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guage
Therap
in Pra ice
Autumn 1997
(publication date 25th August)
ISSN 1368-2105
Published by:
Avril Nicoll
Lynwood Cottage
High Street
Drumlithie
Stonehaven
AB393YZ
Tellfax 01569 740348
e-mail avrilnicoll@rsc.co.uk
Production:
Fiona Reid
Fiona Reid Design
Straitbraes Farm
St. Cyrus
Montrose
Printing:
Manor Group Ltd
Unit 7, Edison Road
Highfield Industrial Estate
Hampden Park
Eastbourne
East Sussex BN23 6PT.
Editor:
Avril Nicoll RegMRCSLT
Subscriptions and advertising:
Tel/fax 01569 740348
Avril Nicoll 1997
Contents of Speech & Language
Therapy in Practice rerect 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.
Cover pictures:
John and Monica Clarke

News/
Comment 2
Video - a
reflective tool 4
Keena Cummins and Sarall
Hulme focus on the strengths of
video playback as a reflective
tool both in therapy and
professional development.
8
ALD and
Training
for
Kenya
lessons
for
all 19
Julie Marshall outlines the
lessons to be learned from an
in-service training project in
Kenya, where formal services are
extremely limited.
22
Reviews
dysphagia: issues
Assessment,
treatment,
and practice
articulation,
interpersonal skills,
Janet Hickman explores the
hearing
concept of dysphagia in ALD,
impairment,
summarises a survey of
language devel
working practices and reports on a
multidisciplinary protocol.
Resource
update 1 1
COVER
STORY
Special
feature
meeting
the
needs of carers
Two articles, the first the Mary Law
ledure 1997, consider how we as
speech and language therapists
should be assessing and meeting
the needs of carers.
SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 1997 1
opment, cerebral
palsy, dysphagia
and anatomy.
H9W I manage
vOice 25
Three speech and language
therapists set out their manage
ment of a client, Sheila.
MyTop
Resources 29
Carole Charters who
works with adults with
a learning disability
describes ten
resources she could
not do without.
ISSN (online) 2045-6174 www.speechmag.com
r
NEWS & COMMENT
Meeting the needs
John and Monica Clarke's lives were shattered
when he became aphasic following a stroke.
Traditional speech and language therapy focuses
on the client with aphasia but increasingly efforts
are being made to include carers In the rehabilitation
process; we are still in the early stages of learning
how to do this effectively. In a special feature,
Carole Pound - with the assistance of Monica
Clarke - and Ashleigh Denman challenge us to
push out the boundaries of our work with carers to
meet their specific needs as well as what we
perceive their needs to be in relation to our clients.
In this feature, and in Julie Marshall's description of
in-service training in Kenya, we are urged to listen
to people and find out what they really want
without presupposing that we know. In the end,
this must lead to more effective provision.
The importance of people being dynamic In their
own management is emphasised throughout the
articles, particularly How I manage voice. Jayne
Comins encourages us to consider whether a
client's attitude falls into the category of ( have a
problem: what can ( do about it? Monica Clarke is
following this course, actively working to establish
a pen club for carers to reduce their isolation as
part of the long and uncomfortable rebuilding
process.
Recognition that there is a problem is the first step
to solving it and one of the challenges of working
with anyone - client, carer, student, peer - is getting
them to find out for themselves when things are
not going to plan, why, and what the solution
might be. Keena Cummins and Sarah Hulme find
video playback has implications beyond therapy
sessions, for professional and service development
as it allows them to question what they are doing
in minute detail.
Janet Hickman's investigation into dysphagia
service developments for adults with a learning
disability also throws up many questions. She
compares the needs of these adults with those in
the acute sector and calls for a re-think of RCSLT
dysphagia policy to allow more appropriate ALD
provision.
Carole Charters also works with clients with a
learning disability and, in the first My Top Resources,
explains the ten items she would not be without in
her clinic and why. This new feature aims to remind
readers of half-forgotten items
at the back of their cupboards,
to suggest innovative ways of
using eqUipment and to
recommend the most useful
new materials available.
If you would like to share your
own experiences and thoughts
on therapy through the pages
of this magazine, please let
me know.
Avril Nicoll
Editor
Lynwood Cottage, High Street, Drumlithie
Stonehaven AB39 3YZ
tel/ ansa/ fax 01569740348
e-mail avrilnicoll@rsc.co.uk
SPEECH & LANGUAGE THERAPY IN PRACilCE AUTUMN 1997
Centre ofexcellence
Queen Margaret College has been awarded 320000 to set up a
centre of excellence for interdisciplinary research into speech
disorders and their treatment.
The Scottish Centre for Research into Speech Disability will pro
vide state of the art facilities customised for specific client
groups including children with phonological disorders, adults
with aphasia and clients using Me.
The Centre, directed by Professor Bill Hardcastle with Dr
Elizabeth Dean as clinical co-ordinator, is expected to be fully
operational by May 1998. There will be close liaison with the
speech and language therapy services of Edinburgh Sick
Children's NHS Trust in particular, although involvement from
services across Scotland will be encouraged.
Funding has been provided by the Scottish Higher Education
Funding Council's 1997 research development grant scheme.
Detnils: Liz Dean, 0131 3173682.
Parkinson's
Talking Point
Charter
The importance of talk for
young people has been
The Parkinson's Disease
highlighted in The
Society believes sufferers are
Samaritans' Week.
not always made aware of the
The charity is concerned
benefits of services such as
that the rate of attempted
speech and language therapy.
suicide by young men has
In a Charter aiming to
risen by 63 per cent since
improve the care and services
1990 and believes young
available to the 120 000 people
men in panirular face
in the UK with Parkinson's
barriers to resolving
they set out claims including
situations because of
the right to access such sup
port services in addition to
problems talking about
diffirult feelings_
drug therapy.
A film resource for 10 - 11
with Parkinson's have the
They state further that people
year olds, Talking Point,
right to: addresses the problem at
an early stage by
a special interest in
be referred to a doctor with
providing information
Parkinson's about who might be
receive an acrurate diagnosis trusted to listen to
receive continuous care anxieties from causes
take part in managing the
such as bullying, name
illness.
calling and the transition
Details: PDS, 0171 391 6705.
to secondary school. No
direct reference is made to
suicide. now the second
NASmove
most common cause of
The National Auti stic Society
death among young
head office has moved to
393 City Road, Islington,
people.
London EClV 1NE
Details: The Samaritans,
tel. 0171 833 2299
01753532713.
fax 0171 833 9666.
SeIVices for stammerers
The British Stammering Association is developing its advisory and
counselling services.
From the autumn, a telephone counselling service funded by a
three year grant from the National Lotteries Chariti es Board and
operated by Clare Lindsay will be available to stammerers and par
ents of children who stammer.
A Schools Liaison Officer is also being recruited for two years as a
result of charity funding. Responsibilities will include developing
and co-ordinating a national programme of teacher training about
stammering which affects 100000 pupils in the UK.
Details: BSA, 0181 983 1003.
2
ISSN (online) 2045-6174 www.speechmag.com
I CAN appointInent
The national educational charity for children with
speech and language difficult.ies has appointed
Gill Edelman as Chief Executive.
Her main responsibility is to lead I CAN forward
in its provision of educational services and sup
port for children with speech and language diffi
culties. Qualifying in 1979 as a speech and lan
guage therapist, Gill Edelman has extensive expe
rience in management within the profession and
more generally in t.he NHS.
She states, "The future of provision for children
with speech and language difficulties will depend
on finding innovative ways to work collabora
tively wit.h Health and Education Authorities and
Social Services and ensuring specialist services are
tailored to children's specific needs. I CAN will
have to carefully balance residential services with
provision delivered in the community, in main
stream schools and in nurseries. We will need to
look carefully at parents' needs and expectations,
as they are often frustrated at the gap between the
services their children require and those that are
available to them."
Details: I C ,0171 374 4422.
Profession not
marginalised
In spite of fears, a Dew report
finds the NHS internal
market has not adversely
affected the provision of
speech and language therapy
services.
The King' s Fund report
reveals managers within the
profession have not really had
their control of budgets and
staff reduced, but are taking
on greater responsibility for
management, administration
and the future shape of their
own services without
necessarily having the
required training, formal
managerial qualifications
and extra resources.
Since 1991 the number of
qualified therapists and the
range of services provided
has increased but managers
perceive demand has also
increased. The report's co
author, Nicholas Mays, has
called for better training and
support from the NHS and a
positive response from the
profession to managerial
developments.
Mays, N. & Pope, C. (1997)
Speech and Language Therapy
Services and Marwgement in
the Intemal Market from
King's Fund bookshop, 0171
3072591, 12.50.
Support for children
A good practice model of therapeut.ic and emotional support for
children in need is being developed in London primary schools.
The charity, The Place to Be, uses art, play, drama and movement
to help children communicate, express their emotions and develop
a sense of self-awareness. It believes it is having an impact on
children's behaviour, social interaction, moods and ability to learn.
Details: TIle BT Forum (sponsor) , 01 71 831 6262.
Helpline for deaf people
The NSPCC has launched a national child protection helpline for
deaf people.
The 24 hour service provides counselling, information and advice
to anyone concerned that a child is at risk of abuse. A textphone,
where deaf people communicate by exchanging messages through
a keyboard and small screen, can be used via the usual telephone
system.
The Society beli eves the 65 000 deaf children in Great Britain
have special child protection needs as they may be more vulnerabl e
to abuse, less able or less willing to tell when they are abused and
have difficulty participating in investigations which rely heavily
on speech. Funding for the service is from the National Lotteries
Charities Board and NSPCC counsellors have received training
from the Royal National Institute for the Deaf.
Helpline number: 0800 800 500.
Internet assessment
As an increasing number of schools go 'online', an evaluation
project is underway to help them make purchasing decisions.
The National Council for Educational Technology plans to publish
performance information on UK Internet Access Providers, such
as first attempt dial-up success, transfer rates, e-mail speeds and
http services. Jt hopes the evaluation will also help the industry
provide more suitable services for education.
Details: NCET, 01203 416994.
Stroke research
EJysarthria is one of the first
areas to be considered by a
new Therapy Research Unit.
Multidisciplinary teams at the
Salford Unit will identify the
most effective ways of helping
people regain independence
following a stroke by evaluat
ing therapy and investigating
new treatments. Other pro
jedS include shoulder pain,
unilateral neglect and retrain
ing of self-care skills.
The Unit is a joint venture
between the Stroke
Association, the University of
Manchester department of
Geriatric Medicine, Manchester
School of Physiotherapy and
the Rehabilitation Services
Directorate of Salford Royal
Hospitals NHS Trust.
Details: Sally Heath, Stroke Association, 0171 4 905089.
Educational need
Schools must regal11 difficulty
with communication as all
educational need, according to
the Royal College of Speech &
Language Therapists. .
In a polie)' statement, RCSLT
states that, for the IJUljority of
children willi special educational
needs imrolvlIIg speech and
language, responsibility for
meeting these nee(is lies with the
education sen/ice rather than the
health seroice IIkllle.
TI,e policy aims to support
therapists conllibuting to
SUllutory of children's
educational1leeds. A range of'
education and Ilealtil professionals
lrave been involved in its
development.
Details: Liz Jepson, 0115 981
4012.
Call for brain
injrny legislation
Why leave people withom
vocational rehabIl Itation and
employment SlIpport st'11
I
ices,
when thf')l lllight be earning their
keep for the next thirty or fony
years?"
Deborah Wellrillg Slimmed up a
Headwa)' semillrl r for disability
t'1nploymenL pecullis/s, who
called for to help people
after a brain injury. The
participants Ulant /0 see a Brain
Injury Act, a dt:dicated national
and local 5e11'icl' 10 provide
specialist tmmmg in put to health,
social wori;, ed'lClltion, emplo),ment
and housing age/lcies and ring
fenced fundin,l(. The illlportallce
of support and /uil'ice in the
long-tenn "'lIS elllphasised.
Details: Deoorall Wearing, 0115
9508700.
Disabili
!_c. ty
1l1lormatIon
An exhibition by cope is to
feature infomlaliOlI, actillities,
opportunities mId products for
disabled people, tlleiT families and
professionals.
This first annllal exhibition was
prompted by the harily's research
revealing 45 per cent of disabled
people have difficult}' getting hold
of the informlilioll which enables
them to access support, aid and
equipment for independent living.
The All Round Ability exhibitioll
at Norcalympia, Blackpool will
11m alongSide Ihe organisation 's
annllal confeTe1lce 011 7-8th
November; 19')7.
Details: Scope, m71 6365020.
SPEECH & LANGUAGE THERAPY IN PRAGflCE AUTUMN 1997 3
ISSN (online) 2045-6174 www.speechmag.com
INTERACTION
C
hildren who have no language dIffi
culties make interaction accessible:
however children with difficulties
immediately have the potential to throw
even the most experienced of clinicians
into a mode of poor timing. All profes
sionals need continually to assess and
reassess their skills in relation to each
child's abilities as, as with 'parents: 'stu
dents' may perceive their skills as very dif
ferent from the reality
'Student' applies in this article to all those
hoping to develop their skills further. be
they cI ient, carer. student therapi st, thera
pi st. supervisor or manager. The use of
video is not intended to be promoted in
isolation, but rather as a sensitive addition
al resource which augments the skills of
the clients and professionals involved.
Partnership with parents
'Parent child interaction' as a therapy tool
has been used within Camden and
Islington for many years. Its main principle
is partnership with parents, enhancing
their knowledge and understanding of
their child with the therapist's theoretical
and clinical experience. Its most unique
feature is the use of video to analyse in
minute detail the transitory nature of
};ommunication. It is this fine detail which
distinguishes it from the Hanen model,
although the basic philosophy of both
programmes is complementary
Both authors feel, having specialised in
working with parent child interaction in its
true form for a number of years, that the
benefits to working practice and the sub
sequent development of the service have
been dramatic.This is particularly in relation
to child language acquisition. the role of the
parent and primary carers such as nursery
workers. and perhaps even more impor
ensures we all practise
and Sarah Hulme focus
tantly - the role of the therapist and the
real development of clinical skills.
Health Centre Service

'I"'"\.' Camden and Islington
r .J....... NHS Trust's Health
Centre Service con-
CAMDEN & ISLINGTON sists of I 3 staff mem
bers - eight employed
in community clinics. two working in pre
school language units, ourselves (commu
nity clinic based) and a speech and lan
guage therapy assistant. The service
addresses the needs of children under five
who present with a variety of language dif
ficulties. classically language delay through
to language disorder. Through the parent
child model. it has been possible to offer
across the Trust an equitable service, which
prioritlses children with language disorder
and maintains waiting lists at an almost
manageable level despite the increased
referral rate of 146 per cent over the last
five years. (Children whose needs include
learning difficulties or pervasi ve develop
mental language disorders are managed
by the child development team.)
Our team consists largely of newly qualified
staff, that is, up to three years post -qualifi
cation. Our team structure is however
unique in having four members of staff
over grade 28, all of whom have spe
cialised in working within health centres in
addition to their varied experience in
other clinical settings.
One of the major tasks in managing the
team has been affording support and super
vision to posts which make potentially
excessi ve demands on team members
with little experience of working in chal
lenging situations. The parent child model
has offered appealing strategies for
addressing the needs of these clinicians
whilst continuing to provide a high level
quality service to children and their carers.
Video philosophy
As this article does not seek to describe
the parent child interaction model per se.
a brief summary of the coul-se of video
sessions is in Appendix I. (The authors
consider Kelman & Schneider. 1994. essen
tial reading for full details.)
Interacti on is a transient experience which
can never be repeated. In therapy we aim
to identify the type and timing of commu
nicative events within an interaction. to
recognise where a child is in their com
munication development process. and
how their timing moulds with the adult's.
In using vi deo a visual record of most
aspects of interaction can be achieved
from which detailed analysis can be made.
Of primary importance is that observa
tion can be made by those involved in the
interaction rather than merely by those
who have looked on. Communication
events can be captured without their
immediacy being lost, and the communica
ti ve partners are in a position to provide a
perspective inaccessible to the observer.
The student is in an active position of
identifying their own behaviour and its
effect on the child. The student can then
modify their behaviour accordingly, either
with the support of another or in isolation.
Observation not
perception
With video playback. therapists are able
not only to assess themselves along the
same parameters as parents, but to
extend self-observation and appraisal into
all areas of work. developing a personal
critique based on observation rather than
SPEECH & lANGUAGE THERAPY IN PRAcnCE AUTUMN 1997 4
ISSN (online) 2045-6174 www.speechmag.com
INTERACTION
The Video Interaction aspect of the parent child course provides a
pre-assessment session, six interaction sessions once weekly. and
a six week consolidation period followed by a review appointment
Video feedback is a sensitive tool, primarily used for self-assessment
and discussion. It is not for providing Judgements -partJcularly by
therapists who have not already analysed themselves In a similar
fashion. The main purpose should be for parents to leave the ses
sion feeling better about themselves. Feedback should therefore be
supportive and realistic, highlighting the strengths of the parent
Session I
A brief rationale is given to the parents advising them thor.
because they are the primary caregivers. they are best placed to
help their child. They are reassured that they and the therapIst will
be working together to develop the child's skills. It IS important to
stress the parent has not done anything wrong - as Fey points
out, 'there is no evidence that children's language impairments
are caused by parents' behaviour' - but that the child's behaviour
does affect the adult's interaction style. The video sessions are for
the therapist and parent to work out where the communication
is breaking down and to use certain strategies to facilitate a
quicker rate of development
The parent is instructed to spend time with the child, talking and
playing in the way they would usually do at home. Care IS taken
that the parent understands not to 'make' the child talk.
The therapy room is arranged with a variety of toys covering the
developmental play stages, from exploratory through to symbolic.
The therapist leaves the room and the session is videotaped for
five to ten minutes.
When the therapist returns to the room, the parent is invited to
comment upon whether the session was typical of how they usu
ally play together at home and, if it was different, how so. Any
issues arising at this stage should be discussed immediately A
commonly arising point may be that the parent felt unnatural
because of the camera. In such a circumstance the parent may
be reassured that. because the child is unaware initially that they
are being videotaped and later IS no self-conscious in the pres
ence of the Video camera, parental behaviour generally remains
natural because the parent responds to the child's interaction,
which is as it would be at home.
On finishing the video recording and returning to the therapy room,
the therapist should first make a positive statement about the
interaction such as 'I like the way you play on the with him'.
The therapist and parent watch the video together Parents are
asked to observe their own behaviour in general, having previously
scanned the self-rating (appendix 2) scale, so they have an idea
of the sort of things the therapist is looking for. A detailed
Interaction Profile (Kelman & Schneider, Appendix 4) is used by
the therapist to analyse the parent's verbal and non-verbal inter
action with the child, non-verbal behaviours being of equal signif
icance.The analysis is not shown to the parent but is kept for ref
erence and comparison at the end of therapy.
Having watched the video, the parent is invited to identify what
they are doing that is helping their child, and the therapist then
highlights in general terms many of the parent's strengths. The
parent and therapist diSCUSS the parameters of the Self-RatJng
Scale in turn. This has been adapted from the Interaction Profile
and is merely used as a conversational tool to
a) focus the parent
b) provide a storting point and
c) obtain the parents understanding of such terms as '{allowing
his lead'.
In utilising and diSCUSSing these terms, the therapist is able to
understand more fully the parent's perspective of the
process.
For each parameter, the parent is guided to rate their use of that
Interaction style in terms of a 0 - 3 rating scale where 0 signifies
they never do something and 3 indicates they always do it. The
ratings are purely subjective, and it is important to remember the
aim is to build parent confidence. The video can be rewound to
highlight specific oints, particularly whe:e the parent and thera
pist do not appear to agree. This is likely to be due to lack of
explanation / unde standing and the video can provide an exam
ple of the therapist's Intended meaning
Once the rating scale has been completed the parent is request
ed CO choose the parameter they would like to work on first If the
parent has difficulty identifying the most important strategy. the
therapist may suggest chOOSIng the one with the lowest score.
It doesn't matter If the therapist doesn't agree completely with
the parent's self-rating, since experience has shown that altering
one of the parameters will have a knock-on effect on the other
parameters, so you get there in the end. What seems to be most
important is that parents choose for themselves what to change,
so they are in control.
The parent is then asked to do another video using the strategy
they have just identified. This is taped once more and fed back
to the parent. Prior to playback the therapist asks the parent if
they feel they achieved their aim, and then the tope IS played
with the therapist focusing on this, for example asking, "Are you
following his lead there?", "and there?", using the pause button
between each interaction.
The aim achieved, the parent IS invited to highlight the effects on
the child. The therapist then summarises, for example, "Yes,
because you're following hiS lead he's staying with one toy for
longer, doing more things with it, asking you for help ei ther with
his eyes or words (which has resulted in more eye contact), and
he's starting to tell you what he wants to talk about."
The parent is requested to carry out a play session at home
doing exactly what they have done within the session. The aim is
also written down.
Sessions 2 - 6
At the stort of each session the parent is asked to recap on their
aim, and to feedback on how the five minute sessions have been
going A short five to ten minute video is taken and the parent
and therapist watch to see If the aim has been maintained. If it
has, the changes In the child are highlighted and a further aim is
chosen, without the use of the self-rating scale.
The parent and child are then videoed once more and if the aim
has been achieved they are requested to spend five minutes a
day using the new strategy as well as the old. Their aims are writ
ten down.
On the last session, the parent IS asked to carry out five minutes
a day during the six week consolidation period. It is stressed
progress will only continue if this is achieved.
Review session
The child is reassessed, and the parent and child videoed for the
last time. Parents re-evaluate themselves using the self-rating
scale with the previous scores concealed. They are then revealed
so the parent can observe their own progress. The first video is
shown, in contrast to the review video, to highlight the child's
progress.
SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 1997 5
ISSN (online) 2045-6174 www.speechmag.com
Please think about the following statements and rate yourself from 0 to 3 for each one.
Rating 0 - never
I - sometimes
2 - often / frequently
3 - always appropriate
DATE:
INITIAL FINAL
Letting him/her choose the t oy
Sitting where it's easy to see me
Following what s/he wants to do
Giving him/her extra t ime to talk ,
Listening t o what s/he says
Talking about what s/he is doing
-
Waiting for him/her t o start talking
Not asking questions
Praising him/her
Talking sl owly
Appendix 2 . Self rating scale
OBSERVATION SHEET
GROUPS
SKILLS UTILISED
Name:
Session I / Date Last Session / Date
Timing
Use of silence
Visual Cues - Sign system / Hands
- ' IE .
FaCia xpresslon
Praise / Reinforcement
Directly relevant language
Volume
Rate
Choices
- -
Turntaking
Anticipati on
.
No Distractions
. - - -
Modelling
Intrigue
Positi oning
- - - - ------
Organisati on
--------c-
Other
perception of their own behaviour, in as
fi ne detail as is required. The Importance
of'RefJection time' is described by Marson
et al ( 1990): we believe video maximises
its use. Therapists are also placing them
selves in a similar situation to the cl ient and
acknowledging their own ski ll s are simi larl y
league or in a group context with their peer
facilitator (Appendix 3). It is important for
the manager to allow self-assessment time
in their timetables.
A valuable tool
Supervision is a controversial concept
which means different things to different
people. W ithin our service it has proven to
be a valuable t ool for generating new ideas
and projects whil st providing support, dis
cussion and advice around complex issues.
We have adapted many of the principles
outli ned in Stengelhofen's book 'Teachi ng
students in Clinical Settings' t o provide
ongoing support for both newly qualified
staff and those wishi ng to continue sharing
their learning experiences and to benefrt
from the experience of t heir coll eagues.
Her principles of supervision have also
been complemented by the Camden &
Islington vi deo interaction technique.
Supervision without the use of vi deo play
back is dependent on the therapist's sel f
perception and awareness of a situation
which occurred in the past, in combination
with subjective observati ons by the super
visor: In recounting situations, the immedi
acy of the moment is lost, as is the behav
iour in re!ation to the emotion / feeling. A
purely objective perspective in fine detail
is difficult
When supported by video, both can be
active part ici pants in the observati on
process, providing a reflecti ve learning
experience benefiting student and super
visor. Marson et al ( 1990) speci fy that
adult learning is achieved through provi d
ing the opportunity to talk through the
experience, using positive feelings and
removing obstructive ones. In t his way, the
adult can be motivated to learn by Inter
nal rewards, such as increased sel f-esteem
and a sense of accompli shment
(Stengelhofen, 199 3). Video offers the
opportunity to complement discussion,
observe issues already discussed and t o
tryout alternative strategies and record
their effects. Students are in a position t o
think through their feelings and define an
area requiring further work. then given the
opportunity to work on that area and
have video feedback on their develop
ment This also highlight s their st rengths,
which often they find so easy to ignore.
Where therapists choose to use video
playback for their supervision sessions, it is
important they take responsibility for the
choice of video, and for obt aini ng support
and gaining confidence in this style of
anal ysis. It is the supervisor's role to pro
vi de a systematic framework for feedback.
As with parent child interaction, the aim
of the session is to 'deepen understanding
of what has taken place through enabl ing
enhancement and modification of skill s
dependent on the unique situation.
We therefore suggest that, in self-analysis
of an interaction with a child, therapists
uti lise an obser vation sheet similar to the
parent's self rating scale (Appendix 2).
Initially they may wish to do so in isolation
t hen, when more confident, with a col-
SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 1997 6
ISSN (online) 2045-6174 www.speechmag.com
being used' (Stengelhofen 1993). The
NON VERBAL VERBAL
supervisor should also identify with the
Directiveness
therapist their exact stage of'learning', and
Following child's lead
adapt accordingly, adjusting their timing in
Tum taking
teaching to gel with the student's needs.
Listening Balance of conversation
Interrupting
Evolution
Giving time to respond
Our service continues to have a long way
Pausing
to go. Supervisory therapists need to
Rate
address their own perceptions and beliefs
Gaining child's attention Intelligibility
about the supervisory process and
require a regular discussion venue to share
Observation Volume
what they have learnt from their 'students'.
Eye contact with child Fluency
Munroe describes supervision as being
Shared focus of attention Prosody
'the opportunity to share experiences, to
acquire fresh insights and new ideas which
Facial expression Complexity: semantic
naturally lead to an assessment of the indi
Animation syntactic
vidual supervisor's own skills and perfor
Intrigue Semantic contingency
mance in relation to patient management'.
Touch
It is this analytical, ongoing assessment of
Gesture Initiation:
the whole therapeutic process that hope
- questions/requests
fully will continue to assist in the evolution
- imperatives
of the service, so that all therapists are in
- comments
a position to provide ideas, knowledge,
- other
intuition and feedback on further desired
Position
developments.
- level
- mobility
Keena Cummins is Principal Speech &
- orientation Commenting
Language Therapist and Sarah Hulme
- proximity Responding
Specialist Speech & Language Therapist
Repetition
working in Parent/Child Interaction for
Camden & Islington Community NHS Trust
Manner Rephrasing
Both are based at Hunter Street Health
- warmth Maintaining topic
Centre in London. The inruence of Lena
- attachment Reinforcement Repair
Rustin in this approach is acknowledged Confiict management
Choice of activity
References
The Hanen Programme - contact UK /
Eire Executive Director Lynne Housman, 8
Campion Close, Eccleshall, Staffordshire
STlI 6SR. Fey, M. E. (1986) Language Intervention Marson, S. (1990) Creating a climate for
Kelman, E. & Schneider, C (1994) Parent with Young Children. San Diego: College learning. Nursing Times 86 (17).
child interaction: an alternative approach Hill Press. Munroe, H. (1988) Modes of operation in
to the management of children's language Stengelhofen, J (1993) Teaching Students Clinical Supervision: How Clinical
difficulties. Child Language Teaching & in Clinical Settings - Therapy in Practice 37. Supervisors perceive themselves. British
Therapy 10 (I). Chapman and Hall. Journal of Occupational Therapy 51 (10).
Questions
How does video
facilitate parent child
interaction therapy?
What are the benefits to
individuals of self
assessment using video
compared with other methods?
How can a service gain from
therapists' self-evaluation
through video?
Answers
A parent is videoed playing with their child and, within a framework
provided by the therapist, identifies from the footage adaptations
In their own behaviour which would help their child's communication.
Observing yourself on video gives a more objective than per
ceptual view of events, your actions and their effects, both
positive and negative.
The ongoing, analytical assessment in minute detail of the
therapeutic process increases understanding and stimulates
ideas for further developments.
SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 1997 7
ISSN (online) 2045-6174 www.speechmag.com
I. Qysphagia in
adults willi a
I .


sa lty
There appears to be some
debate among clinicians
around the notion of dys
phagia in adults with a
learning disability (ALD).
West Berkshire Priority
drinking difficulties.
They employed the
Logemann four phase
framework of the swal
low, (preparatory, oral,
pharyngeal and
oesophageal) and infor
mal observations over
meal-times to c1assi fy
where the difficulty in
swallowing lay and, in
addition, noted who had
DYSPHAGIA
had chest infections.
Care Services make a clear clinical
demarcation between the terms
Incidence
adults who acquire dysphagia and
The results showed an overall
adults with long standing problems
higher incidence of dysphagia
with eating and drinking. The ther
within the hospital population,
apists working in this acute hos
ALDand
36 per cent (40) against 5.3 per
pital service feel adults with a
cent (31) in the community.
learning disability fall into the
(Percentages relate to the total
laller category and do not present
population in each group; the
with dysphagia proper.
actual. number of dients affected
Past and current research also
hagia:
is in brackets.) These figures are
bears out this 'feeling'. Sloan
likely to change again in the next
(1977) studied 40 children with
few years as a result of further
cerebral palsy through barium
resettlement plans.
discerned high ISSUes and swallows and a
The most prevalent difficulty was
proponion of inco-ordination at
in the oral phase, 33 per cent (37)
an oral and pharyngeal level. He
in long stay and 4.6 per cent (23)

concluded that, despite a high


in the community. Difficulties at
percentage having a delayed swal
the pharyngeal phase were 10 per
low reflex, they had sufflcient practice
cent (12) and 2 per cent (11)
laryngeal closure to prevent sig
respectively. Problems in the
nificant aspiration.
oesophageal phase were identi
Rogers et a I (1994) docu mented
In an article in three fied from medical notes stating
links between mealtime respira
where there had been reflux:
tory distress and ALD. McCurley
sections, Janet Hickman
three in the long stay facility and
et al (1975) discovered a signifi
explores the concept of
1.2 per cent (7) in community.
cant link between monality rates
Incidence of chest infections was
and respiratory infections within dysphagia in adults with a
around 10 per cent (10) in the
this population and concluded
long stay facility and 2 per cent
aspiration is, for them, a signifi
learning disability,
(13) in the community.
cant health need. Dysphagia is
summarises a SUlVey of Interestingly, the actual number
known to cause aspiration. What
of people with chest infections in
is not answered is whether the
working practices with the
the community was higher, but
aspiration in the above cases was
client group and reports
when calculated as a percentage
caused by swallowing problems.
of the total community popula
AJI that can be concluded is that on a multidisciplinary
tion the figure was much lower
dysphagia is "informally linked
than that for the long-stay resi
protocol.
to the prediction of aspiration
dents.
pneumonia" (Groher 1994).
PTacticalrecommendations
and chest
Long-stay'vs
are made. mfectlOn
commumty
Clients with a learning disability
lenner and Hickman (1995) car-
appear to have greater difficulties at the oral and the pharyngeal
ried out a survey and comparison of dysphagia in adults with a
phase of the swallow. If calculations are based only on the dys
learning disability in Nonh Warwickshire and Nonh Birmingham
phagic population, the co-occurrence of chest infections and dys
community (31 with dysphagia out of a population of 579) and a
phagia is 25 per cent in the long stay facility and 42 per cent with
long-stay residential setting (40 with dysphagia from a population
in the community. More research is required to establish more pre
of HI). For the purposes of the study, the authors used the Royal
cise causal factors between dysphagia and respiratory difficulties.
College of Speech & Language Therapists' (RCSLT) Communicating
There are other causes of chest infection such as a client's overall
Quality definition of dysphagia: "... difficulty in oral preparation for
mobility and chest and medical status. Perhaps a long-term joint
the swallow or in moving a bolus from the mouth to the stomach.
study involving a speech and language therapist physiotherapist
Subsumed in this definition are problems in positioning food in
and chest physician is needed to examine links in more detail.
the mouth and in oral movements including suckling, sucking and
mastication ".
II. Consensus SUlVey
Method
The dysphagia working pany from RCSLT Central Region Specific
The authors selected subjects with dysphagia from their current
Interest Group for adults with a learning disability (SIG) set out to
caseload and from Birmingham and Nuneaton Special Needs
find what was happening in the field regionally and nationally by
Registers. Those not selected were not reported as having eating or
adapting a Dysphagia Consensus survey devised by Beth Fisher
SPEECH & u.NGUAGE THERAPY IN PRACTlCE AUTUMN 1997 8
ISSN (online) 2045-6174 www.speechmag.com
------
R Res dents
RCSLT Central Region North Birmingham, South
Birmingham (2), Warwickshire,
Shropshire, Dudley, Coventry,
(1996) to review acute services. Solihun
The survey comprised a question- ALD SIGs
naire looking at demographics,
informal assessment, treatment and
management issues and videofluo
r' Th SIC
roscopy c mlCS. e sent out RCS":r Bulletin
surveys to 14 Trusts in the region and"
received eight replies (57 per
cent return rate). Two of the
dl d I d'd

with a learning disability as
there was no multidisCiplinary
back-up. A third did not offer a
specific service, but one via a
dysphagia specialist working
across three units.
third did not due to lack of
multidisciplinary back-up and
lack of access to videofluo
roscopy services. All results
were collated together and 15
forms analysed in total
(respondents named in Table
1). The number may be too
small to be statistically signif
icant but the replies yield use
ful practical information.
Analysis
Thera Ista
Twelve questionnaires were sent out to ALD SICs
nationally and seven were returned (58 per cent).
In addition, a letter was sent to RCSLT's Bulletin in
November 1996 enquiring what dysphagia ser
vices there were to adults with a learning disabili
ty. Two of the three respondents offered a dyspha
gia service to adults with learning disabilities. The
Burnley, Warrington, South
Wales, Cambridge, London and
Home Counties, Southampton,
Riverside Mental Health Trust.
R f h' W Bark h'
en rews Ire, est s Ire,
North Tees Table 1
Postgraduate Training
(Table 4)
Twelve of the fifteen respondents had
up-to-date training in dysphagia
management.
C
Only in the last lew years have there
been any courses designed around
the needs of adults with a
learning disability, ego the
.... ...... ...... There is no external check on
years working with a dysphagia caseload average =6.2, mode =10 Manchester Dysphagia course,
% of caseload with dysphagia average = 21% and only one or two of these
no. dysphagic persons seen per month average =5, range =0-5 are accredited. Most others
access to videofluoroscopy 14 (93%) have a paediauic bias, ego April
difficulty with access to vIdeofluoroscopy 1 (1.95%) Table 2 Winstock and Kay Coombes.
Manchester
Logemann
April Winstock, Kay Coombes, London Hospitals,
SIGs, interdepartmental, proprioceptive
neuromuscular facilitation (PNF)
None since 1980
how up-to-date one is with
uammg, nor on levels of competence unless one
enrols on the Manchester or Logemann courses.
However, West Berkshire Priority Care has set up
in-house policies regarding standards and proto
cols and the London and Home Counties SIC
offers dysphagia training to its members and is
planning to have it accredited by RCSLT.
No. attendln
7
7
various
Client groups
(Table 5)
The ALD client group very
often does not present with
one diagnosis but several
which can conuibute to main
tenance or worsening of symp
1
Table 4 toms, ego progressive or behav
ioural probl ems. It wouI d
Client Grou AddlUonal Dla
Cerebral Palsy 57% (8)
Progressive Disorders 15% (2)
Sensory Impairment 46% (7)
Behavioural 10% (2)
Other (strokes, epilepsy, Turner, Downs) 6.6% (1)
Table 5
were
Environmental factors
used
Noise
Consistency of Food
Position of Carer to Client
Staff Training
66"10 (10)
86% (13)
60% (9)
53% (7)
Table 6
Results of the analysis (15 forms) are
divided into:
1) Demographics
2) Assessment
3) Treatment and management
4) Videofluoroscopy
1) Demographics
Therapists (Table 2)
Numbers on individual caseloads
small , five seen on average per month, sug
gesting the majority of therapists' ALD case
loads comprise people with communication
problems. What is not evident - but is com
mented on in the ueatment and management section - is the inten
sity and frequency of intervention, which can take place daily for a
determined period.
Most therapists had access to videofluoroscopy and relied on med
ical servi ces to accept referrals. The hospital therapist would do
that part of the assessment and usually write up a report thereafter.
of Referrals (Table 3)
The highest source of referrals was day care officers. However, all
referrals for clients with dysphagia need, according to RCSLT
guidelines, to be followed up with written medical approval. One
therapist commented that, in the majority of the cases, the pre
senting dysphagia was not severe enough to be life threatening and
uying to obtain a CP consent could be time consuming and frus
trating, especially as the solution may lie simply in adjusting a
carer's techniques or providing an appropriate piece of equipment.
Another therapist felt it was not necessary to have a medical refer
ral in milder cases. Without a CP fund holder consent, the service
offered was under threat.
have been useful to ask in the survey
how many of the clients concerned
would have sufficient verbal skills to
co-operate with dired Ueatment meth
ods. The author suspects very few, ifher
own and colleagues' caseloads are any
indication.
2) Assessments
Protocols
Informal assessments were used in the main.
Therapists said they did have a protocol (half
a written protocol) but would select
from it depending on the individual needs of
the client. One concern regarding this
approach is the lack of standardisation in
observation made and the effect that has on presenting reliable
research data.
The environment (Table 6)
Apart from the four most common environmental factors cited, replies
were very varied suggesting again a high degree of seledivity as to what
therapists thought was important to assess.
Other environmental aspects only counted once or twice were the phys
ical environment (lighting, routine, c;ultural considerations, utensils),
the dient (communication, likes/dislikes, alertness, disuess, motiva
tion), the carer (concerns, attitude, rate and amount offood presented)
and medical (diet, posture, seating, medication).
Oropharyngeal function
There was a high degree of agreement for four items suggesting ther
apists are looking at similar areas (Table 7).
Other items mentioned but only counted a few times were dentition,
tone, facial symmeUy and mobility, oral sensitivity, pouching, head
position, management of consistency and nasal reflux.
SPEECH & lANGUAGE THERAPY IN PRACTICE ALITUMN 1997 9
ISSN (online) 2045-6174 www.speechmag.com
Abnormal swallow and
aspiration
Methods employed (Table 8) were similar to
I function
Lip seal
Tongue Function
Jaw and Chewing Function
Reflexes, eg cough, gag

87% (13)
66% (10)
87% (13)
Table 7
Evalua tion
Various ev aluation measures were employed
depending on individual need, ego Enderby
therapists who work in acute sefVl ces, sug-
As....ment of swallow
gesting consensus on assessing swallow
function informally. [n addition to the indi-
Griffin 4 finger placement
ca tors of silent aspiration in Table 9, others
Coughing prior/post swallow
were inconsistent laryngeal elevatio n, distress,
TIming of swallow
weight loss, watery eyes and increased tone.
Consistency of foodstuff
46% (7)
13% (2)
27% (4)
Table 8
A....sment of silent asplratfon
The consensus was that the therapist
observed what they saw being served up to History of Chest Infections
the client, assessed how the client managed
Gargly Voice
those foods and made recommendations
Audible Breathing
from there. There is a lack of Sla ndardisa
tion of terms such as liquid,
semi-solid, solid and puree. Only
one therapist administered food
trials.
Physiotherapy and
food dyes
Most therapists generally liaised
with a physiotherapist to com
pare assessment notes, but they
were hardly ever present at the
speech and language therapy
Criteria for resuming oral Intake
Re-emergence of a strong cough reflex
Patient able to cope at a pre-morbid level
assessment, probably because it i s hard to
find suitable times for professio nals con- Standard report format
cerned when working in the community.
letters
Technical procedures such as administering
Medical notes
food dyes would require suction and no
Orally
therapist appeared to use or need to use such
techniques in the community. Programmes
used indirect
management techniques such as positioning, advice on equip
ment, texture modification and work on the physical environment
including training ca rers in techniques to manage the dysphagia.
Direct treatment, offered by only 16 per cent of the sample, includ
ed brushing, ici ng, thermal stimulation and vibration. Several ther
apists did not feel sufficiently trained to ca rry out direct treatments
although some employed the principle of icing by advi sing staff to
give a cold drink to the client prior to eating. One therapist was a
firm advocate of PNF procedures:
Reviews were held on a needs basis from daily to six monthly inter
vals, one to three months being the most common. What was
deemed severe / miJd dysphagia was not specified.
Non-oral intake
The results of the section on cri teria for advising non-oral intake
are interesting in that there was no one answer. People generally
needed to see a cluster of symptoms such as inability to maintain
daily requirements, chest infections, weak swallow, weight loss;
aspiration, weak or absent cough, e.;" treme distress, delay in swal
< low or videofluoroscopi c evidence. (For criteria for resuming oral
intake, see Table 10.)
Some therapists left it to the hospital to make decisions on non
oral intake and others brought their Endings to the multidiscipli
nary team for discussion . Some fe lt carer resistance was too great
for such a decision to take place and others felt it was a great rarity
or not applicable to have to decide on such an issue with ALD
clients.
This last comment reiterated the Jenner/Hickman fll1ding thaI the
"dysphagia" of the ALD client group is milder, and inco-ordinauon
presents mainly at the oral phase. On this account, a minority only
will require acute services because of their eating and drinking dif
ficulties.
10 SPEECH & LANGUAGE THERAPY IN PRACf"ICE AUTU MN 1997
69% (9)
38% (5)
31% (4)
Table 9
Weight gain so client not medically compromised
Decrease In chest infections
Hospital decision only
Communicating Information
60% (9)
600/0 (9)
26% (4)
33% (5)
13% (2)
Table 11
measures, evaluating specific goa ls of indi
vidual programmes, reduction in ches t
infections, weight gain, carer feedback on
techniques and reviews with the multidisci
plinary tearn. Methods of feeding back to
other professionals are in Table 11.
4) Videofluoroscopy
The majority of therapists were not instru
mental in this assessment process although
they wouId attend where they could. (Two
forms rec eived were not analysed as they were
completed by therapists who ran the video
40% (6)
. 13% (2)
30% (5)
13% (2)
Table 10
meetings.
fluoroscopy dinics and not the
community ALD therapists.)
III. ObseIVing a
multidisciplinary
protocol
North Birmingham Community
Trust's ALD service comprising all
disciplines in the learning disabil
ities team holds monthly audit
In June 1995 the group chose to
look at provision for dysphagia.
Review of case notes by the service's audit
officer showed poor co-ordination and com
municati on of assessments between the vari
ous disci plines when a dient exhibited dys
phagia and it was concluded the client was
receiving an ineffiejent servi.ce.
Roles
Discussion about specific roles led to agreement on primary and sec
ondary team members for dysphagia management. Input was
required at a prima!)T level from consultants, dietitians, community
nurses, physiotherapists and speer.h and language therapists. At a sec
ondary level, occupational therapists, the behaviour team and dini
cal psychologists could be involved. Hospital services were referred
to if the primary tea m felt the cl ient presented wi th a severe enough
dysphagia.
Once roles had been decided, the audit group agreed to work to a dys
phagia protocol.
Setting the audit cycle
Standards were set in terms of naming a co-ordinator for the
process, the relevant community nurse. The dysphagia protocol
was triggered using a checklist agreed by the team. A referral had
to be processed within a five day time limit and a review date set
within 28 days for the primary team to present its fll1dings and
agree a multidisciplinary care plan and report. Further review of the
case with the home/day centre had to take place within three
months.
Review of the Dysphagia Protocol
After a si.;" month pilot the protocol was felt to be working well with
urgent cases but milder cases were coming through and wasting time
and valuable resources of the multidisciplinary tcalll.
Changes in the screening checklist were made so the client had to ful
fil three cri teria before the dysphagia protocol would be activated:
1) hi gh incidence of coughing/choking/weak cough when eating
2) high incidence of chest infections
3) long-term/acute weight loss.
At audit feedback sessions, community nurses suggested rethinking
the ro le of co-ordinator. [t required substantial time to organise a
ISSN (online) 2045-6174 www.speechmag.com
review date and write up and send out
minutes, usually to at least seven bodies.
The audit team felt administrative sup
port was required instead of using clini
cal time. Feedback from community
nurses also reflected a desire not to be
the named co-ordinator as they had
minimal input with such cases, mainly
supporting the dietitian. They also felt it
would be a more efficient use of time if
the speech and language therapist carried
out the dysphagia screening checklist first
and co-ordinated the protocol as they
were more informed on this condition.
Implications
Practical points from the three areas cov
ered by this article are listed. The author
would be interested in comments from
other therapists on the notion of dys
phagia in ALD and current practice and
protocols.
fanet Hickman (BSc) is a full-time senior
speech and language therapist with adults for
Practical points
1. Should the term 'dysphagla' be applied to a
group, part icularly li ving in Hle community.
which has coped long-term witll thei r eatmg
and drinking difficu lties and, If the term
"'dysphagia'" were dropped In favour of those
wit h "'eati ng and drinking diffi culties"' . is there a
case to influence RCSLT Dysphagia policy on
the need for written medical approval?
2. Multidisciplinary research into the links
between cil est infect ion and aspirat ion in this
cl ient group IS needed.
3. Dysphagia assessment in ALD IS
predom i nantly Informal/observational.
4. A standardised written assessment and
evaluat ion is necessary and an agreed referral
protocol IS useful.
5. link up with specialist acute therapists is
reqUired for accurate Interpretation of
videofluoroscopy.
6. Treatment methods are on the whole
indirect, fOCUSing on the environment.
7. A stagi ng model as proposed by Sheppard
( 199 1) wou ld be helpful lor assessmg degrees
of severity of dysphagia.
8. Mult idiSCipl inary links and technical support
are reqUired for a dysphagia service to be
offered part icularly when the cli ent presents
with a health status threatening dysphagia.
DYSPHAGIA
Groher, M.E. (1994) The Detection of
Aspiration with Video-fluor<;>scopy.
Dysphagia 9 (147-148).
Jenner, L. & Hiclanan, J. (1995) A Survey
and Description of Adults with a
Learning Disability and Eating and
Drinking Difficulties in Community and
a Long Stay Residential Setting.
Unpublished Paper.
Logemann, J.J. (1983) Evaluation and
Treatment of Swallowing Disorders.
College Hill Press.
McCurley, R., McCay, D.N., and Scally, B.
G. (1975) The Life Expectations of the
Mentally Subnormal under Community
and Hospital Care. fournal of Mental
Deficiencies 19 (163-172).
Rogers, B., Stratton, P., Msall, B., Andres,
M., Champlain, M.K., Koerner, P. and
Piazza, J. (1994) Long Term Morbidity
and Management Strategies of Tracheal
Aspiration in Adults with
Developmental Disabilities. American
foumal of Mental Retardation 4 (490
498).
North Birmingham Commlmity Trust Learning Disabilities Team. The Royal College of Speech and Language Therapists (1991)
Louise fenner (BSc Hans) who jointly earned out the research in section 1 is Guidelines for Working with People with Dysphagia.
a senior speech and language therapist with North Wanuickshire, working Communicating Quality (182-187).
with both children with special needs and adults with a learning disability. Sheppard, J.). (1991) Management of Dysphagia in Mentally
Retarded Adults. Dysphagia 6 (83-87).
Acknowledgements
Sloan, R. (1977) The Cinefluorographic study of Cerebral Palsy
Thanks to members of the working party, people who replied to the
Deglutition Patterns. foumal of Osaka Dental University 11 (58-73).
questionnaire / Bulletin request and audit officer Stephanie Bissaker.
Special Needs Register (1995) Level 6, Louisa Ryland House, 44
References Newhall Street. Birmingham B3 3PL.
Fisher, B. (ApriL 1996) Dysphagia Practice. RCSLT Bulletin. Special Needs Register (1995) Manor Court Rd, Nuneaton.
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to aI/ social by making up
security benejits their own stories
jor disabled from start to
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people claiming My World - Story Book 1 is available
benejit)jrom Sales as part of the My World Resource
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0171 2478776.
Visual impairment
A new dIctionary designedfor young
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an enlarged, easy to read page is
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Keyfeatures Of the Oxford Young
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12.99 from RNIB Customer Services
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Sign and play
An illustrated book Of traditional
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Fragile X
Fragile XSyndrome: An
Introduction and Fragile X
Syndrome: An Introduction to
Educational Needs are two new
booklets updating earlier
editions, from the Fragile X
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The former has completely
revised genetiCS pages and a
new section on the problems
experienced by girls and carri
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most common identifiable
cause of inherited learning
disability.
The latter explains the effects
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and language development,
curriculum strengths and weak
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reading work habits and sodal
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Both are available free to inter
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Winchelsea Lane, Hastings,
East Sussex TN35 4LG.
SPEECH & LANGUAGE THERAPY IN PRACTICE AUTU IN 1997 11
ISSN (online) 2045-6174 www.speechmag.com
We're in this together
I tried to see into your
mind tonight,
But my tears got in the
way,
Flooding the path behind
my eyelids:
It became slippery and
confused,
And forced me
To stand and wait.
Then I saw through the
mist,
A cloud.
Heavy, dense, wet.
But I am there, inside it
With y ou.
Together we sit,
Softly
In its protective centre,
Where all our thoUfJhts.
Our memories,
Your words,
Our plans tmd our hopes
.Are mst.tve4. tn. 84/#8..
Fnmz. wheT8 sit In this
5 ECIALFY REAPHASIA
Change and
involvement
meeting
the neeOs
of carers
Two articles, the first this year's Mary Law
lecture, the second based on a smafl-scale
research project, consider the needs of carers of
people with dysphasia and how we as speech and
language therapists should be assessing and
meeting them.
In Less Words More Respect: Learning to Live
with Dysphasia and Difference, Carole Pound and
Monica Clarke pull together their personal
Carole Pound reflections on the way dysphasia can interrupt the
biography or life path of the dysphasic person and
partner or relative. Allhough the issues will be familiar to dysphasic
people, the prime focus is on the non dysphasic partner, drawing
heavily on the experiences of Monica whose husband, John, haC! a
stroke two years ago, and of other relatives at the City Dysphasic
Group. John's stroKe has left him severely physically and
communicatively disabled, unable to speak, write or walk and subject
to frequent epileptic seizures.
The focus of this Mary Law lecture is on the relative. This is fitting as
Diana Law, who sadly died last year, instituted it 13 years ago in lhe
name of her mother to pay tribute to the enormous contribution she
made to Diana's own struggle to live with dysphasia.
Ashleigh Denman then reports on a study carried out to determine
the self-perceived needs of a small group of carers looking after
someone who has had a stroke. The solutions they felt would have
helped alleviate their difficulties and the practical
ACTION FOR steps taken to meet their needs are described.
DYSPHASIC ADULTS The main practical points of both articles are
__ .... summarised in Questions and Answers.
, Unlocking words'
ISSN (online) 2045-6174 www.speechmag.com
corporats
I would give
continued his
so tve could
SPECIAL FEATURE
have fun ca,npi'ng,.,.rc.ilraV4fiYllt
and travelling. And that's what we
were doing when there came a stroke
and ... boom!"
I. Feelings and
roles
Much has been written about the impres
sions of carers as they deal with the drama
of the acute phase of stroke, but what
thoughts and feelings do relatives
encounter when their dysphasic partner
returns home and they begin to face the
reality of learning to live a new life?
A sense of pervading stress and hard work
" time runs away with you when you've
got so many things to think about "
"it was like living on a knife edge"
"he always helped me with everything
now he sleeps a lot"
Profound loneliness and isolation
" I was cut off ... felt there was only me in
this world that had all these problems
...you forget all about everything"
" I feel I overdosed on loss"
U you just endure the loneliness and feel
grateful when it gets light i.n the morning"
Overwhelming bewilderment at the weight
of responsibilities
" I am hysterical .. .I break down at night
... I'm crying all the time ... I'm not cleaning
up my home ... my daughter is shocked at
me ... I'm confused, a very confused per
son"
"in the hospital it was fine but you don't
realise the sheer responsibility of all the
changes at home .. .I do his physio, his
speech, the standing orders and every
thing"
"pefore ti,e strolle most important
tiling for me was fun with my
partner, to be a the fullest
s ich 11
jealousies and I love 10hn
very, very, very I'm angry
that this stroke come
between us and cut, our '''!lapan. I'm
not ready for the si':lJilll"fdysp .
Less Words
More Respect:
Learning to
Live with
Dysphasia
and Difference
The onset of dysphasia is a huge
and traumatic event. It is as if
unexpectedly whilst minding your
own business .... boom! ... both the
person with dysphasia and those
closest to them fall into a black pit
of confusion and uncertainty. How
can we begin to unravel this com
plicated tangle, and what are some
of the possible hurdles and poten
tial steps to getting back on the
bumpy road of life?
Life and people are very different
and complex. To make sense of
things we have selected three
main themes, our Bermuda
Triangle of caregiving. There are
many points of interaction and
overlap and many similarities in
the way these issues impact on the
dysphasic person:
I. the feelings and roles of the
"Carer" and how these
contribute to the development
and expression of a changed
sense of self and self identity.
II. the barriers and facilitators
to developing new relationships
and partnerships with the
dysphasic person, professionals
and new friends and allies.
III. the role and influence of
society on learning to live in
some ways a new life which
includes dysphasia and long
term disability.
Emotions
People report a wide range of emotions:
l. perhaps relief that the dysphasic person
is still alive, and for some the pleasing dis
covery of strengths and skills previously not
discovered or exercised
2. surprise at some of the strange conse
quences of brain injury
3. uncertainty or suspicion about what to
expect
4. fear about what will happen next and
how to cope
5. anger that this has happened, the unfai r
ness of it, possibly the lack or inadequate
provision of services or the inability of
themselves or their partner to change the
situation
6. sadness for all the change and losses
they, their dysphasic partne r, their family
and friends are faCing daily, not to men
tion the loss of hopes and aspirations for
the future.
Thoughts
People often report how muddled they feel
having to think about long and short term
needs and changes. It can be difficult to be
clear and logical in making decisions at the
best of times, but when we are very
stressed, tired and alone it can be all the
more confusing. The daily whirlwind of
practical and emotional demands
includes:
l. worries about keeping the home and
family running
2. how to maintain interests or a job - crit
ical factors in enabling a clear sense of who
we are
3. significant financial worries when one
person becomes unable to do their job,
and perhaps the carer is in the position of
having to deal with home finances and
accounting for the first time
4. what will happen in the coming
months and years
5. the day to day hassle of appointments with
donors, therapists and social workers, all in
the context of transport, mobility, financial,
time and stress management issues.
"I ditltl't at all for the
first year ... ali to do with lohn
his careplan, his
Roles - before
Relatives of dysphasic people are often
bewildered by the sudden change and cur
tailment in roles. We all have many differ
ent roles which help define who we are
and how we express ourselves and our self
identities:
being a friend or mate, a lover or sexual
partner, a parent
roles relating to personal interests and
hobbies
roles and responsibilities relating to the
work place.
Roles - after
New roles suddenly thrust on the carer, for
which they have neither applied nor been
trained, may include:
1. waitress or home help
SPEECH & LANGUAGE THERAPY IN PRAcrlCE AUTWvtN 1997 13
a year latsr at
I suddenly
tal .
needed to
ourselves.
ISSN (online) 2045-6174 www.speechmag.com
SPECIAL FEATURE
2. conductor of the dysphasic person's life
3. handyman responsible for fixing the
broken plug and the car and also for trying to
fix their partner's ann, leg, speech and life
4. responsibility for disdpline in the home
5. counsellor and social worker, attempting
to respond to the new social and emotional
needs of the dysphasic person
G. chauffeur and transport organiser
7. accountant
8. security guard responsible for the safety
and well-being of the dysphasic person, giv
ing instruaions on what is and is not
allowed.
Given this jack of al.l trades position, the
carer may feel somewhat overwhelmed
and distinctly under confident. No won
der also they may feel they are losing a
clear sense of who they are given that all
their new jobs seem inextricably linked to
their disabled partner.
For Monica, being labelled a "carer" rather
than Mrs Clarke - mother, wife, la'Ayer, polit
ical activist, friend, writer, poetess, wild
woman - is one way of trying to establish a
new self identity but it is also a way of defin
ing a person only in tenns of their new situ
ation, as an appendage rather than a person
in their own right. Some people may feel
reassured by assuming such a well-defined
position but many step rather more reluc
tantly into the role of the full-time unpaid
carer.
Mismatch
One of the other difficulties relatives
report is the frequent mismatch between
how they appear and how they really feel.
Part of needing to appear a good carer to
the outside world means living up to the
public perception which often respects,
martyrs and eulogises the carer as one step
short of sainthood. Meanwhile, inside, the
carer may be feeling incompetent, angry,
disgruntled or capable of quite malevolent
thoughts about their partner. They may
present as all-singing, all-dancing, ail-cop
ing when, behind the facade of cheery
Monica Clarke
competence, they are a volcano of anger
and tears, desperately struggling to keep
their head above water. Tills mismatch can
be one of the key contributors to the carer's
plague - guilt!
Practical help
What routes can we encourage people in
this tight corner to take? The first is to seek
out practical help. It is not necessary to
struggle on alone.
1. use services - don't be put off by the fact
that people are busy; it's their job to pro
vide you with information, ideas and help
2.get advice, ego from the benefits agency,
Citizens Advice Bureau, Local Community
Health Council, Carers National
Association
3. friends, neighbours and other relatives
are often happy to help so accept their
offers and spread the load. Including them
in your daily routine can be a welcome way
to bridge their embarrassment at the sepa
ration dysphasia can impose.
4. have an emergency list by the phone of
friends and family you can ring for a chat,
gossip or just to let off steam
5. use the help and ideas of other people in
the same boat, ego informal chats with
other relatives you meet in the therapy
department or day centre, or contacts at
local carers' groups.
Value needs
The caregiving relative is important; if the
carer becomes ill through excessive tired
ness or stress they lose valuable resources
which can help them cope with the multi
ple demands of caring. Similarly, being
uptight and exhausted will do little for a
communication partner's need to be
patient and flexible in enabling the dys
phasic person to participate in a conversa
tion. Small and manageable personal
treats include:
setting aside a small amount of time for
your own interests - reading, exercise class
es, gardening - or anything which enables
you to escape to your own mental and
physical space for a few moments
a good cry
a good shout (acts like a pressure cooker
valve)
planning ahead to have time out even if
it is only 30 minutes once a week. Without
careful planning it won't happen.
a walk round the block to clear your head
and unwind.
Self-confidence
Dysphasia can happen very suddenly but
often the consequences are very long last
ing. It important as a relative to develop
confidence in coping to help you through
the years ahead. Some ideas include:
1. get appropriate infonnation and training in
an accessible understandable fonn, available at
the right time for you, ego tapes, booklets,
information on groups in your area from
ADA, or from your local therapist/GP
2. form alliances with other carers, a great
source of new ideas for old problems and
help in standing up for your rights
3. emotional support. Living with dyspha
sia can be a difficult and lonely journey for
both the person with dysphasia and their
carer and both need friends, therapists and
other listening and sympathetic ears to
help them through. The dysphasic person
may also want and need to play some part
in emotionally supporting the carer, to
enable them to reconnect in some way
with one of their previous and new
roles in life. As in John's case this may not
be emotional support of a verbal kind but
there are many non-verbal ways.
II. New relationships
and partnerships
What contributes to enabling, empowering
and - conversely - to disabling, less healthy
relationships between carers and their dis
abled partner and carers and professional
health care workers?
Let us consider some famous partnerships
and the faaors which contribute to them
being effective teams: Laurel & Hardy, Patsy
14 SPEECH & lANGUAGE THERAPY IN PRACTICE AUTUMN 1997
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SPECIAL FEATURE
& Edina, Wallace & Gromit and Tony (vice
chairperson of ADA) & Cherie.
l. mutual support
2. love, friendship and respect
3. similar aims/ambitions/direction
4. communication of a verbal and non
verbal nature, not just talking but knowing
what the other is thinking and feeling
without words
5. taking decisions together
6. having fun in each other's company
7. sharing each other's past and important
moments
8. maintaining a sense of balance, equilib
rium and equality in the relationship.
Balance
Balance can be critical in developing new
relationships. Two people can be very dif
ferent, maybe even speaking different lan
guages, but can have a balanced relationship,
contributing different qualities and shar
ing jobs and responsibilities. In living
with dysphasia, the balance can be unset
tled when
one person takes al.1 the decisions
lack of respect creeps in
one person holds all the responsibility
one partner has the lion's share of power
communication is in one direction.
Competence
The concept of competence, the ability to
have and the opportunity to exercise some
control and choice, is an idea developed by
Aura Kagan, who, with Pat Arato from the
North York Aphasia Centre, Toronto, gave
the Mary Law lecture two years ago. In the
context of living with dysphasia, compe
tence refers to the dysphasic person's ability
to participate in
conversation
decisions and choices
relationships
life and the community.
The opposite, incompetence, is being
thought of as stupid, thick, unable to make
decisions or to be rational in the exercise of
choice. Kagan and her colleagues feel the
key problem with dysphasia is that it erects
barriers to conversation, choice and partici
pation in the life of the community, result
ing in the dysphasic person being perceived
as incompetent. Dysphasia masks competence
Kagan proposes we can enable the dyspha
sic person to gain access to conversation,
social relationships and balanced partner
s ~ i p s by
(1) Acknowledging competence through
showing respect
using an adult, non patronising approach
acknowledging their skills and experience
acknowledging their ability and their right
to participate in decisions and choices.
(2) Revealing competence through
changing and adapting our own commu
nication skills to facilitate the communica
tion of the dysphasic individual - slowing
down, repeating and using gesture, writing
or drawing to back up speech
thinking about and providing the com
munication ramps to enable dysphasic
people to access and share our communi
cation environment.
ridiculOll$. As fi
now _1t4l1r II
aauaDy II IDt Df I
understandfng is 'eos I
nonsense... I'm si 1
say and to say onl; the clear things so
John can understand me. "
Competence and caring
Can we use the same notions to develop
more balanced partnerships between pro
fessionals and relatives of dysphasic peo
ple? There are a number of interesting sim
ilarities. Therapists, nurses, doctors and
social workers have a lot of important and
useful knowledge of working with patients,
their illnesses and disabilities. However,
they often have no direct experience of liv
ing 24 hours, day in, day out, with a per
son who has great difficulty communicat
ing and possibly a whole range of other
physical, psychological and emotional
changes to deal with. Relatives often
report they had no idea how difficult and
lonely going home from hospital or cop
ing in the long term with dysphasia and
disability would be. Suddenly, no nurses to
help with daily washing and toileting, no
doctors on hand for urgent medical ques
tions, no contact with the daily bustle of
the hospital ward. Things seem very differ
ent in this new and unfamiliar reality
which the carer has to live, sleep and
breathe, often without help and respite.
As therapists and professionals we need to
acknowledge the competence and experi
ence of the carer by respecting their exper
tise, recognising their skills and experience
and facilitating their real involvement in
choices and decisions.
To establish some semblance of balance in
a professional/non professional partner
ship and reveal the competencies, we
should be careful to:
a) monitor and change our own profes
sionally constructed style of communica
tion with carers
The professional person may maintain
power and the consequent imbalance in a
relationship by using jargon completely
incomprehensible to those outside their
medical culture. We should be careful to
demystify and make accessible our lan
guage, just like the good conversation part
nero Another way professionals disable lay
persons is by not really listening - ,not real
ly hearing how a person's explanation fits
into their own unique life history, and
offering instead off-the-shelf and possibly
quite inappropriate SO'lutions and strate
gies. We have a strong personal and profes
sional impetus to do, when sometimes the
listening rather than the doing is the most
enabling part of our intervention.
b) help carers develop and practise com
munication skills which will help them
get the most out of interactions with
medical, therapy and social service agen
cies
Spend time preparing carers for difficult
interviews and case conferences, helping
them complete complicated forms, devel
op assertiveness skills and strategies and
role play forthcoming interactions with
doctors or solicitors.
III. Role a'nd
influence of
society
What impact can society have on learning
to live with dysphasia, and how might we
enable the dysphasic person and their rela
tive to reconnect to new and old commu
nities?
Here, by society, we are referring to the
people, institutions, structures and services
which make up our life as citizens and our
interaction with the environment. The atti
tudes and assumptions we encounter can
have a significant impact on how we cope
with the new lives, identities and lifestyles
accompanying dysphasia.
Difference
One issue people and society often strug
gle to cope with is the ability to accept,
accommodate and value difference ... men
and women, and people who are disabled
and non disabled, young and old, of dif
ferent colour and ethnic background,
homosexual and heterosexual and with
different religious beliefs.
SPEECH &. LANGUAGE THERAPY IN PRACfICE AUTUMN 1997 15
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SPECIAL FEATURE
When we become overly focused on the
different aspect of a person we may start to
feel embarrassed, uncomfortable or in
some way very distant from the person
before us. Perhaps this is particularly the
case with dysphasia since it undermines
the very ability to communicate and estab
lish some verbal negotiation or explana
tion of the difference.
Attitudes and assumptions
People, including professional health
workers, frequently make assumptions
about the abilities, needs and desires of
both the disabled person and their carer. A
very common assumption we make is that.
once someone has the misfortune to have
a stroke, head injury or other serious acci
dent. they become disabled and shed not
only their intelligence and pre-stroke iden
tity but also their rights and natural
human desires.
We highlight their disabilities, sometimes
even defining them purely in terms of their
condition - "the stroke in bed 5", "Tony is
a young head injury", "she's a brain
tumour" - and forget all their skills, abili
ties and qualities as a person who coinci
dentally has had a stroke, head injury or
brain tumour. Thus John, the psychothera
pist. father, traveller, hippy, husband and
musician becomes, overnight, John - the
dysphasic. The loss of sight of the person
behind the disability may become trans
ferred also to the relative who becomes the
'carer of the stroke' rather than the wife of
the person with dysphasia.
'The people in the hospital seem to
assume we're lrot a couple anymore.
They assume because Joh" is in a
wltnfchair 1 re not together.
The whee ir itself takes us
apart. __ tlM can'&. ld hands and
cuddle allymore
these gadgets ha med up in our
jjfe- __ people pIon. , these gadgets on
one tJf
es me fllrther
or example, with
John's chest pro , the first thing
everyone suggested IUDS u", can
organise a hospital bed.;ut a
Itospital bed is a d ... I
need to tell these people that we still
.like to sleep togetl,er ? Why do they
assume we want to be in single beds?
It makes me very angry. "
Collective responsibility
Changing society and public attitudes is no
easy task. Fundamentally it involves losing
our obsession with the impaired bit of the
disabled person and looking outward at
ourselves, our attitudes and our environ
ment to change. The problem is no longer
the dysphasic
person's but
ours. Thank
heaven for
organisations
like ADA who
champion the
cause of raising
awareness.
But it is not only
ADA's responsibility - we are all a part of
society and share a social and collective
responsibility for challenging ignorance
and bringing about change. John and
Monica have an important role to play in
sharing their experiences with other dys
phasic famities and service providers.
Health professionals too have an impor
tant role not just in sharing information
and experience with service users but in
informing managers, purchasers and oth
ers outside their narrow daily work com
munity about the needs and rights of dys
phasic people. Therapists must recognise
their role is not restricted to traditionally
defined boundaries of speech and lan
guage therapy.
Strategies we might all adopt include:
1) information, education and awareness
raising of
a) the effects of
dysphasia
Acknowledgements
b) the help and
Wc would like to
support families
thank (<Hers, the
who share dys
dysph'lsic people,
phasia need
students and staff at
c) ways non dys
the City Dysphasic
phasic people
16 SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 1997
Croup, the North York
can adapt and
improve their
aphasia centre,
communication Toronto, for SOIlle of
skills and atti the pictorial and
tudes to commu theoretic-al ideas and
nication Anion for Dysphasic
impaired people.
Adults for t heir kind
invitation to present
2) rights
this prestigiolls
The empower
lenure.
ment of con
l.ast, but not least, our
sumers enables
thanks to John for
us to stand up
allowing liS to share
for our rights
some of his and
and complain if
Ivlonica's personal
we do not
receive the ser
expt'rien(cs of living
with dysphasia and
disability.
vices and treatment patients and
citizens are told to exPE;Cl. Often
the last thing one has the time or
inclination to pursue is a letter of
complaint, but using the procedure
is a very powerful way of raising
awareness and changing practices.
Use therapists, advocates,
Community Health Councils,
Carers Groups, hospital complaint
procedures and ADA to support
you. Chief Executives and enthusi
astic new MPs need to be told your
stories to pursue them.
3) support
Therapists and carers may only
think of formal relative groups as a
means of accessing support. They
can be very helpful ; however many
carers find it too difficult to com
mit time to an organised group.
Support from other sources can be
equally beneficial, offering simple
and cheap ways of breaking the
isolation of caring and getting in touch
with one type of new community:
informal contact with relatives at
appointments and the day centre
ringing up someone you know is under
standing of your caring demands
writing and receiving letters from other
carers.
differences to be re
each of us to lin
differences, ullders
differences a,
learn to each other. "
"For me t
vea
... this busilless
1/ differellt -
_ .....,.. dyspluUflt
ai, just tlULt
'd lille for our
ised tmd fOT
up with our
on w
Learning to live wi til dysphasia and
difference is a struggle. There are
no magic wand solutions - it is
hard work. Hopefully people will
find some aspects of our approach
useful to the development of
understanding and reconnection
to a different and new road of life .
Further reading
Kagan, A. (1995) Revealing the
competence of aphasic adults
through conversation: A challenge
to health professionals. Topics in
Stroke Rehabilitation. 2 (1).
Parr, S., Byng, S., Gilpin, S. and
Ireland, C. (1997) Talking about
aphasia: Living with loss of lan
guage after stroke. Open
University Press.
ISSN (online) 2045-6174 www.speechmag.com
Carers Investigating
the needs
"Many professional interventions are inap
propriate, irrelevant or unavailable because
the needs of the carers have been over
looked" (Nolan & Grant,1989).
Over the last ten to fifteen years the role
of carers has started to be recognised for
mally. It is now accepted that carers are
a sizeable and important group. The
1985 General Household Survey into
Informal Carers (Green, 1988) showed
there are six million carers of an elderly
or disabled person, equivalent to one
adult in seven.
The vast majority of all care is by family
members in the community. Sadler
(1989) estimated they save the nation in
the region of seven billion pounds each
year by providing their services.
The need to support carers has also been
identified in Government white papers,
and has even been described as the "first
task" of publicly provided services
(Griffiths, 1988). The "major conuibu
tiona of carers to community care has
been acknowledged in a Government
white paper, Caring for People
(DHSS,1989), and the responsibilities
of community care were clearly set out
in the Government white paper Growing
Older: "The primary sources of support
and care for elderly people are informal
and voluntary. These spring from per
sonal ties of kinship, friendship and
neighbourhood. They are irreplaceable.
It is the role of the public authorities to
sustain, and where necessary, develop
but never to displace - such support and
care. Care in the community must
increasingly mean care by the communi
ty" (DHSS, 1981).
An implementation paper following on
from Caring for People stated the provi
sion of services should be on a needs-led
basis, allowing for carer participation.
It is, however, impossible to implement
these recommendations without under
taking research to determine what carers
perceive as their needs. Little research has
been done looking at carers' needs in the
community, as the majority of research
focuses on types of carer burden or the
evaluation of techniques which aim to
improve the carers' situation. The main
piece of research I.ooking at carers' needs
in the community identified a mismatch
between the services provided and the ser
vices they desired (Nolan & Grant, 1989).
This is borne out in a recent literature
review which stated there is little
research examining what the carer wants
and needs (Goodman, 1986) and by a
survey of community care (Henwood
and Wistow, 1995) which showed there
is limited involvement of users and car
ers in the care management process.
Researching need
In this study, nine semi-struc
tured half hour interviews were
undertaken with a self selected
group of carers known to the
speech and language therapy
service in Stroud,
Gloucestershire. The interviews
were. tape recorded. uanscribed
verbatim and analysed to iden
tify common them . The car
ers expressed needs in fi ve
main areas (Fig. 1).
Simply asking carers "Are you
coping?" is unlikely to give
accurate information. In
everyday practice, therapists
can ask key questions to deter
mine carers' needs (Fig. 2).
Ideally, carers should be seen
separately from the client as
they are understandably
unwilling to open up fully if
the client is within earshot for
fear of upsetting them. This
can be difficult to arrange as
carers often feel they are tak
ing time away from the client
if they are seeing the therapist
alone. There is also the practi
cal issue that carers often do
not have any\vhere else for the
client to go. The client's per
mission for involving carers
should be sought, but can be
difficult to confirm if the
client has severe receptive
problems.
New referrals are less of a prob
lem as the therapeutic process,
induding the involvement of
the carer, can be agreed as a
total package at the first
appointment. Unfortunately
time also does not always
allow for the ideal situation
and some of the most interest
ing information I have
received from carers has been
hal f way down the garden path
on the way back to my car.
Service change and
involvement
Speech and language therapists
are often able to communicate
extremely well with the client
and the carer and so are well
placed to help meet carers'
needs, but some do not see this
as their role. My feeling is that,
for the client to communicate
to their potential , they must
have a communication partner
who is well adjusted to and
1. Support
Carers felt they lacked support from the family,
friends, neighbours and outside agencies and had
to bear the burden of care completely alone, leading
to feelings of desperation.
The lack of family support appeared to be because
family members did not realise the difficulties the
carer was trying to cope with. The carers did not
make the family aware of these difficulties as they
were too proud to ask for specific help and wished
to appear to be coping.
The lack of support from friends and neighbours
seemed to be due to the fact that the carers were
not always available at the right times. With outside
agencies, it appeared the professionals involved
did not have enough time to support the carers
(MacKenzie et ai, 1993) or did not feel this was their
professional role (Association of Carers, 1985).
2. Information
Without full information carers are not able to
choose an appropriate model of care. Nolan and
Grant (1989) stated carers should have the right to
choose the model of care they feel is appropriate.
However, in this study, carers expressed the need
for three main types of information:
a) the condition from which the person was suffering
b) financial entitlements
c) the availability of local services.
Carers felt this information was difficult to access,
but that appropriate information would help them
feel more in control of their situation (Kautzmann,
1993) and so lead to a reduction in carer distress,
as shown by Nolan et al (1990).
3. Role Change
Carers felt their role had changed throughout their
career as a carer in a range of different areas. Such
role changes are well documented (Wahrborg and
Borenstein. 1990) and include changes in practical
tasks, such as carrying out household chores, man
aging the finances, filling in forms and needing to
cook.
However, changes were also seen in social roles as
there were restrictions in recreational activities and
in social relations with friends and some social iso
lation (see Herrmann and Wallesch,1989) .
4. Training
Training has been identified as something a carer
should expect as a "right" (Social Work Services
Development Group, 1984). It is also an area carers
in previous studies have identified as something
they feel they need (Nolan and Grant, 1989).
However, despite this, its provision was felt to be
inadequate by the carers in this study. They
expressed difficulties with having no help to cope
with the practical side of caring, a lack of explanation,
uncertainty and feeling they had to learn on the job.
5. Day and Respite Care
The importance of day and respite care to decrease
carers' stress levels (McKay, 1983) and help them
cope (Oranen et ai, 1987) has been investigated in
previous studies. Even the government white
paper, "Caring for People" (1989) promoted the
importance of day and respite services.
The carers in this study expressed three types of
need in relation to day and respite care:
~ a) time off to themselves
~ b) a break from each other
en c) respite back-up in case of illness or emergency.
~ h
16 T is pattern of lack of provision of day and respite
() care services has been seen before (Martyn. 1995)
and so the concerns expressed by the carers in this
~ study add weight to the argument for service provision
~ in this area to be carefully considered.
SPEECH & LANGUAGE THERAPY IN PRACI,CE AUTUMN 1997 17
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Answers
To meet carers' needs, we have to ask them what they
..,.1 are, then provide the right services at the right time
for each individual.
Carers and other conversation partners can be a
barrier to or facilitator of a dysphasic person's
i communication, so therapists must work with them
to ensure they are comfortable with this role.
Wi For a balanced partnership we need to acknowledge
carers' competence and gIve them the opportunity to
1 reveal it by reducing jargon and helping them access
the system.
happy with their role as a carer. Therefore,
we do need to provide for the carer as welt
as the dient.
Carers in this study identifi ed changes to
services they thought would be beneficial,
but also areas that would allow them to
become more involved in their role of carer.
(A similar pattern of both service change and
involvement was identified by Henwood in
her 1995 study.)
1. access to somebody in an advisory
role
2. regular reassessments
3. involvement in carers groups
4. access to somebody to call on in
emergencies
5. access to support services for carers
6. the provision of co-ordinated
information.
Action
Carers have clear ideas about what difficul
ties they have experienced and how these
may be avoided. Previous studies have
shown that carers are well aware of the
problem areas in their own situation, and
able to determine which ones they are able
to cope with easily and which they need
help with (Sanford, 1975) .
The solutions put forward by the carers
themselves are the areas to be considered
when determining services for this group.
Following this research I have devised an
informat.ion and advice pack, loose leaf, so
I can give the right information at the right
time. I have also contacted the local Carers
organisation to widen my knowledge of
the resources available locally so I can pass
on information as appropriate. Since carry
ing out the research I have become more
aware of the importance of multidiscipli
nary working and now make an effort to
contact other professionals working with
the same clients to attempt to ensure as co
ordinated an approach as possible. As yet
there have been no changes in local service
provision. However, I hope to carry out
further research to persuade service
providers that, whatever cli ent group is
involved, their carers have similar needs,
and a service for them is required.
This study clearly shows present service
4. Do
enough
look
Figure 2 - Key questions to
determine carers' needs
provision is not meeting the needs of car
ers. Future service provision should aim to
ensure carers get the services they feel they
need.
Ashleigh Denman is a speech and language
therapist with Gloucestershire Royal NHS
Trust and Severn NHS Trust.
References
Association of Carers (1985) Response to
the Review of Community Nursing.
Rochester: Association of Carers.
Department of Health (1989) Caring for
People: Community Care in the Next
Decade and Beyond. London: HMSO.
Department of Health and Social Securiry
(1981) Growing Older. Lo ndon: HMSO.
Goodman, C. (1986) Research on the
Informal Carer: A Selected Literature
Review. journal of Advanced Nursing 11.
Green, H. (1988) Informal Carers.
London: OPCS Social Survey Division
Griffiths, R. (1988) Communiry Care - An
Agenda for Action. A Report to the
Secretary of State for the Social Services.
London: HMSO.
Henwood, M. and Wistow, G. (February
1995) The Waiting Game. Community Care.
Henwood, M. (July 1995) Measure for
Measure. Community Care.
Herrmann, i'vl. and Wallesch, c.w. (1989)
Psychosocial changes and psychosocial
adjustment with chronic and severe non-flu
ent aphasia. Aphasiolog), 3 (6).
Kautzmann, A.N. (1993) Linking Patient
and Family Stories to Caregivers' Use of
Cli nical Reasoning. American Journal of
Occupa!ional Therapy. 47 (2).
MacKay, B, orth, N. and Murray-Sykes, K.
(1983) The Effects on Carers of Hospital
Admission of the Elderly. Nursing Times.
83.
MacKenzie, c., Le May, M., Lendrem, W.,
McGuirk, E., Marshall, J. and Rossiter, D.
(1993) A Survey of Aphasia Services in
the United Kingdom. European journal of
Disorders of Communication. 28.
Martyn, P. (1995) Carers: Do They Need to
Talk? Diploma in Counselling (unpub
lished).
Nolan, M.R. and Grant, G. (1989)
Addressing the Needs of Informal Carers: A
Neglected Area of Nursing Practice. journal
of Advanced Nursing. 14.
Nolan, M.R. , Grant, G. and Ellis, N.C.
(1990) Stress is in the Eye of the Beholder:
Reconceptualising the Measurement of
Carer Burden. journal of Advanced Nursing.
15.
Oranen, M. , Sihvonen, R., Aysto, S. and
Hagfors, C. (1987) Different Coping
Strategies in Families of Aphasic People.
Aphasiolog)'. 1 (3).
Sadler, C.(1989) Driven to Depression.
Nursing Tim es. 85 (27).
Sanford, J.R.A. (1975) Tolerance of
Debility in Elderly Dependants by
Support.ers at Home: Its Significance for
Hospital Practice. British Medical Journal.
3.
Social Work Services Development Group
Project (1984) Supporting the Informal
Carers - Fifty Sryles of Caring. London:
DHSS.
Wahrborg, P. and Borenstein, P. (1990)
The Aphasic Person and His/Her Family:
What About the Future? Aphasiolog)'.
4(4).
18 SPEECH & lANGUAGE THERAPY IN PRACTICE AUTUMN 1997
ISSN (online) 2045-6174 www.speechmag.com
IN-SERVICE TRAJNING
Tra'nin fo Ke
ess sora
-
As speech and language therapists are more and more stretched by what they are expected
to achieve, they are offering training to others. Additionally, many are working with cultural
groups with whom they are unfamiliar. Julie Marshall considers the lessons to be learned
from an in-service training project in Kenya, where formal services are extremely limited.
I
na number of counLries, services are beginning to be developed
and materials produced specifically to introduce knowledge of
speech and language difficulties to parents / carers and profes
sionals in related fields, so so me provision is made in the absence
of large numbers of qualifi ed speech and language therapists. (See
Miles (1990), Winterton (1991), Wirz and Winyard (1993) and
House and Morris (in press) .)
Wirz (1995) has suggested 58 million children from 25 countri es
with low infant mortality are served by the majority of the world's
speech and language therapists and that the remainder of the
world's children have virtually no access to services. This is despite
evidence that there may be huge numbers of people with such pro b
lems. Helander (19 93) has estimated 200 mill ion disabled peop le
ill less developed countries and Hartley (1995) calculates as many
as 98. 8 million people in less developed countries may have speech
and [;)nguage difficulti es.
'> There may be many reasons why services for people wit h speech and
language difficulti es are so poor, even in comparison to services for
those wi th other types of disability. Some explored by Marshall
(1992) include:
all emphasis on emergency treaLrnent and / or Primary Health Care
lack of epidemiologi cal data which may support the need for ser
vices
Iack of knowledge of the potential (re)habilitation of speech and
language difficulties
the existence of a wid ra ng of types of speech and language diffi
culties, many of which m, y be associated with other disabiliti es, mak
ing it difficult to identi fY a single population requiring services
the unexplored effects of cultural factors on the identificati o n of
problems and demand for servi ces.
Demand for service initiatives in less developed cou ntri es often
originates from large insti tutions such as government hospit als and
training coll eges. They frequently reques t speech and lal1guage ther
apists from coul1tries such as the United Kingdom and the USA fo r
long term help - perhaps through placement by an organisatio n
such as Voluntary Services Overseas - or short term consultancies,
either to carry out trai ning or to investigate an aspect of service pro
vision, for exampl e the feasibility of setting up a qualification
course for speech and language therapy.
It was in this context that members of the Speech Pathology tea m at
the University of Manchester were asked by the British Council to
run a training course in Nairobi, Kenya in December, 1995. At that
time Kenya had less than five qualifi ed speech and language thera
pists, none working in the public sector. A two week intensive train
ing course was agreed, aimed at qualified professionals who, during
the course of their work, already come into contact with children
with speech and language difficulties and are responsible for offer
ing help to them and their carers. The course was run by t'IVO tutors,
with some co-ordinating assistance from two of the peopl e attend
ing the course. The twenty three participants included Special
Education teadlers who work at District Assess ment Cenlres and are
responsible for children with all types of uisability, Special
Education course tutors and Ministry of Education inspectors .
Planning and preparation
An outline course content had been uevised some months earl ier by
a small group of people in the UK, most of who m had experience
of working and teaching in less developed countri es. This syll abus
was commented on by the course organisers in Kenya, amcl1ded in
response to comments and kept very flexible during the course. The
main topics covereu were:
What is communication ?
The development of prevt'riJaJ com.municalion, language compre
hension, expressive language anu speech sounds.
Areas of communicatjon breakdown.
Special causes of communication breakdown (eg. k<l rning dilTi
culties, phys ical disability, cleft palate).
Assessmen t of pre-vnbal communication, comprehen ion,
e;xpression and speech sounds.
Remedi ati on of pre-verbai commUni GHion, umprehen ion,
expressive language and speech sounus.
A uevelopmental approach was taken, 011 the basis thaI l his model
SPLLUI & 1..A'JClI AGETHERAPY IN PRAClfC[ .\ UTUMN 1997 19
ISSN (online) 2045-6174 www.speechmag.com
- -
IN-SERVICE TRAINING
would be the easiest to introduce in a short space of time and that,
although it may not be the most appropriate approach to use with
all children, it was unlikely to be counter-productive. Additionally,
it was felt it would utilise the knowledge it was suspected partici
pants already had about normal child language development. The
introduction of a wider variety of approaches in a short.space of
time may have been confusing. Similarly, the somewhat outdated
notion of working on comprehension, expression and speech
sounds separately (with limited mention of phonological versus
articulatory problems) was deliberately chosen to simplify assess
ment and remediation; however, during teaching. the inseparability
of these areas was emphasised.
Participation
A substantial course manual (Marshall and Warner, 1996) was pro
duced. The intention was for participants to receive the manual
prior to the course and have the opportunity to familiarise them
selves with its contents. This would hopefully mean for the duration
of the course it would be possible to concentrate on the acquisition
of practical skills and exchange of ideas. ln addition to the course
manual, participants also received a copy of Winterton (1991)
"Communicating with Children " which was used as the basis of
some of the assessment and remediation sections. (Unfortunately
participants were only given the manuals a day or nYo before the
course commenced.) They were also asked to cany out a number of
observation exercises and bring their comments to the course. These
provided useful information about the types of communication prob
lems experienced and panicipants' conceptualisations of speech and
language difficulties.
The teaching day was a long one with participants also given read
ing and practical e.'(ercises to carry out during the evenings and
weekend. The course was evaluated by the tutors each evening and
changes made to the content and style as necessary. Teaching meth
ods were kept as practical as possible with frequent exercises, group
work and a great deal of participation from the group in evaluating
and adapting course materials, providing examples of children they
knew and culture / language specific information about child devel
opment and child-rearing nonns. Local children, both with and
without speech and language difficulties, were used for demonstra
tion assessmenlS by the tutors and for the participants to practise
their skills in assessment and interpretation of their findings.
Positive evaluation
The course evaluation was very positive. The majority of participants
felt it had been at an appropriate level for their needs and reported
they felt more confident in their abilities to work with children with
speech and language difficulties. They had revised their approach
towards children based on the developmental approach and report
edly found the model to be useful. mO\ing away from conceptuali
sations such as that all communication problems are speech based
and due to deafness. All appeared to have an increased grasp of the
complexity of communication disorders and many asked for more
input in certain areas. They reported they had enjoyed the teaching
styles, less didactic than those to which they are accustomed.
Participants and tutors felt more time was needed and there should
be opportunities for more practical experience and observation of
the tutors.
Both also felt the course should be evaluated by observing the par
ticipants in their workplaces at a later date and that at least one per
son from each of the District Assessment Centres in Kenya should
attend a similar course, to ensure each district had a source of spe
cialist knowledge. To facilitate independence from e.'<lernal support
it was suggested that. once they had had the opportunity to put their
skills into practice and the course's impact had been evaluated, a
"Trainer of Trainers" course should be run to help participants pass
on their skills more effectively to others. Unfortunately evaluation
of the course and further follow-up courses have not yet been pos
sible, despite many of the participants continuing to emphasise
their necessity.
Lessons for the future
The course, although apparently a success from the viewpoint of the
participants, highlighted a number of factors the tutors felt should
be taken into consideration when planning and carrying out train
ing. Importantly, account needs to be taken of cultural factors which
.
PractkallmpUcatiODI
1. Before implementing any or other
service developments, more should be
to the type of services parents and other carers want. It is
often aMUmed that demand by' one sector of the population,
eg. service planners, is sufficient justification for
rather than recognisin..& the community itselfmay have db
ferent perceptions of-need. For example, Buchner (1994)
questions die assumption that parents want or have the
resources to out home based Lparent participation
schemes for their children with disabIliues.
2. When training is being planned, account should be taken
of the provision that may already be available within the
community. It is often assumed that fonnal provision for
children WIth disabilities in less develoP,ed countries started
with missionaries, although work by MIles (1994 and 1996)
provides evidence to challenge this. Children with disabilities
may have long been cared for by their families, been casu
ally integrateainto mainstream schools and have received
help from traditional healers. In this country we should
also look at what the family, carers, schools etc. are already
providing for children with speech and language difficulties
as they may be offering good models of service provision.
3. Training is more likely to be successful if there is good
prior understanding on the part of course tutors of the
responsibilities of tfie participants and the knowledge they
already possess.
4. Course materials should be available in written fonn,
preferably before the course starts. Anyone devising new
training should look at other materialS that
have been produced to reduce Mre-inventing the wheel
w

5. Much greater account needs to be taken of cultural factors
which may affect participants' understandi!lg ofand attitudes
towards speech and language difficulties. This applies in any
setting wtiere the tutors mayl>e from different cultural, socio
economic or educational backgrounds from the participants.
6. Cultural influences on service users, includiM socio
economic factors, child-rearing nonns, teaching and reaming
and attitudes towards health care and Children witfi
dIsabilities, may have a considerable effect on the success
participants have in using their new skills and so should be
Invesugated.
7. Trainers should, wherever include local tutors,
partIy to empower them to take over training and also to
ensure appropriateness of teaching and cultural sensitivity.
It may be beneficial to include tramers who are not speech
and ranguage therapists as they may have a better under
standing of the needs of the partIcipants and provide positive
role moClels.
8. Training Pf9&Iammes should be kept as practical as possible,
as these sKilfs seem to be the most difficult to acquire.
Tutors should be as flexible as possible- in style ofp'resentation
and content. It is important to be aware of how much
infonnation people can absorb and to be prepared not to
to teach a comp'Jete speech and dierapy course in
two weeks! 11iis means compromIsing on the amount of
teaching in some areas:- for participants who can only
spend a few minutes with each aient, many of whom have
severe communication problems, is knowing the difference
between phonology and articulation vital?
Training should not be carried out unless some fonn of
evaluation IS built into the programme. This should preferably
include both pre - and p'ost - course evaluation, and, as a
central part, the views of service users. Trainers should be
enco!Jl3&ed to share materials and their successes -and failures!
- with others.
10. Training should not be carried out unless there is a dear
mechanism for its implementation. For example, those who
receive trainin.& shoufd have the necessary resources such as
time, responsil>ility and respect to put into praaice what
haye learned, and should ideally receive some recognition for
domgso.
x
o
<Q
20 SPEECH &. lANGUAGE TH ERAPY IN PRACfICE AUTUMN 1997
ISSN (online) 2045-6174 www.speechmag.com
IN-SERVICE TRAINING
may have influenced participants to be more positive about the
course than they really felt. Many of the factors identified are also
relevant to therapists running training programmes for nurses,
teachers, nursery nurses etc. in this country (box 1- Practical impli
cations).
Although the training course was perceived to have been successful,
it has not been possible to verify this in the field. However, valuable
lessons have been learned in its planning and execution and
revealed inadequacies in current levels of knowledge in many areas.
It is the author's firm belief that, if expatriates continue to be used
in service developments in less developed countries, they should
take account of the factors mentioned and, if the communities of
such countries want service developments, there is an urgent need
for more data. Finally, it is becoming clearer that many of the
lessons learned from introducing services in less developed coun
tri es are applicable to training situations in this country. For tht'se to
be successful, many of the considerations outlined need to be inn'sti
gated further.
Julie Marshall is a ledurer in Speech Pathology at The University of
Manchester. Tel. 0161 275338913376, fax 0161 2753373, e-mail:
Julie.Marshall@man.ac.uk
Acknowledgements
Thanks to Jennifer Warner, my co-tutor on the course, for all her hard
work designing and teaching the course, writing the manual and
commenting on this paper.
Thanks also to Sally Hartley, Dorothy Jejfree, Kath Newton and Tara
Winterton for their contributions to the original course design and
ideas for the manual.
References
Buchner, D. (1994) Community-based rehabilitation: issues and
considerations for providing rehabilitation services in developing
countries. Internatio nal Journal of Special Education. 9 (2).
Hanley, S. (1995) The proportion of children with communication
disorders presenting to Community Development Assistants
(CDAs) in Eastern Uganda and the implications of this on service
delivery in less developed countries. In N. Kotby (ed.) , Proceedings
of the 23rd WOTld CongTess of The International Association of Logopedics
and Phoniatrics. Cairo, Egypt : Secreteriat of the XX111 World
Congress of the International Association of Logopedics and
Phoniatrics [IALPI , 11 El Ansary St., Manshiet El Bakry, ET- 11341 ,
Egypt.
Helander, E. (1993) Prejudice and dignity. An introduction to
Community Based Rehabilitation. New York: United Nations
Development Programme.
House, H. & Morris, J. (in press). Communication manual.
Geneva: WHO.
Marshall, /. (December 1992) Boundaries of duty. Bulletin of the
College of Speech and Language Therapists.
Marshall, /. & Warner, J. (eds.) (1996) An introduction to commu
nication disorders in children. Unpublished manual.
Miles, C. (1990) Special Education for mentally handicapped pupils
- a teaching manual, incorporating speech, language and communi
cation with the special child. Mental Health Centre, Peshawa r,
N.W. Fronti er Province, Pakistan .
.-
.
Miles, M. (1994) Special needs education and disability in Cross
cultural perspective: Pakistan. I n Peters, S.!., Education and
Qisability in Cross-cultural perspective. London: Garland.
Miles, M. (1996) Community, individual or information develop
ment? Dilemmas of concept and culture in South Asian disability
planning. Disability and Socie ty. 11 (4) .
Winterton, T. (1991) Communicating with children. Unpublished.
Available from Communication Therapy International , c/o 25
Hilbre Road, Burnage, Manchester, M19 2PU.
Wirz, S. (1995) Opportunities and responsibilities towards peopl e
with communication disabilities in less developed countries. Paper
presented at Golden Jubilee Conference of the Royal College of
Speech and Language Therapists, York, UK.
Wirz, S. &Winyard, S. (1993) Hearing and communication disorders.
A manual for CBR workers. London: Macmillan.
SPEECH & LANCUACE THERAPY IN PRACfICE AUTUMN 1997 21
ISSN (online) 2045-6174 www.speechmag.com
REVIEWS
LANGUAGE DEVELOPMENT
Professional looking and
user-friendly
Early Listening Skills
Diana Will iams
Winslow
ISBN 0 86388 142 4 32.45
If, I.ike myself, you work with young
childt'en, many of whom have lis
tening / attention problems, you
may come across the following sit
uations:
dated activity sheets that are
beginning to fade at vital points
hand drawn pictures - but you
can't remember what they were
supposed to be!
Well. fear not. 'Ear ly Listening
Skills' is a photocopiable resource
book designed to stimulate and
develop auditory attention / per
ceptual ski ll s. The book can be
used with pre-school children but
can also be adapted for older chil
dren or children with specific lan
guage / learning difficulties. Each
section incl udes ideas for thera
pists, teachers and parents with
easy to understand record sheets.
By photocopying the activity and
record sheets available, you can
access ideas quickly, yet still pro
duce something professional look
ing and user-friendly.
By simpl y placing a tick in relevant
boxes, sheets can be adapted for
the individual child's needs - no
more crossing out or waiting for
Tlppex to dry. Thi s way parents /
teachers know exactly what it is
you want them to do.
While using this resource I have
had positive feedback from both
parents / teachers as well as other
speech and language therapists. It
has enabled me to approach lis
tening work in a more organised
and systematic way and ensures
those wOt'king with the child all
know clearly what they are to do
a situation which can only
Improve quality of care.
The book has also proved to be
invaluabl e for speech and language
therapy assistants both as a clinical
tool and an intmduction to the
concept of listening and attention.
As a final comment the tough,
hard back cover of the book
should ensure it has a better
chance of surviving the attentions
of inquisitive three year olds. A
practical, well presented, competi
tively priced book.
Rebecca Jackson is a speech and
language therapist in Manchester.
INTERPERSONAL SKILLS
Positive, realistic and respectful
Acquiring Interpersonal Skills - A
Handbook of Experiential Learning
for Health Professionals
Philip Burnard
Chapman & Hall
ISBN 412 749602 {1499
This book is an expanded and revised edi
tion of Teaching Interpersonal Skills. The
aut hor has written extensively on com
munication, ethics, counselling, writing and
computing.
In an early chapter he gives a warning about
over simplifying personal relationships. They
are, he says,"complicated, and we should not
underestimate that complexity Quite apart
from people's behaviours and feelings in
relationships, we have, 'sitting behind' these,
people's motives and intentions. These are
much less visible and more difficult to study
or penetl'ate."
However, this is not a book to discourage
professionals from reconsidering their own
styles of relating to each other and their
patients or cl ients, but rather to promote
and encourage our skills.
The book is very well set out and conse
quently possible to study at different levels,
which I hope will make it much appreciated
by busy clinicians and managers in all health
professions. Under each chapter heading
are clearly listed points relating to the topic
being dlscussedThere are clear descriptions
of many aspects of behaviour and stimulat
ing and exercises for exploring
ones own responses to others, It is conse
quently possible to read the book thor
oughly, which is a pleasure, or to sample rel
evant chapters of subjects and quickly gain
new InSights and ideas. I found the recom
mendations positive, realistic and always
respectful of therapists and patients'/clients'
situations and feelings.
The practical nature of this book comes
from Phil ip Burnard's extensive resealu,
and knowledge of the background litera
tut'e. He includes a compreheOSNe bibli
ography where emri es considere<l as
'essential reading' are preceded an
asterisk, The author always appears mind
ful of the pressures of work and t he
scarceness of time in the current climate.
This book will enhance the practice of all
health professionals who read it, whether
teacher, cl inician or manager, at any stage
of their career:
I recommend it to speech and language
therapists, whatever your client group. Our
work with communication Impaired people
deserves the very best in interpersonal skills.
It is our duty to them to constantly monitor
and improve our skills. I have certainly learnt
from reading this book
Judith Beatt is PrinCipal Speech & Language
Therapist for Plymouth Community Trust's
Reablement Teams.
ANATOMY
A stable foundation
Anatomy and Physiology for Speech and
Language
Seikel, J.A. Kmg, DW & Drumright, D.G.
Singular
ISBN 1-56593-6/5-9 {47.50
This book is aimed at speech and language
pathology and audiology students. The text is
divided into four 'classic' areas: respiration,
phonation, articulation and the nervous system.
For each area there is a chapter covering the rel
evant anatomy preceding a chapter on the phys
Iology The text is supported by self tests at the
end of each chapter. software labs and a set of
seven video tapes which enable the study of
structures as seen in the cadaver: The video
tapes are purchased separately and are not
Included in this review.
The authors have succeeded in t he sections on
respiration, phonati on and articulation to "pro
vide a stable foundation" of knowledge and then
to build upon this with further detail.
Derivations of anatomical and technical terms
are provided which are often useful in grasping
an understanding of the material. The 'tours' of
the reader's own body also promote under
standing. As speech students have traditionally
relted . on books for students of other disciplines
the chnlcal notes are refreshing and stimulating.
Thi S Information helps the student to under
stand why the material they are learning is rele
vant. Throughout each chapter there are occa
sional summaries of the preceding material
diViding the text into manageable chunks. The
end of chapter tests are a useful way to assess
understanding of the area covered and could be
incorporated into a student's exam revision.
However, by trying to condense the anatomy
and phySiology of the nervous system into two
chapters the authors have provided little more
than an overview. Speech students using this
book will definitely have to do fut-ther supple
mentary readi ng here.
The software provide onl basi c learning.
The studen h access 0 'the t ext and cadav
ers will perhaps find these no more than a novel
way 0 understanding basic concepts. The
qUIzzes dunng each lab and at the end of each
section do no more than test the student's abil
to recall exact wording and spatial informa
tion about diagrams on a rather short-term
basis. An element of ambiguity means that with
out having worked through each lab the end
section quizzes cou ld not be used for revision
purposes.
The book is mainly restricted to students. It pro
vides knowledge of how speech systems work
and Introduces the subject of how t hings can go
wrong both developmentally and thro gh illness
and trauma. However, a further text for the
nervous system is required so the cost may
seem rather too high for some. Tne practi sing
clinICian may find thiS book useful for revision if
considering changing to an area of practice
requIring more detailed anatomi cal and phYSIO
logical knowledge.
Eugenie E. Booth is 0 student at the Deportment of
Speech, University of Newcastle.
22 SPEECH & lANCUACE THERAPY IN PRACnCE ALJllJMN 1997
ISSN (online) 2045-6174 www.speechmag.com
REVIEWS
DYSPHAGIA
Wider understanding
Deglutition and its Disorders
Eds. Adrienne Perlman and Konrad
Schulze-Delneu
Singular
ISBN 1-56593-62/-3 [49.95
This is an American book and at first
sight appears overwhelming and not
for the faint hearted - the publisher
describes it as "monumental".
However, upon closer acquaintance, it
is much less daunting. Each chapter
ends with a concise summary and
three multiple-choice questions
(answers at the back of the book),
which test understanding and consol
idate information.
The declared aim of the book is to
gather together the current knowl
edge about normal and abnormal
swallowing using Jargon-free language
to bridge gaps between the various
disciplines involved in the field of dys
phagia. In this it mainly succeeds.
Pemaps there is more detail in some
chapters than a Speech & Language
Therapist would strictl y need to
know eg Oesophageal Diseases,
Diseases of the Head and Neck, Tests
for Oesophageal Function. There IS a
good basic chapter on feeding and
swallowing disorders in children. The
only chapter dealing with therapy is
written by Jeri Logemann and is
therefore devoted to her techniques
and principles.
The text is clearly set out and easy to
read. It is computer generated which
can irritate w hen words are hyphen
ated between lines. In the main the
illustrations are helpful and clear but
the x-ray photographs could have
been lightened. There is a good
index, no footnotes to distract, com
prehensive references at the end of
each chapter to help with further
research and an excellent glossary.
This book would be of use to speech
& language therapists working with
dysphagia in an acute setting and will
be of interest to paediatric therapists
working with dysphagia and those
involved with laryngectomy and voice
disorders.
Bearing in mind our small and over
stretched budgets, it would probably
be sensible to borrow it from the
nearest medical library before decid
if1lg to spend the 49.95. Whether it
is on the department's shelves or in
the medical library. it would be a most
useful resource for immediate refer
ence and wider understanding, and a
background for management. It is not
a comprehensive guide to therapy
techniques.
Patri Cia M Mosdell IS ChIef Speech &
Language Therapi st at Derriford District
General Hospital in Plymouth.
HEARING IMPAIRMENT
A comprehensive reference point
Cochlear Implant Rehabilitation in
Children and Adults
Ed Dianne J. Allum
Whurr
ISBN I 897635 [4500 approx.
This book is the first to provide a global
non-device specific overview of service
delivery and rehabilitation strategies for
cochlear implant users. There are chapters
from 17 different clinics representing 4
continents, 12 different countries and 8
different languages. The number of
patients seen by these Teams totals
greater than 3800, or about 1/5 of current
implant users world-wide.
The book is divided into two parts. The
first outlines models for service delivery
and the way in which comprehensive
rehabilitation programmes can be devel
oped including medical, psycho-social,
educational and therapeutic support. The
second part looks at the different
approaches that can be applied to an
individual(s) undertaking a rehabilitation
programme. Thi s encompasses all aspects
from the pre-operati ve to post-operati ve
stages, including counselling, service net
works, adolescent users, auditory training
and bi-lingual environments.
There is a useful first chapter which
guides the reader through the 'Basics of
Cochlear Implant Systems'. It is an easy to
follow text which provides a reference
tool towards understanding the terminol
ogy that abounds in this field. The list of
authors and addresses of the contributing
clinics at the front of the book is an
opportunity for the reader to research
further by contacting those al ready
invol ved in that aspect of rehabilitation,
and to share ideas.
The book is a reference text and gives
reassurance that one's own approach is
on the 'right track' whilst offering plenty of
ideas to try a new approach or to imple
ment the same concept in a different way.
It is a text that is equally valuable to a
speech and language therapist wor king
on a Cochlear Implant Programme as to
one who is supporting an implanted per
son in the community setting. It is a text
that can al so be recommended to all pro
fessionals interested in the management
of deafness. The concepts included are
those that can be generalised for the
rehabilitation of all hearing impai red indi
viduals and not JUst the recipients of a
cochlear implant.
I recommend this book to clinician s, as its
coll aborative approach results in a com
prehensive reference point for t he reha
bilitation of individuals with cochlear
implants which can also be generalised to
the management of hearing impaired
individuals.
Suson Hamrouge is a senior speCIalist speech
and language therapist with dea people on
the Manchester Adult Cochlear Implant
Programme.
ARTICULATION
Useful introductory exercises
Articulation and Phonological
Disorders: A Book of Exercises
Ken M Bleile
Singular
ISBN 1-56593-688-4 [30.00
This is a second edition of the author's previous
book The Manual of Articulation and
Phonological Disorders (Bleile 1995). It is
designed as a workbook which can be used
as a whole, or individual chapters can be
explored independently. The book is divided
into five sections, each divided into 4-5 chap
terS.The chapter starts with a brief discussion
of its title eg "Developmental Age Norms"
followed by up to six exercises to help the
student explore the topic.
The first section introduces and explores the
concepts and terminology used in analysing
speech sounds. The second looks at speech
patterns that present during normal develop
ment, including a chapter on dialect. Section
three looks into the assessment and analysis
of disordered speech. Section four looks at
the principles of treatment and section five
describes some facilitative techniques. At the
end of the book are answers to all the exer
cises and some speech samples of children
with normal and with disordered speech
development.
Despite being titled "Articulation and
Phonological Disorders" the book purpose
fully avoids distinguishing between the two.
This is disappointing as it is an area many stu
dents wrestle with,The book concentrates on
the errors and the patterns of those errors.
There is a lack of emphasis on looking at sys
tems of contrast a child has already devel
oped. Minimal pairs are only given a couple of
paragraphs in Chapter 20, yet are the main
stay of phonological therapy.
The book is very 'American'. This means
some of the symbols are not familiar eg lat
eralised sand velopharyngeal fricative. The
chapter on dialect has very little relevance to
the British English market. While the philosophy
is indisputable, the details and exercises are of
little use. However, these American features
are a small part of the whole book.
Given the impact that phonology, as a means
of anal ysis and an approach to treatment, has
made over the last 15 - 20 years, this book
seems slightly regressive. The book does not
relate practice to theory, however, in its
defence , it is designed as a book of exercises,
not of cl inical theory.
This is an easy to follow book with a lot of
very useful exerci ses. It would be a good
introduction for students as an overview of
speech disorders and strategies for remedia
tion. I feel the impact of phonology on assess
ment and treat ment is not full y appreCiated.
On first reading, I found this bias rather irri
tating and a glaring omission. On re- reading, as
a book of exerci ses for students new to the
whole area of speech disorders, I felt more
positive about it
Cathenne Lander is a speech and language thera
pis[ at Glebefields Health Centre, TIpton. West
Midlands
SPEECH & LANCUACETH ERAPY IN PRACTICE AUTUMN 1997 23
ISSN (online) 2045-6174 www.speechmag.com
ASSESSMENT
An invaluable resource
Pocket Guide to Assessment in Speech
Language Pathology
MN Hegde
Singular
ISBN 1-56593-273-0 [ 27.50
The Pocket Guide t o Assessment is precisely the
kind of book I yearned for as a student, faced w ith
the daunting task of translating lectures-worth of
theory into a practical session with a real, live
patient. This neat. professional-l ooking soft-back vol
ume could have gone some way towards bridging
what seemed at times the yawning chasm between
theoretical knowledge and practice, and would cer
t ainly have provided a much-needed confidence
boost. Genuinely portabl e, the guide would be
equally at home in both the rucksack of the student
and the gleaming briefcase of the freshly-qualified ,
generali st therapist. I am sure, however, that the
more seasoned practitioner could also find some
useful memory-joggers contained within; I would
freely admit that my own knowledge of
' Ectrodactyly-Ectodermal Dysplasia-Clefting
Syndrome' was somewhat rusty!
The Pocket Guide tackles a broader remit than its
title suggest s. Its aim to "combine the most desirable
features of a specialised dictionary of terms, clinical
resource book, textbook and manual" is a huge task,
and although by and large laudably executed, a nar
rower focus on assessment procedures with the
omission of the dicti onary definitions might have
improved clarity. Organised in strict alphabeti cal
order; most major headings are t he names of either
communi cation or medical disorders, from Aphasia
through to Voice Disorders, with both adult and pae
diatric clients groups being well served. In addition,
other more general issues such as ethnocultural
considerations in assessment are manfully tackled.
Inevitably there will be gaps; my search for cognitive
neuropsychological and linguistic assessment methods
proved regrettably fruitless. The US bias, although
not an insurmountable problem, may account for
such omissions which could be disconcerting t o the
British audience; in other cases, the informati on may
be there but lurking under unfamiliar t erritory - for
learning difficulties, see 'mental retardation' for
example.
Certain areas, however; contain almost too much
information for a practical book which aims to
"specify... procedures in a 'do this' format"The section
on 'Standard/Common Assessment Procedures' is a
case in point: I was left pitying the student (and her
clients) who might come away with the impression
that it was mandatory to carry out. amongst other
things, a hearing screen and lengthy orofacial assess
ment in every si ngle case. Clearly these are areas
which could not have been ignored, but my concern
is that there is no cauti onary note against trundling
through every area in detail with each client, nor any
guidelines as to which of those listed might be most
pertinent for various disorders. This skill which
comes with experience is precisely what the book's
most obvious t arget audience is lacking.
Notwithstanding such criticisms, The Pocket Guide
remains an invaluable resource, which I only regret
was not available to smooth my own bumpy transition
into the world of clinical practice.
Michelle Grist is a speech and language therapist working
with children and adults at Mid Anglia Community Health
NHS Trust in Bury St Edmunds.
TREATMENT
Quick and easy reference
Pocket Guide to Treatment
MN Hegde
Singular
ISBN 1-56593-274-9 [2750
Thi s book has been produced alongside
another; "A Pocket Guide t o Assessment".
The two are linked in that, whatever disor
ders are covered in t he assessment manual
are followed through and di scussed in the
treatment volume.
The title certainly lives up to its name, in terms
of being compact and very easy to carry
around. The soft-back red cover with gold let
tering is very professional in appearance.
The contents of the book itself are laid out
like a dictionary, where disorders are labelled
alphabetically. I relished the opportunity to
gai n extra t herapy ideas around specifi C
t opics. I was pleasantl y surprised t o find a set
of general treatment principles and several
specific techniques outlined under the disorder
heading.
The writer is very honest in the descripti on
of treatment procedures, stating, in certain
instances, that there is no empirical evidence
on which to base the treatment This is an
interesting point in the climate of outcome
measures and clinicians becoming increasing
ly aware of efficacy of treatment
The book provides the clinician with t he
basic skeleton of treatment principles. It is not
a blow by blow account of how to do a ther
apy session. I found it an excellent first point
of reference. However; it only occasionally
cites any references where a clinician could
read a more det ai led account about a specif
ic treatment A bibliography would have been
very useful.
Whilst leafing through the disorders, I noticed
that the section on aphasia did not include
any information on cognitive neuropsychology
Instead, it focused only on the neo classical
categorisati on, eg Broca's / Wernicke's dys
phasia. I found th is disappoi nting as it would
have been intrigui ng to see what type of
treatment would have been suggested and t o
be able to relate theoretical knowledge to
everyday treatment sessions in thi s area.
I think the book would have been most useful
to me as a student or newly qualified thera
pist feeling very cagey about treating real-life
clients. However; as a generalist therapist
working in a community clinic with a mixed
caseload, the book cert ainly does not go
amiss. It is almost impossible t o have a men
tal treatment plan for almost any and every
client who walks through the door: It is at this
poi nt that the book comes into its own. It is
a quick, easy to read outline of the general
treatment a therapist might employ with a
client.
The book is an easy reference guide t o treat
ing disorders from Aphasia to Voice. It w ill be
well thumbed by therapists like me who see
a range of disorders on a dail y basis.
Keri Morrow is a community speech and language
therapist working with a mixed caseload (or Mid
Anglia NHS Trust In Sudbury
CEREBRAL PALSY
An introductory text
Cerebral Palsy: Problems
and Practice
Margaret Griffiths & Mary Clegg
Souvenir Press
ISBN 0285 6507 I 8 [8.99
Initial reacti ons to thi s entire
text were mixed, with phrases
such as "old-fash ioned",
"good basic information" and
"too much technical informa
tion" recurring throughout.
The book does highlight mul
tidisciplinary working, one of
the most important issues for
any parents or professional
working ith a child with
cerebral patsy However;
throughout the majority of
the chapters, the onl y therapy
mentioned is physiotherapy.
This book certainly holds a
one profession biased opinion.
A highlight was in chapter 8
w hi ch dealt with "After
School". This is often a long
term worry for many parents
of children with cerebral
palsy and the personal expe
riences written in the text
would be of benefit t o many
parents. The experiences of
young people with cerebral
palsy could offer hope and a
realisation that many children
do go on to lead independent
and sem i-independent lives.
Within these experiences, it
must be noted that the
majority come from intelli
gent and / or mild / moder
atel y affect ed individual s.
Could thi s raise expectat ions
t oo high for some parents)
It was difficult to deci de who
the text was aimed at as
there appeared to be t oo
much medical jargon, which
was not always explained, for
it to be of full use to any parents,
yet up-to-date detailed medical
information and terminology
was lacking for experienced
professionals.
Eventually. we decided that.
for newly-qualified profes
sionals, thi s text may well
offer an insight into cerebral
palsy and the difficult ies facing
children / adults and their
families. It cou ld act as an
introductory text t o the field
from which the reader cou ld
move on to more specific
works.
Gillian Steel IS speech and lan
guage therapist and Sandra-Dee
Ogilvie occupational therapist
With Grampian Heal thcare's
Kincardine & Deeside Child
Development Team.
24 SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 1997
ISSN (online) 2045-6174 www.speechmag.com
Howl
manage

vOice
Three speech and language therapists, given the
case history information opposite, set out their
management of Sheila.
Myra Lockhart is Chief speech ft language therapist
for adult services in Lanarkshire and the RCSLT West
of Scotland advisor on voice and laryngectomy.
Sarah Price is a senior speech ft language therapist
(ENT) at the Freeman Hospital, Newcastle upon Tyne.
Jayne Comins is a specialist speech and language
therapist with the Lewisham and the Royal Free
Hospitals, London.
Sheila
Sheila, a 66 year old
retired clealfer who
stopped smokin ei ht
months a a, is r fe ed at
her six m nth review
followin2 an operation to
remove Vocal flodules.
Althou2h the nodules
have nnt returned and
her vocal cords are only
mil!d oedematous, her
hus voice is no better,
sDea n2 needs a lot of
effort atYd she complains
of feeling a lump ir1 her
throat. Sfle to
consider sDeech and
therapy referral
fTrst seen.
When Sheila mentioned a
friend and two familv
members died recently
from cancer, the ENT
Consultant was at pains to
reassure her. The
Consultant notes that
Sheila, divorced for ten
years, talks a lot about
her dIfficult relationship
with her witvward
wno stc}vs
nearby. She also Ifas a
son arid his family in
Australia. Most ofher
time is spent at home but
she goeS to Bingo twice a
weeR.
SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 1997 25
ISSN (online) 2045-6174 www.speechmag.com
---
HOWl.
so she feels free to make current choic
Myra Lockhart builds an
es regarding her vocal rehabilit.lIion.
individualised programme
We must not assume that she refused
because of lack of interest, as it may
on a foundation of
have been for many reasons from
objective measures.
ignorance to fear. It may also be nec
~
, , \ i , ; ;1 ; ~ Over some years now, I have been
~ : , , , ~ , ; . ~ - - - interested in using objective mea
sures to help demonstrate efficacy of therapy
with the rationale that these measurements provide
valuable information for planning therapy and
monitoring progress. However, this does not deny
the need for subjective assessments and must be
seen as part of a package or care plan which is spe
cific to each patient.
If Sheila was referred to a therapist in our area, this
would be the general package offered:
1.a full case history.
2.a subjective voice assessment using whatever for
mat or questionnaires are preferred.
3. a computer-assisted assessment (CAA) by one of
the voice specialists, covering 21 parameters of res
piration and phonation (approx. 30 minutes).
4. possible attendance at the voice clinic for
videostroboscopy (specialist therapist and an ENT
Consultant).
5.a combined report on the objective assessment and
videostroboscopy, sent to the patient's therapist, GP
and ENT Consultant. This gives recommendations for
targets of therapy, ie. the parameters most disordered,
and suggests the future management of the patient in
terms of timescale and review appointments.
6. time for explanation and discussion with Sheila
during all of the above, so she is in an informed posi
tion regarding the options for vocal rehabilitation.
7. re-assessment (CAA) at between 6-10 weeks and
an updated report sent to encourage further
progress and focus therapy on any remaining target
parameters.
The initial interview with Sheila gives the opportuni
ty to begin to relate to her, not just to give or gain
factual detail but to observe and form impressions
of her attitudes, tensions, motivation, and to assess
posture, articulation, resonance, prosody, respiration
and phonation. Generally my style of interviewing
would be conversational, gleaning the information
by focusing on certain topics, and reflecting back to
Sheila the relevance of what she is telling me.
Similarly, it is often helpful to refer to aspects of the
proposed CAA and videostroboscopy which may
clarify our understanding of cause and effect and
the likely resolution of the disorder. Towards the
end of the intelview, I would usualJy summarise her
description and history and outline my perception
of her voice production, possible contributing fac
tors and possible options for therapy. By spending
this time initiaUy, Sheila should then approach the
remaining assessment procedures with some under
.standing of their relevance.
In Sheila's history there are keys issues of:
her underlying motivation
general levels of SlIess, anxiety, and tension
her general health
the disturbance to respiration and phonation
parameters
her understanding of her disorder and awareness
of the possible solutions.
However, there are gaps in what we know.
We do know she was reluctant, at least at one time, to
be referred for therapy and it would be important to
identify the cause of this and to address it if possible
26 SPEECH & lANGUAGE THERAPY IN PRACTICE AIITUMN 1997
essary to reassure her by discussing the
discomfort and effort she experiences in voice usage.
possible causative faoors, treatment and therapy to
resolve these.
We have little information on her voice history and
patterns of voice loss, general heah.h 3l1d reaaions
to stress and it would be important to know more
about all of these. There is insuffident spaCe in this
article to detail all the possible influen es on respi
ration and phonation of health problems and/or
medication, but suffice it to say it is crucial to know
this to piece together the jigsa\\' of contributi ng fac
tors, some of which may be very physical ego gamo
oesophageal rellux or the use of inhaled teroids.
Although we ha\-e indiCollion that she. frels anxious
and stresse.d, has she ever uffered lTom any symp
toms of stress or anxie . and.
if so, how were they treated,
Finally, although she seems J
rather solitary person with
few social contacts apan from
bingo, her lifestyle may ha\
altered substantially ovcr t
years with divorce, family
breakdown and reti rement
and may not currently refl
her past behaviour vocally r
socially. This alone could be
an important area of streSS r
tension for her.
There are probably st?\ rol l
options for Sheila's rehdbill
talion. from
advice alone and review
appointments
conventional therapy, focus
ing on target pardmeters,
through to
Further reading
lockhart, M.S., Paton, F.
and Pearson, L. 0 997)
Targets and timescales: a
stUdy of dysphonia using
objective assessment.
Logopedics, Phoniatrics and
Vocology 22 (1).
Gordon, M.T. artd lockhart,
M5. Efficacy of speech and
language therapy for
dysphonia
and
lockhart, M.S., Paton. F.
and Pearson. L. Identifying
parameters of improve
ment in voice disorders
using objective measure
ment techniques in (1996)
Proceedings of the Golden
Jubilee Conference. RCSlT.
Fi gure I
counselling or dealing with her anxiety.
My own suggestion to her would be for a combina
tion, beginning with attendance al d StresS reduaion
group which I have run a number of times. This
would usually involve some informal teaching on
stress. its effects generally and on the voice, easily
understood handouts with personal targets. group
discussion, relaxation and voice produaion exercises.
The relaxation would lead illlo targeting parameters
of breathing and voice speci fic to each patient. I feel
this would address many of heila's apparent diffi
culties in a package suited to her, as she might well
benefit from the support of others in the group.
In summarising my approach, it is probably accu
rate to say I am fairly trongly in favour of a foun
dation of objective measurement (see Figure 1),
but that we then need to use everything at our fin
ger tips to build the programme that is tailored to
the individual patient whether it iJwolves certain
methods of approach such as the Accent method,
targeting parameters, stre s reduction groups, or any
combination of these. The care plan is unique to that
patient and can be monitored for its clinical effective
ness through the objective assessments and altered
or terminated when appropriate. The efficacy of
therapy is then clearly demonstrated to all con
cerned - the therapist, GP, Con uJtant and, most
importantly, the patient.
Sarah Price
believes
motivation is
the
crucial
factor
for this
client.
Sheila was
initially reluc
tant to attend
for a speech
and language therapy
assessment - the first consulta
tion is therefore crucial to
encourage motiva
tion. Sheila may
also need careful
explanations of my
role and how I may
be able to help her
improve her voice
quality. She proba
bly already has
some ideas about
speech and lan
guage therapy, pos
sibly confusing us
with elocution
teachers and these
ideas may have
influenced her origi
nal refusal. It
would be important
to discover Sheila's
expectations and
preconceptions and
I would envisage spending quite
a substantial amount of time
discussing these during the first
session.
When discussing Sheila's dys
phonia I would use her termi
nology in an attempt to put her
at ease. For example, Sheila may
refer to her voice quality as
"husky" or "rusty" so 1 would
use these words in my questions
and e>..-planations. 1 would start
by asking Sheila to tell me what
the ENT consultant had said.
This would give me an indica
tion of her understanding of her
dysphonia and its possible
causes.
During this information gather
ing I would be beginning to get
a feel for the level of Sheila 's
motivation to change. I would
stress the imponance of a com
mitment to regular therapy as
well as the need for Sheila to be
prepared to follow advice and
do voice exercises at home, if
appropriate. She would require
ISSN (online) 2045-6174 www.speechmag.com
the start of a programme of insight into her dysphonia
vocal hygiene. A printed list of and why the exercises are
"Do's and Dont's" would include imponant. I hope I would
"Drink plenty of fluids",. "Don't be able to encourage this.
She would need to learn
that speech and language
therapy is not prescriptive and that [ am not going to 'cure' the voice
problem by giving tablets or waving a magic wand. Sheila would be
required to take a vel)' active role in her ueatment.
A patient's motivation / insight - or lack of it - is crucial to my criteria
of prioritising for treatment.
Having established ground rules
of expectations and motivation I
lem directly to voice use or may
feel family stresses have played a
pan. The fact that one of Sheila's
friends and two family members
died recently from cancer may have caused an increased level of anxi
ety. She may have feared she herself had cancer, panicularly since,
until recently, she had a history of smoking. Sheila may also still be
going through the grieving process after the loss of these people.
It may emerge that counselling would be appropriate for Sheila along
side a course of therapy. Sheila has had many suessful events through
out her life. Some of these may have contributed towards excessive
muscle tension in the laryngeal area which could result in the feeling
of a lump in the throat as well as the dysphonia. Sheila mayor may
not choose to discuss these life events during therapy. I would, of
course, allow Sheila to set the pace of this discussion and be careful not
to make her feel too uncomfonable. In my experience, voice patients
tend to introduce the topic of stress and anxiety in later sessions once
a rappon has been more firmly established. The clinician needs to be
flexible enough to adapt his / her style of interviewing and indeed
treatment to fit all personality types.
Voice assessment begins the moment Sheila walks in. I would observe
her posture (standing and sitting) and breathing (at rest as well as dur
ing speech). I would notice specifically the jaw, neck, shoulders, chest,
diaphragm, general sitting position and any tension in the hands
(clenched fists). Tension in any of these areas can be addressed in
relaxa tion exercises.
The voice itself could be assessed using a number of different tools.
We use a seven point rating scale at Freeman Hospital, including:
Voice stability 234 5 6 7
Breathiness 234 5 6 7
Other areas rated are overall severity, harshness, tension, pitch level,
pitch range, loudness, resonance, diplophonia, pitch breaks, hard glot
tal attack and breath suppon. This is a useful screen to do before and
after treatment. I would also use Pam Enderby's WHO Outcome
Measures.
I am lucky to have access to instrumentation and could use the laryn
gograph and / or fibreoptic nasendoscopy to assess voice quality fur
ther. These methods may also be useful in giving Sheila visual feedback
as pan of my explanation and as a baseline for treatment.
Having assessed voice quality and taken a tape recording of her voice,
I would explain the results of the assessments. A repon would be sent
immediately to the ENT Consultant and GP.
During the first session I would give Sheila general voice care advice as
smoke", "Avoid talking above background
nOise. I would also give simple exercises to practise at home, ego relax
ation, neck and shoulder stretches, breath control or direct voice work.
These would be given in written form after I had demonstrated the exer
cises and we had gone through them together.
At the end of the session I would give Sheila a diary to take home and
would begin an informal case
Sample question from A Questionnaire
history. Much information can
of Vocal Performance, Paul N. Carding,
be gleaned from medical notes,
Freeman Hospital.
referral letters and fibreoptic
nasendoscopy results but r would
also ask questions relating to
"How much do you worry about your
Sheila's voice use, hobbies, social
voice problem?"
life, family life, smoking, drink
ing, anxiety / suess and medical a. Not at all
history.
b. Hardly at all
The answers are like pieces of a
jigsaw, some of which may fit
c. Quite a lot
together to make a clearer picture.
d. A good deal
Sheila may relate her voice prob
e. Almost all of the time.
(:igU1T 2
explain how useful this will be to
us both to establish the pattern of
her voice use and dysphonia over
one week. Attached to it is a brief
voice questionnaire (figure 2)
which is easy and quick to com
plete and again gives a clearer pic
ture of Sheila's dysphonia and
how she feels about it. The ques
tionnaire and diary also act as
indicators of Sheila's motivation;
she mayor may not bring them
back. completed, to the next ses
sion.
I would generally offer 6-10
weekly sessions of voice therapy
to someone like Sheila but this
would be flexible to fit around
her other commitments. Sheila's
case seems fairly typical of a lot of
the voice patients I see and I am
confident that, if motivated enough to attend regularly and carry out
her exercises and voice care, Sheila's voice quality would improve.
ATTENTION-DEFICIT / HYPERACTIVITY
DISORDER (ADIHD)
An Intensive Training Day for Health and Education
Professionals
Speaker: Jenny Lyon, Chartered Educational Psychologist
(100 plus VAT, including course pack / text book,
refreshments and buffet lunch)
University of Stirling - 4th September, 1997
Birmingham - 6th October
University of Manchester - 7th November
Charing Cross Medical School, London - (5th December)
Napier University, Edinburgh - 6th February 1998
In addition, there will be a Medical AD/HD Training Day
at Regent's College, London on 22nd September 1997
Speakers will include Dr Veira Bailey (Consultant Child
Psychiatrist), Dr Deborah Christie (Principal Clinical Psychologist,
Great Ormond Street Hospital), Prof. Philip Graham (Chair,
National Children's Bureau), Prof. Peter HilJ (Professor of Child
and Adolescent Psychiatry, St. George's Hospital Medical School)
We are pleased to announce ADfHD'98, a four-day residential
conference at the University of Cambridge, 6th - 9th April, 1998.
Papers, symposia and posters are invited.
A list of audio/video recordings from ADfHD'97 (held at University of
Oxford, 7th - 9th April, 1997), is now available on request, together
with the official conference publication.
Further details are available from Remy Marckus
IPS (International Psychology Services)
17 High Street, Hurstpierpoint, West Sussex BN6 9SL
Telephone 01273 835533 Facsimile 01273 833250
SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 1997 27
ISSN (online) 2045-6174 www.speechmag.com
Jayne Comins
seeks to
activate the
'doctor'
in the
patient.
I draw on several
professional
trainings in
;;:'"OSp"AL voice work,
developed over Tl'us:
, the last twenty
.. . I "'" years: speech
--- , ;. and language
therapy, psy
chology,
psychother
apy, massage and my
singing training.
What strikes me about Sheila is
how late she has got to ENTwith
her nodules. Nodules in a
woman of this age are less com
mon than some other voice
pathologies. This would not have
been a referral from any of the
ENT teams I work for, as all
patients are expected to have pre
operative voice assessment,
advice and counselling. Most
will take up the offer of therapy
to see whether the nodules
shrink, or whether any laryngeal
tension which may be exacerbat
ing the dysphoni a goes away
with therapy. I find that general
ly patients are much more likely
to pursue a course of therapy for
nodules if they are seen pre-oper-
Practical points
1. Pre-operative voice assessment,
advice and counselling allows the
relevance of voice therapy to be
established and may mal<e clients more
likely to pursue a course of therapy.
2. It is important to find out, without
making any assumptions, why someone
may refuse treatment, and to address
this.
3. Time spent initially in discussion with
a client is crucial in establishing
perceptions and motivation. It also
ensures they will understand the
relevance of assessment procedures.
4. To be effective, packages of care
must be individualised depending on
contributing factors and the wisfies of
the client. symptomatic and / or
counselling approach may be chosen. A
gtoup may provide support.
5. Assessments can be objective and
Questionnaires and a voice
(:Jiary can provide further useful
information.
6. Clients must take an active role in their
management. Methods include using
their terminology and enabling them to
decide why theyl1ave the difficulty and
what they could do about it.
7. Efficacy must be demonstrated
clearly to the therapist, GP, Consultant
and most of all the client.
I have a problem and nothing
can be done about it
I have a problem; whai are you
going to do about it?
I have a problem; what can I do
about it?
Sheila may well be experiencing
some anxieties about oncoming
old age, and may have constrict
ed her voice in response to a
number of stressful life events, It
sounds from the referral that she
is a sociable person but does not
have anyone particul arly close
with whom she shares problems,
At the first session, I would try to
establish a diagnosis and possi
ble causes of her dysphonia,
Evidence from her case history
and from the medi cal referral
will guide me on this, If she
seems ready, and it feels appro
priate, I would briefly explain
how the voice works, how diffi
cult feelings can tighten muscles
in the throat and elsewhere, and
how a voice disorder can cause
people to feel anxious, I always
say there is no one cause to a
voice problem, and that therapy
is about understanding the dif
ferent ingredients that go into
the disorder. The bala nce of the
ingredients differs with each
patient.
I like Andrews and House's work
on 'Conflict over speaking out',
While they found this to be a
problem for women with func
tional dysphonia, [ think it is
common to most voice disorders
in that there are dift1culties and
frus trati ons about self-expres
sion and being vocal.
atively, as the relevance of voice therapy can be established.
Smoking, add reflux and the side-effects of some medications can con
tribute to mild oedema as well as voice use. The psychotherapy side of
me wants to understand why someone needs to inhale from a ciga
rette, why they may feel they are 'boiling up' inside and what the ill
nesses that require medication are all about. A lot of illnesses are psy
chosomatic, and it can be a breakthrough for patients to make a con
nection between their laryngeal state and their emotional condition.
However, it can be cruel to insist on a psychological explanation when
a patient does not view their problems as being rooted in their psyche.
If you think about it, these patients would be seeing counsellors and
psychotherapists about their voice if they thought the cause was psy
chological.
Whilst I have used instrumentation in therapy and research projects, I
do think that the Vocal Profile Analysis is an excellent auditory-per
ceptual rating scale. VPA training sharpens our listening skills and
helps with planning therapy. You can get good 'before' and 'after' rat
ings, and it is non-invasive,
I would let Sheila form her own ideas about why she might have got
the nodules, By encouraging her to take an active role in therapy, we
would have a more successful therapeutic alliance, I believe there is a
'doctor-patient' in all of us, and the role of the therapist is to activate
the 'doctor' part of the patients, Likewise we as therapists need to acti
vate the 'patient' part in ourselves to understand the patient's problems.
The initial interview helps me to decide which, if any, of the following cat
egories the patient's attitude falls into:
I would give - hei la informati.on on oice care and go over any ques
tions she might still have about her diagnosis, In addition, I would
offer her the choice of \\'orki ng on releasing laryngeal
constriction and bod\' tension generally, or a counselling approach if
it became apparent that she had a greater need to talk out her prob
lems with her voice. Sometimes, neither the patient or [ know at the
first visit which would be the better approach, in which case I suggest
we meet again to se.e whether the first session has been helpful, and to
review progress. Often, when patients have time to think through their
first visit, a lot can happen. Either they may gain useful insights, or
they might 'fly into health' by suddenly getting better, to avoid having
to take part in their recovery process. This is an unconscious process,
and can lead the therapist to think they have got better when there
actually has not been any change.
My report-writing is based on 'Communicating Quality', and I would
follow up Sheila's progress in ENT or the voice cliIlic. I write down our
goals on a management plan, and evaluate progress at the end of a
course of therapy. I do a qualitative outcome measure form, and I also
rate patients on the VPA before and after treatment, In one trust r work
for, we do a symptom change wheel before and after treatment.
Sheila might need anything from four to twelve sessions to work on
her vocal nodules. Patients with long-standing voice problems may
require longer, and 1rarely treat patients for more than a year. The deci
sion for discharge is by mutual agreement with the patient. Obviously,
the aim is to reduce Sheila's oedema and to enable her to use a com
fortable voice that she is happy with.
28 SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 1997
ISSN (online) 2045-6174 www.speechmag.com
EVENTS
16 October
UK SIC in Cerebral Palsy Study
Day - Visuallmpainnent a
Cerebral Palsy
Speakers: Prof. Alislnir ReIder:
Assessment and Management of
VI; Dr John Wann: Eye Movements,
Cerebral Palsy and Co-ordination;
April Winstock: Feeding and VISUal
Impairment; Helen Hendrickson,
Mike MdJnden: Communication
and VI; Laura Pease: Teaching
O1ildren with Cortical Blindness.
Venue: Chartered Society of
Physiotherapy, 14 Bedford Row,
LONDON WCl R 4ED
Details: R Bacon (SIG in CP)
m81 -531 3426
University of East AngIia
PosIgtaduate Courses
fr70ct0ber
Emotional and Behavioural
Disorders in Language
bnpaired Children
Tutor: Kate Malcomess, Speech &
Language Therapist Fee: 95
17-18 November
Communication Disorders
Assodated with Child Abuse
Presentationsfrom a variety of
professions. Fee: 95
24-25 November
Understanding ChaDenging
and Violent Behaviour
Tutor: wdlle Bennett, Training
Consultant, BILD Fee: 95
1-2 December
Evaluation and Treatment of
Oral Feeding Disorders in the
NICU and After Discharge
Course designedjar therapists,
nurses and otherprofessionals in
neonatal intensivecare.
Tutor: Marjorie Meyer-Palmer,
Speech Pathologist and Oral
Feeding Specialist Fee: 175
15 or 16 December
Ward Infant Language
Screening Test: Assessment
Acceleration and Remediation
(WIlSfAAR)
Tutors: Sally Ward and Deirdre
Birkett Fee: 75
January
Aphasia Therapy - A State of
the Art
Tutors: various Fee: 95
February
The Udcombe Programme of
Earty Stuttering Intervention
5days -details on request
9-10 March
Communication in Children
with a Severe\IisuaI bnpaflnent
Tutor: Ian Bell Fee: 95
Venue: University of East Anglia,
Norwich. Details: Sally Wynne,
Course Co-ordinator, Continuing
Vocational Education Office, The
Registry, University of East Anglia,
FREEPOST, Norwich NR4 7BR
... . - , " , ... . .. . .
ISSN (online) 2045-6174 www.speechmag.com
Nom
6 ore assessme
D My well nts. so m
raWlngslll1 thumbed yother five ch .
Not a lot UStrarions 0 ' . Makaton y,0l ces are'
I do nor abo
u
; developed Book
language boo bOther too ept It is an es y Margaret W: of line
and get u k. symbol bo mU ch with th sentlal refere alker in 1980
sed Occasionally ok) - they are 0 e Makaton bOok for me'
. n my shelves 'pmem (pictures:
7 \s a boOk I have only had for about a year. Obi
ects
of Reference by Adam
ockelford. published by the Royal National Institute for the Blind. It only
cost 5.95 and for my work with some clients it is invaluable. It was origi
nally developed for visually impaired children who have learning disabilities
but its use has wider implications. The book is concerned with symboliC rep
"From an early age the maiority of children come to accept that people. resentation:
activities and the things that surround them in everyday life can be repre
sented symboliCally in a number of different ways through photographs.
paintings and drawings. through spoken language and later on the written
word. For some youngsters. however. this aspect of learning. whose prelimi
nary stages most of us grasp intuitively and take quite for granted may have
_
:-_-:___ One teaching methOd in which
M
--.:: obi"" ,re ",;,,,d ",dlk m""..... I'
b
18 t in this booklet" (Ockelford.
es U
Obiects of Reference is only a 30 page
es
book with lots of illustrations and ideas. I
have lent it out to care staff to read in res
1 ------ idential I day care establishments so they
can fully understand the approach before
the teaching method is intrOduced to some
of their clients. As a teaching method I have
- G))
SOUTH DUR H AM --
H NH S fRlI
f! a lthco n ' in I 1 -' ...c)ca ( o mm u ll l t. I O
Carole Charters is as " '
& Language Thera Speech
Durham NHS T Plst With South
rust, Commun'
Learning Disabilities. ,tyTeam
M . b
J am am b YJO
em er of a mult'd ' ,
working with adul ts h I Is n plinary tea m
ability. Over th e p w a have a leaming dis-
C ast seven ye '
ommullity Team Le . .ars wllh the
llature of my job ha a;;lng Dlsabilities, the
do very little "h d s c anged a great deal J
an s on" k .
more consultative . war and now offer a
ing to have very SeTVlce. My clients are tend
complex needs d -
great deal of my in volvem , indeed, a
found it very successful.
clients is as join t' ent Wlth carers and
5 Sorry.I Thl's Bella . mpllt with the team
Vlour Nurse Th '
"""m, " ,'''' , " h" nn< b"n difF'
Scheme) nb
t
D l S (DerbyCsOhm"rPerehenSion could not do with1 ICU t to select 10 items J
K
Y M
l
out 111 everyd
now'" .' M";d' >og"'g' ""''' ,rom 'h' or " " ",, "
errors.
..; >nd W 8"" deo' of'" ,mm' P''''''' """ , 1 '''' '
0
fum (. e oped as . It Was . ' cliellt programm y eqUIpment for individual
or an ESN parr of th ong es /l eeds to be h
b
,om, """"" (S) "hoo' " 'u";'u ,m'M'",d fnc 'h . ,m,-mod, " UJ
'cau,. '001 00, ,bou, d,d h", ' """w'" ";'n'.
the Pictu y use select C udlng it 10 --------- -
tarts of It _ top , 1
0
resourc
With adults. erefore a lot of mOSt excellent Rapid Screenin purely
there was a It Would be the content scheme. it is fog est and
oafs could ; adult versio Wonderful if not approp ' r children
but an so be adapte; and likeWise if t S Co uld be for Use
,'".'" WOClhWhi
h
" ,,"u'd b. ;'.<wo "'" ,,,;nd'd '0
_____.:. g-t- 's _ If so pI I e one. Mayb time consumin 109 man
_____ e-ase let me k e somewher g exerCise
now. e someone is
10 Last but not least. a human
choice my assistant!
I have had a full time assistant for tWO years noW and could not
manage without one. She does so much of the liaison work for
me between variouS residential/day care establishments and
with carers/families. She holds her own small caselo
ad
of clientS
which I oversee and assists in facilitating group work with
clients (eg- on social skills) . A large part of her lob also InvolveS
making equipment for me. for example taking personalised pho
tograPhs for client programmes. Without her I could not
attempt to meet the needs of my growing caseload.
ISSN (online) 2045-6174 www.speechmag.com