Health Nursing 14 (6),
332-8. Review.
Sheridan, J. (2000) Only five hours therapy for pre-
school children. Bulletin, Royal College of Speech
& Language Therapists July, 6.
Sheridan, J. (1999) Early Communication: evaluat-
ing the service. Bulletin, Royal College of Speech &
Language Therapists August, 1.
Stringer, H. (1999) Are three-year-olds predictible?
Bulletin, Royal College of Speech & Language
Therapists October, 12.
SEOND OPlNlON ONvARD RElERRAl e.g. Educatona Psychoogy
nca Nedca Ocer, ENT
in my experience
want to recrut the rght
peope to the proesson
cannot accommodate a
observaton requests
have ost sght o the
postve aspects o the
Read this
everal years ago I took on the role of
coordinating observation requests and
information to prospective speech and
language therapists in addition to coor-
dinating student placements at Kings
College Hospital. As well as developing the help
we can offer to these people, I have become
increasingly aware not only of the importance of
being able to offer such help, but also of the asso-
ciated difficulties for busy services.
There seems to be a great variation in the
amount and variety of observation that prospec-
tive speech and language therapists manage to
achieve: some have tried contacting many differ-
ent services with no success whatsoever; others
have been provided with a long, varied and infor-
mative programme of observation in their local
area. The reported difficulties are mainly as
expected: lack of time, caseload pressures, confi-
dentiality and the need to commit to student
speech and language therapist training.
Whilst these problems are clearly very real it con-
cerns me that, with the professions current recruit-
ment and retention difficulties, we need to ensure
we are attracting the right candidates for training.
Those embarking on a training course should be
doing so with as clear and realistic an idea as possible
about speech and language therapy, and should be
sure that it is the right decision to suit their skills,
interests and personality. For this reason it is impor-
tant that they are able to meet and talk to speech
and language therapists and are able to get as
broad an idea as possible of the range of work.
It is also vital that, as well as promoting the pos-
itive aspects of speech and language therapy, we
make people aware of the difficulties and frustra-
tions that they might encounter. It is very disap-
pointing to hear about trained speech and lan-
guage therapists who only stay in the profession
for a short time. This is a huge waste of resources,
In a profession with
recruitment and
retention difficulties, we
need to be proactive in
encouraging the right
people into the
profession. As
Lucy Wood found
through organising
speech and language
therapy as a career
courses, such efforts
also bring personal
benefits by reminding
us that our work is
interesting, varied
and challenging.
of valuable clinical placements and, not least, of
the individuals time, effort and money.
Although, like everyone else, we have time pres-
sures and a primary commitment to our patients,
we are lucky at Kings in being a fairly large hospital
service, with 15 speech and language therapists and
a range of adult specialisms. This has been helpful
in organising our two day Speech and Language
Therapy as a Career courses.
We have continued to offer a day or half day of
observation to local people but cannot accom-
modate every request, especially as they come
from all over London and further afield. The
two day courses developed on from shorter, free
group sessions we had been running, and were
in response to the large number of requests (up
to 50 over a year) being made for observation.
The first group sessions we ran included talks,
videos, displays and the chance to meet several
speech and language therapists, but could not
accommodate direct observation and, we felt,
could not truly represent the diversity within
speech and language therapy. To provide a
much more thorough introduction, coupled
with income generation for the service, I devised
a programme for a two day course in Autumn
2000, costing 40.00 per person. As Kings is pre-
dominantly an adult service, community col-
leagues from paediatric and learning difficulties
services were also involved.
The course included:
an overview of communication and swallowing
an introduction to working in the fields of
paediatrics, learning difficulties and adult
acquired disorders
information on the Royal College of Speech &
Language Therapists, career structure and
The right
the job
the content [but] glad to make a decision on real-
istic information. Another said, it has complete-
ly done its job. All three rated the course highly
for enjoyment and value for money.
Interestingly, direct observation was felt to be
the most important part of the course, although
my own view is that the other information and
the discussions were what really helped to give
maximum impact and value. However, it is impor-
tant that showing a range of videoed sessions to
groups is acknowledged as being very valuable
and counts towards a candidates application
needs. Appropriate sessions can be shown, with
explanations and detailed discussion, in a much
more time-efficient way for the speech and lan-
guage therapist than individual live sessions.
We also asked for adjectives to describe their
feelings about speech and language therapy. The
most frequently used words are listed in figure 2.
Personal responses
The range of adjectives was much wider for feelings
about studying speech and language therapy
than for overall views on speech and language
therapy, and ranged from scared and apprehensive
to determined, enthusiastic and passionate. This
emphasises the differing personal responses to
actually being a speech and language therapist
and stresses the need to provide potential recruits
with information that can really help them to
make an informed decision. (It is interesting to
note that badly paid was used several times at
the first course, but not at the second and third,
when the regrading exercise was in progress.)
Nine of thirteen questionnaires were returned
six months after the first course. All but one per-
son had applied to study speech and language
therapy (with one person gaining additional
experience before deciding) and all of those were
offered interviews. One interview was considered
in my experience
a morning of direct observation (each participant
in a different setting) with guidance towards
observation questions to answer
group discussion about direct observation.
Information packs included:
working in different settings
Royal College of Speech & Language Therapists
leaflets and magazines from relevant charities
and organisations
salary scales
reading list
suggestions for voluntary work.
The course has been repeated twice, with
Autumn courses coming at the best time, when
applicants are filling in their forms.
In total, 33 people attended the courses. Thirty
were female, but only three male (8 per cent).
Almost all (26) were considering applying for a
postgraduate course, with another five considering
a four year course as a mature student. Only two
participants were still at school, studying A-levels.
This pattern reflects the situation of the people
who contact us directly, and continues to surprise
me. Perhaps we should be doing much more to
publicise speech and language therapy to school
pupils or, if a similar pattern also exists for course
applications, perhaps education establishments
should consider a larger percentage of postgrad-
uate places.
Questionnaires were filled in at the end of each
course (figure 1), and a follow-up questionnaire
sent to the thirteen participants from the first
course. Overall feedback was good. All partici-
pants felt more knowledgeable about speech and
language therapy afterwards, and all but three
felt keener to study. The comments of those who
became less keen suggested that we had achieved
our aim of giving an honest and realistic
overview; one person was surprised by some of
Figure 1 Pre and post course questionnaire responses
Question Range Average
(out of 10)
1. How knowledgeable did you feel before
the course? 1 - 7 4.7
2. How knowledgeable did you feel after
the course? 6 - 9 7.8
3. How keen were you to study speech and
language therapy before the course? 2 - 10 7.1
4. How keen were you to study speech and
language therapy after the course? 4 - 10 8
5. How enjoyable was the course? 5 - 10 9.1
6. How did the course rate for value for money? 3 - 10 8.5
Figure 2 Most frequently used words
How do you
view speech and
language therapy
as a career?
varied (22)
rewarding (17)
challenging (13)
interesting (8)
fulfilling (7)
Do we do our bit to
help people make
informed decisions
about speech and
language therapy as
a career?
Do we take
opportunities to
encourage school
children to consider
the job?
Do we remember why
we joined the
profession in the
first place?
too late, but the other seven attended inter-
view and were offered places. This seems like a
good success rate, but it isnt possible to say how
much difference the course made - the fact that
people were prepared to pay to attend suggests
they were already fairly well motivated.
Even if you are not in a position to run courses
such as the one I have described, there are many
other things you can do to help ensure the pro-
fession attracts people who are right for the job
while minimising the disruption to your depart-
ment. For example:
1. having a coordinator can help with monitoring
and planning
2. developing a departmental policy can help
manage a large number of requests (for example,
specifying local area or minimum age, if the setting
is very acute)
3. taking observers in pairs is more time-efficient
4. showing videos to groups allows for more
detailed explanation during the session
5. introducing them to students can provide
additional valuable insights.
Although each course was time-consuming for
me as the organiser, the five Kings speech and
language therapists who gave talks, and the
speech and language therapists who took individ-
uals on observation, there are personal benefits as
well as the benefits to the profession and the
speech and language therapy service. I found it
motivating to be thinking about and explaining
the diversity of speech and language therapy. I
think we can sometimes become too aware of the
pressures and frustrations of the job and lose
sight of some of the positive aspects of working as
a speech and language therapist.
Lucy Wood is a speech and language therapist
and student coordinator at Kings College
Hospital, London.
How do you feel
about studying
speech and
language therapy?
enthusiastic (6)
excited (6)
nervous (5)
motivated (4)
confident (4)
pecial education was placed within the
educational system as a whole with the
publication of The Warnock Report
(1978) and was no longer viewed as a
separate entity (Beveridge, 1993).
However, in practice, this often resulted in differ-
ent forms of segregation; for integration is usual-
ly dependent on the childs level of need, focusing
on the level of support required to help the child
cope with the existing system (Clark et al, 1995). In
inclusive education, on the other hand, the
majority of resources and focus is on the system
and not the individual child (Stubbs,1997, p8).
The aim of inclusion is for changes to be made
within the educational system to enable all chil-
dren to achieve curricular goals. Ainscow & Sebba
(1996) suggest that inclusive education should be
viewed as a process rather than a fixed state. Part
of that process includes restructuring teaching
approaches, pupil groupings and the use of support.
Inclusion differs from integration in three
important ways. Firstly, inclusion is considered to
be a human right, regardless of the level or type
of needs of the child; secondly inclusion is not
merely an educational aim, rather it is part of the
broader aim of creating an inclusive society; and
thirdly all children are viewed as equal individuals
with different learning needs (UNESCO, 1994).
In the UK, the commitment towards the devel-
opment of a more inclusive education system has
been well documented. For example, between
1995 and 1999 the percentage of pupils with
statements placed in mainstream schools
increased from fifty four percent to sixty percent,
while those placed in special schools fell from
forty four to thirty eight percent (DfEE, 1999).
There are implications, however, not only for
schools but also for support services such as
speech and language therapy in this shift of edu-
cational philosophy. Changes in provision have
been necessary to accommodate the individual
needs of children with communication problems
now in mainstream schools.
A small study was therefore set up to:
investigate the ways in which the move towards
inclusive education may have impacted on local
find out what changes have occurred within the
services as a response to these developments
investigate the nature of such changes, how they
you are
changng your stye o
juggng numbers o
paces and types o cases
consderng servce
Read this
Clueing up
for inclusion
Legislative change means
more children with
difficulties are now being
educated in mainstream
schools - but are our
services keeping pace? In a
small-scale study, speech
and language therapy
managers were asked how
they are meeting the
challenge. Myra Kersner
and Ann Coxon report.
are being implemented, and the effect of the
changes on the staff and the structure of the service.
Interviews were conducted with 10 speech and
language therapy managers in the South East of
England. The managers had to be in their jobs for
at least two years at the level of paediatric service
manager or manager of the schools team. The
interview tapes were transcribed and analysed
using a grounded theory approach (Strauss &
Corbin, 1998) so that themes were identified from
the data. Major themes meant that five or more
managers gave the same response; minor themes
that four or less gave the same response.
There were considerable differences reported by
the managers in the type of service offered and
the ways in which they were organised:
Seven of the ten ran a mainstream school-based
service where therapists worked within a number
of schools. They provided a service to all children
with communication difficulties within these
schools, irrespective of whether they had a
Statement of Special Educational Needs.
Two of the ten ran a local health centre-based service.
After seeing the children initially at the clinic the
same therapist then saw the children in school.
They provided a service to children with
communication difficulties in mainstream schools
only who had a Statement of Special Educational
One of the managers ran a child-based service where
each therapist in the mainstream schools team
was assigned to work with specific children. These
children were on or above Stage Three of the Code
of Practice (1994) and the therapist continued to
work with them even if they changed schools.
All ten interviewees reported that legislation had
influenced their services (figure 1). Historically, there
have been many instances of legislation impacting
on services in England and Wales. The Code of
Practice (1994; 2000) attempts to clarify speech and
language therapists involvement in special needs
provision although this does not preclude disputes
and the use of litigation (Law et al, 2001). Speech
and language therapy funding has also been affected
by legislation. There is still confusion about who
provides and funds the service and this has led to
some difficulties in funding the provision for children
in mainstream schools (Law et al, 2000).
Diversity and complexity
The biggest change reported by 80 per cent of the
managers was an increase in the caseload of thera-
Myra Kersner Ann Coxon
pists working within mainstream schools. Another
major theme was an increase in the diversity and
complexity of the needs of children with SEN includ-
ing communication difficulties in mainstream: the
therapists are being asked to see children with a
huge range of complex needs now within main-
stream, and you suspect that five to ten years ago
they would have been in a special school or unit.
This goes some way to proving the effectiveness of
the legislation regarding the inclusion of children with
special educational needs into mainstream educa-
tion. However, a minor theme was the reported
insufficiency of funding to support the numbers of
children on therapists caseloads and, when consid-
ering whether those needs are being met, this has
to be seen against the backdrop of long waiting lists
and poor funding and resources, and raises serious
questions concerning prioritisation. Although the
government speech and language therapy working
group has suggested that future arrangements
should encompass all children with communication
difficulties, not just those with statements of SEN
(DfEE, 2000), and the Royal College of Speech &
Language Therapists agrees that access to therapy
should not be seen as a priority for statemented
pupils only (RCSLT, 1997, p3), evidence from this study
illustrates that currently this is not always possible.
The increase in multi-agency working, from the
policy level of the local education authorities, to
headteachers, classroom teachers, Special
Educational Needs Coordinators (SENCOs) and
learning support assistants, also emerged as a
major theme. Indeed, the majority of those inter-
viewed described collaboration with schools staff
as one of the major factors which made their service
successful (figure 2). Managers reported that
increasing inclusion had led to changes in styles of
working and models of service delivery, as more
collaboration with other professionals was
required when working within an educational con-
text. They reported that schools were now aware
of what speech and language therapy involved and
this meant that they could work more effectively.
The change in style of intervention by the ther-
apists emerged as a major theme. Eight of the
managers reported that their therapists spend a
considerable amount of time training the educa-
tion staff to carry out therapy in their absence.
Although the majority of the interviewees saw
this as an aspect of positive collaboration, four
managers reported that teachers and parents
found this style of intervention difficult to accept:
I think that has been the hardest thing to get
over [to schools] is that our input is not always
direct, when we provide programmes and advice
it is still speech and language therapy.
I think another task that is very difficult is trying
to get parents to understand that indirect work
can be just as appropriate as direct intervention.
A lot of parents still phone and ask us why their
child is not receiving one to one therapy.
Important aspect
When there are limited resources and there is no
therapist permanently on-site, training other pro-
fessionals becomes an impor-
tant aspect of the therapists
work (Patterson, 2001). Indeed
the government speech and
language therapy working
group concluded that, in
future, arrangements will need
to be based on providing a
range of therapy provision, not
just direct intervention from
the therapist (DfEE, 2000).
However, the fact that many
teachers and parents are dissat-
isfied with this form of inter-
vention and do not understand
the therapists ways of working
is a concern. It emphasises the
necessity for better communi-
cation, and for therapists to
explain the relative merits of
different forms of intervention
to the education staff and to
parents. It also underlines the
importance of evaluative stud-
ies demonstrating that indirect
intervention is an effective
form of therapy (Wood, 1998).
Much of the collaboration in
the classroom was described as
being between the learning
support assistant and the ther-
apist, rather than between the
teacher and therapist which
has been the focus of most of
the recent research into collab-
oration (Stevens & Roulstone,
1991; Kersner, 1996; Miller, 1996;
Wright & Kersner, 1999). It would
seem that working with non
teaching staff is just as essential
an aspect of work in a main-
stream setting as collaborating
with teachers. This is an area
which warrants further investi-
gation and must be an important
consideration for all speech and
language therapy services, par-
ticularly in terms of training.
Despite the fact that the majority of managers
described collaboration as one of the major fac-
tors that made their service successful, only three
of those interviewed had written policies on col-
laborative working practices. A similar lack was
found in Wrights (1996) study when none of the
teacher/speech and language therapist dyads
interviewed had a written policy within their ser-
vice about collaborative working practices.
This is a pertinent issue. Collaboration does not just
happen because teachers and therapists spend time
together in the classroom (Wright, 1996). Indeed,
several of the managers reported that their staff reg-
ularly attended training courses on collaboration
and how to work effectively in mainstream
schools, as well as running courses for the educa-
tional staff. Written policies about collaborative
working practices might be
helpful particularly for
newly qualified therapists.
However, 70 per cent of
those interviewed reported
that training for SENCOs
and learning support assis-
tants was a major part of
their collaborative working
practices. This training was
about the role of speech
and language therapists,
their services and how they
can be utilised within the
school. Training was also
given on running groups
and carrying out therapy
programmes, and some was
organised specifically for
SENCOs to help them recog-
nise mild language problems.
Six of the managers also
reported that additional
training was available for
speech and language thera-
pists. They said that their
staff had attended formal
training sessions on collabo-
rating with education staff.
In addition, four managers
mentioned that informal
training from more experi-
enced therapists within the
team was also an integral
part of working within
mainstream schools.
In agreement with Miller et
al (1995), fifty per cent of
the managers felt that
working in mainstream
schools should be seen as a
specialism in its own right: I
feel quite strongly that it is
just as specialist a skill to
have knowledge about the
national curriculum, working
with teachers, and individual education plans and
planning, as it is to have knowledge about autism.
Managers commented that specific skills such as nego-
tiation needed to be valued as much as clinical skills.
Large caseloads, understaffing and lack of
resources have all contributed to the increasing
level of pressure on therapists working within
mainstream schools teams. However, where main-
stream therapists work from the same administra-
tive base, the managers reported that they are
able to support each other and so reduce stress
levels and develop more effective teamwork.
Six of the managers suggested that therapists
with specialist expertise who had worked in the
special schools which were now closing down
might be re-deployed in central resources.
Outreach teams could then offer assistance with
Figure 1 The main changes that have taken
place in speech and language therapy
services as a result of recent legislation


1. Increase in caseload
2. Increase in complexity of needs
3. Multi-agency working
4. Working in the classroom and
not in a clinic setting
5. Not enough funding for number
of cases
6. Increase in threat of litigation
Figure 2 Factors reported by managers as
those that make their services successful
1. Collaboration with school staff
2. Collaboration with the local
education authority
3. Training of learning support
assistants and SENCOs
4. Working in schools and not in
clinic settings
5. Speech and language therapy
staff training on working in
mainstream schools
6. Teamwork within the speech
and language therapy teams



guage needs in England and

Wales - A project summary.
DfEE: London.
Law, J., Lindsay, G., Peacey, N.,
Gascoigne, M., Soloff, N.,
Radford, J., & Band, S. (2001)
Facilitating communication
between education and heath
services: the provision for chil-
dren with speech and language
needs. British Journal of Special
Education 28 (3), 133-137.
Miller, C., Morrison, K.,
Pentland, B. & Stansfield, J.
(1995) Specialists and
Generalists. College of Speech
and Language Therapists
Bulletin 513, 6-7.
Miller, C. (1996) Relationships
between teachers and speech
and language therapists: influ-
encing practice by distance edu-
cation. Child Language
Teaching and Therapy 12, 29-38.
Patterson, A. (2001) Training
and Educating Colleagues, in
Kersner, M. & Wright, J.A.,
Speech and Language Therapy: the decision mak-
ing process when working with children. London:
David Fulton Publishers.
RCSLT (1997) The role of the speech and language
therapist in the multi-professional assessment of
children with special educational needs. London:
Royal College of Speech and Language Therapists.
Stevens, L. & Roulstone, S. (1991) Speech thera-
pists and teachers working together: a model for
the 1990s. Journal of Educational and Child
Psychology 8, 84-92.
Strauss, A. and Corbin, J. (1998) (2nd ed) Basics of
Qualitative Research: techniques and procedures
for developing grounded theory. London: Sage
Stubbs, S. (1997) Towards Inclusive Education: The
Global Experience of Save The Children (UK).
Camberwell: Save The Children Fund UK.
UNESCO (1994) The Salamanca Statement and the
Framework for Action on Special Needs
Education. Paris: UNESCO.
Warnock, H.M. (1978) Special Educational Needs:
Report of the Committee of Enquiry into the
Education of Handicapped Children and Young
People. London: HMSO.
Wood, J. (1998) Styles of interaction used by learning
support assistants: The effectiveness of training.
International Journal of Language and
Communication Disorders 33 (supplement) 614- 619.
Wright, J.A. (1996) Teachers and therapists: the
evolution of a partnership. Child Language
Teaching and Therapy 12, 3-16.
Wright, J.A. & Kersner, M. (1999) Teachers and
speech and language therapists working with chil-
dren with physical disabilities: Implications for
inclusive education. British Journal of Special
Education 26 (4) 201- 205.
assessment and therapy; or the specialist thera-
pists could act as a resource, their expertise being
called on by mainstream therapists. This idea is
seen as effective practice in inclusion by the DfEE
(1999). Two managers however expressed concern
about therapists with specialist knowledge being
seen as experts as this could undermine the posi-
tion of the mainstream speech and language ther-
apists and adversely affect collaboration with
The increasing numbers of children requiring
therapy highlights the serious issue of under-
staffing as the managers described their main-
stream therapy teams coping with long waiting
lists. Whilst this in part is due to the lack of fund-
ing for additional recruitment, the lack of the
appropriate skills for working in mainstream edu-
cation among newly qualified staff was also cited
as a related issue to be addressed. In addition, it
was not possible for all therapists from the special
schools which were closing to become members of
the mainstream team automatically. Some of the
managers in the study suggested that, as different
skills were required, some therapists needed to
undertake additional training before they could
be re-deployed in this way.
Another theme which emerged from the inter-
views involved speech and language therapy stu-
dent education and training. Half of the managers
felt that students did not have the skills or knowl-
edge to work in mainstream schools, and that this
was an issue which needs to be addressed.
Although issues regarding litigation are often
raised as an area of concern (Law et al, 2001) it is
interesting that in this study they were only
referred to by one manager.
More effective
There was a diversity of responses when the man-
agers were asked to describe changes which might
make their services more effective. More funding
and more therapists arose as a theme. Managers
acknowledged that there had been some confusion
over the source of funding (Law et al, 2000) but
felt that generally there were not enough funds
available. Three managers talked specifically about
not being able to set up a mainstream service to
secondary schools because of lack of funds.
Another referred to difficulties at pre-school level:
If I was going to make one major change, that
would be to have more resources to put in services
early enough so that we might even be able to
prevent statementing.
We recognise that the small sample of interviewees
was taken from a limited geographical area so
that any generalisations from the data may only
be tentative. Nevertheless, it is interesting to note
that several of the issues raised by the interviewees
were reflected in a larger study which has recently
been undertaken (Law et al, 2000) which was sum-
marised in an article by Law et al (2001) as well as
in the conclusions of the governmental working
group (DfEE, 2000) which was set up to address the
problems posed by the provision of services to chil-
dren in special and main-
stream settings.
We hope that there may
be a commitment for
increased funding to sup-
port recruitment as well as
reorganisation of thera-
pists working in an inclu-
sive educational system so
that services may continue
to develop. From this
study there would seem to
be a need to investigate
parental opinion about
direct and indirect service
delivery and to ensure that
parents can make informed
judgements about what
provision is offered.
As the findings of this
study highlight the
increasing training role of
therapists when working
with learning support
assistants it is important
for therapists to be sup-
ported in this work, possibly
through the use of funding from the DfES
Standards Funds for speech and language. There
is also a need for further investigations into the
ways in which support services are delivered and
the ways in which all staff in the educational setting
may work together effectively with speech and
language therapists for the benefit of the chil-
dren with communication problems.
Myra Kersner is senior lecturer in the Department of
Human Communication Science, University College
London, and Ann Coxon is a speech and language
therapist for Bracknell Forest Primary Care Trust.
Ainscow, M. & Sebba, J. (eds) (1996)
Developments in Inclusive Education. Cambridge
Journal of Education 26 (1).
Beveridge, S. (1993) Special Educational Needs in
Schools. London: Routledge.
Clark, C., Dyson, A. & Millward, A. (1995) Towards
Inclusive Schools: Mapping the fields in Clark, C.,
Dyson, A. & Millward, A. (eds) Towards Inclusive
Schools? London: David Fulton.
Department of Education (1994) Code of Practice
on the Identification and Assessment of Special
Educational Needs. London: HMSO.
Department for Employment and Education
(1999) Special Educational Needs in England:
January 1999. London: HMSO.
Department for Employment and Education
(2000) Draft Revised Code of Practice for Special
Educational Needs. London: The Stationery Office.
Kersner, M. (1996) Working together for children
with severe learning disabilities. Child Language
Teaching and Therapy 12, 17-28.
Law, J., Lindsay, G., Peacey, N. and Gascoigne, M.
(2000) Provision for children with speech and lan-

1. consider operating a
multi-site service from
a central resource
2. work with colleagues in
other professions to
produce a written policy
on collaboration
3. provide other
professionals and
parents / carers with
information on styles
of working
4. apply for funding to
develop work with and
training of support staff
5. give students the
opportunity to
experience work in
different environments.
Five steps to
better practice
1. Assess overt and covert behaviours, reactions and coping strategies.
2. Adapt to individuals, using a mix of approaches and time-scales.
3. Highlight the strengths and resources clients have within themselves.
4. Shift a clients focus from cure to maintainable progress.
5. Pace the flow of information.
6. Use rating scales as therapy tools and outcome measures.
7. Ensure techniques can be incorporated in real life.
8. Empower clients to manage their own communication over time.
9. Let clients know it is OK to have set-backs and to return for help.
10. Take opportunities to share skills with non-NHS ventures.

how I
l manage
stammerng n
Stammerng n aduts and The NcGure
Programme have receved a great dea o
pubcty recenty through Gareth Gates rom
teevsons Pop ldo. Athough Gareth hmse
has nspred many young peope wth
communcaton dcutes, t s debatabe how
much the nature o the meda exposure has
ncreased understandng and acceptance o
stammerng - n peope wth a stammer as we
as n the non-stammerng pubc.
Has the message got across that stammerng s
a mutactora and compex phenomenon'
That there s no known cure' That peope have
the rght to be heard whether or not they
stammer' Nost mportanty, do peope now
apprecate that the management o stammerng
n aduts needs to be hostc and taored to an
ndvduas needs and wshes - and that
overcomng a stammer means derent
thngs to derent peope' Three peope who
understand ths more than most share
ther experences.
Louise Wright, formerly of the
Manchester Metropolitan
University, is now specialist
speech and language therapist
in dysfluency and Sure Start
Lescudjack with West Cornwall
Primary Care Trust.
Claire McNeil is a specialist
speech and language therapist
in dysfluency with Swindon
Primary Care Trust.
Anne Blight started training as
a speech therapist but, feeling
there was not enough
in-depth work for stammerers,
got involved as a volunteer
instead. Excited by the
potential of diaphragmatic
retraining - but disillusioned
with the way it was being
introduced in the UK - she
founded the Starfish Project in
1998 as a non-profit making
venture aimed at helping
adults and young people
recover from stammering.
you want to
oer therapy taored to
be postve and reastc
about prognoss
equp cents to manage
ther own communcaton
Read this
how I
have worked with people who stammer (of all ages) for the
past 22 years and find it as enjoyable and challenging now as
when I first started. I worked for 11 years in the NHS, latterly
as a specialist in dysfluency, moving on to teach disorders of flu-
ency at undergraduate and postgraduate levels at the Manchester
Metropolitan University. Whilst there I also ran a weekly special-
ist dysfluency clinic supervising students, and carried out research
into employment and family issues for adults who stammer.
I have worked with adults who stammer individually, in weekly
groups, in the workplace involving managers and colleagues, in
intensive groups and also on residential intensive courses
involving families and friends. Anne Ayre and I developed The
Wright and Ayre Stuttering Self-Rating Profile (WASSP, 2000) as
an outcome measure for therapy with adults who stammer as a
result of our work with adults in the workplace (Ayre et al,
1998) and I use this as a tool both to plan and evaluate therapy
My approach to therapy is influenced by a number of over-arching
principles. I always work with the clients stammer within the
context of him or her as a person. I adapt my approach to suit
their personality, lifestyle, impact of their stammer on their life,
experience of past therapy and their readiness for change
(Prochaska & Di Clemente, 1986). I do this by taking time to get
to know them, listening to them and involving them in therapy
decisions by explaining possible options, experimenting and
evaluating the results. I see stammering therapy as a long-term
process of change that may impact on many areas of their lives.
I begin to understand them and their stammer through an ini-
tial semi-structured interview (severity of the stammer permit-
ting) and I may follow this up later with additional exploratory
tools such as the S-24 Attitudes to Communication Scale
(Andrews & Cutler, 1974), Locus of Control of Behaviour Scale
(Craig et al, 1984) and Self-Characterisation (Kelly, 1991).
I always aim to address the overt and covert aspects of the clients
stammer, their reactions to stammering and their current coping
strategies. I use WASSP to explore the following aspects of their stam-
mer and to obtain a baseline self-rating measure from which we can
measure change following a block of therapy. WASSP includes:
Stammering behaviours including frequency of stammers,
amount of physical struggle or tension during stammers,
urgency or fast speech rate, associated physical movements made
as a reaction to stammering, general level of physical tension,
eye contact and any other behaviours which are significant.
Negative thoughts about stammering before, during and
after stammering.
Feelings about stammering such as frustration, embarrassment,
fear, anger, helplessness.
Avoidance as a coping strategy at the levels of words, situations,
talking about stammering with others and admitting their
problem to themselves.
Disadvantage experienced at home, socially, educationally
or at work as a result of their stammer.
I will usually ask the client to complete WASSP at the end of
the initial interview when they have spent some time reflecting
on and discussing aspects of their stammer which they may not
have considered for some time, if ever. The client at this point
records their aims and expectations of therapy.
Use of WASSP also helps me to illustrate which areas therapy will
address and where they may expect change to occur. Some clients
are surprised that I am not just going to address the mechanics of
speech. Others are relieved that I understand the complex multidi-
mensional nature of stammering and will be helping them to
address it on many levels. For many it is the first step in under-
standing their stammer and how therapy is going to work.
At the end of the first meeting I will describe possible thera-
py options that will help them to achieve their aims. If they
to know
therapy s a
ong-term process
o change that may
mpact on many
areas o a
stammerers e.
But s your cent
ready to change'
Do they have
sucent support
n the workpace
and at home'
vhat approach(es)
woud work best
or them'
louse vrght
expans her
makng process.
have a stammer with mixed overt and covert components but
with some natural fluency I might suggest Van Ripers approach
of initial identification, desensitisation and variation leading up
to modificaton of the stammer (Van Riper, 1973). I tend to
favour Contures simpler version of stammering easily by mov-
ing through stammers (Conture, 1990) rather then Van Ripers
different types of modification. If the client is very fluent with
high levels of anxiety about stammering and frequent avoid-
ance then I would suggest Sheehans avoidance reduction ther-
apy (Sheehan, 1975) with easy introductions to voluntary stam-
mering and sliding. However, if they are stammering very
severely our first option may be a fluency technique such as
slowed speech that will give them more fluency initially and can
later be augmented with easy stammering techniques (Neilson
& Andrews, 1993). Whatever path is finally embarked upon I
usually find it helpful to begin therapy with a period of identi-
fication and understanding of normal speech production.
Although I would normally outline these three main therapy
options to the client at the end of our first exploratory session,
in reality of course most clients require a mixture of these types
of therapy, either simultaneously or sequentially as their stam-
mer changes and their therapy needs evolve. WASSP can again
be helpful here in monitoring progress, discussing change and
planning new phases of therapy with the client.
In getting to know the person it may become apparent that
they would also benefit from help with wider aspects of com-
munication such as improved social skills, assertiveness training,
anxiety management, relaxation, cognitive-behavioural coun-
selling and problem solving. They may benefit from a mix of
individual therapy, various types of group therapy and involve-
ment of significant others depending upon their needs and rate
of progress. Clients usually attend on a weekly or fortnightly
basis interspersed with breaks to consolidate change and take
responsibility for their own maintenance and therapy problem
solving. Long breaks are appropriate when the client decides
that therapy has fulfilled their needs for the present and they
always have the option of stepping back into therapy should
their needs change.
My aim in all therapy is to empower the client to manage their own
stammer long-term, by helping them to acquire the understanding,
therapy tools and confidence needed to react to their changing
needs and circumstances. If those around them at home and at work
can also understand their stammer and how they are dealing with it,
I believe that the person who stammers is more likely to manage and
maintain change and those around them are more likely to feel com-
fortable and positive about the stammer and therapy.
Ayre A., Wright, L. & Grogan, S. (1998) Therapys Long Term
Impact on Attitudes Towards Stuttering in the Work-place. In:
Healey, E. & Peters, H. (Eds) 2nd World Congress on fluency
Disorders, 18-22 August 1997, San Francisco, 403-406.
Nigmegen University Press, Nigmegen.
Andrews, G. & Cutler, J. (1974) S-24 Scale. Stuttering Therapy:
The Relations Between Changes in Symptom Level and
Attitudes. Journal of Speech and Hearing Disorders 39, 312-310.
Conture, E. (1990) Stuttering (Second Edition). Prentice Hall,
Englewood Cliffs, New Jersey.
Craig, A., Franklin, J. & Andrews, G. (1984) A Scale to Measure
Locus of Control of Behaviour. British Journal of Medical
Psychology 57, 173-180.
Kelly, G. (1991) The Psychology of Personal Constructs.
Routledge, London.
Neilson, M. & Andrews, G. (1993) Intensive Fluency Training of
Chronic Stutterers. In: Curlee, R. (Ed) Stuttering and related
Disorders of Fluency. Thieme, New York.
Harper and Row, New York.
Van Riper, C. (1973) The Treatment of Stuttering. Prentice Hall,
Englewood Cliffs, New Jersey.
Wright, L. & Ayre, A. (2000) WASSP: The Wright and Ayre
Stuttering Self-Rating Profile. Speechmark, Bicester.
how I
n Swindon we have a specialist Fluency Service with four
speech and language therapists working part-time. We see
all ages and run intensive residential courses for children
and teenagers. I have worked in the area of stammering
for the past 15 years. During this time ways of thinking and
types of therapy have tended to come and go. I feel privileged
to work with adults who stammer and have met and learnt
from many fascinating and brave individuals. The uncertainties
in the causes of stammering and its variability make it a chal-
lenging area of work. I use a range of therapy approaches but
have been influenced greatly by learning more about Neuro
Linguistic Programming (NLP) and brief therapy. I have not given
up my old favourites of block modification, breath control and
relaxation strategies, but tend to mix the ideas and approaches.
The great thing about working in this area is that you can keep
asking, how is it going?, how are you finding this approach?
and gain instant feedback, something not possible in areas where
clients are unable to communicate with us so directly. The influence
of NLP is evident in my initial assessment where my priority is to
build rapport. My aim is to understand as much as possible about
the meaning and the experience that stammering has for the indi-
vidual, to see it through the clients frame of reference. I aim to get
a sense of how the person learns - are they mainly visual, auditory or
kinaesthetic in the way they use information? This helps us select the
kind of therapy activities that will create changes for the individual.
In NLP the therapist is aiming to create the conditions where-
by the client may choose to change and find new and interest-
ing ways to carry out these changes (Bailey, 2001). I also take
the usual case history, gathering information about the nature
of the individuals stammering, both overt and covert features.
During this process I look for clues to help understand the
meaning all this has for the individual.
Pace the flow
Something I have learnt with experience is to try to pace the flow
of information. At one time, following the principles of block
modification during its phase of identification, much time was
spent analysing behaviours and covert symptoms. Whilst this
information is necessary, I feel that to do too much of this straight
away can be daunting for the individual, and I am sure I have lost
some clients in the past through too much analysis, too soon.
Trying to get a balance between identifying the problems and
looking for solutions early on in therapy is important. It is at this
point that the ideas of brief therapy really help. Also known as
solution focused brief therapy, it looks at the clients hopes for
the future. Rather than trying to understand and fix problems,
it works by charting your way forward and seeking the resources
needed to embark on the journey. The essence of it is to:
work with the person rather than the problem.
look for resources rather than deficits.
explore possible and preferred futures.
explain what is already contributing to those possible futures.
treat clients as the experts in all aspects of their lives.
(Taken from a Brief Therapy Practice course.)
Bearing this in mind, when dealing with the initial assessment
I try to take history details so as not just to get a picture of what
has gone before, but also to encourage the client to express
their preferred future. Looking for the clients strengths and
resources is extremely helpful right from the first session.
I like to use scales as part of outcome measures. The client is
asked to consider what they would like to achieve as a result of
vhat does a
stammer mean or
an ndvdua' And
what nner
resources do they
have whch w
gude therapy'
Drawng on a
range o
partcuary neuro
programmng and
bre therapy,
are NcNe asks
the questons to
brng about
the work we will do together - their preferred future. Then, on
a scale of 0 - 10, I ask Where are you now?, How will you
know when you have moved up just one point on the scale?,
What will you notice?, How have you managed to get to
where you are now? Clients very rarely put themselves at 0, so
they are already some way up the scale. One particular client
said he had been feeling very depressed and could not see anything
positive in his life. When we worked on the scale I noticed he was
able to give lots of details of how he would know when he was
moving up. He very clearly had a step by step view of what he
would be doing as he moved towards his goal or preferred
future. I was then able to highlight these strengths to him.
Helping him to see that he was able to plan in detail and have an
accurate picture of what he wanted was a great resource for pos-
itive change in therapy, and it continued successfully.
Acknowledge feelings
Using brief therapy scales helps to set goals and keep client and
therapist forward thinking. Although I do not dwell on past expe-
riences, I do not ignore memories that may block future work. It
is important to acknowledge feelings. If there are issues that need
addressing, using the NLP strategies to soften the impact of these
negative memories helps. While thinking about NLP, it is necessary
to put in a word of warning. These strategies are powerful and
need to be explored in a trusting and supportive environment. I
have become aware of these ideas being used in a group, without
appropriate support, and this has a very negative effect on a client.
In an appropriate supportive environment I have found this way of
working very useful in helping to neutralise past experiences and
enabling clients to recognise and hold onto positive experiences.
In the process of assessment I also use a general outcome scale
to have a broad view of stammering behaviours, feelings and
attitudes. Avoidance schedules are also useful and it is helpful
to look back on these to gauge success. During therapy I like to
use a range of strategies which vary according to an individuals
needs. I believe it is important to explore practical ways of deal-
ing with stammering at the same time as working to change
feelings and attitudes. Having practical to do tasks in a session
can really help, as too much talking about things can be hard for
some clients. I very often use practical relaxation, and breath
control work is also helpful, enabling clients to start to take con-
trol of the situation. I use block modification ideas including
voluntary stammering which can be a real breakthrough for
some individuals. It is important not to forget some of the older
ideas which can be very useful. I am now on a Charity commit-
tee with someone I worked with 15 years ago; he still uses soft
contacts and found this one of the most helpful strategies.
It is important not to forget the need to maintain progress. By
using techniques to manage both the covert and overt symp-
toms of stammering I hope clients become aware that they have
the necessary tools to deal with the inevitable set-backs.
Therapy goals do not include 100 per cent fluency, and creating
a positive attitude leads on to an acceptable level of fluency
control. Life events do have an impact and we need to say it is
okay to have set-backs and to return for help if needed. Past
clients will sometimes call if a reminder is needed. Recently a
client I had seen in his teens came back, after 10 years, to run
through a work presentation. After two sessions to refresh ideas
on managing his stammering he completed his presentation suc-
cessfully and kindly rang me to let me know how it had gone.
Stammering can be a chronic, ongoing disability in adults and

Prochaska, J. & Di Clemente, C. (1986) Towards a Comprehensive

Model in Change. In: Miller, W.R. & Heather, N. (Eds) Treating
Addictive Behaviours: Processes of Change. Plenum, New York.
Sheehan, J. (1975) Conflict Theory and Avoidance Reduction
Therapy. In: Stuttering. A Second Symposium. (Ed) Eisenson, J.
how I
manage stammering in adults by initiating change and by
empowering the individual, with lifetime support, to man-
age their own recovery - to become in effect their own
speech and language therapist.
Because of the multifactorial nature of stammering, every
person who stammers does so differently; there may be certain
similarities but they are all different, all individuals. Therefore,
individuality must be respected and therapy adjusted accord-
ingly for it be effective. For this reason, I always discuss at
length everything that is involved with anyone considering a
Starfish course as it is essential that no one has any false hopes
of a non-existent cure or promises of fluency.
It is important to try and answer as many questions as possi-
ble before the course so that people can come with an open
mind and are prepared. I always make it clear that we make no
promises. Our aim is for effortless speech; we do not chase a
goal of fluency or eloquence, and believe that seeking such per-
fection in an imperfect world is an impossible task.
As much as each individual stammers differently, so too they
will recover differently, at their own pace and in their own time.
We use the term recovering stammerer as an acceptance that
we are doing something about controlling the stammer. We are
not cured and never will be. We are - and no doubt always will
be - recovering. There is a pride to recovering stammerers even
in saying the phrase. Rather than Im trying to... it states posi-
tively I AM a recovering stammerer and signals the change in
attitude and avoidance that prevailed when I WAS a stammerer.
I strongly believe that it is wrong to take financial or psycho-
logical advantage of the misfortune of other people. I do not
believe in intensive therapy courses that involve large numbers
of students working long hours. Because of the construction of
such courses there is no allowance for the individual, and a one
size fits all approach has to prevail. Short-term fluency gains are
seen from such volume therapy approaches but, since so much
emphasis is placed on technique, these gains are rarely main-
tainable in the real life situation. I also do not believe that the
solution to years of confirmed stammering can be that rapid.
Small groups
Starfish courses involve small groups of people (around 10)
working for the most part on a one-to-one basis with a refresh-
ing recovering stammerer. We feel that we can respond and
adjust to the individual needs of the new student this way yet
still have the opportunity to carry out telephone training and
role plays and to have the support of peers. Course days are gen-
erally 9am until around 6pm with plenty of breaks. We believe
that this pace provides an environment to absorb and adopt the
training and the new techniques. Since everyone involved in the
course is staying at the same country house hotel, training
(though not in the workshop) continues into the evening, with
the opportunity of using the control techniques in real life situ-
ations of ordering the evening meal and after-dinner socialising.
On the final day of the three day course we visit the local
shopping centre in Eastbourne to give individuals the opportu-
nity of using the technique in the real world, again always tak-
ing each contact at the individuals pace.
Over the years many people have believed that if we could
only find the cause of stammering we will resultantly find the
cure. In an article written some 30 years ago, Frederick Murray
PhD (author of A stutterers story) asks, Will the fire that is
consuming a house extinguish itself merely because the match
that started it has been discovered in an adjacent field?
I have always referred to this quotation early on in courses as
I have found that, to many of the hundreds of stammerers that I have
worked with, there is an affinity to the house fire allusion and stam-
mering. Stammering, like a fire, is self-perpetuating with situation
and word avoidances working as fuel to feed the fire, and many
stammerers at times must have felt as out of control as a fire often is.
As in the case of a fire, the first and most important action is to
get the problem under control and this is achieved in Starfish with
diaphragmatic retraining, a technique pioneered by Lionel Logue,
notably with the late King George VI. This involves learning to
breathe using the intercostal muscles and the costal area of the
diaphragm. The key to the technique is timing and learning to
breathe, speak and release air as a cycle. Once we have put out the
fire we do not want it to start up again and so we train with cer-
tain safety net ways of getting out of potential blocks or stress
related situations, such as voluntary sliding and block and release.
We then start on the most important job of all, and that is
rebuilding the house, by such techniques as avoidance reduc-
tion therapy and positive attitude development.
Rebuilding will be a long process that will involve much rethinking
of the original plans - these were no doubt the plans of a stam-
merer designed around word, situation and relationship avoid-
ance. To rebuild, the recovering stammerer will need to consider
and be prepared to adjust these plans as recovery continues, vital-
ly seeking help and involving friends and family in the process.
Essential to this rebuilding programme is support and on
Starfish we provide this in various ways:
1. A nationwide phone list of recovering stammerers available
day and night every day of the year. We feel that the certain
knowledge that there is always available, at the end of a
phone, a person who has walked in your shoes is a great
strength for recovery, and that you can contact someone at the
time that you may be having some problem is vital.
2. Local Starfish support groups meet to practise and discuss
recovery in a friendly social atmosphere.
3. Groups of recovering stammerers meet to practise the tech-
nique in real life situations such as shopping centres and airports.
4. Anyone can, without fee, come back on any course at any
time to refresh. There is no pressure or dependence on this
refreshing; it is again an individual decision. Some people may
come back once a year. For others, this may be more regularly,
say a day a quarter - whatever suits the individuals recovery.
During the four years of Starfish we have worked to build
close links with speech and language therapists. We positively
welcome speech and language therapists on their own or
accompanying a client on a course. Many have attended the full
course and learned the techniques and are now able to offer
advice and backup to clients who attend a Starfish course.
I have been involved now in helping people who stammer for 18
years. My lifetime dream would be to have the Starfish Project
techniques available to everyone on the NHS. Till that day we
operate on a cost-covering basis and will give lifetime support, as
a Starfish course only initiates change which will continue after the
course with all the support that we put on unconditional offer.
Hood, S. (ed) (2000) Advice to Those Who Stutter (2nd ed). The
Stuttering Foundation of America (publication #09, $2.00).
Murray, F. (2001) A Stutterers Story (2nd ed). The Stuttering
Foundation of America (publication #61, $5.00).
(For both see the catalog at, or contact the
British Stammering Association at
re wth
Anne Bght
doesnt waste tme
ookng or a non-
exstent cure or
lnstead, her
Starsh project
oers sma,
ntensve courses
and uncondtona
etme support to
seekng eortess

Bailey, R. (2001) NLP Counselling. Speechmark.
For information on Solution Focused Brief Therapy,
see for example
I hope that, in our work settings, we are able to offer support
when it is needed. Different types of therapies may well be
appropriate in different phases in a persons life.
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Body Worlds Anatomical Exhibition of Real Human Bodies
Now until 29 September, 2002
All bodies on display are authentic, permanently
preserved (with permission) by plastination.
Tickets 10 (concessions available).
Atlantis Gallery, London, tel. 020 7053 0000,
Motor Neurone Disease Association: Study Day for Health and
Social Care Professionals
4 July, 2002
NEC, Birmingham
Includes food and nutrition and managing communication.
Details: tel. 01604 611845,
Estill Voice Craft UK
8-12 July, 2002
The Original Complete Five Day Workshop in the Estill Model
with Anne-Marie Speed, Paul Farrington and Kiereen Lock
Royal Academy of Music, London
Details: Rahel Wagner, tel. 020 7625 2352, e-mail
The British Stammering Association 8th National Conference
6-8 September, 2002
Imperial College, South Kensington, London From 120
Details: tel. 020 8983 1003.
Encephalitis Support Group
10-11 September, 2002
1st International Conference: Encephalitis Defined
Multidisciplinary event with a significantly practical focus.
Keele University, Staffs
Details: tel. 01653 692583,
eHealth 2002 Conference and Exhibition
18-20 September, 2002
The Barbican, London
Johansen Sound Therapy with Dr Kjeld Johansen
8-11 October, 2002
Edinburgh 320 (inc. coffee, tea and lunch)
Tackles underlying difficulties with auditory processing at a
fundamental level, enabling the individual to process sounds
efficiently and thus benefit fully from therapy and teaching.
Details: Camilla Leslie, tel/fax 0131 337 5427.
One Voice - Communicating Together - 3rd annual residential
weekend conference
15-17 November 2002
For families who have a child (6-13) who uses a communication
aid and their siblings. Professionals also welcome.
Details: One Voice, tel. 0845 3307826.
25 personal UK
21 part-time (5 or fewer sessions) (UK only)
18 student / unpaid / assistant (UK only)
30 Europe personal
34 other overseas personal
45 authorities UK / Europe
50 other overseas authorities
Bulk orders (sent to any single work address):
2 copies for 52 3 copies for 72 4 copies for 88
5 6 or 7 copies for 20 each. Total price
48 Personal
38 student / unpaid
73 Authority / department
Bulk orders (sent to any single work address):
2 copies for 84 3 copies for 116 4 copies for 141
5 6 or 7 copies for 33 each. Total price
Note: Cheque and direct payment only. Credit card payments can only be deducted in sterling at the rates advertised above.
Tracey Narsh and
ar Brookes are
speech and
anguage therapsts
or Barnsey
(NHS) Prmary
are Trust. Both
work wthn the
paedatrc team n
cncs, homes and
settngs, seeng
chdren wth a
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Deang wth such
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caseoad demands
that they are
creatve and
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cosey wth other
eary years
5. Screening Tool
An audit of new referrals discovered
that we werent always receiving all
the children who would benefit from
our input at the appropriate age.
A working party of speech and language
therapists and health visitors met to
develop a screening tool and a training
package. The screening tool is used at
the health visitor 18-month assessment.
This enables the health visitor to
make appropriate referrals or give
advice to parents. The training package,
run by the health visitors and speech
and language therapists, comprises
information about the rationale and
use of the screening tool, develop-
mental norms and advice leaflets.
The screening tool is being piloted by
the health visitors and is undergoing
audit. If proven to be useful and effec-
tive, we will extend its use to cover
other health visitor assessment stages.
Community Practitioners and Health
Visitors Association, see
6. Early Listening and Early
Communication Skills
These photocopiable books are very
popular amongst the whole team and we
find them user friendly and full of good
ideas. The activities can be given to other
professionals to reinforce communication
development. The Early Listening Skills
book provides suggestions specific to dif-
ferent settings such as nursery or the home,
whilst Early Communication Skills remains
more general.
Activities to enhance pre-verbal skills,
listening, vocalisations, discrimination,
memory and early words are covered in
developmental sequence. They allow
the child to generalise skills in different
environments and can easily be integrated
into the educational curriculum which
we find is effective and rewarding for
the teachers and children.
Early Communication Skills by Charlotte
Lynch & Julia Kidd, ISBN 0 86388 223 4 is
33.45 and Early Listening Skills by Diana
Williams, ISBN 0 86388 142 4 is 35.45. Both
from Speechmark, tel. 01869 244644.
1. Health promotion
Health promotion is becoming increasingly recognised as an
effective method of collaboration. In Barnsley we take pride in
working closely with Bookstart and Sure Start, in addition supporting
other local health initiatives such as bottle to cup exchange.
Invitations to represent speech and language therapy at health
promotion events - for example Baby Day, Early Years Exhibition
- are received with enthusiasm.
We have produced displays to educate others about early
communication development. In addition we felt it was useful
to give information about who we are, what we do and our
level of training. These displays, including Talking Tips, Caring
about Communication and Come on Lets Play rotate around our
community clinics, a new one being created every three months.
4. Newsletter
Our team has recently started a quarterly newsletter,
Lets Talk, to inform the public and a wide range of
professionals (including health visitors, school staff and
paediatricians) about our service and topical projects.
So far we have included an overview of the role of the
speech and language therapist and our department, our
innovative new therapy groups in clinics and changes in
our school service, where we have moved from a needs
based to a location based caseload to help with consistency
of therapists in schools, and are offering a group social
skills package in secondary schools rather than one to one
therapy or programmes. In future we aim to cover
resources useful to other professionals and book reviews.
3. Joint Visits
Joint visits with both a range of multidisciplinary professionals and
our own team members form a central part of our collaborative
working. We find working alongside health visitors, nursery
nurses, teachers, Portage workers, psychology services, the
sensory impaired team, physiotherapy and occupational therapy
particularly valuable.
Multidisciplinary visits provide opportunities for liaison but also
offer insight into roles and working practices. Further benefits are
in generating a holistic view of the child and the impact of their
needs on the family which is useful for setting our own aims.
Joint visits with colleagues give us the opportunity to gain
new ideas and second opinions and to problem solve, which
can offer reassurance and improve productivity.
2. Team Meetings
Having the opportunity to meet with other profession-
als at team meetings (such as Annual Reviews) on a
regular basis is something we enjoy, and the most
effective way of ensuring all professionals are singing
from the same song sheet.
We find the most useful outcome is in the joint goal
setting. It is also a useful arena to inform others of the
nature and extent of a childs communication needs
and help them to have appropriate expectations. For
example we encounter a lot of children with poor
attention skills alongside their communication difficul-
ties. Informing school staff that a child may need time
out between tasks facilitates a happier and more coop-
erative child for all concerned.
7. Spotlight on Special Educational
Needs - Speech and Language
We both find this book helpful in
promoting collaborative working in an
educational context. Written by a
teacher, psychologist and speech and
language therapist, it offers insight
into the roles of the various
professionals. Although it acknowledges
there can be difficulties, collaborative
working is nevertheless strongly
advised as essential.
The book provides practical suggestions
to support children with communication
difficulties in the classroom. These
strategies can then be managed
collaboratively with joint planning. We
have recommended it to many schools
and it has already appeared in our
newsletter Lets Talk (see no. 4).
Spotlight on SEN - Speech and Language
Difficulties by Bob Daines, Pam Fleming &
Carol Miller, ISBN 0 906730872, published
by NASEN, has been reduced to 4.50.
8. Hanen - Learning Language and
Loving It (LLLI)
This programme is new to us in Barnsley and
is running as part of a Sure Start project.
Having a regular opportunity to work closely
with and train early childhood educators
seems to be collaborative working at its best.
The fundamental principles of LLLI are
derived from the It Takes Two To Talk
programme, which we also enjoy running
here. We try to foster links between LLLI and
Sure Start by empowering the nursery staff
to encourage language stimulation,
intervention and enrichment. In addition we
are running weekly speech and language
groups in a project nursery. Session plans and
materials are provided for the nursery so they
can continue the groups on a daily basis.
For Learning Language and Loving It: A Guide
Promoting Childrens Social and Language
Development in Early Childhood Settings
resources see the Winslow catalogue (freephone
0845 921 1777) or contact Anne McDade,
Hanen UK/Ireland Co-ordinator, tel. 0141 946
5433, e-mail
9. Advice Sheets
In Barnsley, we have created a number
of advice sheets for a range of needs.
Those we use most frequently are
Talking Tips primarily for language
delay, Two Word Toy Time to encourage
language modelling through play and
Let Your Child be in Charge reflecting
Hanens allow your child to lead. All
have minimal language and are presented
with graphics, as we find information
presented in this way the most accessible
and likely to be taken on board.
These advice sheets are useful for parents
and for other professionals. Talking Tips
was produced for health visitors to dis-
tribute at the 18 month assessment.
Clipart from Corel Gallery Magic CD Rom,
Leaflets available for a small charge from
Barnsley (NHS) Primary Care Trust, Speech
and Language Therapy Department,
New Street Health Centre, Upper New
Street, Barnsley, South Yorks S70 1LP.
10. Time / Organisation /
For collaborative working to take
place, time is essential. We feel
recently there has been a shift
towards greater recognition that
collaborative working is effective. In
Barnsley we have seen an increase in
joint working practices including the
multidisciplinary projects mentioned
previously and a stroke unit. To create
time for collaborative working we
decided that the numbers of direct
client contacts had to decrease.
In addition to time, organisation and
communication is paramount. For us
letters and telephone calls are our
primary means of communication.
We look forward to a time when
there is more widespread use of e-mail.
Our team is lucky to have full-time
clerical support. We would be lost
without Julia and, without her
efficiency, would find collaborative
working impossible to achieve.
Clair Brookes Tracey Marsh