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WINTER 1999

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I Yo" ,..
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Contents
1999
*
www.speechmag.com
WINTER 1999
(publication date 29th November)
ISSN 1368-2105
Published by:
Avril Nicoll
33 Kinnear Square
Laurencekirk
AB30 1UL
Tel/fax 01561377415
e-mail: avrilnicoll@speechmag .com
Production:
Fiona Reid
Fiona Reid Design
Straitbraes Farm
St. Cyrus
ontrose
Printing:
Manor Group Ltd
Unit 7, Ed ison Road
Highfield Industrial Estate
Hampden Park
Eastbourne
East Sussex BN23 6PT
Editor:
Avril Nicoll RegMRCSLT
Subscriptions and advertising:
- el /fax 01561377415
>4vril Nicoll 1999
Contents of Speech & Language
Th erapy in Practice reflect the views
of the individual authors and not
necessarily the views of the publish­
er. Publication of advertisements is
not an endorsement of the adver­
tiser or product or service offered.
Any contributions may also appear
on the magazine's Internet site.
Cover picture:
Carers' workshop ­
see page
2 News I Comment 17 Ethics
"... there is potential for conflict between parents and
professionals when the parents wish their child to
4 Life stories
receive more treatment. The parents may feel that
"Both professionals were able to monitor and support
this should be part of the child's rights, and withhold­
each other within the group. Speech and language
ing such therapy is contrary to the just needs of the
therapists may inadvertently come across emotional
child. The therapist, in disagreeing, does not see this
issues with clients which they are unprepared I not
as an issue of justice but of clinical need. "
trained to address, particularly in such a group where
Jois Stansfield and Christine Hobden find out if
issues from the past may come up. Therefore, it was
an ethical perspective can help resolve disagreements
important to have a clinical psychologist present who
about intervention.
was trained to take on a counselling role. "
Lucie Hamilton, speech and language therapist, and
Karen McKenzie, clinical psychologist, share their
20 Reviews
thoughts on the advantages and limitations of life
Head and neck, assessment, parental needs, visual
story work with adults with learning disabilities.
perception, dementia, dysphagia, brain injury,
aphasia, autism.
8 Conference report
22 In my experience
"Always test what was best about a conference by
the things that are still going round in your head"
"". to be able to continue to deliver useful support to
(Beryl Kellow).
the patients, the inner motivation to help
The Association of Speech & Language Therapy
must be channelled through the medium
Managers' conference, Countdown 2000.
of respect."
10 COVER STORY
Working with carers
"We were able to develop some unique and sensitive measures to aid
us in our attempts to evaluate the day These and similar measures
may be useful for others engaged in providing support and counselling
days for people with communication disorders and their carers."
Chris Code reports on an Action for Dysphasic Adults (ADA) pilot day
for carers of people with aphasia.
bilingual community are explored.
13 Further Reading
Psychiatry, staff attitudes, phonology, hearing
impairment, stammering.
30 My Top Resources
"Do you know the names of the
members of 'Steps'? What is
14 Assessments assessed Britney Spears' latest single? What
happened this week on 'Home and
rigorous evaluation by practising therapists. Find out what
Published assessments and programmes are again given a
Away' and 'Eastenders'? Who did
they really think of the Work Readiness Profile, Dysphagia Man Utd play this week?"
Evaluation Protocol, Assessing and Teaching Phonological Audrey Richardson gives the low
Knowledge, the Burns Brief Inventory of Communication down on working with
and Cognition and the Test of Pretend Play. adolescents.
IN FUTURE ISSUES
• dysphagia • more assessments assessed • autism • more ethics • cleft palate •
head and neck cancer· voice • transitions
Speech 8r. Language Therapy in Pradice has moved.
All correspondence should now be sent to: Avril Nicoll, Speech & Language Therapy in Practice, 33 Kinnear SquarE.
laurencekirk. Abedeenshire, AB30 1UL tel/fax 01561 377415. For subscribers in the UK, the FREEPOST IS noYt Avril
Nicoll. Speech & Language Therapy in Practice. FREEP05T 5C02255. LAURENCEKIRK. Aberdeenshire. AB30 1ZL
The magazine's complementary intemet site, speechmag, has also moved to http://www.5pI!echmag.com e-maij
(Mail is being re-directed from the old address and callers to the old telephone number will hear a recorded message ...,m rhe fJ€ >'o '
numbed Apologies for any inconvenience caused by these changes.
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 1999
Jan Roach reflects on her work in
the mental health field.
24 How I manage
biUnguaUsm
Assessment of pre-school minority
ethnic children, creative
partnerships to bring benefits for
adult clients and speech and
language therapy in a truly
ISSN (online) 2045-6174 www.speechmag.com
____________________~ ~ e ~
Working
together
Research aimed at improving sup­
port for children with speech and
language difficulties has been joint­
ly funded by the government's edu­
cation and health departments.
Recognising the difficulties caused
by the local health and education
authorities' different legal and
funding responsibilities, and the
variation in services across England
and Wales, the researchers are clar­
ifying current provision. Therapy
commissioners and providers, past
and present users and parents and
teachers will then contribute
through interviews and meetings to
a plan for better services.
The team, led by Dr James Law,
comprises researchers from City
Un iversity, the Institute of
Education and Warwick University.
A web site is under development:
www.city.ac.uk.css.
Common sense for
cerebral palsy
Follow up care for children with cerebral palsy once they the specific advice on standards for speech and language
are discharged from paediatric services is criticised in a therapists drawn largely from Communicating Quality 2
expert report. (Royal College of Speech & Language Therapists, 1996).
The recommendations for minimum standards of health­ The panel recommends referral to speech and language
care in children with cerebral palsy state that, without therapy should take place as soon as potential communi­
further clearly organised provision for their care, a criti­ cation difficulties are identified, and that therapists
cal period in their physical and social development can be should take into account "how much time the family has,
missed. Lack of continuity of care is a general problem or is expecting, to provide to help their child. This .. . can
for parents of children with cerebral palsy which can be be the main variable when planning treatment."
helped by the involvement of 'senior professionals'. The Supervision and specialist training should be available to
importance of a seamless, team approach and working in therapists working with this client group.
partnership with parents and the voluntary sector is The report, which aims to improve equity of service, was
emphasised. compiled based on the best available evidence from ran­
The expert panel who made up the report . included domised, controlled trials, consensus among appropriate
research psychologist Dr Carole Yude who has a 25 year experts and "the often forgotten factor in assessing pro­
old son with a hemilegia and is chair of the voluntary fessional opinion - common sense."
organisation Hemi-Help. Speech and language therapist Available from: Bell Pottinger Healthcare, tel. 01932
Debbie Onslow provided additional information, with 350005, e-mail enquiries@bell-pottinger.co.uk
New network
An innovative plan for an independent,
charitable network of therapy, research and
educational services for people living with
communication disability is to go ahead.
A £2.5 million grant has been secured by
the CONNECT - Communication
Disability Network - initiative from the
Dunhill Medical Trust, who will provide a
building for the first Centre in London.
This Centre will draw upon the expertise
of the City Dysphasic Group and will ini­
tially focus on providing services to peo­
ple living with aphasia following stroke.
In future, a network of regional centres
will be formed across the UK, funded in
whole or part by CONNECT, with the
remit extended to include a wider spec­
trum of communication disabilities.
The first Internet global disability conference has highlighted the growing use A key concept of CONNECT is working in
of the Internet as an information source for parents and clients. partnership with individuals, their families
At the time of going to press, the autism99 site had been visited by more par­ and friends, communities, volunteers and
ents than medical, social services and education professionals put together. students, health and social care decision
Updated information on this will be available in the Spring 2000 issue. makers and providers of public services.
Running from 2 - 23 November, the conference emphasis was on the practical Professor Sally Byng, Carole Pound and
issues surrounding autistic spectrum disorder, with new research and thera­ Dr Susie Parr, who are lead­
pies highlighted. ing the initiative, are keen
Papers,included David Holmes discussing how the needs of adults with autism to hear from people inter­
are both similar to and different from their needs as children and adolescents. ested in forming partner­
The success of the Picture Exchange Communication System was described by ships with CONNECT to
Andrew Bondy and Lori Frost. Peter Vermeulen, who has produced 'I'm develop regional Centres (c/o
Special', a method and workbook for introducing children, adolescents and Department of Language and
young adults to their autistic spectrum disorder, says the "content and design Communication Science, City
are compatible with an autistic style of reading, understanding and think­ University, Northampton
ing." Partnership with parents was considered in Paul Bartolo's paper on Square, London EC1V OHB, tel.
delivering a diagnosis. 0171 477 8290, e-mail
Autism 99 was co-sponsored by The Shirley Foundation and The National s.c.byng@city.ac.uk)
Autistic Society (tel. 020 7833 2299, http://www.nas.org.uk).
www.autism99.org
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 1999 2
ISSN (online) 2045-6174 www.speechmag.com

In better voice
Voice therapy is included in an extended specialist
service aimed at getting performing artists back to
work more quickly.
The British Performing Arts Medicine Trust provides free
clinics in London and Manchester for performance­
related injury and illness. Osteopathy, the Alexander
Technique and counselling are also available.
Details: tel. 020 7240 3331, e-mail
bpampt@dial.pipex.com
Training
expanded
The national educational charity for children with
speech and language difficulties is expanding its
training programme.
I CAN hopes its training centre's move to a London
base combined with provision of courses in more
locations in England will make its courses more
widely accessible to a range of health and education
professionals. To support this, speech and language
therapist Fiona McMahon has been appointed as
Training and Information Manager.
New courses include detection and treatment of
oragmatic language impairment and the role of
speech and language therapy in multiprofessional
assessment and special educational needs tribunals.
Meanwhile, I CAN's Dawn House School has been
praised in an Ofsted inspection, with the successful
' eamwork between teachers, classroom support
assistants and speech and language therapists get­
ting special mention.
Details: I CAN tel. 08700107088.
Advocaqt
volunteers
SIGNALONG is looking for volunteers to help with
t he testing stage of its self advocacy project.
With initial funding through a Department of
Health grant, the group aims to cover signs for body
awareness, emotional developmental, self advocacy
and citizenship, coping with bereavement, coping
with violence and crime and possibly general health.
Details: 01634 832469.
Child stroke
A study is to investigate the number of children in
t he UK who suffer strokes.
The year long Stroke Association funded project will
also determine how the children are investigated
and managed and the problems faced by survivors.
The Association has welcomed the development of a
communication system for Sarah Chandler, unable to
speak after two severe strokes at the age of six and
seven . BT worked with the Oxford ACE Centre to
bring together a variety of components including
t he Laureate speech synthesiser, an Internet service
and a high speed network link. The technology has
been licensed to her school and could therefore be
developed for use by others.
The Stroke Association, tel. 0171 5660300.
Avril Nicoll,
Editor
33 Kinnear Square
Laurencekirk
AB30 1 UL
tel/ansa/fax 01561
377415
e-mail
avnlnicoll@speechmag.com
... comment. ..
Respect .
costs nothing
A simple dictionary definition of respect is 'treat with consideraton'_
Jan Roach's experience leads her to ask what sort of models for gooo
communication are we if we can't start our relationships with cl ient; a
position of respect?
We know this is far from easy, as people and their experiences are so diverse..
Two elements of the Ethical Grid, cited by Jois Stansfield and Christine
Hobden, specify respect - 'respect persons equally' and 'respect autonomy.
Using an approach grounded in ethics gives an added perspective to decisi o
making. Not only can it increase your confidence in what you are doing and
guide you in making it explicit, it can help identify opportunities for
compromise and working together with parents, carers and other disciplines
with whom you may have little in common.
Respect means recognising and responding to different needs. Chris Code and
colleagues found out what the participants in a carers' day hoped to gain,
planned the day accordingly and measured how far it had met expectations.
We need to be in the habit of routinely checking what people want from us ­
at least then we can be open with them about what we can actually provide.
We have to make an effort to get on the same wavelength as the people we
work with; as Audrey Richardson says, 'street cred' matters when it comes te
communicating with her adolescent groups.
Fear of the new or challenging puts up barriers to respect . In sharing their
experience of working with bilingual clients and families, Jane Stokes, Rita
Thakaria and Christine MacLeod inspire readers to approach such clients {
an open mind and honesty. Although resource constraints make a nonsense
of 'equity of service', we can at least offer equity of respect.
Like adults with learning disabilities, many of our clients have huge gaps .
their understanding of self now, self in the past and future self. For speech
and language therapists wary of venturing too far into potentially
'emotional' territory, Lucie Hamilton and Karen McKenzie's life story "
serves to remind us of the support offered by multidisciplinary
starts from a position of respect.
Lack of funding for equipment and service development is a
real challenge. While addressing this, we mustn' t forget the most ',,..,,.,..-=
resources such as respect cost nothing and have a high ra:e of re, IL
SPEECH & LANGUAGE THERAPY IN PRACT1C.E ER 99'l 3
ISSN (online) 2045-6174 www.speechmag.com

II
Life story work offers individuals with a learning
disability the opportunity to review both the positive
and negative aspects of their lives, in a format that
allows them to take control over those aspects which
they wish to share, reflect upon and discuss. Following
a joint group, Lucie Hamilton, speech and language
therapist, and Karen McKenzie, clinical psychologist,
share their thoughts on the advantages and
limitations of this approach.
t has been suggested that the need to review
one's life is universal and required to help the
person reach a sense of completeness about
what has been achieved (Butler, 1963). A
number of techniques have been used to try
and meet these needs in different client
groups, including reminiscent work and life
reviews with older adults (Butler, )963) and life
story work. The latter arose from work with chil­
dren who had been in long-term or foster care,
with the aim of helping them make sense of their
disrupted past (Hussain & Raczka, 1997).
More recently, life story work has been introduced
to individuals with a learning disability. Previous
researchers have reported on the use of this
approach with individuals who live in hospital
who are in transition from institutions to commu­
nity residential homes (Hussain & Raczka, 1997;
Hewitt et ai, 1997). This work notes that most of
the information available about clients from these
settings arises from clinical reports in casenotes
and may be sparse or irrelevant. As many clients
with a learning disability have communication dif­
ficulties (Department of Health, 1995) and cogni­
tive impairments which may lead to difficulties
with memory and sequencing, it may be hard for
them both to link their past to the present and to
communicate it to others.
These communication difficulties impact on a
number of levels. There has been increasing
recognition that individuals with learning disabil­
ities may have greater difficulties than non dis­
abled people in recognising and identifying emo­
tional states in themselves and others (Moffat et
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 1999 4
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team working
ai, 1995; Rojahn et ai, 1995). The recognition and professionals and group members involved.
expression of feelings associated with past events Each professional had different roles within the
may pose additional group. The clinical psy­
chologist's was to ensure
, .. individuals with
the group was emotion­
events outwith the ally therapeutic and to
" here and now" may
learning disabilities may
monitor the emotional
also present problems impact on the individu­
(Bradshaw, 199B). Such als within the group.
have greater difficulties than
difficulties have been The speech and lan­
linked with the expres­ guage therapist's role
sion of challenging was to ensure each non disabled people in
behaviours (Moffat et group member could
ai, 1995). There has understand and respond
recognising and
therefore been an to what was being dis­
increasing recognition cussed and to graphical­
of the importance of
identifying emotional states
ly record discussions.
the emotional aspect of Both professionals were
the lives of individuals in themselves and others able to monitor and sup­
with a learning disabili­
ty (Gardner, 1997).
Stories have been identified as offering a thera­
peutic medium to explore emotional themes
(Dwivedi, 1997) as well as a way for individuals to
make sense of their history (Hewitt et ai, 1997).
Life story work therefore offers a means of allow­
;ng clients to make sense of their past to record
information which is personally relevant to them
and explore feelings that this brings (Atkinson &
Williams, 1990).
Filling the gaps
Our life story work with clients who live in com­
munity settings arose from the realisation that
these people had the same difficulty of making
sense of their past as has been reported about
individuals who have lived in hospitals (Hewitt et
ai, 1997). The aims for the group were to allow
the participants to explore issues relating to their
past in a safe environment, to record their experi­
ences in a form that would enable them to com­
municate them to others and to provide an oppor­
:unity for group members to look at the similari­
ties and differences in their life experiences. In
addition, it was also hoped to identify if individu­
als had gaps in their memory or information about
periods in their life and, if so, that these could be
at least acknowledged and hopefully filled.
The group was run weekly by a speech and lan­
guage therapist and a clinical psychologist.
Working jointly was beneficial for both of the
professionals involved and the group members.
We hear we should be working with other pro­
fessionals but rarely how people go about doing
it. Our starting point for this group was to
acknowledge each other's different backgrounds
and training and to identify areas of different
knowledge / skills and of overlap. We had regu­
lar planning and review meetings for the group;
initially for long-term planning and then short­
term deciding what to do before each session and
"how it went" after each session . These meet­
ings were extremely important to ensure there
was continuity and development for both the
port each other within
the group. Speech and
language therapists may inadvertently come
across emotional issues with clients which they
are unprepared / not trained to address, particu­
larly in such a group where issues from the past
may come up. Therefore, it was important to
have a clinical psychologist present who was
trained to take on a counselling role. From the
clinical psychologist's point of view, the speech
and language therapist was important to ensure
that the members understood what was being
said and were able to express themselves, partic­
ularly to communicate their feelings - a require­
ment for any "emotional therapy" .
Predictable and safe
Each session was run for one hour and had a sim­
ilar structure with the aim of creating a pre­
dictable and safe environment (Hussain & Raczka,
1997). The members were welcomed and the ini­
tial group rules were developed. ·These included
confidentiality, listening to others and turn-tak­
ing. The group members were reminded of these
rules at subsequent sessions. They were then
asked to mark how they were feeling on a visual
analogue scale which ranged from "good"
through "OK" to "bad". This was repeated at
the end of each session to give a crude measure of
the impact of the group on the members.
The group were reminded of the last session's
topic to help aid memory and to enable continu­
ity of the work before the current topic was intro­
duced. Individuals could either work on their
own with support or in the group setting, but
everyone would return to the main group to dis­
cuss the results of their work and compare their
own experiences.
All the individuals had communication and mem­
ory difficulties and, as a result, each aspect of the
group work was supplemented with symbols,
drawings, photographs, pictures chosen from
magazines or anything that helped put the indi­
vidual's story in context for them. Each new topic
was introduced, initially in the form of a question,
for example, "What sort of things did you 0 as a
child?" Such questions usually produced ve Ii e
response so it was necessary to introduce pictu es
/ objects for discussion to help prompt responses.
All responses were recorded. Each individual vas
asked to try to draw / wri te down their re5pO/lSe'S
with support from the group leaders. One of e
group leaders also graphically recorded the main
themes of the group disC1.J ssion. Once disrus - os
about a particular topic had finished, e " d­
ual and group records were combined and a e
more formal using symbols and t
individual an overall record of the gro p_
the record 'formal ' made it possi c
group member to share informa 'on J (
cate about what had happened in e 9
gave what they had talked about more stE
others (see figure 1).
Initially, each piece of work was placed 0 a . _
line. This consisted of a long piece of pc
anchored at one end with a photo of - me as a
baby" and at the other with a picture of -me
now". The group members, however, appea ed
to find the presentation of so much information a:
one time confusing. The time line was t herefore
replaced by a life story book, with a ne age
being added at each session and placed in the co'­
rect sequence to represent that individual's life.
Life changes
The group covered a variety of topics similar t o
those outlined by Hussain and Raczka (199n,
However, an emphasis was placed on he life
changes associated with the transition from child
to being an adult. The themes broadly ranged
from birth to childhood, school and family t o ado­
lescence, friendships and places we have lived and
our current life. Group members were a so
offered the opportunity to discuss how they lei
about each period of their life.
While previous authors have acknowledged so -=
of the potential disadvantages of life story r
including the disruption to the individual's e ' ­
ing concept of their life (Hewitt et ai, 1997),
has been little discussion of the problems i ere
in this work which result from the individ ­
cognitive and communication difficulti es.
A number of themes and difficulties arose d -­
the life story work, and the ways in hich hE: __ _
ics were approached had to be adapted Of
carded to meet the needs of the client5.
ticular, it became apparent that t he grot:
some difficulty with abstract concepts ­
the concept of time itself. For examp G
such as "what did you look like as a
became irrelevant until the group • ...erE
difference between a baby, a child
All discussions had to be related to a
or picture to make them more meM'
keep the participants' attention 'oc
Continuous process
Some group members also had
their memory of their h'st I'f ..
SPEECH & LANGUAGE THERAPY IN PRACTICE
5
ISSN (online) 2045-6174 www.speechmag.com
team working "*
Figure 1 - Examples from a Life Story Book. (Written information has been made less s
Things that I did I had as a child
...eacn aspect
01 the group
work was
supplemented
wi th symbols,
drawings,
photographs,
pictures
chosen from
magazines or
anything that
helped put
the
individual's
story in
context for
them.
5 0 + 5
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Played in the park. I
liked the swings best. I
once feU Off the
roundabout. ,
Liked going horse
riding when I was at
school.
Used to bake cakes
with my mum.
Did computers at
school.
Played the guitar with
my mum.
Had a pet dog called
___ who was brown.
Played cards with my
mum.
.... of information they'd been given about it. As a
result, it was necessary to obtain additional back­
ground information from family members, key
workers and support staff to help fill in these
gaps. This information was then brought to the
group, discussed and recorded in a form that
made it accessible to the participants, that is, a life
story book. This also allowed them to view their
life as a continuous process, rather than a series of
unconnected discrete events.
In common with many individuals with a learning
disability (Moffat et ai, 1995) the recognition and
expression of emotions posed some difficulties for
the group members. It was however of interest
that sessions felt by the therapist to have been
difficult or painful for the group tended to be
First went to school in
____, then went to
____ School.
My teachers at ____
school were called ____
and . I really liked
them.
I was a quiet baby and ate
loads.
Cried a lot and didn't eat
much.
Liked doing jigsaws and
dancing.
rated as such by the majority of group members
on the analogue scale.
Two main themes arose from the group. The first
was the need to produce a document that sum­
marised the individual's life so far and which
could be used to link the past with the next stage
in the individual's development. This document
was therefore not static, but continued to be
added to after the group ended.
The second theme was of the emotional need of
participants. Life story work offered an opportu­
nity to focus on a particular period of life and
explore how it felt at that time. The life story
book also offered a way to develop existing rela­
tionships with others. It gave people a quick and
easy way of relating to the participants, as infor­
mation was laid out in a way that was accessible.
The participants could also control how much of
this information they wished to share with others,
for example only the factual parts about where
they lived as a child, or also how they felt about
this.
The success of the life story work described above
did however rely on four main factors:
• The use of concrete visual examples and
reminders of all the topics discussed, that is, every­
thing was illustrated with a picture, photo, draw­
ing or symbol
• the necessity of obtaining detailed information
from others to help fill in the gaps in the person's
history
• an awareness that some concepts central to life
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 1999 6
ISSN (online) 2045-6174 www.speechmag.com
work..::i'-"ng "-____
ecific to protect identities.)
Things I have done I do I would like to do. now. as a grown up...
Do the housework at home.
I r this year
ego dishes. making my bed.
I( 1·1 Watch vldeos. ego Hary
Ploy tennis .and squash with
: Popplns. Lion King.
;;::=:;:;;;:;::::=:-:-:t1l Aintstones.
If :::::::::J. • eo!
CJ 0 Made a vase.
Don1 go fishing.
Dressed up as a witch. I wore
a pointy hat and a black Sometimes wash staff
coat. members' cars.
() Don1 do computers. bul
Go swimming in ____
.: :: : would like to.
or ________
Get my hair cut In
with my mum. Do some gardening at home. J..
Go shopping for clothes,
music and food. Don't like sometimes take _____'s
shopping If It's busy. dogs for a walk.
eece
Went to hospital when I broke • going on trips In the cor.
ecce
my leg.

story work may be unclear to clients and require clar· of Learning Disabilities 26, 62·66. from hospital to community based se • " .
ification or teaching as life story work progresses Butler, R.N. (1963) The Life Review: an interpreta' Journal of Learning Disabilities for Nun =­
• time to obtain information before the group, tion of reminiscences in the aged. Psychiatry 26, Health & Social Care 1(3), 105·109.
for the group itself, and to help the individuals 368·378. Hussain, F. & Raczka, R. (1997) Life Story
put the resulting information in a format which is Department of Health (1995) The Health of the People with Learning Disabilities. Bri tish
useful \lnd meaningful to them. Nation· a strategy for people with learning dis· of Learning Disabilities 25, 73·76.
abilities. HMSO, London. Moffat, c.w., Hanley, M. & Donnell an.
Lucie Hamilton is a speech and language therapist Dwivedi, K.N. (Ed) (1997) The Therapeutic Use of Discrimination of Emotion, Affective en
and Karen McKenzie a clinical psychologist at Stories. Routledge, London. Taking & Empathy in Individual s \ '
Roodlands Hospital, 9 Hospital Road, Haddington. Gardner, A. (1997) How Do We Stop Doing and Retardation. Education and train '
Start Listening: responding to the emotional retardation and developmental disa
References needs of people with learning disabilities. British 76·85.
Atkinson, D. & Williams, F. (1990) Know Me As I Journal of Learning Disabilities 25, 26·29.
Am. Hodder & Stoughton, London. Hewitt, c., Branton, J., Dunn, J. & Wil lcocks, A.
Bradshaw, J. (1998) Assessing and Intervening in (1997) Life Story Work: issues and applications for
the Communication Environment. British Journal learning disabled people undergoing transition
SPEECH & LANGUAGE THERAPY IN PRACTICE ';o?S
ISSN (online) 2045-6174 www.speechmag.com
'
,
con ference report

Avril Nicoll went.to fil
Information technolo
work, provides the data needed to make
purse strings listen
8ill Mutch
b€li eves an
aspect of
cl inica I
governance
is managers \
taking stock
and
defining
)
V
l
a culture
which is
patient
focused
and values
staff.
"The world Is
moving very
fast and
there is an
anxiety to
'get it all
together'.
There are
so many
problems in
work practice
- Jane
Richardson
and others
talked
about the
importance
of taking
time to
reflect and
take stock
instead of
having
constant
knee jerk
reactions. "
Jan Roach
\
Training - 'a
culture of
enquiry'
He advocates investment
in training and enabling
access to information to
develop staff to their full
potential and adopting a
'no blame' approach
which lets everyone learn
lessons when things don't
work out. Gill Edelman
points out that there are
always gaps in learning,
and always new things to
find out.
The bigger picture
Managers are charged with interpret­
ing and implementing government
policy. They need to be aware of 'the
bigger picture' . The conference began
with discussion of the implications of
devolution, and delegates and speak­
ers were from all over the United
Kingdom.
The value of the networking opportu­
nities of a conference are inestimable ­
a chance to step back from everyday
work and exchange ideas about man­
agement with people working to the
same agenda but in very different set­
tings and circumstances.
We need to be aware of the influence
of developments such as the Internet
on the awareness of the general public
and make sure we keep working to
make our message heard.
Pat Oakley offered delegates a
strategic view, recognising speech and
language therapy as a small service in
a period of extreme change. She
challenged delegates to take time to
reflect and focus on what we are
actually trying to do with the profession.
"We have to
think about
how we
avoId
\
'.
\
tokenism in
\
staff and
I
professional
development
For example,
how does a /
j
study day
actually
change
practice?"
Joe Reynolds
Kate
Malcomess
finds
1\
clinicians
can identify
their own
training
)
needs when
they have /
access to a
suitable IT
system.
"We need to work
with others and cross
barriers - an
interchange of ideas.
We are enthusiastic
about this and would
like to do more of it,
and are now being
actively encouraged
to do so by
government policy. R
Jenny Wood
Bill Mutch says we need a massive investmen
IT systems. The system in use by Irene Morris'
hours of input time wasted and no useful feE
van der Gaag slammed the waste of money i
However, as Kate Malcomess points out, peol
say you cannot measure what you are doing.
must be seen as valid and robust by clinicians
produce data for change. Her Trust's system ~
clinicians on a daily basis which helps them rE
practice, and this bottom-up, continuous refll
continuous change,
A system t hat recognises that caseload is nc
workload, and that there is much complexi
Partnership
<
I CAN, Afasic and the Royal
College of Speech &
Language Therapists are
working on a partnership to
offer a one-stop shop infor­
mation service. Gill Edelman
believes partnership is the
way forward as exemplified
by I CAN's collaboration
with many different
agencies.
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 1999 8
ISSN (online) 2045-6174 www.speechmag.com
conferen ce repoft
enee What re evance would the
erapy managers' conference have to therapis
d out.
Acknowledgement
Thanks to delegates Lesley
Culling, Liz Duff, Hil ary
Hood, Beryl Kellow, Joe
Reynolds, Jan Roach,
Kirsteen Shilson and Jenny
Wood for their insig hts.
collection systems
managers and
direct feedback to
to find out
more about
the care aims
and care
partnerships
between
patients and
carers they
engender as I
am very
enthused by
what she
said."
Lesley Cu lling
User involvement
Bill Mutch on clinical governance again reminds us about
humanity and humility and that self-regulation is a privilege
not a right. He asks, are we listening to patients and carers?
Sally Byng concurs: if th e user perspective is not included,
any 'evidence' is scien t ifically flawed. Her qualitative
research found peop e with aphasia suffered from a lack
of respect in attitudes of professionals. They ended up
disempowered and passivi sed, typified by the statement
from one client, " After a time he Ithe therapist) found I
was doing alright ."
The research also highlighted the need for clients to be
given information over and over again about their
condition and therapy to make sure they get the opportu·
nity to hear it at the time they are ready.
"/ shared this with all my staff, as it has a wider releva nce
than stroke. We have to think, how am I explaining myself,
what is th is person's perception of me, have I made myself
clear? People felt humiliated by their speech and language
therapy experience, which is an awful indictment."
Kirsteen Shilson
-
Irene Morris' group have adopted user involvement to the
extent that patients and carers are now an integral part of
the selection process for key staff posts.
meaningful
11m has been axed ­
lack received. Anna
. as 'iniquitous'.
don't trust you if you
"/t hill taken
Kate
Ma/eomess five
years 'heart
and soul' to
her
system. / want
Delegates at the (
dinner were enfi? .
Maire-Louise
harp and sing;
Kirsteen 5hils
Do you know your area and
Power and
Secondment is
its culture - the populati0n
a useful influence
and the economy? Do you
approach to
"Irene Morris heads up a
know who has the power, asks
partnership
consortia of small services like
Irene Morris? Who needs to
working and
speech and language therapy.
be cultivated? Who can help
can help bring
This is pertinent for me because
you effect change? Transitions
about the
we have just merged with anoth­
need work. What partners do
necessary
er Trust and we - speech and
you need to be collaborating
understanding,
language therapy and other
with - social work, education,
collaboration
housing, user groups, volun­
small services - are working hard
and
ta ry sector, GPs, private sector,
on influencing our new board. "
compromise.
the public, another Trust?
Beryl Kellow
SPEECH & LANGUAGE THERAPY IN PRACTICE • :: ' :::; 9
ISSN (online) 2045-6174 www.speechmag.com

ee In

ex e a Ions
A pilot support scheme in the aphasia field has applications for therapists working with
carers of people with any communication difficulty. Chris Code reports.
esearch over the years has highlighted
the situation of relatives of aphasic
people. Every student is familiar with
the cliche ' aphasia is a family problem',
but we are nevertheless very aware of
its truth. There is now clear evidence
that carers and relatives of aphasic people can
experience significant difficulties with psychologi­
cal and social adjustment. (For more details, recent
accessible reviews of the research literature can be
found in Taylor Sarno (1995), Elman and Bernstein­
Ellis (1999) and Johannsen-Horbach et ai, 1999.)
In acknowledgment of this, Action for Dysphasic
Adults (ADA) has been concerned to improve and
increase the provision of support for the partners,
relatives and carers of aphasic people. There is now
a useful body of literature on providing various
kinds of support groups for the relatives and carers
of aphasic people, for example Rice et ai, 1987;
Wahrborg & Borenstein, 1989; Hoen et ai, 1997.
ADA has developed an approach to provide one-off
support days for relatives and carers, with a pilot
carers' day taking place in Exeter in February 1999.
Framework
The support day was designed so it might easily
be used as a model or framework around the
country by the Regional Development Advisers
(RDAs) who make up the professional regional
arm of ADA, and other professionals engaged in
running carers' support days. We were able to
develop some unique and sensitive measures to
aid us in our attempts to evaluate the day. These
and similar measures may be useful for others
engaged in providing support and counselling
days for people with communication disorders
and their carers.
Eight employees of ADA, including five Regional
Development Advisers, made up a two-day brain­
storming workshop at City University, London,
facilitated by Carole Pound. Here the group dis­
cussed and developed the topics and issues they
considered should be covered in a day for relatives
and carers. This resulted in the development of a
range of ideas and materials to incorporate into a
resource that could be utilised by facilitators plan­
ning to run a Carers' day. The workshop partici­
pants identified the main domains of concern as:
i. provision of information;
ii. communication I conversation training;
iii. emotional support;
iv. practical coping strategies.
The resulting resource manual, Conversation &
Coping, is split into a trainer's manual and a par­
ticipant's manual, with overhead transparencies
and handout masters. It also includes the basic
structure and content for three sample days for
carers and relatives with a variety of aims:
1. developing confidence in conversation;
2. developing confidence in coping and managing
disability;
3. developing confidence in coping with emotion­
al issues.
The manual is also a flexible resource of ideas and
materials. ADA decided to run a pilot carers'/rela­
tives' day before introducing the model more
widely, and Exeter was chosen for this.
There are a number of ways to decide what to put
into a support day of this kind. We could have
decided on the basis of our past experience or by
reference to published reports on carers' support
days. However, although this was to be a 'group'
support day, we decided we would attempt to find
out what the individual participants felt was impor­
tant to cover, rather than us professionals deciding
the complete contents. We started with our past
experience, the ideas we had generated at our
workshop and our knowledge of the published
materials available, so the broad domains of the
day were pre-determined and planned from the
perspective of our professional knowledge base.
Maximising time
Having established the broad topics to cover, an
important constraint is the limited time in a work­
ing day. How could we maximise the four hours or
so available to us? We decided to ask the partici­
10 SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 1999
ISSN (online) 2045-6174 www.speechmag.com
~ cover story
Table 1. Planning questionnaire Table 2. The seven topic areas and the overall percentage that
the participants requested the day should cover.
Your name: Date: ____
Approximate date of my partner's stroke ___-----,- Topic Percentage
Please read the statements on the following page carefully. Coping with Emotions 14.5
Under each statement is aline with the words AGREE and DISAGREE The Nature of Aphasia/Stroke 9.5
at each end. Please place an 'X' on the line nearest the end which Services for My Aphasic Relative 18
you agree with. Community SUpport for Carers 17
For instance, for the statement, "I would like to spend time on the Developing My Own Personal Support 14.5
Carers' Day talking about community support for carers of aphasic Coping 8. Problem Solving 17
people" you might agree just a little and therefore place the 'X' New Roles 8. Responsibilities 9.5
towards the DISAGREE end. On the other hand, you might agree
Table 3 . Programme for Exeter Carers' Day
with the statement quite a lot You would therefore place your 'X'
towards the AGREE end, like this:
lOam Introductions
DISAGREE__________ --"- X___ .AGREE
10JOam Outline of the Day
Stroke and Aphasia and Your Relative. (PARTICIPANTS' CONTRIBUTIONS· What is your partner's aphasia
Now please read through the statements first and then make your
like? The differences between the spouses' aphasia. What happened when he/she had his/her stroke?
choices.
Effects of brain damage.)
llam Identifying Services and Support
1) I would like to spend time on the Carers' Day discussing feelings
(PARTICIPANTS IDENTIFYING· Services for People with Stroke and Aphasia; Stroke Association I
of depression, anger, stress and other emotions, and how to cope
Dysphasia Support / Family Support, ADA, Community Groups; Community Help.)
with them.
11.45am Identifying Emotions
DISAGREE_ ________ _____ ,AGREE
(ACTIVITY· Feelings' analysis, dealing with anger.)
2) I would like to spend time on the Carers' Day trying to 12 noon Lunch
understand more about the nature of aphasia and stroke. l2.4Spm Personal Support
DISAGREE,______________,AGREE
(ACTIVITIES to identify sources of personal support.)
1.4Spm Identifying and Solving Problems
3) I would like to spend time on the Carers' Day trying to
(PARTICIPANTS' ACTIVITY)
understand more about the services available for my aphasic partner. 2.1Spm
Tea
DISAGREE AGREE 2JOpm
Partner's Roles and Responsibilities
4) I would like to spend time on the Carers' Day on community (PARTICIPANTS Identifying roles before and after.)
support for carers of aphasic people. 3JOpm Close· Educate the community
OISAGREE_ _____________ ,AGREE
(Advocacy, assertiveness, mutual.)
145pm Close
5) I would like to spend time on the Carers' Day on ways to
develop my own personal support.
DISAGREE _____ ___ ______,AGREE
We decided we would attempt to find out what the
6) I would like to spend time on the Carers' Day discussing ways to
develop skills in coping and solving problems.
DISAGREE_ ____ ________ _ ,AGREE individual participants felt was important to cover, rather
7) I would like to spend time on the Carers' Day discussing
than us professionals deciding the complete contents.
responsibilities I have taken on which used to be my partner's.
DISAGREE AGREE
pants how much time they wanted to devote to between the amount of time individuals felt they difficult, if practically possible at all. However, we
dJferent topics and devised a questionnaire to would like to spend on a topic, and how impor­ can directly assess whether we have met the par­
help us (Table 1). It asked participants to rate, on tant or relevant that topic is to them. The pro­ ticipants' expectations. Given that we had asked
a semantic differential scale, the degree to which gramme planned for the day (Table 3) was based them to contribute to the planning, we devised
t hey agreed or disagreed with seven statements very closely on the participants' averaged ratings. another questionnaire, completed at the end of
'[Overing a range of topics. Thus, about 17 per cent was devoted to coping the carers' day, to measure if the contents had
Potential participants were contacted by letter and problem solving and about 9.5 per cent to met with their expectations.
and by phone to establish if they would like to background information on the nature of stroke For the evaluation questionnaire we asked partici­
attend. A comfortable room was provided free by and aphasia. pants to rate the same seven questions as before, but
~ a m a l o t pic, the operators of The National The day had a main facilitator (Chris Code), a this time each statement was prefaced "From my
l ottery, which had parking and easy access. Stroke Counsellor (Jackie Byrne) and two more point of view, we spent enough of the day.. ," thus:
?articipants were nine spouses (seven females and 'neutral' observers. The observers' role was to help 1. From my point of view, we spent enough of the
t ,vo males) living in or near Exeter in Devon us evaluate the usefulness of the day. One was day discussing feelings of depression, anger, stress
whose aphasic partners ranged from very severe· Regional Development Adviser Margaret Conan, a and other emotions, and how to cope with them.
Iy to mildly impaired and disabled. Most aphasic speech and language therapist with experience The mean responses for the group are shown in
partners had been aphasic for several years with working with Carers National Association, and the Table 4. The overall mean score was 8.3 out of 10,
the most recent being 12 months post-onset. other was retired Chief Speech and Language suggesting that overall the day met 83 per cent of
We summed the questionnaire responses and Ther apist Janet Howitt, with extensive experience the group's expectations. The lowest mean score
t urned them into percentages. We then sectioned of aphasia. They did not sit outside the group, but (7.25 out of 10) was for 'ways to develop my own
t he 4 hours 15 minutes available and planned participated in the activities. personal support'. Although this was he lowest.
activities that directly reflected their requests it still seems we met 72 per cent of expect ations
able 2). This indicates that, for the participants, Success) for this topic. The highest mean was 9.25 for 'dis­
services for aphasia, community support for carers We wanted to assess the usefulness of the day so cussing feelings of depression, anger, stress and
and problem solving were their main concerns. we could improve things for similar days that ADA other emotions, and how to cope with t hem'.
Coping with emotions and developing personal or others would run in the future in different Interestingly, despite the fact that \ e actually
support were next in importance, ' followed by · parts of the country. Deciding if such a day was spent a large proportion of the day discussing
Knowledge of the nature of aphasia and stroke 'successful' depends on what the aims were. personal support, and li ttle t ime discussing emo­
and taking on new roles and responsibilities. Establishing the difference it might have on the tions and how to cope wit h them, it was the par­
e reasoned there should be a close relationship everyday lives of the participants would be very ticipants' group perception that we did enough ~
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 1999 11
ISSN (online) 2045-6174 www.speechmag.com
cover story
.... on the latter but less than enough on the former.
(The development of personal support refers to
such things as phoning a friend when things get
bad, talking t o neighbours / doctor / vicar / family,
enjoying 'treats' such as wine or chocolate cake
and involvement with a support group.)
Agreement
Two facili tator/observers independently complet­
ed the same questionnaire within a couple of
days. Their overall averages were very close (7.71
and 7.57) suggesting excellent agreement that
the day had been between 76 and 77 per cent suc­
cessful in meeting their expectations. Both scored
'developing my own personal support' and 'dis­
cussing ways to develop skills in coping and solv­
ing problems' as being covered the least satisfac­
torily. This agrees well with the relatives.
What have we learnt for future days of this kind?
1. Participants appeared to get a great deal from
the day. Despite the fact that many had husbands
and wives who had been aphasic for many years,
the day met some of their needs.
2. We provided a great deal of 'paper' informa­
tion in the way of leaflets, addresses and names
and phone numbers of organisations, agencies
and individuals who
might be useful to
them. While we were
under no illusions that
all or even much of this
material would be
Re ections:
1. Do I consider
read, participants were
working in
encouraged to keep
partnership with the information some­
where accessible as a
the voluntary and
resource.
private sectors
3. We were struck by
when providing the amount of help
available in the com­
services?
munity to support car­
2. Do I recognise
ers and how little some
carers' needs for
participants knew
about the sources of
long-term
support. We were
support?
equally impressed by
the amount of infor­
3. Do I find out
mation some partici­
what people
pants already had and
want from me were able to share
with other group
and then check
members.
that what I
4. We decided before­
provided met
hand on seven impor­
tant domains that
their expectations?
could be covered ade­
quately and usefully in
one day. Clearly, a different group, at a different
time and in a different place, might have come up
with different topics. We would have found it
harder to meet expectations if we had decided
how much of what to include without consulta­
ti on wi t h participants.
5. Our method of evaluating the day provided us
Table 4: Participant's ratings on how they perceived the
content of the day had met their expectations.
Topic Percentage
Score (Out of to)
Coping with Emotions 9.25
The Nature of Aphasia I Stroke 9.12
Services for My Aphasic Relative 8.25
Community Support for Carers 8.0
Developing My Own Personal Support 7.25
Coping & Problem Solving 8.12
New Roles & Responsibilities 8.12
Total 58.1117
=Mean 8.30
(83%)
... despite the fact that we actually
spent a large proportion of the day
discussing personal support, and little
time discussing emotions and how to
cope with them, it was the
participants' group perception that
we did enough on the latter but less
than enough on the former.
Action for Dysphasic Adults (ADA) is the only
British charity concerned solely with improv·
ing awareness and services for people with
aphasia and their partners, relatives and car­
ers. ADA has been concerned in recent years
to increase the number of self-help groups
for aphasic people around England, and cur­
rently there are over 20 such groups with
more in the pipeline. There are now six
Regional Development Advisers employed
on a part-time basis to provide support on a
regional basis, covering all of England, as
well as parts of South and West Wales. There
is also a completely independent ADA in
Northern Ireland with similar aims.
ADA
1 Royal Street
London
SEl 7LL
tel. 0171 261 9572
http://www.ada-uk.org
with some clear information. If we had properly
reflected the participants' wishes for the amount
of time spent on each topic, we would expect
high agreement that the day had met expecta­
tions. The day appeared to meet 83 per cent of
the group's overall expectations.
6. Predetermining the areas to cover reduces the
time involved in planning. An alternative and
more time consuming procedure would be to ask
potential participants to provide topic areas that
can be narrowed down into a range which could
be included in a day and could involve individual
consultation and interview.
7. We felt it was useful to tap not only the rela­
tives' perceptions on the day but also the p o f ~ ­
sionals' to give us a broader view of its impact.
There was a very high level of agreement.
8. Given that the amount of time spent on deve
oping personal support fell short byabout 17
cent of participant's expectations, there may 'i .
be an unmet need for the development of p€r­
sonal support for the relatives and carers of apha·
sic people in the group. This is despite the faa
that we spent as much time on the topic as the
participants appeared to request. Of courSt­
because we spent time on the topic does no
mean we spent quality time on it. The issues mao
not have been covered adequately. The mismatc
between the participants' ratings suggests per­
haps we did not.
9. We know that measuring people's perceptions
and expectations is a tricky process (CampbeJ
1976), whether we are using interviews or stan.
dardised questionnaires. For future relatives' a
carers' days of this kind we need to consider carE­
fully possible mismatches between participants
perceptions and expectations.
Chris Code is the Research Officer with Action for
Dysphasic Adults (ADA). The address for corre­
spondence is Professor Chris Code, School o ·
Psychology, University of Exeter, Exeter EX4 4QG,
tel. 0136383900, e-mail c.f.s.code@exeter.ac.uk.
Acknowledgement
The initial two day workshop, and the develop­
ment of the resulting resource manual.
Conversation and Coping, was supported by tile
Prudential Carer's Initiative.
References
Conversation & Coping (1999) London: Acti on fOI
Dysphasic Adults.
Campbell, A. (1976) Subjective measures of we'
being. American Psychologist 31, 117-124.
Elman, R. & Bernstein-Ellis, M.A. (1999
Psychosocial aspects of group communication
treatment: preliminary findings. Seminars in
Speech & Language 20, 65-72.
Hoen, B., Thelander, M. & Worsley, J. (1997)
Improvements in psychological wellbeing of peo­
ple with aphasia and their families: evaluation of
a community based programme. Aphasiology
681-691.
Johannsen-Horbach, H., Crone, M. & Wallesch, ( .
W. (1999) Group therapy for spouses of aphasic
patients. Seminars in Speech & Language 20,73·
83.
Rice, B., Pauli, A. & Muller, D.J. (1987) An eva lua­
tion of a social support group for spouses and
aphasic adults. Aphasiology 1, 247-256.
Taylor Sarno, M. (Ed.) (1995) Aphasia Recovery:
Family-Consumer Issues. Special Issue of Topics In
Stroke Rehabilitation 2,3, 1-87.
Wahrborg, P. and Borenstein, P. (1989) Famil
therapy in families with an aphasic member.
Aphasiology 3, 93-98. 0
ISSN (online) 2045-6174 www.speechmag.com
further readi n g
This regular feature aims to provide information about articles in
•••other journals which may be of interest to readers. urther readin
The Editor has selected these summaries from a Speech & Language Database compiled by Biomedical Research Indexing. Every article in over
rl

thirty journals is abstracted for this database, supplemented by a monthly scan of Medline to pick out relevant articles from others. --,- ­
To subscribe to the Index to Recent Literature on Speech & Language contact Chr istopher Norris, Downe, Baldersby, Thirsk, North Yorkshire 1)
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Annual rates are
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S"",MMERING
PHONOLOGY
Hancock, K., Craig, A., McCready, c., McCaul, A., Costello, D., Campbell, K. and Gilmore, G.
Rvachew, S., Rafaat. S. and Martin, M.
(1998)
(1999) Stimulability, speech perception
Two· to six·year controlled·trial stuttering outcomes for children and adolescents. J Speech
skills, and the treatment of phonological
Lang Hear Res 41(6)1242·52.
disorders. Am J Speech Lang Pathol 8 (1)
This research is a long-term follow-up of a previously published, controlled trial on the effectiveness of
33·43.
three stuttering treatments (intensive smooth speech. parent-home smooth speech, and intensive elec­
The relationship between stimulability, speech
tromyography feedback) for children and adolescents aged 11 to 18 years, who stutter. The previous
perception ability, and phonolog ical learning
controlled trial showed all three treatments to be effective compared to nontreatment after 12 months.
was examined in two descriptive studies. In
This paper reports on the treatment effect iveness after an average of four years post -treatment. Results
Study 1, the children received nine group
demonstrate that treatment gains were maintained in the long term, with rates of stuttering similar to
treatment sessions targeting three phonologi ·
the one-year postoutcomes. There were no signifi·
cal processes using the cycles approach.
cant differences among the three treatments in
Treatment progress was not observed for
long-term effectiveness. This controlled study sub­
STAFF ATTITUDES
sounds that were unstimulable before treat­
stantiates the claim that the treatments investigat­
Upton, D. (1999) Clinical effectiveness
ment. Given stimulability, treatment progress
ed will more than likely have substantiallong-ter
and EBP 2: attitudes of health·care pro·
was greater for sounds that were well per­
benefits for the fluency and personality of children
fessionals. elin Linguist Phonet 13 (1) 26·
ceived before treatment in contrast with
who stutter.
30.
treatment. In Study 2, the cycles approach was
sounds that were poorly perceived before
The concepts of evidence-based practice (EBP)
modified so that each child received three
and clinical effectiveness have become more
brief, individual treatment sessions followed
important within the NHS in recent years. In
by si x group treatment sessions. Each individ­
order to enable suitable initiatives to be
PSYCHIATRY
developed and for future policy to be shaped
ual session targeted stimulability of target
Hoffman, R.E. (1999) New methods
and evaluated, it is important that the current
sounds. using phonetic placement, and per­
for studying hallucinated 'voices' in
level of attitudes towards and knowledge of
ception of target sounds, using the Speech
schizophrenia. Acta Psychiatr Scand
these concepts are ascertained. This survey
Assessment and Interactive Learning System
Suppl 395, 89·94.
recorded the level of knowledge of EBP and
(SAILS). In Study 2, good progress was
The mechanism of hallucinated speech or
clinical effectiveness and examined the atti­
observed for most target phonemes, including
'voices', a symptom commonly reported by
tudes of a sample of 207 podiatrists, speech
those that were unstimulable or poorly per­
schizophrenic patients, is poorly understood.
and language therapists, occupational thera­
ceived before treatment.
We have undertaken two types of study -0
pists and physiotherapists towards these con­
explore the hypothesis that th is symptom aris­
cepts. Results showed that the participants
es from pathologically altered speech percep­
rated their level of knowledge of evidence­
HEARING tion networks. The first consists of neural net­
based practice/clinical effectiveness as poor,
work computer simulations of narrati e
although they expressed a positive attitude
IMPAIRMENT speech perception. We have shown hat "
towards the concepts. In part icular, profes­
these networ ks are partially disconnected
Miyamoto, R.T., Kirk, K.I., Svirsky, M.A. and
sionals considered themselves to have poor
undergo a 'monamine' neuromodul a ory y
Sehgal, S.T. (1999) Communication skills in
research and information technology skills
turbance, ' hallucinated speech' (speech
pediatric cochlear implant recipients. Acta
and lacked an ability to undertake computer
cepts occurring in the absence of p on ::::':
Otolaryngol (Stockh) 119 (2) 219·24.
literature searches.
input) are simulated as well as specj c
Detailed longitudinal stud ies of speech percep­
perception impairments. The latta'
tion, speech production and language acquisition
prompted us to conduct parall el
have justified a significant change in the demographics of congenitally and prelingually deaf children
actual schizophrenic patients using a
who receive cochlear implants. A trend toward earlier cochlear implantation has been justified by
speech tracking' (MST) task. 5f r6: 0,
improvements in measures assessi ng these areas. To assess the influence of age at implantation on
jects to track narrative speec
age five years was used as a benchmark. Thirty-one children who received a Nucleus
clarity of wh ich is reduced
cochlear implant and use the SPEAK speech processing strategy and two children who received a
multispeaker 'babble.' Ha
Clarion cochlear implant and use the CIS strategy served as subjects. The subjects were divided into
strated speech percep -Oli
three groups based on age at implantation. The groups comprised children implanted before the age
experimentally indlKed 1=- =J
of 3 years (n = 14), children implanted between 3 years and 3 years 11 months (n = 11) and those
which clearly differe. u2: '!--:1
imp lanted between 4 years and 5 years 3 months (n = 8). The children were further divided according
hallucinators a d
to whether they used oral or total communication. The earlier-implanted groups demonstrated sta­
support the h
tistical ly significant improvements on measures of speech perception. Improvements in speech intelli­
ous products
gibility as a function of age at implant were seen but did not reach statistical significance. The results
networks.
of the present study demonstrate that ear ly implantation promotes the acquisition of speaking and
listening skills.
SPE.ECH & LA.NGUAGE l1fERAPY 13
ISSN (online) 2045-6174 www.speechmag.com
assessments
assesse
Speech &Language Therapy in Practice readers continue to find out if the marketing
speak for published assessments and programmes matches the reality.
Helpful teaching activities
Assessing and Teaching
Phonological Knowledge
John Munro
Australian Council for
Educational Research
$89.00 (Aust)
If you work in an educational
setting and have an interest in
literacy, Helen Cheal suggests you
check out this package.
The introduction to this assessment proposes to
serve two main purposes:
1) to check children's readiness for particular
aspects of reading teaching
2) to understand and diagnose a child's reading
difficulty.
The author suggests it is applicable for use with
children in their first three years of schooling but
also for older children to assess the extent of their
phonological knowledge.
A profile is compiled for each child based on their
assessment results, which highlights any areas of
difficulty and the manual recommends specific
teaching activities to target these. The author states
this assessment / teaching package is suitable for
teachers and / or 'educational diagnosticians'. It is
not therefore designed specifically for use by
speech and language therapists. The assessment
does not claim to be a definitive test of a child's
phonological knowledge and the author recom­
mends using it alongside other tests of reading abil­
ity, vocabulary knowledge and language function.
The involvement of speech and language thera­
pists in literacy assessment / teaching is somewhat
controversial and depends largely on the policy of
individual departments and / or work settings.
However, recent research (for example,
Stackhouse and Wells, 1997) emphasises the
importance of phonological skills for both oral
communication and literacy development.
When I agreed to pilot this assessment I was work­
ing in the Junior Department of a Language Unit
in addition to a community clinic with a paediatric
case load. I decided to use the assessment and
teaching activities in the language unit setting as
many of the children there had literacy difficulties
and I was, therefore, more involved in this area
than with most of my community clinic caseload.
CASE EXAMPLE: H (chronological
age 8;11years)
H presents with a phonological disorder with large­
ly age appropriate language skills. His reading and
spelling were approximately at a 6;6 year level.
Before I began any assessment with H, I complet­
ed the accompanying Screening Checklist with his
teacher which looks broadly at four areas: oral
communication, pronunciation of words, reading
aloud and spelling. It was useful to complete this
jointly and helped clarify H's strengths and weak­
nesses. However, some of the questions were
rather vague, for example, 'Does the child express
ideas in the appropriate way?' There is also a par­
ent questionnaire which explores factors such as
early language development and family history
which could be used to accompany a speech and
language therapy case history.
Difficult to keep attention
The actual assessment is divided into five main
tasks and includes activities such as the identifica­
tion of rhyme, alliteration, segmentation of
words and manipulation of sounds in words.
These are said 'to cover the span of phonological
development relevant to early literacy develop­
ment'. I found the assessment quite time con­
suming and it was difficult to keep H's interest,
even though he has good attention skills and is
used to doing therapy / assessment activities.
The tasks involve a mixture of auditory and visual
stimuli with line drawings and printed letters,
words and non-words. All the pictures are verbally
labelled by the tester which is just as well, as many
are quite obscure, for example, plank, tramp, twist.
However, this means it is not possible to assess the
full extent of the child's own phonological repre­
sentations as the tester is always giving the labels.
The assessment was useful for highlighting some
deficiencies in H's rhyming skills, which I had not
been aware of during therapy activities. Although
H could detect rhyme easily and produce rhyming
words in isolation, he had difficulty generating
rhyming words in prose. The teaching section in
the manual provided some helpful ideas which I
utilised during therapy and discussed with his
teacher to incorporate during literacy activities.
I also discovered that H's production difficulties
with consonant clusters / blends was reflected in
his ability to segment words with clusters / blends
and read non-words containing them . This did
not come as a particular surprise but confirmed
my therapy aim to focus on these in more details.
H could manipulate words with three sounds quite
well, for example, deleting sounds, substituting
sounds and blending them, but he began to fail when
another sound was added. This was encouraging as
we had focused on blending three sound words in
therapy for a long period and it appeared to have
been successful. It also highlighted that it was now
appropriate to move on to four sound words.
Although I feel the assessment did provide some
useful information, much of this could also have
been gained informally. It does not cater fully for a
child with a speech sound difficulty as many of the
tasks rely on the child producing words / sounds and
there are no clear guidelines to testers about how
to score the child's speech if it deviates because of
an articulatory and / or phonological difficulty. It
may be useful to use the assessment alongside the
psycholinguistic framework developed by
Stackhouse and Wells (1997) to gain a deeper
understanding of the child's level of functioning.
I am no longer working in the language unit and
doubt I will have time to use the assessment in the
community clinic. However, I may select some of
the assessment tasks and adapt them to my work­
ing practice. The teaching activities are helpful
and I will be able to refer to these for school pro­
grammes and therapy planning. I would recom­
mend the package to therapists who work in an
intensive educational setting who have a particu­
lar interest in literacy, but do not feel it is a vital
tool for community clinic work.
Helen Cheal is a speech and language therapist with
Sandwell Healthcare Trust in the West Midlands.
14 SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 1999
ISSN (online) 2045-6174 www.speechmag.com
assessments
Easy to complete
Work Readiness Profile
Helga A. H. Rowe
Australian Council for
Educational Research
$70.00 (Aust.)
Despite some reservations, Sue
Harris recommends this profile
designed for use with older
adolescents and adults with
disabilities.
I work in a college of further education with stu­
dents who have special educational needs (both
physical and learning disabilities). Although I am
a speech and language therapist, I am employed
as a teacher, my speciality being communication.
like most people in this field, I am always looking
for effective assessments for this cl ient group.
The profile comes neatly packaged in a folder and
contains a set of answer booklets, individual
record forms, group record forms and an instruc­
ti on manual. Unlike some instruction manuals,
this one is not enormous and was easy and quick
to read. The information in the first chapter is
useful as background to the assessment. The
notes on administration were clear and my col­
leagues - less experienced than myself in the
administration of test material - found them sim­
ple to follow.
The administration of the test itself takes only 10­
15 minutes. Despite the fact that the author
claims it can be self-administered, there were no
students at my college who had the reading abil­
ity needed. However, this assessment is also
designed for clients who have physical disabilities
where self-administration would be appropriate.
My teaching colleagues found it easy to complete
on behalf of those students whom they were hop­
ing to place in work experience. Following com­
pletion of the answer booklet, the scores are then
transferred to an individual record form and an
average score for physical and personal effective­
ness is obtained. Again, this took just a few min­
utes to carry out. The record form shows an indi­
vidual's strengths and weaknesses and also those
areas which need support and further training .
We did not use the group record form as we were
looking at students' individual abilities.
We found a number of drawbacks:
1. A high level of reading competency is needed
for clients to complete the forms themselves.
Makes you think
The Test of Pretend Play
Vicky Lewis and Jill Boucher
The Psychological Corporation
£312.63
Given the strengths and
limitations of this test, Alison
Webb believes a checklist of skills
with suggestions for suitable
materials would have been more
useful.
The Test of Pretend Play (ToPP) is designed to test
th ree different types of symbolic play:
• substituting' up to four items to represent some­
thing else
• attributing an imagined property to an object or
person
• reference to an absent object, person or sub­
stance .
"'herefore it assesses types of play not tackled by
other tests. For example, the Test of Symbolic Play
lowe and Costello) on Iy tests functional (repre­
sentational) play.
as both a verbal and non-verbal section, plus a
useful structured observation sheet. The verbal
test, although recommended for three years and
over, places heavy demand on comprehension
and I would only use it with older children. For
example, it asks the child to "make the dolly go
down the hill in a sledge into the snow."
Bored
I had expected the materials to provide a rich lan­
guage sample. They in fact had the opposite
effect, and the children became bored with the
materials. They have to interact with the doll for
five sub-tests and with the teddy for four. The
teddy does not have jointed arms or legs, which
made interpreting the distinct movements for
scripted play difficult. The section where the child
is expected to pretend to be a tree, or cold, made
them very self conscious and it would probably be
better to assess those skills informally.
A five year old autistic boy refused to participate
in any of the test, as he dislikes dolls and teddies.
The test confirmed my clinical judgement on both
the three year olds I used it with:
• case 1 - three years old, language delay, mainly
expressive - ToPP revealed age appropriate play
• case 2 - three years, four months old with possi­
ble general developmental delay in addition to
2. It can be difficult to come to conclusions about
individuals exhibiting patchy performances; how­
ever, this would also prove the case when other
assessments are used.
3. Given the client group which the assessment is
aimed at (learning disabled clients, those who
have "other" disabilities and those with multiple
disabilities) there is a distinct bias towards those
skills suited to manual types of work. At times the
instructions mention physically disabled clients
without taking into account that their intelli­
gence is often unaffected and therefore they may
be capable of more complex work.
4. The sections relating to physical abil ity have
some discrepancies, for example, in the same sec­
tion picking up a matchbox is equated w ith usi ng
modified computer systems.
One of the main strengths of the assessment is
that it is easy to administer and score. The results
usually corresponded with the observations we
had made about clients. The assessment can be
used to monitor progress. This could be a useful
tool when assessing prospective students for entry
to college courses. Despite some reservations, I
would recommend this as a useful addition to our
repertoire.
Sue Harris, a speech and language therapist, works
as a teacher at Oxford College of Further Education.
language delay - ToPP revealed a delay of around
one year in pretend play.
Would I recommend it' It certainly assesses areas
not covered by other tests in a clear, structured
way, and the observation sheets are very useful . It
made me think about areas of play I normally
ignore. It would be useful to clinicians who work
with developmentally delayed children, where
structured play targets are part of the therapy
programme. However, I looked at it with a col­
league, both of us experienced in work with chil­
dren, and there are aspects we found difficult
ourselves and which we would find hard to
explain to a parent or carer. For example, you are
required to elicit four 'substitutions', that is, four
different things representing other things, yet
today so many of the representational toys
around are very detailed and do not require the
same level of pretence .
A checklist of skills with examples of equipment you
could use would be more beneficial, as it felt very
artificial to try and elicit some of the beha '0 rs.
Alison Webb is an independent speech and lan­
guage therapist in Peterborough. She Ylon the
Test of Pretend Play in the Reader Offer of the
Spring 99 issue of Speech & Language Therapy in
Practice.
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 1999 15
ISSN (online) 2045-6174 www.speechmag.com
assessments
Thorough, but layout is poor
Dysphagia Evaluation
Protocol
W Avery-Smith, A.B.
Rosen, and D. M.
Dellarosa
From The Psychological
Corporation
£56.00
While Elsje Prins found this
protocol thorough and consistent,
existing assessments may be as
useful to experienced cltnicians.
How many times have we asked fellow clinicians,
"What do you use as a bedside assessment? Have
you got a formal I informal assessment - and can
we borrow it?" Most frequently the answer is
"well, we have sort of devised our own." 50, it
was quite a novelty to be given the task of
reviewing this protocol, consisting of a 43 page
manual, a spiral bound pocket manual , and a
four-page record form. The authors are all occu ­
pational therapists, thereby reflecting that the
assessment, diagnosis, and treatment of dyspha­
gia is not the sole province of speech and lan­
guage therapists.
The manual consists of four distinct areas: admin­
istering the protocol; guidelines for initiating,
continu ing and halting a dysphagia evaluation;
alternative administration of the protocol for
confused or non-communicat ive patients; and a
section on validity and reliability which includes
two case studies comparing the protocol with
videofluoroscopy. The pocket manual provides
guidelines for bedside assessment.
My first criticism is that this American product has
not been adapted for use in the UK. American
terminology such as 'NPO/PO' or 'manual muscle
testing' is used. Weight is measured in pounds
rather than kilograms.
Squashed
My main concern is not so much the content of
the protocol but the way the record form is
designed. The layout is confusing with little room
for recording information. Important informa­
tion gets squashed together with little room to
record additional comments. There is no space
Try before you buy
,
Burns Brief Inventory
of Communication and
Cognition
Martha S. Burns
The Psychological
Corporation
£137.00
Lynne Couzens finds this
assessment quick and portable
but of limited use.
If you are looking for a screening assessment for
adults with acquired disorders which is broad
ranging and quick to administer, then this may be
just what you are looking for. It covers a wide
range' of functional skills associated with: left
hemisphere (relating to aphasia); right hemi­
sphere (abstract language, visuo-spatial skills,
prosody) and complex neuropathology (memory
and attention). It is highly portable, containing
everything you need other than pens, paper and
a tape recorder. The three inventories can be used
independently to determine clients' intervention
needs in particular areas. Some sub-sections have
'predictor tasks' - success on these eliminates the
need to administer the whole section, very useful
when pressed for time. Treatment grids classify
skills deficits as severe, moderate (and most likely
targets for intervention), and mild. Whilst the
author acknowledges that there is no substitute
for "knowledge and know how" she provides an
excellent rationale for each task and a very useful
"goal bank" to be used as a guide, if needed,
when setting functional goals.
What is it like to admini ster? Just as it claims, it is
'brief'. The stimulus pictures and words are clear­
ly drawn in black and white and you won't be
searching for mislaid objects as you don't require
any. The scoring system is simple, there are sepa­
rate record booklets for each inventory, each with
a very clear treatment grid. The addition of sub­
tests for memory, attention and visuo-perception
extends the appropriateness of the assessment to
those clients presenting with closed head injury or
early dementing disease processes.
Disappointing
On the negative side, those looking for a cogni ­
tive neuropsychological approach will not find it
here. The language sub-tests on the left hemi­
sphere inventory are disappointing. Some of the
sub-tests require customising for use in this coun­
try and will therefore lose validity (unless of
course your clients eat 'grits' for breakfast or reg­
ularly visit the 'movies' - particularly if starring
Lucille Ball) . Some may find the 'functional goal
for a medical history or information on the results
of procedures such as a or MRI scans.
Having canvassed some colleagues and invited
them to try out the protocol, their replies were
similar to my own views:
• good to see that cervical auscultation is used,
but the jury is still out on its effectiveness .
• useful for a thorough examination with space
for a summary and advice that can be passed on
in written form .
• .. useful for clinicians new to dysphagia.
• helpful for training purposes.
• usefu l for the private sector as it provides con­
sistent documentation.
• pity about the forms.
The protocol does have a positive value in that it
is thorough and will remind the clinician to be
consistent in the assessment of dysphagia. As a
training tool, it can have a role to play. It is a pity
that not more thought has gone into the design
of a user-friendly record form. I am not sure that
an experienced clinician on acute wards will find
the protocol any more useful than the one s/he
has already designed or pinched from colleagues.
Elsje Prins is a speech and language therapist at
Harrogate District Hospital.
bank' useful; others may feel the inventories sim­
ply direct more in-depth assessment.
Would we buy this assessment? We tried it with
clients in long-stay rehabilitation following trau­
matic brain injury - the complex neuropathology
inventory is standardised for thi s client group ­
and did not find it particularly useful in this set­
ting. However, those new to this area or working
in more acute settings may find it useful.
Colleagues working with adults with early
dementing diseases such as Alzheimers were very
interested in trying out the inventories, particu­
larly those who had limited access to psychologi­
cal reports.
Our recommendation
7
1t is well worth looking at,
but borrow it if you can before you think about
buying it.
Lynne Couzens is a speech and language therapist
at the National Centre for Brain Injury
Rehabilitation at St Andrew's Hospital in
Northampton.
Orders for The Psychological Corporation on tel.
0181 308 5750 and the Australian Council for
Educational Research at http://www.acer.edu.au.
tel. (03) 9277 5651.
Under the spotlight in the future issues are the
Hearing Attitudes in Rehabilitation
Questionnaire, PETAL, Phonological Abilities Test,
Clicker 3 and Earobics.
16 SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 1999
ISSN (online) 2045-6174 www.speechmag.com
ethics

ose I
0'5 ri
t?
thics is concerned with the funda­
mental principles, norms or val­
ues which lie behind particular
moral judgements (Campbell and
Higgs, 1982). Four major princi­
ples of health ethics are outlined
by Beauchamp and Childress (1994):
• autonomy: deliberated self-rule, or the
ability of the individual to make choices;
• beneficence: working for the benefit of
th e individual;
• non-maleficence: doing no harm;
• justice: a moral obligation to act on a
fair adjudication between conflicting claims.
The Code of Ethics presented by the Royal
College of Speech and Language Therapists
(RCSLT) in Communicating Quality 2 (1996)
i s based in social conventions about accept­
able behaviour and what conduct is claimed
to be good or bad, right or wrong, in accor­
dance with the principles of health care
ethics as shown above. There is, however,
f requently a tension between these basic
principles when they come to be applied in
practice and a number of authors have
developed protocols to help health care pro­
f essionals consider all aspects of their ethical
decision-making in clinical situations. One of
the best known of these is the Ethical
(5eedhouse) Grid (Seed house and Lovett, 1992).
The grid divides decision-making into four levels:
• health care principles (inner, blue, level),
• the duties of the health worker (second, red,
level)
• the nature of the outcome to be achieved
(third, green, level)
• relevant practical features (outer, black, level).
Into these levels are embedded boxes which draw
attention to particular areas for consideration
(see figure 1). The aim of using the grid is to select
the box or boxes which best solve the problem at
hand. The use of the grid is exemplified in consid­
ering work with Jack, a child with cerebral palsy.
Great deal of therapy
Jad< is a 10-year-old boy with spastic quadripleg­
tao He attends a special school in Scotland and his
Jack is a 10 year old boy with
cerebral palsy. His parents and his
speech and language therapist
have very different opinions on
how his therapy should be
delivered, as does Jack himself. Can
an ethical perspective help them
come to an agreement?
Jois Stansfield and Christine
Hobden find out.
Record of Needs specifies physiotherapy, occupa­
tional therapy and speech and language therapy
as being required . Jack's speech is severely
dysarthric and his language comprehension varies
depending upon his physical health, the commu­
nicative environment and the assessment used,
but it is estimated to be around a si x year level.
Jack has had a great deal of therapy over the
years and has been provided with a TouchTalker,
although he is not keen to use this, preferring to
use vocal communication. Jack's parents are very
anxious that he receives daily individual speech
and language therapy input from the therapist,
and the school is purchasing sufficient time for
this to be a possibility. Jack himself is uncoopera­
tive in individual therapy sessions and his speech
and language therapist believes he requires a
complete break from regular direct work, fol­
lowed by a period of group work to encour­
age functional use of the TouchTalker.
In considering her actions from an ethical per­
spective, Jack's speech and language therapist
found the following elements of t he
Seedhouse Ethical grid helpful:
1. Blue: respect autonomy
2. Red : do most positive good
3. Green : most positive outcome for self
4. B lack: wishes of others
1. Principle: autonomy
Jack's ability to chose freely what he wants to
do is compromised by his physical disability and
his limited cognition and communicative skills.
Competence can be seen as the ability to
understand information, make a jUdgement,
intend a certain outcome and communicate
the wish (Beauchamp and Childress, 1994).
Jack is restricted in the ability to communicate
his wishes, but may not anyway be competent
to make informed decisions. Parental consent
would normally be required for therapy, so
autonomy needs to be balanced against the
child's best interest (Lefton-Greif and
Arvedson, 1997).
As a child with a cognitive impairment, Jack
himself has not ever been asked to give con­
sent for therapy, so his autonomy has not been
taken into account formally, although his par­
ents are not only giving consent but requesting a
particular form of intervention. He is clearly with­
drawing cooperation, although he has not got
the physical ability to carry out his wish to avoid
therapy as he is non-ambulant and cannot physi ­
cally refuse to attend. Assuming that therapy
which parents request is available and appropri ­
ate, difficulties arise when the child refuses to
cooperate in therapy.
2. Principle: beneficence
The best way to enable Jack to develop his co
munication skills is in dispute.
Beneficence is the principle of enhanc' 9 • e \ el ­
fare of the child by doing good. I Jack' s case,
'good' is seen by his parents as t e provision of a
particular style and amount of int erventi on.
Parents often have to invest a great deal of energy ~
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 1999 17
ISSN (online) 2045-6174 www.speechmag.com
ethics
.... before they get t he services they want
to( their children, often feeling that
' all is not well' long before any profes­
sional is concerned. A Record (or
Stat ement) of Needs, once established,
I ~ the mi nimum standard against
parents can measure service
provision and they are unsurprisingly
ery protective of its contents.
The speech and language therapist's
j udgement is that Jack will not cur­
rentl y benefit from the type of inter­
vention requested by parents. At
some points, intervention with a
child with learning difficulties can
involve their environment being
made more conducive to communica­
tion and there being support from
carers, rather than direct work.
Dilemmas occur when there is con­
flict between the parent's choice and
professional judgement, and the
speech and language therapist has to
make decisions about how to address
the parents' concerns while maintain­
ing a principled decision about intervention which
does most positive good, in addition achieving
the best personal outcome as seen in the grid.
3. Principle: non·maleficence
Jack himself is making it clear by his behaviour
Re ections:
1. Do I make use
of ethical models
and clinical
guidelines when
reaching decisions
on client
management?
2. Do I seek to
balance
profeSSi onal
judgement and
parental I client
choice?
3. Do I have an
awareness of my
own moral values
and the influence
they have on
clinical decisions
and outcomes?
that the current type
of speech and lan­
guage therapy input
is not to his liking. In
itself this is not a rea­
son for curtailing
therapy: changes in
the style of input
could enable the
therapist to continue
individual work.
However, it may in
fact be counter-pro­
ductive to force a par­
ticular style of inter­
vention upon the
child in these circum­
stances. There may be
a discrepancy
between the thera­
pist's or parents'
judgement of benefi­
cence and non-malef­
icence. Should Jack
become completely
resistant to speech
and language thera­
py, his attitude to
speech and language
therapy and to com­
munication in general
could become nega­
tive, thus producing a
red level
green level blue level
Assuming that therapy
which parents request is
available and appropriate,
difficulties arise when the
child refuses to cooperate
in therapy.
harmful outcome. On the other hand, Jack's par­
ents are considering the therapist's advice as
being potentially harmful to Jack and thus in itself
unethical.
4. Principle: justice
In moral reasoning we should serve the needs of
the client before the wants. Consideration of the
availability of resources occurs in the last level of
the Grid.
Resources can affect who is taken on for therapy
and when children are discharged. At times the
intervention programme that a therapist wishes
to use may create conflict because the resources
are not available to do what the therapist sees as
'best' for the child. The RCSLT Bulletin (1999) sug­
gests that services to pupils with special education
needs are being skewed towards the children of
articulate or influential parents. Sometimes it is
easier to cite lack of resources than to risk con­
frontation by saying that intensive intervention is,
from the speech and language therapist's point of
view, clinically undesirable. It is, however, impor­
tant for the speech and language therapist to tell
the truth as she sees it and be prepared to justify
that decision.
Potential for conflict
In this case, there is sufficient funding to
allow for the best type of input to meet
Jack's needs, but his parents and his
speech and language therapist have dif­
ferent perceptions of what the best type
of intervention is. Here, therefore, there
is potential for conflict between parents
and professionals when the parents
wish their child to receive more treat­
ment. The parents may feel that this
should be part of the child's rights, and
withholding such therapy is contrary to
the just needs of the child. The thera­
pist, in disagreeing, does not see this as
an issue of j ustice but of clinical need.
Once she had addressed the various
ethical issues brought to the surface by
the parents' request for daily individual
intervention, the therapist turned to
the RCSLT code of ethics. Here her
actions were guided by recommenda­
tions on professional conduct and
responsibility towards clients.
a. Professional conduct: abstain
from unnecessary therapy
She decided that she should abstain from unnec­
essary therapy, but that, to do so, she had to jus­
tify clearly why she considered individual daily
therapy to be unnecessary and what was a desir­
able alternative. She was able to use the
Communicating Quality guidelines on working
with cerebral palsy (RCSLT, 1996 ppI00-105) to
demonstrate that indirect classroom based work
could be valuable and effective in promoting
communication and, in fulfilling the requirements
of the Record of Needs, could still be considered
to be speech and language therapy intervention.
b. Responsibility towards clients:
• respect the needs and opinions of
the client
· ensure well·being of the client
· keep clients informed
The speech and language therapist found this a
rather more difficult area to address. It was hard to
decide whether Jack was resisting speech and lan­
guage therapy input because he was frustrated, dis­
tressed, afraid of failure, bored, unhappy about
leaving his class, or for some other reason. He clear­
ly still had a communication disability and there was
no question that he had a long term need for inter­
vention. While Jack's parents were not actually the
clients, their needs and opinions are also very much
part of what the therapist needed to consider.
Eventually, she decided to video her work with
Jack in individual sessions and the direct and indi­
rect work on communication skills in the class­
room as a focus for discussion with the parents.
She sent the videos home and then arranged a
date to view and discuss them with Jack's parents
in his home. Jack's parents suggested a number of
reasons for his resistance, in particular the thera­
pist's pacing of sessions and the noise outside the
room. They, in turn, were able to appreciate the
18 SPHCH & LANGUAGE THERAPY IN PRACTICE WINTER 1999
ISSN (online) 2045-6174 www.speechmag.com
.'f ethics
value of the classroom based work being carried
out by the teacher and classroom assistant to pro­
mote Jack's abilities to communicate with chil­
dren and adults within the school.
Agreement
The outcome of this case was that Jack's parents
accepted the need for group work rather than
individual during the coming school term, but
requested that he be seen at home over the sum­
mer holidays so they could be more involved in his
therapy and contribute to the therapist's aware­
ness of Jack's strengths as well as his needs. It was
agreed that the therapist would visit once weekly
for five weeks. They also requested that individ­
ual therapy in school would be reintroduced after
the summer. It was agreed that, in the new school
year, Jack would have a term of once weekly indi­
vidual therapy, followed by two terms of group
work, with clearly defined objectives which corre­
sponded with his individual education plan.
After seeing the classroom videos Jack's parents also
initiated an after-school link with the local primary
and secondary schools, in collaboration with the
school and other parents, to encourage communi­
cation with children from the local community. This
has met once a week throughout the summer term.
Different dilemmas
Applying ethical principles is not easy even when
using guidance from the Ethical grid or the RCSLT
code of ethics. In discussing ethical issues it is
important to note that Jack's case may present
different ethical dilemmas for different thera­
pists. Each of us has a value system which is influ­
enced by personal life experiences, education,
religion and / or culture. Moral values underpin all
ethical decision-making and the ethical decisi ons
made will influence the outcome of each case.
Jois Stansfield is a senior lecturer and Christine
Hobden a recent graduate from the Department
of Speech and Language Sciences, Queen
Margaret University College, Edinburgh.
References
Beauchamp, T.L. and Childress, J.F. (1994)
Principles of Biomedical Ethics. Oxford: Oxford
University Press.
Campbell, A.v. and Higgs, R. (1982) In That Case.
Medical Ethics in Everyday Practice. London:
Darton, Longman and Todd.
Lefton-Greif, MA and Arvedson, J.e. (1997)
Ethical Considerations in Paediatric Dysphagia.
Seminars tn Speech and Language 18(1), 79-87.
Seed house, D. & Lovett, L. (1992) Practical medical
ethics. Chichester: John Wiley.
RCSLT (1996) Communicating Quality 2. London: The
Royal College of Speech and Language Therapists.
RCSLT (1999) SEN tribunal appeals rise. RCSLT
Bulletin 565, 1-2.
Resources
The TouchTalker is available from Liberator Ltd,
Whitegates, Swinstead, NG33 4PA. D
r--------------------------------
- and cus·
e-mail avrilnicoll @speem­
-,
Macintosh PI 5
Cambridge Adaptive Communication, Do
Win Boardmaker™
Do you need quick and easy access
to a wide range of picture
material? Then this offer is for
you! Speech & Language Therapy in Practice has a copy
of Boardmaker™ software to give away FREE to a lucky
subscriber. courtesy of the Mayer-Johnson Co.
Boardmaker™ is a graphics database containing over 3000 Picture Communication Symbols.
you to make communication boards - with or without text accompanying the symbol
tomised therapy worksheets. You control the size, shape, content and layout. It normally ret ail s at
£239 and the package includes a manual and an explanatory video.
To enter, simply send your name and subscriber number / address marked 'Board maker' to Avril
Nicoll, 33 Kinnear Square, Laurencekirk AB30 1UL, tel. 01561 377415,
mag.com by 15th January, 2000. The winner will be drawn randomly from all valid entries and
be required to review Boardmaker™ for Speech & Language Therapy in Practice.
Boardmaker™ is available in Windows (3.1. or above) or Mac (System 7 and
greater) format. You will need 4megs of RAM and 14 (22 for Mac) megs of hard disk space.
The Mayer-Johnson company produces a range of augmentative communication products (PO Box
1579, Solana Beach, CA 92075-7579, USA, e-mail mayerj@mayer-johnson.com, http://www.mayer­
johnson. com). Software distributors in the UK are
Johnston Special Needs Ltd, Inclusive Technology and SEMERC.
Competition rules:
1. Entrants must subscribe personally or as one of a department to Speech & Language Therapy in Practice, and only
one entry per subscriber number is allowed.
2. Entries must be received by the editor on or before 15th January, 2000.
3. The winner will be randomly selected from all valid entries.
4. The winner will be notified by 22nd January, 2000.
5. The winner will provide a review of Boardmaker
rM
by a date agreed with the editor.
6. The winner will have access at work to suitable computer hardware.
r - ~ - - - - - - - - - - - - - - - - ~ - - ~ ~ - - - - ~ - - - -
I Winslow winners
I The winner of the Autumn 99 reader offer of £400 worth of Winslow resources for work­
I ing with the elderly is Corinne Garvie in Cambridge - happy reading!
: Barbara Birrane and Patricia Gillivan-Murphy each win runners up prizes of £5 vouchen for
use against any product In the Winslow catalogue.
http://www.speechm
See the 'open f orum
Jean McGowan's repa O(l
her voice talk to soeech a
language therapist>
Cyprus.
"My comment5 o ~ :re"
patient Jiving a /OrTE
experiencing VOIC!" P " ­ ?
fol/owmg periods c- ~ ~ , =
".it - .:­ =
SPEECH & LANGUAGE THERAPY CT1CE
ISSN (online) 2045-6174 www.speechmag.com
an
f o
Promoting Mobility for People with Dementia
Rosemary Oddy
Age Concern
ISBN 0-86242-242-6
The focus of this book's
Unfortunately nowhere does it mention speech and language therapists, although
it does address certain communication issues and there are many snippets of advice
of value to speech and language therapists.
approach to problems. For example why might someone who is normally co-oper­
ative become aggressive) She lists possible reasons, obvious when you read them,
reviews
eVlews
but not reIevant_ _ 1
Tracheotomy - Airway management, Communication and Swallowing
to students

Myers, Johnson, Murry

Singular remlnuer
I Assessment in Speech and
ISBN 1-56593-990-5 £57.50
language Pathology
Care for Caring Parents - A
This book takes a strong medical/surgical approach to tracheotomy management,
(course book and CD ROM)
program for parents of
and contains only two chapters relating to communication and swallowing. These
Kenneth G. Shipley and
children with special needs
are well written by experienced cl inicians and usefully illustrated by case studies.
Julie G. McAfee
leader's manual
- parent's book and Although it contains interesting chapters on specialist client groups such as sleep
Singular
Cynthia and Noel Schultz
apnoea, HIV, burns and paediatrics, it does not address issues relevant to head and
ISBN 1-56593-870-4 £34.00
Australian Council for
neck cancer in any detail and provides very little information on different methods
of respiratory support . The book is relatively easy to read, but several chapters may This is a full and comprehensive
not be relevant to the everyday clinical situation. It is suitable for therapists begin­ account of assessment of Educational Research
ning to practise in this field and as such provides a good source of background
ISBN 0 86431 2202 I language, phonology, fluency, voice
information. However, considering the cost, therapists may be better directed to
0864312199 and resonance, neurologically
other texts that have a more clinical focus.
$16.95 1$75.00 (Aust) based disorders,
Annette Zuydam is a speech and language therapist at the University Hospital,
Th is nine session group dysphagia, AAC, laryngectomy
Aintree.
programme addresses the and hearing. It gives detailed
emotional needs of families
chapters on evaluation of clinical
.J
parenting a child with a
information and report writing.
disability.
ar;lY,sn ppets
It is good value for money and
The Leader's manual contains
is most suited to students or a aavlce
• theory, including their
library. Assessment sheets can
"model for living" - based on
be photocopied. Pre-assessment
affective-cog n itive-behaviou ra I
information is well described
theory within a family systems
£14.99 and includes medical conditions
orientation
practical examples and exercises is on mobility.
and syndromes associated with
• group principles and leader
communication disorders. The
qualities
book is easy to read and all
• outlines of each session. The author has a common sense
medical terms are explained.
The Parent's companion book
References are both to texts
contains
and to the internet. There is
and suggests appropriate action . • a summary of issues covered
an accompanying CD-ROM . If
It is clearly presented, each chapter having key points and training exercises. It is
• exercises to apply the theory.
you are stuck on a desert
easy and quick to read and reference, providing much which can be applied to
The books are very easy to
island and need a text book,
both hospital and community settings by therapists, nurses and carers of all sorts,
read and enjoyable. The focus
this is the one to take as it is
with varying levels of experience.
is on the parent, not the child
so detailed.
Although not essential reading for speech and language therapists, it is a very prac­
or disability. Reading them
Ann Gosman is a speech and
tical book which should be available to every appropriate multi-disciplinary team .
was an evocative reminder of
language therapist with Mrs SJ Stevens is head of speech and language therapy at Hammersmith Hospital
the context in which speech
in London. Orkney Health Board.
and language therapists and
other agencies provide input.
The skills and theoretical
VISUAL PERCEPTION
Easily photocopied
knowledge required by the
leaders and the premise
Early Visual Skills
Diana Williams
Winslow
behind the programme make
it most likely to be run by a
ISBN 0 86388 1874 £33.45
"counsellor or psychologist.
As in the style of other books in the "Early" developmental skills series, Diana Williams has produced a practical
However, a suitably
manual of use to both student and experienced clinician .
experienced and skilled
Each section is prefaced with a very brief theoretical introduction ranging from early visual attention through per­
speech and language
ception and visual memory to visual skills in the school curriculum, but the focus of the manual provides a wide
therapist may want to lead or
range of practical and fun activities.
co-lead it.
The final section concludes with an excellent quick reference of visual resources. Although initially appearing visu­
Fiona Soutar is a specialist
ally less attractive and robust than the previous books in the series, the paperback volume is easier to photocopy
speech and language
and the black and white pages can be reproduced to a high quality for parents or carers.
therapist for the Islington
A useful addition to the clinic, children's centre or school.
Child Development Team.
Catherine Porter is a paediatric special needs speech and language therapist with York NHS Trust.
20 SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 1999
ISSN (online) 2045-6174 www.speechmag.com
reviews
reviews
Comprehensive Management of Swallowing Disorders
State of the art
More;l- I
t--J ease.
Manual of Dysphagia Assessment
Carrau & 1. Murray
in Adults
Singular
Joseph Murray
ISBN 1·56593·955·7 £99.00
5ingular
The diversity of topics in these 55 chapters by expert clinicians is a reflection of
ISBN 1·56593·871·2
the complex web that is dysphagia.
Assessment and diagnostic procedures are discussed by seven disciplines from each
perspective and, while this may cause some overlap, it shows dysphagia is best man­
aged within a truly interdisciplinary team.
Much needed documentation on such topics as the effects of medication, radio- and
chemotherapy, tracheotomy and intubation, laryngectomy, cervical spine surgery and
5 ull base surgery is provided. Non-surgical treatments such as diet modifi cation, ther­
apeutic strategies, dental prosthetics, and tracheostomy related dysphagia disorders
are discussed as are surgical interventions.
Specific populations such as paediatrics, the elderly, the critically-ill patient and
management of the terminally ill patient are covered, closing with patients with
Each topic is covered in detail
chronic aspiration pneumonia.
with evaluation as well as descrip­
Each chapter comes fully referenced and provides a starting point for
tion of techniques where appropri ­
research . An invaluable resource for clinicians new to the field and
ate. The text is easy to read although
experienced clinicians who want to update their knowledge,
as an undergraduate I would have
refresh their memory, or consult the current state of the art.
struggled with some of the terminology.
Elsje Prins is a speech and language therapist at
There is a good index and excellent use of
Harrogate District Hospital.
.1Q=M"" --­
A struggle
for the non-expert
Linguistic Levels in Aphasia
Ed. Visch·Brink and Bastiaanse
Singular
ISBN 1-56593-860·7 £54.00
The 25 international contributors, "some
of the finest minds in neurolinguistics",
attempt to explain the unknown in apha­
sia. This is a study of brain and language
behaviour and the conditions that arise
from brain and nervous system damage
that can affect human cognition and com­
munication functions .
Looking at aphasia from the point of view
of linguistic, psycholinguistic and neu­
rolinguistic research, there are three main
areas of focus: semantics, phonology and
syntax. Based on previous research, the
studies look at some new aspects of
breakdown in information processing.
It would be most valuable reading for the
expert but a bit of a struggle for the rest.
However, there are some therapy sugges­
tions to stir the innovative mind and pro­
vide a challenging experience. Because of
the elevated price, it should perhaps be
purchased by departments, especially
those with neuro rehabilitation units.
Anais Nassar is a speech and language
therapist (acute adult neurosciences) in
East London.
illustrations.
The author only deals briefly with dysphagia assess­
ment of tracheostomised patients and those with degenera­
tive disorders. I would be interested to read more of his writing on
these topics.
The book is reasonably priced and a valuable resource for every
adult clinic. The chapters on taking a history and the clinical swal­
lowing exam will be parti cularly useful to therapists starting their
post basic training in dysphagia. I look forward to reading other
books in this series.
Lisa Cox is a speech and language therapist (adult neurology) at
Brighton General Hospital.
.____ •
An invaluable tool
Autism· A social skills approach for children and
adolescents (practical sourcebook)
Maureen Aarons and Tessa Gittens
Winslow 1998
ISBN 0·86388·202·1 £27.50
For both experienced and new clini cians working with young peo­
ple who have autism this will be an invaluable tool. The introduc­
tion gives an clear overview as to the current understanding of the
disorder. The manual then takes one through assessment, setting
the scene for intervention at the pre-school, infant, junior and
adolescent levels.
Each chapter is full of well explained age appropriate activities,
resource ideas and guidelines for the running of groups. A useful
checklist at the end of each chapter summarises what is required
to develop an efficient service. The appendices comprise useful
photocopiable letters, record sheets and parent handouts that can
be used when running a social skills group.
Theresa M. Drake MA reg.MRCSLT is a specialist speech and lan­
guage therapist with South Buckinghamshire NHS Trust.
£35.00
Part of the Dysphagia series
edited by John Rosenbek, si x
chapters cover
• case history
• clinical swallowing exam
• videofluroscopic exam
• FEES
• reporting
• final thoughts.
at
BlftII'I"!'Mi bedti me
reading
Collaborative Brain Injury
Intervention· Positive Everyday
Routines
Mark Ylvisaker and Timothy J.
Feeney
Singular
ISBN 1· S6593 . 733 . 3
£39.95
This provides comprehensive
theoretical and practical guide­
lines for the assessment and
management of cognitive,
behavioural, executive system
and communication problems
following traumatic brain injury
in children and adults. The
purpose is to provide an
approach that is "functional and
practical yet consistent with
current theory".
It contains detail of the epide·
mology and pathophysiology of
traumatic brain injury. The
theoretical discussion of cogni1jve.
behavioural, executive system
and communication problems
following brain injury is well
presented and would make cl ear
reading for students or
professionals new to this area.
Practical management ide.as
were of little value, mainly
because the book is aimed at a
American audience and e
book's illustrative ca se histories
have a paediatric bias .
Not bedtime reading. it has 0
be read from cover to CD¥'EJ" as
many chapters are i.rrter-re
Whilst being intere.· I
find it heavy going al
Would I buy it ?
borrow a c.opy.
Amanda Forrester is a ...
speech and
Bamsley.
SPEECH & LANGUAGE THERAPY PRAcncE 2
ISSN (online) 2045-6174 www.speechmag.com

Reflecting on her
experience in the
mental health field,
Jan Roach finds
everything begins
with respect.
am lucky to be working in a setting where
quality and not quantity is still the key
word. The work is exhausting and frustrat­
ing, and self fulfilment is not easily
achieved. But I'm still here and continue to
be very interested in the work I do.
Venturing into the world of Mental Health was a
leap into the dark. It took place eight years ago
following a decision to "specialise" and yet hav­
ing no clear idea what I meant by this. A chance
phone call led me to St. Andrew's Hospital, a char­
itable, medium-secure, psychiatric hospital. So
much for being in charge of one's destiny.
It is indeed a humbling experience. One of the first
outcomes for me was that, at the very least, I could
show some respect. I have been questioned on var­
ious occasio ns how I could possibly respect some­
one who might have battered a fellow member of
staff, or carried out some other atrocious or malev­
olent deed. Perhaps if I had been the recipient of
the battering I might not be delivering this sancti­
monious message; I am sure it would redirect one's
feelings for a considerable time. However, to be
able to continue to deliver useful support to the
patients, the inner motivation to help must be
channelled through the medium of respect.
This has been different from all the other speech
and language therapy jobs I've had. I have had to
learn about what life can really be like for fellow
human beings. Such things as aggression directed
not only at others, which is bad enough, but also
self-directed. The list of self-abuses is endless. One
thinks of one's own children when reading case
notes about other people's kids who have been
abused and humiliated, and scarred physically and
mentally for life. Some life, eh?
Consistent
Our business is communication. What sort of mod­
els are we if we belittle or ignore vulnerable peo­
ple? To get beyond the endless effing and blind­
ing, you have to show a consistent readiness to lis­
ten, and grab opportunities to move away from
the paranoid ramblings. I wonder what it is like to
hear voices in your head? Is it anything like listen­
ing to our inner thoughts? At least they have a
semblance of logic and balance to them. Imagine
them taking you over. Delivering messages with
all sorts of instructions, some of which are decid­
edly evil. It just gives me a different perspective,
and I am aware that I am sometimes competing
with these voices during my sessions.
So, we begin with 'showing respect. ' I am very
conscious that many of the patients have little or
no awareness of my approach . Its effect is proba­
bly shown by the trust that they gradually impart
towards me.
Sometimes you just run out of ideas. It doesn't
matter how many times you share your kind
words about self-monitoring - it isn't going to
happen. What a complete and utter failure you
are. Outcome statistics indicate a nil return. Why
should any purchaser pay anything towards your
continued presence in this hospital? The only
thing is that when they see you, they now smile
and acknowledge you and indicate that they are
looking forward to their next session with you.
They weren't offhand and they weren't inappro­
priate. That felt good. Do you think they felt some
empathy with their fellow (wo)man? But there
are as many who do not respond as those that do.
If I have achieved at least one thing for each per­
son I see, that has improved their quality of life,
then I don't feel so useless.
Respect demands that you listen, something all
speech and language therapists do. But I remem­
ber being told by a young girl that a lot of her
problems were caused because no one listened to
her description of her problem. She found it diffi­
cult to understand what people said to her
because they seemed to be speaking too quickly.
Some training from this department, with sugges­
tions to her carers, made a radical difference to
her behaviour, and she was eventually able to
function in a normal environment, knowing how
to help herself.
Respect needs time and space. I give people time,
in an environment that is quiet, comfortable and
hopefully relaxing. The wards are frenetic, noisy
and often smoky. It isn't always possible to find
peace and quiet in their own rooms. When you
have serious mental health problems it must be
very difficult at times to live with others who have
similar problems. Many of the patients are ego­
centric and are unable to give empathic support .
Respect requires confidence - in yourself, your col­
leagues and your patients. 'Thank you' is very sel­
22 SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 1999
ISSN (online) 2045-6174 www.speechmag.com
In mJ! experience I
dom heard. You will however hear immediately if
you have done something wrong. This is the sort
of job where you really do need the backup from
other members of staff. The multidisciplinary
team is often required to help you through fallow
periods. All the patients have such complex needs.
Not one of us has all the answers. One also has to
acknowledge that even if the answers are appar­
ent, the patients may not wish to avail themselves
of the help on offer. For the most part we do the
best we can and learn fairly soon on to live with
the limitations the various illnesses impose.
Safer
Danger must be respected. No one can work in
this field without paying heed to risk assessment.
Any psychiatric patient is potentially dangerous.
We organise our clinical environments with the
aim of reducing these risks to a minimum.
However, my general experience is that, if the
patient arrives (that is, the nursing carers consider
the patient is at a low risk for unstable outbursts),
the tone of a speech and language therapy ses­
sion is sufficiently positive for the patient to enjoy
and hopefully benefit from the activities. When
analysed, this mode of consideration of risk to
oneself seems a long way from lectures at the
Oldrey-Fleming School of Speech Therapy! Media
stories suggest that
safety is now an issue
for many speech and
Re ections:
language therapists. In
a strange way we may
be safer in a psychiatric
environment where all
staff are taught mea­
sures of self-survival.
Respect leads to hon­
esty and partnership. I
always try to give the
patient an awareness
of their communica­
tion problem and how
this might affect inter­
actions with other peo­
ple. Similarly, it helps
carers and other mem­
bers of the multidisci­
plinary team if they
have an awareness of
how a communication
problem affects some­
one's life, and how
they can change their mode of approach to make
communication as effective as possible. The effect
of not having to battle so hard to communicate
with others can sometimes improve self esteem,
which in turn can reduce aggressive outbursts.
I look forward to the day when all people who have
mental health problems have access to our services
if required. After all, it's a matter of respect.
Jan Roach is head of speech and language therapy
at St. Andrew's Psychiatric Hospital, Northampton.
R£SOURCES...R£SOURCES...R£SOURCES...RESOURCES...
Health on the Games for small groups
Internet Speech and language therapist Judith Thomas has produced
A new Internet search a practical language and listening resource book for use .
engine aims to classify sites sma II grou ps.
containing only 'authorita­ Targeting a range of non-verbal and verbal communica ' 00
tive' medical information. It skills, the games are suitable for nursery and infant children
is intended to help health and for short 'circle time' activities. Judith has also found e
professionals keeping up book a useful training tool for helping people create an i IJ­
with new research and sive environment for children with communication difficu ' 6.
patients looking for reliable Language and Listening Games for Small Groups, D.50 i _
medical information. p+p from Devon Learning Resources, 12 Old Mill
http://www.medisearch.co.uk Torquay, South Devon TQ2 6AU, tel. 01803605531. (Fu
information is on http://www.speechmag.com)
Deaf directory Encephalitis
An up-to-date directory of Deaf organi· An new information pack is aimed at adults
sations and services in the UK is aimed affected by encephalitis and their families a
at anybody with a personal or profes· carers and includes fact sheets on all aspects o·
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sive and easy to use as possible. behavioural, cognitive and emotional difficulties_
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SPEECH & LANGUAGE THERAPY IN PRACTIC.E 23
ISSN (online) 2045-6174 www.speechmag.com
how I
Jane Stokes works as
clinical manager speech
and language therapy
(preschool & community)
for Greenwich Healthcare
Trust.
Rita Thakaria joined the
adult speech and language
therapy service of
Redbridge Health Care
I\IHS Trust in the north east
of london in 1 996. She is
senior specialist at King
George Hospital, Essex.
Christine Macleod is a
generalist speech and
language therapist in
lewis and Harris, one of
only two Gaelic speaking
speech and language
therapists there.
.. manage
bilingualism
The social, linguistic and cognitive
advantages of bilingualism are
well documented. Respect for
diverse cultures and languages has
been growing and in recent years we
have witnessed a revival of indigenous
languages in the UK.
What does this mean for people with
communication disorders who have
been or are being raised bilingually
and for their speech and language
therapists? Professional guidelines
are unequivocal but still incomplete,
and the meaning of 'bilingualism'
seems increasingly hard to define. Our
management of it must be responsive
to individual circumstances and an
evolving society.
Three contributors share their up-to­
date experience. Assessment of
pre-school minority ethnic children,
creative partnerships to bring benefits
for adult clients and speech
and language therapy in a truly
bilingual community are explored.
24 SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 1999
ISSN (online) 2045-6174 www.speechmag.com
I
approach the assessment of a pre-school bilingual child with
enthusiasm and enjoyment. I could not work anywhere
where I did not meet people who speak different languages
and have different cultural backgrounds to mine. So I count
myself lucky to have worked in London's East End, in China and
Hong Kong and now in Greenwich with families and profes­
sionals from a range of linguistic and cultural backgrounds. I
feel privileged to have worked with speech and language ther­
apists in the national and London Special Interest Groups on
bilingualism, and to have had contact with nursery staff, health
visitors, teachers, bilingual support workers, educational psy­
chologists and voluntary community organisations. When a
potentially bilingual child comes for me to assess, I am helped
and guided by people I have worked with over the years. And
like any speech and language therapist I am constantly review­
ing my approaches to assessment.
Assessing a bilingual pre-school child is not so different to assess­
ing a monolingual one. Of course, it is vital to have access to a
bilingual co-worker or interpreter, preferably trained, and if
possible to develop a relationship with someone you can turn to
with questions about language and culture. While this may be
difficult in places where there are relatively small numbers of
bilingual children on the caseload, every effort must be made to
find local community resources or support staff within educa­
tion. Otherwise we are not offering linguistic minority groups
equal access to our service. If we only assess a bilingual child in
English using assessments standardised on English populations,
then we must acknowledge the limitations of the assessment
and should be questioning the validity of the results.
Opportunity to learn
Therapists may feel apprehensive about 'getting it wrong'
because they know nothing about the language or cultural
background of the family. But if the assessment process is
viewed as an opportunity to learn about and become involved
in the communication of the child, the therapist need not be
constrained by the fact that s/he knows nothing about the way
the child's home language is structured, or the family's reli­
gious beliefs. Working in the UK, there are over 100 languages
we may come into contact with and we cannot expect to have
an encyclopaedic knowledge of them. We are experts in com­
munication, so we can draw on our skills of observation and
informal assessment, and use our abilities to listen to what the
family is telling us, non-verbally as well as verbally.
There are significant cultural differences in how children are
spoken to, expected to behave and encouraged to develop.
Colleagues sometimes ask me for information on, for exam­
ple, whether a particular ethnic or linguistic group play with
dolls, or what eye contact means in different societies. We
all know this can be very different but beware the racial and
cultural stereotyping this way of thinking can lead to. Think
how people might typically describe the British cultural
group ('They have a roast dinner every Sunday' or 'They
always have their babies in hospital' ... )
When working with families from different linguistic and cul­
tural backgrounds I am forced to abandon the 'I'm the
expert' approach. I learn so much: one day that Vietnamese
is a tonal language and the next day that birthday cakes do
not feature in the life of a Jehovah Witness. With an open
approach to the case-history taking and a curiosity about the
child's communicative competence we can learn so much
more than if we are held back by thoughts such as 'I must
remember to ask .. .' or 'I must be careful not to.. '
In assessing a pre-school bilingual child, the areas of investi­
gation are common to the assessment of any child. The
London Special Interest Group on bilingualism has produced
a checklist for assessing the communication of young bilin­
gual children and some of the key points are listed:
1. Listening and attention:
Expectations about whether a child should sit and attend will
vary and this may be reflected in the child's actual attention
and listening abilities. The child may have greater difficulties
listening to an unfamiliar language. The name given as the
child's 'official' name may not be the name s/he is called by,
so the child may not respond when called. It is important to
check what the child is called in the family and what the child
is to be called at school.
2. Auditory comprehension
Always check the familiarity of the vocabulary and the cultur­
al appropriacy of the objects and pictures used in assessment.
If you are not sure, ask the family or bilingual colleague you
are working with . When working with an interpreter consid­
er whether the questions you might typically ask in English
can readily be translated. For example, 'Which one do we
drink from?', that old favourite of speech and language ther­
apists, is almost impossible to translate word for word in any
language. Consider in advance how you can make your lan­
guage easy to understand and discuss with the interpreter or
bilingual colleague how best to translate certain key phrases.
3. Expression
In some languages a short sentence may be equivalent to a
much longer one in English so, again, that seemingly inno­
cent question 'How many words does your child put togeth­
er?' may not be very useful. The sentence 'I don't want to eat
any rice' (seven words in English) can be expressed in two or
three words in Bengali or Cantonese.
4. Phonology
The phonotactic structures of different languages and the
influence of tones make it almost impossible to do a detailed
analysis of phonology without a trained native speaker. We
do know that processes such as fronting and stopping occur
across languages, and that clusters are not a feature of many
languages. Without access to developmental norms and
phonological data, the therapist needs to rely on reports of
intelligibility and work with this.
5. Interaction and Behaviour
Consider how appropriate it is in other cultures for a child to
initiate interaction with an adult. This may influence how the
child behaves in the clinical setting. Observation in the home
is invaluable. In school or nursery, learners of English as an
additional language may have a 'silent' period of at least six
months before embarking on the daunting challenge of
speaking in another language.
6. Play
Again, think about cultural variations in the attitudes to play
and observe the child in different contexts. Do not be afraid
to ask the family or a bilingual colleague and don't make any
hasty or unsubstantiated judgements. I still hear colleagues
in health and education say 'But they don't play.. .'
In the words of an Irish song
'There's a thousand things to do
So let's start here with me and you
Gonna take a little time
Let's see what we can find
Walk with me, talk with me
Tell me your stories
I'll do my best to understand you'
(Flesh and Blood, by Shane Howard, from Mary Black's album
'The Holy Ground'.)
how I
A roast
dinner
everY
Sunday?
Jane Stokes
finds an open
approach to the
assessment of
pre-school
bilingual
children reaps
rewards.
Ed Hooke with Jane Stokes
SP£ECH & LArtGlJAGE THERAPY IN I'ttACTlCE WINTER 1999 25
ISSN (online) 2045-6174 www.speechmag.com
.00
howl *
.... Recommended reading
Duncan, D.M. (ed) (1989) Working with bilingual language Miller, N. (ed) 1984 Bilingualism and Language Disability.
disability. Chapman & Hall, London. Croom Helm Ltd, UK.
Baker, C. (1995) A Parents' and Teachers' Guide to Abudarham, S. (ed) (1987) Bilingualism and the bilingual.
Bilingualism. Multilingual Matters Ltd, UK. NFER-Nelson.
The Special Interest Group on bilingualism exists as a forum for promoting professional development for speech
and language therapists and seeks to promote awareness of the issues related to bilingualism in the profession.
It is one of many special interest groups supported and linked by the Royal College of Speech and Language
Therapists. It was founded in May 1985 and the current chairperson is Dr. Deirdre Martin, School of Education,
University of Birmingham, UK. The London SIG on bilingualism is a local group with similar aims. Its current chair­
person is Ed Hooke, Speech and Language Therapy, Newham Community Health Services NHS Trust.
Strp_nger
IInKS,
sigrificant
cnange
Rita Thakaria
demonstrates
how creative
partnerships
can lead to a
more equitable
service for
minority ethnic
clients.
A
Pproximately one in five of the population served
by my Trust is from an ethnic minority, half of
these from the Indian sub-continent. The Health of
the Nation White Paper (1993) states services must
be sensitive and respond to the unique and diverse needs of
different ethnic groups. When developing culturally sensitive
services four priority areas are: Communication; Information
provision; Diet; Religious and cultural needs (Mciver, 1994).
I work closely with my team, senior Bilingual Specialist and
the Clinical Audit department, and take an active role in the
London SIG (special interest group) Bilingualism.
Achieving equal care for all patients can be considered a
major challenge in the present economic and political cli­
mate. However, as the following projects demonstrate, devel­
oping stronger links within and across the professions, the
health service, charities and our training establishments can
bring about small but significant changes.
1. The Bilingual Speech & Language Therapy Student
Register
Our service does not currently have co-workers or trained
interpreters. To develop improved service access, an audit was
conducted over one month on the 'Adequacy of initial assess­
ments with bilingual inpatients'. It revealed:
• 7 out of 37 new patients were from an ethnic minority group
• a diversity of languages, ego Punjabi, Urdu, Gujarati,
Turkish, Spanish
• only 1 of the 7 patients was fluent in English
• 85 per cent of initial dysphagia assessments with bilingual
clients were considered adequate
• 50 per cent of initial speech and language assessments with
bilingual clients were considered adequate
• there was ad hoc information gathering by nursing and med­
ical staff regarding the first language and knowledge of English.
Strategies employed with bilingual clients which allowed for
adequate initial assessments were:
• assessments conducted by a bilingual speech and language
therapist
• member of ward staff 1 family used as a communication
link and interpreter
• in-depth discussions with relat ives and ward staff.
The audit concluded there was a need to have a more stan­
dardised approach and access to speakers of a diversity of lan­
guages who have knowledge of speech and language therapy,
with the ideal being trained speech and language therapists.
The outcome was the implementation of a new referral proce­
dure and the introduction of the Bilingual Student Register.
The new referral procedure allows for a more systematic
response to bilingual patient referrals. A new referral card for
the wards includes first language and family 1carer contact
number. On being informed of the referral, the therapists
gather information from staff on the spoken language and
the availability of informal interpreters in addition to med­
ical, communication and swallowing information.
The Bilingual Student Register is a measure towards accessing
speakers with competence in a range of languages and basic
knowledge of speech and language therapy. Created in part­
nership with the London colleges, it is updated each academ­
ic year and contains a list of speech and language therapy
students who feel competent in other languages as well as
English. This unique partnership equally benefits clients, stu­
dents and therapists.
Opportunity to participate
The register has been in operation for a year. To access it, the
therapist identifies her client's spoken language by liaising
with the referrer, client or family. The therapist is then given
a list of students from the register who are speakers of the
given language. The therapist contacts the student and
invites them to the clinic for a session or whole day. During
the appointment with the bilingual client, the student is
responsible for interpreting and being the communication
link between the client and the therapist. In return, for the
remainder of that session or day, they are given the opportu­
nity to participate in the clinic caseload.
The level of participation is dependent upon their clinical
knowledge and familiarity with the service. Training is pro­
vided and confidentiality is discussed. The register currently
holds speakers with Urdu, Punjabi, Gujarati, Mandarin,
Greek, Italian, French, Spanish, Malay, German, Arabic,
Chinese dialects, Portuguese, Shona, Chewa and Swahili .
Due to logistical issues such as exams, holidays and commit­
ments to ongoing clinic placement, the register has been
most useful for outpatient clinics and home visits. We have
received positive feedback from the training establishments
involved. Suzanne Beeke and Ann Parker from the Clinical
Placements Team of University College London are keen that
placements should reflect the reality of speech and language
therapy, including work with bilingual clients. They plan to
audit the experiences of the students volunteering for the
1999/2000 register so they can further develop their support
for the initiative.
Marie Gascoigne, Clinical Coordinator at City University
believes a more formal arrangement would help fill in gaps.
If the speech and language therapy service could predict,
based on retrospective figures, the frequency and volume of
referrals needing certain languages, placements could be
arranged to include a regular translation session.
Clients and staff of this service have also been extremely
encouraging and the paediatric service now accesses the reg­
ister. However, to ensure effectiveness of the register and its
development, further research in liaison with the training
establishments is necessary. More demographic studies are
also needed to gain a better understanding of our resident
population. Furthermore, as the value of working with
speech and language therapy co-workers has been well
established, it would be beneficial to compare this with
working with a bilingual student.
26 SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 1999
ISSN (online) 2045-6174 www.speechmag.com
~ h O W I _______________________
2. Stroke and dysphasia information booklet
The London SIG Bilingualism has representation from mono­
lingual and some bilingual speech and language therapists
who are specialists in bilingualism and from bilingual co­
w orkers. With such a wide spectrum of individuals it is an
ideal opportunity for identifying and addressing needs which
are shared across London and the South East of England. One
planned outcome has been the publication of an information
booklet on stroke and dysphasia.
'The incidence of stroke in men from the Indian sub-continent is
igh... People born in the Indian sub-continent and the African
Commonwealth also experience significantly higher mortality
from stroke' (Balarajan and Raleigh, 1993). It can be expected
that the incidence of dysphasia is also high. In striving to provide
an equal service, we were concerned to provide an explanation
of stroke and dysphasia to people who do not speak English.
Little meaning
The adult sub-group of the SIG together with the co-workers
evaluated available translated material and established that the
majority contained literal translations which held little mean­
ing, and were too lengthy. This was further compounded by the
knowledge that often people may not read the language they
speak (Mciver 1994). One successful format was the Action for
Dysphasic Adults (ADA) Stroke and Dysphasia information
booklet - "Drawing the picture together". This is presented as
simple line drawings accompanied by short simple text. We
approached ADA to see if they were interested in collaborating
to produce a new booklet based around the original format.
Using pictures to aid understanding in three community lan­
guages - Bengali, Punjabi and Urdu - the booklet has been
designed as a tool for speech and language therapists to facil­
itate the client and carers' understanding of communication
disability following stroke. In a simple format, it covers the
cause of stroke, how a stroke can cause language difficulties
and the role of the rehabilitation team.
Bilingual co-workers are an integral part of the project. They
have translated the written material and added their knowledge
of common cultural beliefs. Together with the bilingual thera­
pist, they have been able to combine their knowledge of the
medical and social consequences of stroke and communication
difficulties with knowledge of different cultural backgrounds.
The information in the booklet has been redesigned to take
account of and confront these issues, such as the common mis­
conception of there being medication to 'cure' the stroke and
restore function and the frequent tendency for clients from this
culture to see themselves as the passive recipient of care from
the rehabilitation team and their family. By bridging the lan­
guage barrier, the new booklet offers a starting point towards
culturally sensitive rehabilitation of bilingual clients.
References
Balarajan, Prof. R. and Raleigh, Dr. S. (1993) The Health of the
Nation: Ethnicity and Health - A guide for the NHS. NHS Executive.
Mciver, S (1994) Obtaining the views of Black Users of Health
Services. Kings Fund Centre.
It is anticipated the' Bilingual Stroke and Dysphasia information
booklet' will be available from March 2000. • .0
S
cottish Gaelic is a Celtic language spoken by 68 per cent
of the population of the Western Isles of Scotland.
However, Gaelic monolingualism is now vestigial, being
a feature of pre-school age children. Code-switching
between languages is not infrequent among bilinguals, and in
our community is quite common. Is this because ours is a truly
bilingual community, both Gaelic and English having co-existed
over the last hundred years (figure 1)7 Though once the nation­
al language of Scotland, Gaelic was gradually overtaken by
Scots and in the 19th Century its use was actively discouraged.
Educational policy has changed over the past 40 years with a
subsequent shift in attitude towards the language. Two gener­
ations ago it was mostly English that was used in the schools.
The next generation, taught in English, had a choice on enter­
ing Secondary education and taking a two-language course, of
French and Latin, or French and Gaelic. However, those
brought up in the Stornoway town area and thus not thought
to be fluent Gaelic speakers were not allowed to take Gaelic.
Nowadays, we have another picture altogether. Gaelic medi­
um education began in Breasclete School (Lewis) in 1985,
w ith nine pupils. By 1994, there were 545 pupils in 18 schools
th roughout the country. Gaelic-medium education is on the
i ncrease, with units springing up all over Scotland. There are
likewise numerous Gaelic pre-school playgroups interspersed
hroughout the country. These were initiated by CNSA
(Comhairle nan Sgoiltean Araich) and are a common feature
of our culture, catering for native speakers and English
incomers alike. It is now compulsory for all pupils entering
5econdary education in the Western Isles to take Gaelic for
the fi rst two years.
The education department supports Gaelic medium educa­
ti on in recognition of Gaelic's importance in the life and cul­
lure of the Highlands, and endeavours to take into account
the wishes of parents and individual needs when considering
entry to it. It is however policy that certain children, for
example those with severe language difficulties (case 1).
should not enter Gaelic medium education unless Gaelic is
their first or only language, because the demands on them
would be too great. "If it is probable that a pupil can devel­
op basic competence in only one language, then efforts
should be directed to the development of communication in
the language which will be most important and widely useful
throughout the pupil's life" (Iliffe and Macleod, 1994). Gaelic
medium education is mostly available in mainstream settings
and the main problem at the moment is lack of funds for its
advancement.
No research
A research project with three to five year old children in the
Western Isles (Donaldson, et ai, 1997) suggested age, lan­
guage input from parents and the child's own language pref­
erence all influenced children's mastery of Gaelic grammar. It
needs to be made clear to parents that no research has been
carried out in the learning difficulties field in Gaelic, and
there is insufficient support. Specialised provision is only
available in English (case 2).
There are no Gaelic resources for learning difficulties. Only
now is a commercially produced reading scheme being
devised for mainstream education. Previously, teachers have
been putting material together themselves. The same is true
for speech and language therapy. I have produced a Gaelic
phonology assessment, and adapted some language assess­
ments, as no standardised ones are available. Assessments
cannot be translated from English, since the structures of the
two languages differ so much. There are very few Gaelic
speaking therapists and more are needed to address the
needs of Gaelic speaking children and adults.
For most older clients, Gaelic is an oral language. Often they
prefer to communicate with professionals in English, as they
may not have learned Gaelic literacy skills (case 3). With bilin­
guals, it is sometimes difficult to know which language to use,
but usually I let them set the pace and adapt accordingly. ~
Adapting
to
change
Christine MacLeod
shares her unique
experience of
living and working
in a bilingual
community.
SPEECH & LANGUAGE THERAPY IN PRAOICE WINTER 1999 27
ISSN (online) 2045-6174 www.speechmag.com
• ••
how 1
Practical points
1 . To enable equity
of service, ways of
bridging language
and cultural divides
between therapists
and clients must be
identified and
funded.
2. Openness to
leaming about
different cultures
and individuals is an
opportunity for
personal and
professional
development.
3. Speech and
language therapy
management will
necessarily be
influenced by client
I parental wishes,
the environment
and, for children,
educational policy
and resources.
4. Special interest
groups are a useful
medium for
identifying need and
bringing about
change.
5. When working
together, partners
should consider
how they can pool
resources and bring
benefit to both.
6. Literacy levels
should always be
taken into account
when planning
information leaflets
and therapy.
References
Donaldson, M.L., Gillies, w., Reid, J. and Macleod, C. (1997)
Children's acquisition of Scottish Gaelic grammar: a preliminary
investigation. ESRC Final Report. Project number R000221466.
IIiffe, S. and Macleod, D.J. (1994) Gaelic Medium Education:
Pupils with Special Educational
Council Education Department.
Mackinnon, K. (1986) Scottish
Highlands. Accents of English 2.
Needs. Highland Regional
Gaelic and English in the
Cambridge University Press.
Figure 1 - The progress of Gaelic
In 1891, Gaelic was spoken by over 75 per cent of the population of the area of Scotland stretching north from Islay, across
through South Argyle, the Grampian and Perth regions up to Inverness and most of Ross shire and Sutherlandshire along
with the Western Islands. By 1981, the region where over 75 per cent of the population spoke the language was restricted
to the Western Isles, (apart from Benbecula and the town of Stornoway - areas of adventitious incomer settlement), the
northern tip of Skye and the small island of Canna (Mackinnon, 1986). The 1981 Census showed 82,620 people in Scotland
able to speak, read or write Gaelic.
Case 1
P is a nine year old with a specific language
disorder. He was first referred by his GP at
4.04 years when he mimed a lot. Only Gaelic
was used at home. He watched both Gaelic
and English programmes on television, and
mixed the two languages frequently when
he entered a Gaelic medium unit. P had much
difficulty receptively and expressively in both
languages, and preferred his own company.
He echoed a lot and was fastidious about
placing his writing materials back in the same
position each time he used them.
Therapy was initially given in Gaelic, his first
and preferred language. In accordance with
policy, the first two school years were spent
working entirely in the Gaelic language. By
primary 3, Pwas reading English fluently but
developing dysfluent speech. Was it the
introduction of the functional use of English
in school that had caused the problem? Was
he undergoing some emotional trauma? Was
he becoming more aware of his inability to
understand and be understood?
He also became confused with mutations and
lenitions within Gaelic and argued these
were wrongly spelt. With Gaelic the basic
order of words is verb-subject-object as
opposed to the more usual form of subject­
verb-object.
Should P have gone into Gaelic-medium edu­
cation? In the end it is the parents' preroga­
tive, and there are very sensitive issues
involved, but probably not. P has now trans­
ferred to English based education and is mak­
ing good progress.
Case 2
R, who has Down's syndrome,
is a child of English-speaking
parents, who was in a special
school for two years. The par­
ents decided to send him into
Gaelic-medium education,
hoping it would be successful,
although they had no knowl­
edge of any precedent. Both
R's Gaelic and English were dif­
ficult to understand largely
because of phonological diffi­
culties.
At age seven, his language
level was such that he was able
to put two to three English
words together. These were
difficult to understand because
of his poor sound system. After
three to four months in the
Gaelic Unit he could speak a
few Gaelic words and produce
one typically Gaelic vowel.
Our opinion was that perhaps
this parent was being too
ambitious, and the child's most
realistic chance of achieving
his potential would have been
in a special class. However, he
is now progressing well, speak­
ing some Gaelic and beginning
to read and write it, beyond
the school's expectations.
Policy has now become more
relaxed.
Case 3
M is a 77 year old lady referred two
weeks after suffering a second
stroke. She was assessed informally
and with the Whurr Aphasia
Screening Test for comprehension
and expression, using her first lan­
guage, Gaelic, then English.
Her comprehension skills were poor,
and expressive language consisted
of "yes" and "no". She attempted
spelling out words though these
were almost invariably wrong. She
could not copy shapes, letters or fig­
ures. Automatic speech was possible.
English was her preferred language
in counting, though she could also
count in Gaelic. In picture-naming,
code-switching and association were
used frequently, ego the Gaelic 'Iitir'
(letter) was used for 'letter-box'
without the letter picture cue.
Gradually, she learned to address
members of her residential home
appropriately. Two to three years
post-stroke, her communication
skills in both languages have
markedly improved, giving her a
better quality of life. M's pre-morbid
situation was such that she would
have spoken mostly Gaelic, living in
a Gaelic-speaking environment,
which is still the case. Although her
conversational speech is mostly in
Gaelic, she likes to use English when
attempting any set work.
r--------------------------------------------------,
Free translated stammering tapes "
Speech and Language Therapy in Practice has five audio taped translations of ..
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date is 15 January, 2000 and the winner, drawn randomly from valid entries, will be notified by 22 January.
The British Stammering Association is at 15 Old Ford Road, London E2 9PJ, tel. 0181 983 1003. L __________________________________________________
28 SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 1999
ISSN (online) 2045-6174 www.speechmag.com
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ISSN (online) 2045-6174 www.speechmag.com
1. Talkabout . A social communications
skills paCkage
by l e x t<elly, Wlnslow £32.50
This practical manual provides a framework
for the development of social skills, It has six
levels, each concerned with a particular
aspect of communication, starting with self
awareness and awareness of others, moving
through general communication skills within
a group, body language, talking and conver­
sation skills and assertiveness, Each level has
photocopiable worksheets which are very
appealing to young people, help to promote
thought and discussion and can be kept by
the client as a record. It is a well organised,
invaluable guide to planning stimulating
programmes for groups - I use the work­
sheets as a base and supplement them with
other practical activities,
2. The social skills game
by Yvanne Searle & Isabelle Sireng, from
Wfegames (approx no). pUb Jessica
Kingsley. 116 Pentonvl!le Rd, London NI 9JB
A therapeutic board game to help children
and adolescents who experience difficulties
with relationships, Intended for group work,
it focuses on a positive and fun group expe­
rience and can be adapted for older or
younger children. It aims to improve self
awareness, interpersonal relationships ,ver­
bal and non verbal communication and
assertiveness, and to facilitate discussion of
emotional and behavioural issues,
It includes cards which promote thought /
discussion, as well as social games and role
play activities designed to target eye contact,
concentration, group interaction, listening
and confidence,
I play this with a group of autistic children
(12-14 years) and we have a good time as
well as improving our social skills,
3. Knowledge Of teenage culture
A definite advantage, Do you know the names
of the members of 'Steps'? What is Britney
Spears' latest single? What happened this
week on 'Home and Away' and 'Eastenders'?
Who did Man Utd play this week?
This stimulates group discussion and gives
you an advantage when planning turn tak­
ing games, for example guessing the famous
person or TV programme from description or
playing '20 questions',
It gives you 'street cred' and helps your popular­
ity with the group as well as motivating them.
4, Social skills Training
Sue Spence, NFER-Nelson £100
A comprehensive package for assessing and
enhancing social skills with children and ado­
lescents.
It includes useful theory on the nature of social
competence, and a comprehensive assessment
procedure in the form of questionnaires and
checklists for parents, teachers and clients,
Basic social skills assessment charts give the
client a rating before and after social skills
therapy and so measure outcomes,
After assessment, the package gives practical
guidelines for improving social competence
as well as detailed session plans and home
task sheets on topics such as feelings, saying
'no', dealing with teasing and bullying and
giving compliments,
This can be easily adapted to suit a variety of
client groups but is particularly useful for more
able children with good basic language skills,
5. Wnlteboord
I used to go through vast quantities of large
sheets of paper to record ideas my groups had
during brainstorming sessions, so I invested in
a portable whiteboard (approx, 18" x 24"), It
is used for many other activities too - making
charts of likes and dislikes, playing games such
as variations of 'hangman' and making a com­
munication board by sticking on pictures, sym­
bols or photographs with blue-tac.
The children enjoy writing on the board
themselves and this can be used as a reward,
6 ,A,5slstan Is
A speech and language therapy assistant
works with me and runs some of the groups,
She .is well qualified having masses of expe­
rience and being a church youth leader as
well as having three teenagers. She has some
excellent practical ideas and provides me
with endless photocopies of useful material,
Some of the children have learning support
assistants who accompany them to the groups,
They give me information about the child,
help to control any behaviour problems, and
participate in role play activities, They also
carry on ideas from the group into the child's
everyday social and educational programmes,
7 Colarcords
Winslow
I use many of the sets but the most useful are
the Color Libraries, particularly Food, Animals
and Birds, Sport and Leisure and Occupations as
the pictures are suitable and appealing to ado­
lescents, They are used endlessly for social games
such as '20 questions', 'what am I describing?'
and memory games, as well as providing visual
stimulation for discussion of likes and dislikes.
The sport and leisure cards are useful when dis­
cussing 'What I am good at' or 'What would
like to try'. A selection can help clients remem­
ber what they have done during that week and
so share experiences with the rest of the group.
When discussing personality types, occupation
cards provide a cue to thinking of the person­
al characteristics required for various jobs.
Emotion cards are also well used, They can
illustrate body language and promote dis­
cussion on 'feelings',
oJ
is a speech and
language therapist
with East
Cheshire NHS
trust who works in
a mainstream
secondary school
which has special
provision for
children with
learning difficulties.
Groups Of
adolescents work
on communication
skills and social
use of language.
The groups usually
have five or six
members
matched as far
as possible for
age. ability and
level of social
skills.
Skills targeted
vary from basic
communication
skills such as
listening, turn­
taking and eye
contact with the
younger or less
able groups. to
feelings and
emotions,
friendship,
bullying, social
appropriateness
and moral issues
with the more
able and autistic
groups.
.--__""­
8. 'Guess who?'
MB Games
This great game is fun for everyone. It is
meant for two players but can be adapted
for group use.
There are boards with male and female
faces bearing different characteristics (hair
colour, eye colour, glasses, etc.) Someone
chooses a card which matches a face on the
board and the other players must determine
who was chosen by asking questions like
"does (s)he have blue eyes?"
Apart from reinforcing language structures
such as question forms, the game is invalu­
able when working on 'describing people'
during the awareness part of the social use
of language programme.
There is also the bonus of turn taking skills
and discussion forming part of the activity.
9. What would yau do'
L D ~ £!O 95
These cards depict eight social situations,
each with five possible outcomes,
The situations include vandalism, bullying
and robbery. The children discuss them and
give their own opinions as to how they
would respond, The five outcome cards can
give further ideas and they can rate each one
as a good or bad response, Moral aspects of
the action choices can be discussed.
The cards help increase the children's awareness
of the effect their actions may have on other
people. They also help reasoning skills (what
would happen if ...) and decision making,
Useful when addressing such topics as friend­
ship, or feelings, I find these cards particular­
ly valuable when working with a group of
autistic children.
10 Party fOod
At the end of term and when one of the
group has a birthday, we have a relaxed ses­
sion and bring in some popular party snacks
such as crisps, chocolate biscuits, mince pies
(at Christmas), and drinks.
The 'party' session is useful for encouraging
such social skills as turn taking, sharing and
good manners,
Likes and dislikes can be discussed as well as such
issues as dietary constraints or food presentation,
The relaxed nature of the sessions gives rise
to much informal conversation and is excel­
lent as a group gel activity, I can often sit
back while the conversation flows and
observe the progress being made in social
communication skills,
The celebration of someone's birthday helps
to develop awareness of others and, for the
birthday person, an increase in self-esteem,
as their friends make them feel important.
ISSN (online) 2045-6174 www.speechmag.com