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Research that had its compensations
DO INTERACTIVE MULTI-MEDIA DEVICES HAVE A PLACE IN THE SPEECH AND LANGUAGE THERAPY TOOLBOX? TO FIND OUT, HANNAH KAY RESEARCHED THE IMPACT OF CLICKER® 4 ON THE EXPRESSIVE LANGUAGE SKILLS OF CHILDREN WITH EPILEPSY AND LEARNING AND COMMUNICATION NEEDS. WHILE NO EFFECTS OF THE TREATMENT WERE SHOWN, HER EXPERIENCE SUGGESTS SUCH TOOLS CAN HELP CHILDREN COMPENSATE FOR THEIR DIFFICULTIES.
echnology has created opportunities for greater access across the national curriculum, particularly for those with special educational needs (Stevens, 2004), and the government is clear that Information and Communication Technology (ICT) should be a significant part of every child’s experience of learning (DfES, 2003). It is therefore important that speech and language therapists take advantage of the opportunities of ICT, and can offer appropriate advice on its use with our clients. ICT enables educators to combine speech, pictures, words and animation in a flexible, interactive and dynamic format, so concepts are structured in a way that suits the learner’s level of understanding (Blamires, 1999). For those with learning difficulties, appropriately selected technology is likely to provide more control over the learning process, increase opportunities for practice and be more suited to individual learning styles and needs. Anecdotal evidence suggests that the majority of school aged children have been exposed to interactive television, gaming devices, computers and mobile phones, and are confident in using and generalising these skills. Classroom computers are favoured during ‘reward’ time, suggesting technology is motivating to children and may be better able to maintain their attention and concentration for longer periods of time. In my research I used a multi-media tool, Clicker® 4, with children with epilepsy, learning and communication difficulties. I was aiming to find out if controlled practice using a visually based intervention programme resulted in skill development in spoken language (clause and sentence structure). The 10 secondary school aged participants attend The National Centre for Young People with Epilepsy, which is the UK’s major provider of specialist services for children and young people with complex epilepsy. Epilepsy is the second most common neurological condition to migraine and may cause, or co-exist with, a number of language, speech or communication impairments. Characterised by transitory but recurrent disturbance of the electrical activity of the brain (Lebrun & Fabbro, 2002), there are many types of epilepsy and seizures. Children with epilepsy frequently underachieve at school, and 50 per cent achieve less than would be predicted from their IQ (Epilepsy Task Force, 1999). More than one in five people with epilepsy have a learning or intellectual disability (Sander, 2004). Educators and therapists need to consider the specific learning and language impairments associated with an individual’s epilepsy and seizure activity. Cognitive impairment is frequently seen in children with epilepsy. At least 20 per
Figure 1 Clicker Grids

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cent of patients with epilepsy present with features of Attention Deficit Hyperactivity Disorder (Gucuyener et al., 2003) compared to the general population, where the prevalence is reported to be approximately 5 per cent (Dunn et al., 2003). Memory function and its potential impact on academic achievement are vital considerations when managing children with epilepsy (Nolan et al., 2004) and, as such, careful consideration needs to be given to individual learning styles and therapeutic approaches. This group may also present with adverse side effects from their anti-epileptic medications, which can include motor slowing, ataxia, dysarthria, hypotonia, word finding problems, increased levels of activity, attention difficulties, memory impairment, poor concentration, delayed speed of processing and fatigue.

Context and structure
For many children with epilepsy a visual approach to learning is essential - particularly in terms of teaching key skills such as speaking and listening. While learners with learning disabilities and sensory impairments often benefit from a kinaesthetic / hands-on approach to learning, not all academic skills can easily be taught in this way. The advantage of a visual approach is that strategies adopted remain ‘static’, allowing the learner with processing difficulties to understand and internalise the information at a pace which best suits them. Visually presented information allows for revision, and can provide a context and a structure to a child with poor or variable attention. I used colour coding as a way of visually supporting language development in my therapy. The idea was driven from established schemes such as ‘Language Through Reading’ and work described by Bryan (1997) called ‘colourful semantics’. I used a colour code based on the modified Fitzgerald Key, which forms the basis of the system used by commercially written language programmes and software such as Clicker. While different colour coding systems have evolved, I have found that it is the consistency for the individual or education setting which is important. Clicker 4 is a powerful multi-media tool that enables children to write with whole words, phrases or pictures. A talking word processor, you can type into it directly using the keyboard, or by clicking the mouse on items such as words or pictures which are presented within the Grid. It comes with high-quality speech software so learners can hear words before they ‘write’. It includes a large picture library plus the option of using your own

pictures, enabling written words to be supported with an additional visual aid (see figure 1). For my study, I developed a resource of 36 individual Clicker Grids presenting vocabulary needed to describe each of the 36 ColorCards® selected from the Familiar Verbs pack (Speechmark, 2004) to promote the use of the relative, coordinate and subordinate clause and to stimulate the subject to provide information about every possible aspect of the picture presented. If spontaneously generated by subjects, it was also possible to insert additional vocabulary during the session. Vocabulary was supported by symbols or photographs where possible. I selected symbols from the traditional Clicker library, Mayer Johnson’s PCS set and Clicker animations add-on library. Clicker animations allow moving pictures to be inserted into the grid. The animation provides additional visual cues and further supports the meaning of action words and the correct use of the present participle.

Colour coded
I colour coded each cell to support the selection of appropriate vocabulary and sequence, and presented a basic visual key using prompt cards prior to each training item, to remind subjects of a possible word order and the questions that may need to be answered when describing the ColorCard®. Subjects were also shown cards of sentence starters, ‘little’ words and the common auxiliary verb (is) required for the planning frame being developed. The card system was used to facilitate independent use of the Clicker grids on the screen (figure 2, p.26). The cards also prompted the subjects to find the appropriate content word from the grid.
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2006

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Figure 2 Prompt cards

Figure 4 Change in two subjects (Renfrew, 1997)

Subjects were reminded as necessary that the answer to the question would be found by looking for a button of the same colour from the grid. At this point, if more than one option was available and the subjects were still unsure of the word they wanted to select, they were encouraged to look at the symbol and / or ‘right click’ on the mouse to receive an auditory cue. The basic colour coding system used is in figure 3.
Figure 3 Colour Coding System Colour Yellow Red Green Blue Tan Referent People/animals Noun Verb Adjectives Prepositions Question Who? What? Doing? What is it like? Where is it?

Item 3 Prompt question: What HAS been done to the dog? Subject 3 5 Before Therapy Tied up (1,1) Tied on a string (2,1) After Therapy He put on the dog (0,0) He’s been tied on wood (2,5)

Item 5 Prompt question: What has the cat just done? Subject 3 5 Before Therapy Got some rats (1,3) Catching mice (2,2) After Therapy He’s caught the mice (2,4) Catching the mouses (2,1)

Item 6 Prompt question : What has happened to the girl? Subject 3 5 Before Therapy Fallen over the stairs and she’s broken her glass (4,5) Broken glasses (2,0) After Therapy She’s fallen down the stairs and broken her glasses (5,6) She fell down the stairs and hurt her glasses (4,1)

Item 10 Prompt question: Now, look at this picture (Take your time!) Tell me what is happening. Subject Before Therapy Lady’s dropping her apples and the boy is picking them up (5,4) Lady dropping fruit (3,1) After Therapy The woman is… the apples are all falling out of the bag and the boy’s picking them up (6,5) The lady dropped her apples inside the hole..boy’s picking them up (6,2) 3

At the beginning of the intervention all subjects were tested on the Renfrew Action Picture Test (Renfrew, 1995) and ColorCards® training items. Subjects from both groups were tested in the same weeks to account for variables such as maturation. Half of the sample population were randomly selected and placed into the experimental group. The experimental group were seen during the first block of intervention, while the remaining subjects were the control group and received intervention during stage two. Intervention was 12 individual sessions, twice a week for a period of six weeks (one half term).

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Prompts
Individual sessions involved 3-4 pre-planned tasks using Clicker 4. Subjects were presented with ColorCards® and a question, and asked to generate a visual response (words with keyword symbolisation), using the Clicker Grid. Support and prompts were provided to promote language and sentence building as needed. Subjects were taught to activate auditory feedback after each sentence had been completed and then asked to generate a verbal response based on the sentence they had formulated, using the grid as a prompt. Following the completion of intervention by the experimental group, all subjects were re-tested. The control group were then seen in the same way. All subjects were again re-tested, and training items and assessment record sheets from the each stage of the intervention were scored. Unfortunately, an effect of treatment was not shown. There are many possible reasons for this, including:

1. The therapy was not effective. 2. The timescale was too short and / or the amount of therapy too little for it to be effective. 3. The assessment tools were not sensitive enough to change, particularly in those who were already achieving scores approaching ceiling level. It would have been useful to assess more functional situations such as sharing of weekend news with staff and peers, and to question parents and staff. 4. The individuals involved were just too different for effectiveness to be shown. (The standard deviations, calculated at each stage of testing, confirm that there were considerable subject differences within groups, and considerable variation in test performance and response over time to intervention.) However, two subjects did show general functional improvement over time (see examples in figure 4). Some variables, such as a fluctuating word finding difficulty, were difficult to control. My observation was that such difficulties were better supported during sessions, when the therapy tool providing visual cues in the form of symbols and colour coding was available. Although not generalised to the post-intervention assessment, this may be possible given more time. Five additional test items randomly selected from the original set of 36 training items appeared three times during

Compensatory strategies
In addition to the subjects’ own positive attitude, this research gives some indication of the potential benefits of using a multi-media tool with our clients in individual and group work. Firstly, they can support children’s receptive skills and give them a way to demonstrate their comprehension and evidence their development. Secondly, they can enable our clients to use compensatory strategies independently in the classroom. Over the six week intervention period, my subjects became more independent in the use of the Clicker Grids, and the majority required no additional input from the therapist to complete the task after two to three weeks.

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SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2006

Photo by Paul Reid - a liveACTIVE Makaton group

intervention as well as once during each assessment phase. Figure 5 shows pre- and post- intervention responses as well as one of the sentences generated by the pupil during the intervention using the Clicker Grid. I asked all subjects to answer a symbolised questionnaire, supported by staff independent of the research, to comment on their performance and effectiveness of the intervention (figure 6). I also recorded their willingness to attend, distinguishing ‘unable to attend’ from ‘did not attend’, as an indication of how motivating they found the therapy (figure 7). Both suggest that multi-media tools can be a useful way of making therapy more stimulating and exciting.

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Figure 5 Intervention responses Item 13 Prompt question: What is the little boy doing? Subject 3 Before therapy Assessment Paying for a drink and there’s a man behind the stall Intervention The big boy is giving some coke to the little boy. The little boy is giving the big boy some money to buy some coke The boy is giving the money to the man and buying a coke After therapy Assessment Paying for his drink

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Buying a coke

Paying money for man buys coke

Item 15 Prompt question: What is the boy doing? Subject 3 Before therapy Assessment Intervention After therapy Assessment The boy’s grating the cheese, he’s gonna put it on the jacket potato Scraping the cheese

Figure 7 Attendance Figure 7 Attendance

He’s grating some cheese The boy is grating the cheese and putting it on the potato Scraping cheese The boy is grating the cheese and putting cheese on the potato

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Figure 6 Questionnaires responses

You could say that similar studies in the future may do best to focus on those whose epilepsy is better controlled, and on groups without additional complex learning, language or behavioural difficulties. Historically, many of the children included in my study may have been excluded from therapeutic interventions - never mind research - on medical grounds, due to the complexity of their needs. Yet is this right? The question I would ask is whether the goal of intervention should always be something that is measured in terms of a child learning or developing a new skill. Should we not, for some children, be focusing more on functional progress, for example by reporting on when and how a child has learnt to apply a compensatory strategy? This is of particular importance when those strategies may result in them having better access to the curriculum.

The National Centre for Young People with Epilepsy (NCYPE) is the UK’s major provider of specialist services for children and young people with complex epilepsy. A national charity, The NCYPE works in partnership with Great Ormond Street Hospital for Children NHS Trust and the Institute of Child Health. Located in Lingfield, Surrey, The NCYPE’s 200-acre campus includes St Piers School, St Piers Further Education College and a range of epilepsy diagnostic, assessment and rehabilitation services. www.ncype.org.uk

References
Blamires, M. (Ed) (1999) Enabling Technology for inclusion. London: Paul Chapman Bryan, A. (1997) ‘Colourful semantics’, in Chiat, S., Law, J. and Marshall, J. (eds.) Language Disorder in children and adults; Psycholinguistic Approaches to Therapy. London: Whurr Publishers Ltd. Department for Education and Skills (2003) The National Literacy Strategy, ICT in the literacy hour: Whole class teaching. Date of issue 04/03 Ref: DfES 0296/2003. London: Dfes Publications. Dunn, D.W., Austin, J.K., Harezlak, J. & Ambrosius, W.T. (2003) ‘ADHD and epilepsy in childhood’, Dev Med Child Neurology 45(1), pp.50-4.

Epilepsy Task Force (1999) Burden of Epilepsy; a health economics perspective. Leeds: Joint Epilepsy Council. Gucuyener, K., Erdemoglu, A.K., Senol, S., Serdaloglu, A., Soysal, S. & Kockar, A.I. (2003) ‘Use of methylphenidate for attention-deficit hyperactivity disorder in patients with epilepsy or electroencephalographic abnormalities’, J Child Neurol 18(2), pp.109-12. Lebrun, Y. and Fabbro, F. (2002) Language and Epilepsy. London: Whurr Publishers Ltd. Nolan, M.A., Redoblado, M.A., Lah, S., Sabaz, M., Lawson, J.A., Cunningham, A.M., Bleasel, A.F. & Bye, A.M. (2004) ‘Memory function in childhood epilepsy syndromes’, Journal of Paediatric and Child Health 40(1-2), pp. 20-27. Renfrew. C. E. (1997) The Renfrew Language Scales: ACTION PICTURE TEST. Bicester: Speechmark Publishing Ltd. Sander, J.W. (2004) ‘The use of Antiepileptic Drugs – Principles and Practice’, Epilepsia 45 (Suppl 6), pp. 28-34. Stevens, C. (2004) ‘Information and Communications Technology, Special Educational needs and school; A historical perspective of UK government initiatives’, in Florian, L. and Hegarty, J. (eds.) ICT and Special Educational Needs; A tool for inclusion. Maidenhead: Open University Press

Resources
• Clicker® software, see www.cricksoft.com/uk/ • ColorCards® Familiar Verbs in context, from Speechmark Publishing, ISBN 0 86388 519 5 • Language Through Reading 1/2/3, contact John Horniman School, 2 Park Road, Worthing, West Sussex, BN11 2AS • PCS Metafiles UK version from Mayer Johnson is available through various suppliers. SLTP
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2006

Hannah Kay is currently working as a locum speech and language therapist at The National Centre for Young People with Epilepsy Assessment and Rehabilitation Unit, Lingfield, and The Children’s Trust, Tadworth, e-mail hkay@ homechoice.co.uk. This article is based on a dissertation submitted in partial fulfilment of the MSc in Speech and Language Therapy, City University London, Department of Language and Communication Science (December 2005).

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