ISSN 1368-1205

Spring 2009

Changing you, changing me Video interaction guidance User involvement Advocating partnership

Oropharyngeal dysphagia The search for new techniques Oral motor exercises A lot of hot air? Adductor spasmodic dysphonia This House Believes in Botox

How I put learning into practice Bilingual insights Our Top Resources Head and neck

PLUSWinning WaysHeres one I made earliersoftware solutionsgreat reader offersreviewsand introducing In Brief Developing patience www.speechmag.com

reader offers

Win Memory Magic!

sTAss publications has released Memory Magic, a resource for therapists and teachers to assess and develop crucial memory skills in children with language and learning difficulties at Key stages 1-3 / aged 4-14 years. speech and language therapist Janie Booth devised the programme with 7 Magic Tricks (focus; rehearse; group; picture it; map; link; your spell) to help children discover how to support their working memory and learning. The package includes an introduction to working memory, assessment material, worksheets and advice about classroom and parental support. As the material is on CD rOM, and pictures are in both black and white and colour, users can print out copies as and when they are required. Memory Magic retails at 60.00 + VAT, but sTAss publications is offering a copy Free to a lucky reader of Speech & Language Therapy in Practice. For your chance to win, e-mail your name and address with sLTip Memory Offer in the subject line to stass@stass.co.uk by 25th April 2009. The winner will hear by 1st May. Further information about this and a full catalogue of STASS products is at www.stasspublications.co.uk.

Win Bambas First Comforts!

Are you looking for an early learning toy to help inspire parents communication with their babies? Bambas First Comforts has been designed by two speech and language therapists for parents of 6-18 month old babies. As well as promoting simple baby signing, the set encourages a focus on first spoken words. The toy kit usually retails at 29.99 + 3.95 p&p, but you can win one of two Free copies courtesy of The Baby sign Factory. All you have to do is e-mail your name and address with sLTip Bamba offer in the subject line to info@babysignlanguage.org. Your entry must be received by 25th April 2009 and the winners will be notified by 1st May. This award-winning product consists of a cuddly monkey called Bamba and five toys each representing an important word / concept for a baby. Yvonne Bruton-Miller and Amanda rees designed it to enable parents to explore baby signing at home if they are unable to commit to attending classes, and it is also being used by playgroups, nursery classes, health visitors and early intervention initiatives. Details are at www.babysignfactory.com/. Further Bambas Chatter Boxes are in development.

reader Offer winners

we had two reader offers in our winter 08 issue. The CLeAr phonology assessment, courtesy of Clear resources, goes to Kasey rees. Meanwhile the lucky winner of signalongs Basic Vocabulary Dictionary is Claire Brown. Congratulations to you both, and good luck to everyone with our new offers.

Spring 09 speechmag
Members area For a reminder of your user name and password, e-mail avrilnicoll@speechmag.com.

Articles now freely available online at www.speechmag.com/resources/reprints Francis, H. & Lloyd, J. (2008) About a Boy, Speech & Language Therapy in Practice Autumn, pp.12-14. gravill, p. (2007) Face value, Speech & Language Therapy in Practice summer, pp.20-21. Coming soon at www.speechmag.com/ resources/Originals editor Avril nicoll reports on the relevance of the nursing and Midwifery Councils 2008 Annual Midwifery Conference for speech and language therapists. notable presentations included progress Theatre and LD Caring solutions.

www.speechmag.com/Members/
new! Only online article added for spring 09! If at first you dont succeed Part 2: Tools of the trade in part 1 (p.12), Liz Ackroyd reflected on her management of David (46) who has chronic oropharyngeal dysphagia following basilar meningitis and a left medullary infarct. part 2 offers more detail about the various tools and procedures she tried out in the course of his treatment.

Back issues www.speechmag.com/ Members/ spring, summer, Autumn and winter 2007 issues now available as pdfs!

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spring 2009 (publication date 28 February 2009) issn 1368-2105

Spring09contents
Thanks to Andrea Ruck and Susan Scotland for our cover photo of a Video Interaction Guidance supervision session by Chris Lomas, www.chrislomasphotography.com.

Published by: Avril nicoll, 33 Kinnear square Laurencekirk AB30 1UL Tel/fax 01561 377415 e-mail: avrilnicoll@speechmag.com

4 COVER STORY: POSITIVE INTERACTION VIG leads to various positive ripple effects each time I use it. These ripples affect the clients daily routines, opportunities for communication and other physical environment factors, as well as the carers relationship with others around them Video interaction guidance (Vig) has transformed Andrea Rucks practice, enabling her to address attitudinal barriers of care staff and to be more positive in her work with adults with learning disabilities. Jane Young (p.7) then briefly explains the advantages of using Vig with parents of children with speech, language and communication needs.
15 AUDIT the collective opinion of authors contributing to a recent clinical forum into oral motor exercises for the treatment of speech sound difficulties in children suggests that this treatment should be viewed as experimental Deirdre Cosgrave, with the support of Jill Titterington, conducts a preliminary audit in a language unit to see if controversial sucking and blowing games can improve phonology. 18 IN BRIEF Lynn Griffiths launches our new section to showcase short, practical ideas with a child-friendly visual representation of speed of speech. 19 winning wAYs You can learn to say no with firmness, sweetness and genuineness. And you can be effective without being a people pleaser. Life coach Jo Middlemiss addresses readers concerns about time management. 20 THIS HOUSE BELIEVES IN BOTOX Speech and language therapists are frequently involved in the care of people with adductor spasmodic dysphonia. Should clinicians advise and encourage these clients to receive botulinum toxin injections? in our new series for 2009, Kendrea Focht and Paula Leslie debate both sides of the argument and reach a conclusion based on the available evidence. 22 REVIEWS Children and families, aphasia, language for health, learning preferences, coordination, behaviour, stammering, special needs, emotional issues, students, dementia, psychology, childrens book, ABA. 26 HOW I PUT LEARNING INTO PRACTICE (1) I found that, if I had the opportunity to say, to hear or to write a word or phrase in an incorrect form, then it would seem to stick in my language system, and it took extra effort to convert it back to the correct target. The benefits of errorless learning is just one of the insights into the experience of clients with communication difficulties that Dawn Leoni has gained from immersion in welsh. 28 SOFTWARE SOLUTIONS Avril Nicoll meets the directors of propeller rehabilitation software and Katie Spear reviews story Teller 7-12. 28 CORRECTION An apology to Ann nordberg and colleagues for a proofing error with figures in the winter 2008 issue. 30 OUR TOP RESOURCES We find anatomical models simply invaluable for teaching and providing informative counselling to patients and relativesWe use the larynx model and head and neck model daily. Eryl Evans, Jodie McCord and Ruth Best are specialist speech and language therapists working in enT and head and neck cancer.

Design & Production: Fiona reid, Fiona reid Design straitbraes Farm, st. Cyrus, Montrose Angus DD10 0Ds Printing: Manor Creative, 7 & 8, edison road eastbourne, east sussex Bn23 6pT Editor: Avril nicoll, speech and Language Therapist

Subscriptions and advertising: Tel / fax 01561 377415 Avril nicoll 2009 Contents of speech & Language Therapy in practice reflect the views of the individual authors and not necessarily the views of the publisher. publication of advertisements is not an endorsement of the advertiser or product or service offered. Any contributions may also appear on the magazines internet site. speech & Language Therapy in practice can be found on eBsCOhost research databases

INSIDE FRONT win Memory Magic and Bambas First Comforts. 8 USER INVOLVEMENT At the end of the course all the participants could use the framework, but different levels of support were needed to complete a successful interview using Talking Mats. Lois Cameron and Sally Boa describe a joint project with their local advocacy service for people with learning disabilities, whereby service users collect and give feedback using Talking Mats. 10 AAC E-MAIL Gill Townend seeks participants for a national AAC survey being conducted as part of the Devices for Dignity project. 11 HERES ONE I MADE EARLIER Alison Roberts with two low cost therapy suggestions to promote friendship Friendship Bands and Fields of interest. 12 CLINICAL DECISIONS The severe nature of Davids swallowing disordermay indicate that the damage to the cranial nerves was too severe to make a perceptible change in the safety or effectiveness of his swallowit is possible that this intervention was too early for him. Liz Ackroyd undertakes a two part reflection on therapy over 12 months with a client with severe oropharyngeal dysphagia. part 1 concentrates on the overall picture and clinical surface electromyography while part 2 (at www.speechmag.com/Members/) details other methods and tools used. peer review is offered by Penny Gravill. 14 CRITICAL FRIENDS As part of a speech & Language Therapy in practice peer review pilot, Deborah Green and Nicola Hayton comment on About a Boy (Autumn 08) by Helen Frances and Joanna Llloyd.

WINTER 08s e-article at www.speechmag.com/Members/ E1 THE THIRD PERSON IN THE ROOM Talking Mats has had a profound impact, not just in the UK, but across the world. It has raised awareness that successful communication is everyones business. [Mary Turnbull] Talking Mats is a low tech communication framework designed to help people with communication difficulties express their views. Avril Nicoll reports on a symposium held to celebrate the first 10 years where speakers included Joan Murphy, Lois Cameron, Mary Turnbull, Charmaine gordon, Alex gillespie, Tracey Oliver, Maria Venditozzi, pam Crawford, elaine watson and Laura Coakes. in FUTUre issUes: ADULT LeArning DisABiLiTYsYMBOLsgrOUp LeArningpHOnOLOgYDOwns sYnDrOMeDYspHAgiAMOTOr neUrOne DiseAse...LeArning inTO prACTiCe.

news

The Talk To Your Baby Campaign has succeeded in attracting a large amount of media attention to two studies suggesting that the style of baby buggies can contribute to parent-child interaction and childrens communication development. The most common and affordable buggies in the UK for children aged from 6 months face away from the pusher. Dr Suzanne Zeedyk, a Developmental Psychologist at Dundee University, questions our cultural assumption that small children benefit most from looking out at the world around them as, research repeatedly shows that in order for babies to make effective use of that experience of the wider world, they need parents to help mediate and make sense of it for them. Dr Zeedyk carried out two studies for the campaign. The first was an observation of 2,722 parent-infant pairs across the UK. Away-facing buggies were associated with a reduction in speaking for both parents (half) and infants (a third) and, unexpectedly, infants in towards facing buggies were twice as likely to be sleeping. Observers were shocked by how little communication was going on between parents and babies. One saw that,Lots of people came past with their dogs, and at least half were talking to them, but not the children! And so many parents on mobiles! Another said, Why dont people talk to their children more? Missed opportunities for a bit of fun! I noticed a number of occasions where the child was babbling to itself, playing with pram toys, or babbling to a doll, but because the buggy was facing away, the parent was unable to join in with or encourage this interaction. As the pattern of parent talking observed may have reflected parent personality rather than buggy orientation, Dr Zeedyk undertook a second pilot experimental study of 20 babies. While half a mile was spent in an away-facing buggy, the other half mile was spent in a toward-facing buggy, with 10 starting in one condition and 10 in the other. The findings suggest that not only does buggy orientation influence the amount of parental talking to the child, but that the talking with toward-facing buggies is more varied and interesting. Given that the theory of away-facing buggies

Wheels of change
People affected by Parkinsons Disease comment on access to services at the launch of an All Party Parliamentary Group inquiry

is to enable the child to see the world, it is interesting that when mothers did point things out to infants it appeared to be more likely to occur in a toward-facing buggy. And, although there was no significant difference in infant speech, both mothers and babies had more laughter when the buggy was toward-facing. Only one baby ever laughed in the away-facing journey, while 10 did so in the toward-facing one. The pilot study also made tentative suggestions about infant stress levels being lower in towardfacing buggies, and Dr Zeedyk says that life in a buggy is more isolated than many adults realise and may be more emotionally impoverished than is good for childrens development. Interestingly, while mothers experienced the two orientations differently, they did not think their infants did (at least in terms of comfort or stress. Comments from mothers involved add weight to the findings that changing orientation can be powerful. It was interesting with her facing towards me. Because I was talking to her all the time, because she was looking at me and so you react with her. Whereas, when shes facing away, yes I talk, but not quite as much. Because, you know you cant see her facial movements and you know shes not looking at you to get feedback. ..I didnt expect that. I thought if she was in one like this (toward-facing), she would spend most of her time craning out. Dr Zeedyk hopes manufacturers will now work to make toward-facing buggies more affordable and acceptable, and that she can use the results of the pilot study to conduct larger-scale research. The full report is at www.literacytrust.org.uk/talk toyourbaby/Buggy_research.pdf.

Communication issues were well represented at the first Parkinsons Disease Society Research Conference, with a keynote presentation by Nick Miller backed up by several posters. Nearly 200 scientists and researchers from around the world met in York in November 2008 to discuss a range of topics including gene therapy, tissue implants, pharmacotherapy, gait rehabilitation and service delivery. Nicks platform presentation was on a pilot study looking at the effect of altered facial expression on comprehension of emotional content of utterances. Nickss personal highlights as an attendee were both about service provision. Bastiaan Bloem explained how services in the Netherlands are organised around trained specialists for each area, and presented evidence that this is more effective in terms of rehabilitation and cost than generalist provision. Nick also believes speech and language therapists should take note of George Kernohans address about the gap in provision of services at the palliative stage. The three posters with which Nick was involved reported the findings from a survey of people with Parkinsons disease, their carers and speech and language therapists. In addition to highlighting the need for our involvement at the palliative stage, it was clear that we need to get better at recognising how we can support clients with the psychosocial aspects of the disease. The Parkinsons Disease Society survey findings have also been used to inform an All Party Parliamentary Group inquiry into access to health and social services. The Society says a third of people diagnosed in the last year were not given clear information about the condition. More than a quarter of people living with Parkinsons had never spoken to a specialist nurse whilst the majority had not been assessed for key therapies including speech and language. www.parkinsons.org.uk

Parkinsons research

The government in England has accepted most of the recommendations of the 2008 Bercow Review of services for children and young people with speech, language and communication needs. The Action Plan Better Communication sets out what the government will do in response to each of the recommendations, when it will be done by and how it will be evaluated. New initiatives include the three year appointment of a Communication Champion and a Communication Council, with a National Year of Speech, Language and Communication planned for 2011-12. The Council will include a parent and a young person representative. There will also be a research programme and up to 20 local area pathfinders which will consider the appropriate capacity for speech and language therapy, and how that capacity is best used (p.23) as well as informing the development of best practice in joint commissioning.

Better Communication

The plan is unequivocal in saying that all members of the mainstream childrens workforce should support the development of all childrens speech, language and communication skills (p.12) and that all people working with children should know how to work with specialists, such as speech and language therapists, to build an effective environment for all children to develop speech, language and communication skills (p.12). The Royal College of Speech & Language Therapists is charged with engaging the profession and promoting best practice. The contribution of the Every Child a Talker and the Child Health Promotion programmes is discussed, and special mention is made of provision of services for young offenders and children who use communication aids. Afasic, the British Stammering Association and I CAN are all receiving funding to develop support for families. www.dcsf.gov.uk/slcnaction/

SPEECH & LANGUAGE THERAPY IN PRACTICE spring 2009

news & COMMenT

Somewhere over the Rainbow

Comment:

The UK-based peruvian charity Kiya survivors has put out an urgent call for donors, Nichola with Nadya sponsors and speech and language therapy volunteers to sustain one of its educational and therapy centres. Volunteers at the rainbow Centre have worked with over 400 children and families since it opened in 2001. it is the only support available in the area for children with special needs who are living in severe poverty. Volunteers aim to enable those attending to become as independent as possible. Alex Brandon, a spokesperson for the charity, said, Kiya survivors is currently experiencing great financial troubles and we are desperate for donors, sponsors and volunteers to help us continue to provide this support and offer these families the chance of a positive future. To illustrate the difference that speech and language therapy volunteers can make, she went on to describe how in 2008 nichola sutcliffe spent a month volunteering at the rainbow Centre just before she qualified as a speech and language therapist from sheffield University: One of nicholas charges was nadya, a thirteen year old girl who is deaf. As there are no schools or facilities for deaf children in this area of peru, nadya had never been to school or learnt any formal means of communication before starting at the rainbow Centre three years before. when nichola arrived nadya had learned basic sign language and Makaton, but was hungry for more. nichola used Cued Articulation (passy, 1995), teaching nadya the hand cue for each individual sound. soon, for the first time in her life, nadya was able to produce sounds and read out words so that they were understood by others. nichola also taught the technique to naydas class teacher Yessica who found it hugely beneficial when working with nayda and other children with speech and language difficulties. Alex is clear that, what nichola managed to achieve in a just one month at the rainbow Centre has opened up a whole new world of communication for nayda. For more information on Kiya Survivors and how to volunteer or donate, visit www.kiyasurvivors.org or e-mail volunteers@kiyasurvivors.org.

Developing patience
when i worked clinically parents and carers often asked, How can you be so patient? This made me laugh as, although i have persistence and staying power, other aspects of patience such as tolerance and serenity have never come naturally. perhaps thats why Jo Middlemisss suggestion (p.19) of mentally minimising to do items until we are ready to deal with them just as we minimise documents on a computer - seems to work for me? in any case, it helps to know that patience is something that can be developed. An important part of our role is making clients and families aware of the benefits of patience, as well as recognising when we may simply be trying to do too much too soon. Liz Ackroyd (p.12) had the opportunity to reflect on both while writing about her journey to date with a client and going through the process of a critical friend peer review. But impatience has its upside it drove Andrea Ruck (p.4) towards a video interaction approach that is opening up communication opportunities for her clients with learning disabilities and their carers. And, having undertaken an intensive course in welsh, Dawn Leoni (p.26) is getting the chance to experience something of the frustration which must be felt by our clients, as well as the impact of helpful strategies such as errorless learning. This insight has introduced a whole new dimension to her practice. some academics are impatient with clinicians who persist in using oral motor activities in spite of a lack of evidence that they do any good. Deirdre Cosgrave and Jill Titteringtons audit (p.15) contributes to the debate. engaging in a debate and considering both sides of the argument is a great way of developing critical thinking skills as our new series shows, beginning with Kendrea Focht and Paula Leslie (p.20). However it is also a useful tool in developing patience, as we become more tolerant and understanding of shades of grey and of other points of view and influences. it is certainly easier to be patient when we understand why something is happening. Lois Cameron and Sally Boa (p.8) successfully trained people with learning disabilities to use an interview framework with their peers, but careful evaluation showed that further support was needed with the social aspects of conducting an interview. Eryl Evans, Jodie McCord and Ruth Best (back page) also appreciate that clients are often our best teachers, as they constantly surprise us with their ability to cope with the unthinkable. i am impatient to hear your in Brief contributions (p.18). You could write about a therapy resource, advice you have had, something you have read, what you wish you had known, or something that has changed your perception. Or maybe even how you have learned to have a little patience?

Supervision solutions

Thanks to all readers who have given their feedback on the 2008 supervision series by sam simpson and Cathy sparkes. Many of you have used it to reflect on the supervision that is already available, while others have found it helpful when setting up departmental supervision. sam and Cathy are also following up a readers request for an article focused on supervision for senior speech and language therapists who have been in practice for many years. we hope to bring you that article later this year. Meanwhile, you can read about a solution Focused Brief Therapy approach to peer and student supervision at www.solution-news.co.uk (December 2008 issue). speech and language therapist Kidge Burns explains how theTen Minute Burn was conceived and the impact it has on wellbeing and practice.

WellChild nominations

The national charity wellChild is seeking nominations for its fifth annual awards. These go to children who have shown outstanding courage in coping with serious illness or disability, to children who have given extraordinary care to a friend or sibling with serious health problems, and to any health, education or social care professional who is exceptionally dedicated to improving the lives of one or more sick children. Children who are nominated must be aged between 2 and 18, and entries must be in by 20th May 2009. Nomination details at www.wellchild.org.uk.

PABA problem

A reader in new Zealand is asking for support in her efforts to get the pABA (personalised Advice Books for Aphasia) software upgraded to work with windows Xp. The Medical illustrations Department at glasgow royal infirmary, which produced the original CDs, has advised her that they have no plans to do this work. she is hoping that if enough therapists contact them they will have a change of heart.
SPEECH & LANGUAGE THERAPY IN PRACTICE spring 2009

Cover story: Interaction

Changing you, changing me

Andrea Ruck was looking for a therapy approach that would address attitudinal barriers of care staff and generally help her to be more positive in her work with adults with learning disabilities. Video Interaction Guidance, originally developed for work with families, proved transformational for her practice.
s a new graduate practitioner in the adults with learning disabilities field, my work was heavily reliant on traditional advisory methods such as writing reports and discussing recommendations with staff. I felt frustrated that my recommendations were often not followed, and that communication training workshops were not effecting any real change in carers communication behaviours. I realised a different approach was needed, which would allow me to address the underlying attitudes of staff. Another significant moment in my development was when a staff member said a report I had written was too negative, and I decided I wanted a more positive angle to my work. Having heard a nursing colleague mention Video Interaction Guidance (VIG), I attended the VIG International Research Conference in Dundee in 2005. VIG sets out to improve communication and relationships using video. The approach appeared to combine everything that I was looking for, and I was instantly hooked. I have since used VIG in various ways to benefit adult clients with a learning disability and their carers / support workers, and the process continues to influence my attitudes and day-to-day clinical practice. A. VIDEO INTERACTION GUIDANCE THE BACKGROUND VIG emphasises that change can be achieved more effectively and in a more empowering way in the context of a coaching relationship, which is collaborative rather than prescriptive, empowering rather than deskilling and conveys respect for strengths and potential. (http://www.cpdeducation.co.uk/veroc/vig.php (Accessed 22 January 2009)) Video Interaction Guidance is based on a model developed in the early 1980s by a Dutch psychologist, Harrie Biemans. Originally used with dysfunctional families in the Netherlands, VIG is now practised widely across the world. There are currently 800 accredited Video Interaction Guiders and 75 accredited supervisors in the UK. Professionals using

the approach include adult psychiatry teams, health visitors, educational psychologists, behaviour support teachers and social workers. Whilst it is widely used by those working with children and families, the approach equally lends itself to work with adults with learning disabilities. Whatever the client group, all VIG practitioners hold several basic assumptions in common: People wish to communicate People in troubled situations do want to change People do really care about each other Everybody is doing the best they can at the time Every crisis is an opportunity for change Change always comes from within the individual. As a Video Interaction Guider (VIGer) I film 5-10 minutes of interaction between a carer / support worker and an adult with learning disabilities. I then edit the material and return on another day to view and discuss several short video clips with the carer / support worker (figure 1). These feedback sessions take about an hour. Usually the participant rather than the VIGer decides when they want to stop, but 3 - 4 recording and feedback sessions are generally sufficient to effect a change in attitude and / or communication behaviour, or to make the carer feel confident that they can now independently use their improved communication skills. Figure 1 VIG filming and feedback

It is very important that only positive video clips are used as a basis for reflection during the feedback. This positive video self-modelling has a long history of being used to radically reshape behaviours (Biggs, 1983). All films are micro-analysed and edited with reference to the Contact Principles (figure 2), a set of descriptive categories which include attentiveness, looking and tone of voice. When appropriate, higher order communication skills such as making suggestions, offering choices and solving problems together are also incorporated. This has the advantage that the VIG approach can be used with clients across the entire spectrum of learning disability. I have used VIG with staff and carers interacting with clients with: severe learning disabilities and autism and / or challenging behaviour severe learning disability and severe visual impairment Downs syndrome and a stammer moderate learning disability and hearing loss. I have also used the approach directly with clients to change their communication skills. This includes a client with autism, others with social skills difficulties, one with a stammer and a mother with a learning disability interacting with her young child. Figure 2 VIG Contact Principles of communication

READ THIS IF YOU ARE INTERESTED IN CHANGING UNDERLYING PERCEPTIONS FOCUSING ON STRENGTHS AND POTENTIAL USING VIDEO AND GIVING VIDEO FEEDBACK

SPEECH & LANGUAGE THERAPY IN PRACTICE spring 2009

Cover story: Interaction

Andrea Ruck with John (see case example 2, p.6)

At another level VIG teaches the practitioner to give effective feedback to the carer / support worker. All work during training is supervised by a qualified VIG trainer. The VIG trainee brings micro-analysed video clips of him / herself interacting positively with the carer / member of staff to the supervision sessions (figure 3) and reflects collaboratively with the supervisor on use of the Contact Principles during feedback. This includes different initiative and reception patterns, what is being said and what is being conveyed without words. Because the VIGer is focusing on moment-tomoment pleasurable and successful interactions, s/he is perceived by the carer to create a positive atmosphere. As well as providing a scaffold for new thinking for the carer, s/he is also acting as a model for positive interaction. Looking at the different factors which may be contributing to the effectiveness of VIG, Vermeulen (2006, p.8) notes that Lambert (1992) identifies a positive carertherapist relationship as one of the most important factors that predict success in a programme. Figure 3 VIG supervision

B. VIDEO INTERACTION GUIDANCE WHY I FIND IT EXCITING AND REWARDING a) Carers change their perception of a clients communicative competence During the feedback sessions, the practitioner listens and responds to the participants own views, thoughts and feelings about the situation and vice versa. New shared meanings, possibilities and ideas for solutions appear (figure 4). Figure 4 New perspectives develop

perfect sense whereas beforehand she had simply disagreed with them. b) VIG generates positive effects in the carers and clients environment Beyond the pure technical aspects of communication, VIG leads to various positive ripple effects each time I use it. These ripples affect the clients daily routines, opportunities for communication and other physical environment factors, as well as the carers relationship with others around them, including ways of accessing support for themselves and for the client. Such associated positive outcomes often take place between feedback sessions, without the need for advice. The carer finds their own solutions to problems and starts putting them into practice. When I worked with a visually impaired client and her support worker Paul (case example 1), Paul talked to the other residential staff and persuaded them to switch off the radio while the client was indoors. It is worth noting that the creation of a quiet acoustic environment had formed part of my recommendations for the last two years. c) VIG establishes collaborative relationships I sometimes use VIG with individual members of staff in situations where a staff group has failed to implement a communication programme due to a difference in attitudes or beliefs. Because VIG focuses on developing a collaborative relationship with an individual staff member, who gains a more realistic view of the clients communication needs, the staff member may start to act as the clients advocate and pass good practice on to other staff.

I filmed a carer with a client who had a severe learning disability and severe challenging behaviours in a residential setting. Initially the carer clearly overestimated the level of the clients communication skills. She voiced the opinion that using close proximity and a sing-song voice with the client was babyish. She began experimenting with positioning herself closer to the client. On seeing the clients positive response in the video clips, she engaged in a very open dialogue about the meaning of age appropriateness. Her perception changed in that even adults like being silly and enjoy a bit of fun. She also began to monitor and reduce the number of key words that she used with the client. She said that the recommendations in my report now made

SPEECH & LANGUAGE THERAPY IN PRACTICE spring 2009

Cover story: Interaction

Following a clients autism diagnosis, our local Learning Disability Team carried out some communication / autism training for staff, who remained unconvinced that the client had autism. I then carried out VIG with an individual volunteer member of staff. She picked up straight away from the video that the client had a verbal processing delay and revised her opinion about the diagnosis. After two VIG sessions, she reported that incidences of challenging behaviour had drastically reduced when she was on shift with the client. She asked me whether I could do another couple of VIG sessions with another interested member of staff. The two staff members drew up their own set of communication guidelines and we shared video clips with the rest of their colleagues. The next time I visited, I found the staff much more attuned to the clients communication. d) I can work with clients directly I have also used VIG very successfully with clients themselves. Biggs (1983, p.119) states that, for people with mental retardation, self-modelling has enjoyed considerable success it is visual, rather than language based, and the self element makes it engaging and concrete. Video also readily enables clients with a learning disability to repeatedly view their own adaptive behaviours. Because all filming is done in a natural context, at the clients Day Centre, at home or out in the community, using VIG with clients offers exciting opportunities to address the difficulty with generalisation experienced by people with learning disabilities (Krantz et al., 1983). e) Clients show a high degree of involvement in their own therapy Probably more than anything else, I have been amazed by the way clients have involved themselves in decisions about their own therapy. All too often we as therapists decide on the number and content of therapy sessions. With VIG, clients usually take control over who they want to be filmed with and the pace of therapy, and they may request additional sessions. I worked with a client with a moderate learning disability and a severe stammer (case study 2). VIG therapy with the client was aimed at improving his confidence in talking to staff. We viewed and discussed brief video clips, which showed the client engaging in pleasurable and relaxed conversations with a member of staff. When I asked the client whether I could film him with another staff member, he initially admitted to feeling very nervous and was reluctant to be filmed. Two months on, he approached me, asking if I could help him to feel proud when he was talking to other staff. f) The unexpected happens Work with another client with autism whose comprehension was at a 3 Information Carrying Word level (Knowles & Masidlover, 1982) led to exploration of the Contact Principle of using a friendly voice. A pivotal moment was when the client engaged in some reflection. On noticing her friendly voice on video (repeated playback), and on seeing the other persons reaction, she said, wellmaybe thats a good thing! and began to actively experiment with her tone of voice. Seeing herself and others on video enabled the client to identify how her conversation partners felt during conversations, and whether they were interested or bored. Due to the clients autism and poor comprehension ability, I would not normally have envisaged or thought it possible to target intonation in therapy. C. POSITIVE IMPACT ON MY PRACTICE i) New perspectives appear In my role as VIGer, I am constantly gaining new insights. I have come to appreciate how crises resulting from challenging behaviours can profoundly undermine staffs self-esteem and belief in their own personal competence as communicators. For me, it has been extremely rewarding helping these staff to feel more positive about themselves, and to re-establish a mutual and positive trust between them and the clients in their care. ii) My interactions with other professionals have changed profoundly Approximately 4 - 6 months into the VIG training, I noticed on leaving professional meetings how they had gone extremely well and led to very positive outcomes. I realised this was due to effective carryover of the Contact Principles. When I enter into negotiations with other professionals and students, I now rely much less on persuading, convincing or arguing my point, and much more on listening, bringing out the other persons resources and strengths and enabling them to come up with their own solutions to problems.

Case example 1: Vicky and Paul

Vicky is a woman with Downs syndrome, a severe learning disability and severe visual impairment. She was at the pre-intentional / early intentional stage of communication development and presented with several challenging and self-stimulatory behaviours. I was first approached by Paul, Vickys new 1:1 support worker at the clients residential home, as he felt unsure how to communicate with Vicky. I carried out four filming and feedback sessions over a four month period. At the beginning, Paul described communication with Vicky as hard work. He felt he would never be able to have a longer conversation with her. During the first feedback session, Paul became aware of the Contact Principle of using a friendly voice. He had been a football coach and used the terminology of cheering Vicky on, which I reinforced. Paul subsequently experimented with his tone of voice between filming sessions and reported back on his success: Im so thrilled I now feel that Vicky knows who I am! The final film was done whilst Vicky and Paul were in a busy caf. Normally Vicky did not tolerate such noisy environments and would start screaming. However, on this occasion, she calmly engaged in vocal and tactile turn-taking behaviours with Paul for 10 minutes. Paul noted that Vickys communication was now much more directed at him. The video revealed how, for the first time, Vicky touched Pauls arm to gain his attention, as opposed to throwing objects or stripping off her clothes. Other staff also noticed a change in Vicky and reported that her challenging behaviours had decreased.

Case example 2: John and George

John is 25. He has Downs syndrome, a moderate learning disability and a severe stammer. John frequently isolated himself at his Day Centre. He only engaged with his key worker and tended not to speak to other staff or join in with any groups. His brother reported that, at home, John did not usually talk to visitors and would often disappear to his room. I filmed John interacting with George, a less familiar staff member from the Day Centre. First, I did VIG with George. Following one film and feedback, George reported how John had talked to him in the corridor, asking him how he was. Another breakthrough was when John joined in with Georges Art Group. George had set up a table at the back of the art room especially for John and came over to speak to him at regular intervals. I then carried out some VIG therapy with John himself. To my surprise, John soon started talking about his thoughts and feelings about having a learning disability. To him it meant he was rubbish at talking. I showed John several video clips highlighting laughter and him feeling relaxed during conversations. No severe stammering episodes were shown. The VIG therapy gave John a real sense that both he and George had fun and enjoyed talking to each other. Towards the end of therapy John thought differently about his learning disability: My learning disability is alright. Talking to George is fun! After three filming and feedback sessions, there were signs that Johns communication behaviours started to change and that these changes were carried over into different environments. Staff noticed that he spoke to other staff members at the Day Centre more often. At home, John began to socialise more with visitors.

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iii) My observation and reporting skills have shifted towards the positive When I observe staff now, I find myself focusing on the positives, however small. I no longer say to students or colleagues that certain staff members are poor communicators. I also no longer only work with staff who are good communicators because I carry a strong conviction that everybody can communicate well, given the right support. I now adopt much more positive language in my reports, highlighting strengths of both staff and clients. D. LIMITATIONS WHEN USING VIG WITH ADULTS WITH LEARNING DISABILITIES Where the videoing forms part of the clients treatment, I need to ensure that I follow consent procedures as outlined in the Adults with Incapacity Scotland (2000) Act. Filming clients in group homes or other group situations can also be tricky, as it is important to seek everyones consent prior to the filming. At a practical level this means that the camcorder has to be switched off each time a client who has not consented, or is incapable of giving consent, walks into the video. There are also several drawbacks to using old-fashioned VCR equipment of television with video playback and remote control: Having to rely on clients VCR recorders when most households no longer have them, and / or carrying around bulky equipment Clients may get confused by seeing film rewinding on a VCR recorder and this may lead to less efficient feedback sessions Some clients with autism greatly benefit from viewing the video clips in slow motion; this is not possible with VCR equipment. In my experience, a laptop computer and a digital camcorder are essential pieces of equipment which can overcome many of these problems. E. FAST FORWARD As a recently qualified VIG supervisor, I remain enthusiastic about the approach. I continue to learn about it through networking meetings with other VIG practitioners and through supervising other trainee practitioners. My current supervisees are a health visitor and a community learning disability nurse colleague. I would like to see VIG used more widely by colleagues in my own multidisciplinary team and ultimately across the service as a whole. I am also interested in research on the effectiveness of using VIG with adults with learning disabilities. I feel I am just at the beginning of the process of exploring VIGs wide range of applications, and look forward to using it in many creative ways, for example with clients with dementia and their carers. For those who wish to find out more about VIG and / or training to be a VIG practitioner, visit the VERoC website, http://www.cpdeducation. co.uk/veroc, or please contact me. Andrea Ruck is a specialist speech and language therapist in Edinburgh with NHS Lothian, e-mail andrea.ruck@nhslothian.scot.nhs.uk. Acknowledgements My special thanks to Sandra Montgomery, Educational Psychologist and VIG UK supervisor, to my speech and language therapy colleagues Siobhan Mack and Tracy Paterson and to Anne Edmonstone, Head of Speech and Language Therapy, for their encouragement and support in writing this article. Thanks also to John for agreeing to me sharing his story and to Susan Scotland for her insights during supervision sessions. SLTP REFLECTIONS DO I RECOGNISE THAT FACILITATING SMALL CHANGES IN ATTITUDES AND BEHAVIOUR CAN BE ENOUGH TO START A RIPPLE EFFECT? DO I APPRECIATE THAT THE RELATIONSHIP I HAVE WITH SUPPORT STAFF AND CARERS IS ONE OF THE MOST IMPORTANT PREDICTORS OF THERAPY SUCCESS? DO I BELIEVE THAT EVERYONE CARES ABOUT OTHERS, DOES THEIR BEST AT THE TIME AND HAS THE POTENTIAL TO CHANGE THEMSELVES WITH THE RIGHT SUPPORT?

Respect for what is working

Like Andrea Ruck in Changing you, changing me , Jane Young rates Video Interaction Guidance highly. Here she explains briefly the advantages of its use with parents of children with speech, language and communication needs.
I have had the special opportunity of a rigorous and lively multidisciplinary training in the use of Video Interaction Guidance (VIG), a way of reviewing, with clients, video clips of successful communication. Video Interaction Guidance is very much in harmony with Hanen. Based on the premise that the key to future development is in the quality of interactions, it creates a heightened awareness of the verbal and non verbal communication skills which promote positive interaction. It is proving to be a dynamic way to support change, as it has a deep respect for basic communication and never underestimates its value. My use of it at present is with parents of children with speech, language and communication difficulties. We look at selected clips of a film of their interaction with their child. Based on the Contact Principles of VIG, I share what I have seen and discover what they have seen to create a mutualunderstanding of what is working. It is amazing the difference only looking at what has gone well can do to build confidence andbring a dramatic increase in the parents response to their childs initiatives. It has strengthened my belief that people want to communicate well and that people in trouble want to change. Even in the most unpromising situations there is always something - however fleeting - which is happening in a positive way between the parent and the child. Review meetings can often be intimidating or dispiriting experiences for parents. I am now encouraging them to show their video clips at such meetings as a way of developing confidence - and sometimesindependence - and to sustain change by engaging them as equal partners in the process. Jane Youngis a speech and language therapist in early years with Community Childrens Services, Newcastle upon Tyne. Resources Hanen, see www.hanen.org Video Interaction Guidance, see www. cpdeducation.co.uk/veroc/.

References What therapy tools have changed you Biggs, S.J. (1983) Feedforward and self-modelas well as your clients? Let us know via ling, in Dowrick, P.W. & Biggs, S.J. (eds.) Using the Spring 09 forum at http://members. Video in the Behavioural Sciences. London: Wispeechmag.com/forum/. ley, pp.109-126. Knowles & Masidlover (1982) The Derbyshire Language Scheme. Matlock: Derbyshire County Council. Krantz, P.J., MacDuff, G.S., Wadstrom, O. & McClannahan, L.E. (1983) Using video with developmentally disabled learners, in Dowrick, P.W. & Biggs, S.J. (eds.) Using Video in the Behavioural Sciences. London: Wiley, pp.256-266. Vermeulen, H. (2006) Video-Interaction Guidance in Pedagogical Family and Child Support Programs (VHT) in Relation to Effectiveness and Positive Behaviour Change, Video Interaction Guidance: International Research Network Conference. University of Dundee, 19 May. Recommended reading Hodgkinson, P. (1998) Communication in ALD what do carers think?, Speech & Language Therapy in Practice Spring, pp.4-7. Kennedy, H. & Sked, H. (2006) Video Interaction Guidance: A bridge to better interactions for individuals with communication impairments, in Kennedy, H. (ed.) VIG Handbook. Dundee: University of Dundee, pp.1-19. Nicoll, A. (2005) Speaking skilfully, Speech & Language Therapy in Practice Autumn, pp.18-19.

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Advocating partnership
Lois Cameron and Sally Boa describe a joint project with their local advocacy service for people with learning disabilities, which is enabling service users to collect and give useful feedback to advocacy workers using the low tech communication framework Talking Mats.
User involvement whats your experience? Let us know at the Spring 09 forum, http://members. speechmag.com/forum/.
dvocacy into Action provides a range of independent advocacy services to people with learning disabilities in Falkirk and Clackmannanshire. It aims to help, support, and promote the welfare of adults with a learning disability by enabling them to make decisions and have their voices heard. The advocacy group wanted to involve people with a learning disability in collecting and giving feedback to their advocacy workers. They had recognised that their existing method of gaining feedback from service users via a questionnaire was inaccessible for many of the users, and that the quality of the information gained was not always helpful for improving services. Advocacy into Action therefore approached the AAC Research Unit at the University of Stirling to see if a tool could be developed which would allow more people with a learning disability to give their views about advocacy services. We are grateful to Stirling University Research and Enterprise (SURE) who funded our subsequent joint project through a European Regional Development Fund and to Clackmannanshire Council and Falkirk Council for funding the travel of the participants. We began by holding a course for people with learning disabilities to: 1. Teach them to use the Talking Mats framework as a method of interviewing people 2. Involve them in selecting the most appropriate symbols so that Talking Mats could be used to help people give feedback about their experience of using advocacy services. Talking Mats is a low tech communication framework involving a textured doormat and sets of symbols. It was ideal for this project as it is designed to help people with communication difficulties reflect on their experiences and express their views. The course was run by two trainers and comprised of six sessions lasting two and half hours each. There was a three week break after the third session to accommodate the Christmas holidays. The training was planned for 8 people but, as 10 people from the advocacy group wished to come, we accommodated them all. The participants had all volunteered to participate. They all had a learning disability and
OUR SERIES AIMS TO SHOW THAT USER INVOLVEMENT CAN BE TRANSFORMATIONAL FOR CLIENTS, THERAPISTS AND SERVICES PUT INTO PRACTICE AT MANY DIFFERENT LEVELS A POWERFUL TOOL FOR INFLUENCING COMMISSIONERS

good verbal communication skills. Their literacy skills varied; l-r Sally Boa and Lois Cameron some had good reading skills and some had no or very limited literacy. Attendance was i. We taught the concept of open and closed exemplary over the six sessions - only two peoquestions using open and closed boxes with ple missed a total of three sessions through illdiffering amounts of Christmas decorations ness. All the participants played an active and inside to get over the idea that you gain much enthusiastic part in the training. more information from an open question than We customised the training using the princia closed one. ples of accessible information (SEAT, 2007). Ses- ii. We adapted the game of Family Fortunes to sion programmes and handouts all had simple enable participants to begin to think about the language, bullet points and key pictures (figure options they would include in a Talking Mat. In 1). We gave thought to both the amount of inthe first session after Christmas, we asked group formation and the pictorial support required to members to think about which symbols they aid and support understanding. We structured might use to find out someones views about sessions so that the format was familiar but Christmas. Prior to the session, we had made a each session contained something that was list of possible options which were important different, new and fun. We hoped this would to us (such as Christmas dinner, presents, TV). stimulate conversation and aid memory and We asked group members to come up with retention of concepts. We gave consideration their own suggestions to see if they matched. to the way information was delivered and used Using the Family Fortunes format made the games and visual signifiers to teach abstract session fun and also helped the group to see concepts, for example: that different things are important to different people and that there were no right or wrong Figure 1 Accessible session programme answers. It also helped to reinforce the importance of having blanks available so people can come up with their own options. Throughout the course, there was plenty of time for repetition and over learning. Each session began with a recap of the previous weeks learning. As the course progressed, the participants became more confident about taking responsibility for their own learning and, by the end, one participant took charge of the recap session. Recap session

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USER INVOLVEMENT (4)

Active learners

Figure 2 Prompt sheet

The participants were active learners, asking lots of questions and making many comments. They were very supportive and encouraging to each other as the following dialogue shows: The one thing I forgot is how to ask open questions. (Debbie) No, I didnt think so, you did a good job last week. (Julian) I seen you, and you were confident. (Mary) As a group, the participants were extremely skilled and sensitive about giving each other feedback. The experience of receiving communication feedback appeared to be new to them and they needed to be reassured so they did not overplay any negative comments. Creating an atmosphere in which it was alright to make mistakes and learn from them was important. Giving each other feedback At the end of the course all the participants could use the framework, but different levels of support were needed to complete a successful interview using Talking Mats: Four of the group could complete an interview independently and without prompts, remembering the five stages. (Each participant was given a symbolised prompt sheet to help them remember the stages see figure 2.) Two of the group could complete an interview with some prompts and support and with continued practice could achieve independent interviewing. Four people needed support to remember the individual stages but with that support could complete an interview using Talking Mats.

Figure 3 Completed Mat tening has been placed on the negative side, suggesting that the person did not feel that they had been fully listened to. The person also commented that the changes that had taken place since they had worked with their advocate had happened too slowly. On the positive side, the person was able to comment that they had been satisfied with their advocacy workers communication, time keeping and work and that they would use advocacy services again. This feedback was very useful for advocacy staff in terms of gaining more objective responses about their services. We have also discussed a sustainable interview procedure with the manager of Advocacy into Action to enable this to continue when the project is finished. There have been five clear outcomes to the project: 1. A training course suitable for people with learning disabilities has been designed and used. 2. Ten people completed the course and received certificates of achievement. There was considerable commitment to the course by all participants and evidence of significant personal development. 3. A customised interview schedule and symbol sets have been designed for use by Advocacy into Action. 4. The schedule and symbols will be used to give feedback and contribute to the quality assurance of the Advocacy into Action service. 5. Discussions will take place about use of the skills developed in the group with advocacy and local organisations through Falkirk and Clackmannanshire Council and NHS Forth Valley. We were confident that at least four of the participants would be able to use Talking Mats independently to interview people about their experience of using advocacy services. However, a number of issues have arisen while we have been supporting participants to carry out their first interviews, which will be important to note when planning future initiatives: People require support with many of the social aspects of starting and finishing an interview. Getting through the door and starting introductions involves a number of skills that our interviewers need help with. People who use Advocacy into Action have a range of learning disabilities. Not all people will be able to use Talking Mats, so information about potential interviewees is

We gathered participants views about the training on an ongoing basis and recorded the quotes used in this article verbatim as the training was carried out. All the participants seemed to get a lot from the training. Initially several seemed nervous and unsure, but this diminished over the first few sessions and their confidence appeared to build week on week. a) The participants appreciated the customised session programmes and handouts: If I did not have the notes I would forget; my memory is like a sieve. (John) b) The participants appreciated the way information was delivered: I like the way you explain it you make it easy, its not double dutch. (Julian) c) The participants felt they had changed and developed: I think we have all improved. (Michael) d) The participants reported practising and using Talking Mats outside the sessions: I was showing how to do Talking Mats with Jim. He thought it was brilliant and I showed him all about it. (Angela) e) We have some workers down at our projects and they dont understand what Talking Mats is all about and we do. (Stuart) These comments reflected the growing sense of self-esteem and feeling of achievement that developed among participants as the course progressed.

Involving people

The group developed the Advocacy Talking Mat, an interview tool which will be used to gain feedback on the advocacy service. They discussed and chose the symbols and then trialled them through interviews involving role play. This resulted in some honest discussion about the symbols which were chosen from Boardmaker and clip art. For example, participants were keen to ensure that the symbol chosen for independence reflected the concept for a wheelchair user as well as someone who was able to walk. Discussion about one of the symbols for communication resulted in the following comment: why has he got a fish bone coming out of his mouth? This reiterates the importance of involving people with learning disability in discussions about symbol selection for accessible materials. We have provided follow-up sessions to support the participants in carrying out real life interviews with people who have used the Advocacy into Action service. Figure 3 is an example of a completed Mat where someone is giving their views about their advocate. Here, symbols have been placed on both the negative and positive sides of the mat. Lis-

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USER INVOLVEMENT (4) / AAc

needed ahead of time. We have developed a pro forma which will provide information about peoples comprehension levels as well as vision, hearing and physical abilities. Consideration needs to be given to matching interviewers with the right interviewee. This will be done on a case by case basis through discussion with people who know the client well. For those who are not confident as interviewers, we are looking for projects to enable them to work in pairs so that they can continue to maintain and develop their skills. Overall, this project has been successful in terms of developing an interview schedule and symbol sets for using Talking Mats to find out peoples views of advocacy services. The process of teaching people with a learning disability to use Talking Mats was a rich experience for all involved and resulted in increased confidence for all participants: This group is great cause everybody gets involved. (Julian) It just shows what a lot of information you can get from such a small thing. (John) I was really scared at first. I nearly did not come the first time but I have enjoyed it and I can do Talking Mats now. (Corrine) Sally Boa and Lois Cameron are speech and language therapists at the AAC Research Unit, University of Stirling and NHS Forth Valley, e-mail sally.boa@nhs.net. SLTP

E-MAIL TO THE EDITOR

COMMUNICATION AIDS RESEARCH: Call for participation
Hi Avril, I would like to invite speech and language therapists to participate in a national survey being conducted as part of the Devices for Dignity (D4D) project. D4D is one of two pilot Healthcare Technology Co-operatives in England funded by the Department of Health. The D4D-HTC is a collaboration between clinicians, patients, academia and industry. It addresses issues of dignity and independence through its focus on the design, development and evaluation of medical devices to improve healthcare quality and well-being for patients with long-term conditions. One of the three themes identified in D4D is that of assistive technology. Of particular relevance for speech and language therapists is the Alternative and Augmentative Communication (AAC) project within this theme. The AAC project is being led by myself and Simon Judge, Senior Clinical Scientist with Barnsley Assistive Technology Team. We will be exploring users, carers and professionals perceptions of communication aid design. We aim to identify areas for improvement, future research and development in the design of communication aids. We are currently recruiting participants for the survey: 1. speech and language therapists with experience of working with clients who use aided communication 2. clients who use any form of aided communication (high tech, low tech, even no tech), or who have done so in the past, and 3. their carers. Clients can be of any age, medical diagnosis, language level and physical ability. Our only inclusion criteria are that they have an opinion about voice output communication aids (positive and negative views welcomed) and are able to complete a questionnaire with or without support from a carer. When our survey is complete we aim to disseminate the findings through a number of speech and language therapy / AAC channels and to share the information with communication aid manufacturers. If any readers would like to know more about D4D or are interested in participating in the survey, either by completing a questionnaire or by distributing questionnaires to clients and carers, you can do one of the following: go to http://www.devicesfordignity.org.uk/aac (to download the questionnaire after 1st April 2009) email your request and your contact details to alison.keys@nhs.net phone 01226 432159 to ask for further information or to request copies of the questionnaire. Stamped addressed return envelopes will be provided with the questionnaires. The questionnaires will be available as text, large print and symbolised (specify PCS or Rebus when requesting them). Thank you, Gill Townend Research Speech and Language Therapist, Sheffield PCT e-mail gill.townend@nhs.net

Acknowledgements

Our thanks go to Angela, Corrine, Debbie, Eddie, John, Julian, Michael, Ross and Stuart, who took part in this training course, for their enthusiasm and commitment. All photographs and quotes are used with permission from the participants.

Reference

SEAT Learning Disabilities Managed Care Network Making things clearer Group (2007) Guidance for making written information easier to understand. Edinburgh: NHS Scotland. Available at: http:// www.ldmcn.scot.nhs.uk/accessible_comms. htm (Accessed 20 January 2009).

Boardmaker - www.mayer-johnson.com/ Talking Mats www.talkingmats.com REFLECTIONS DO I INVOLVE CLIENTS IN SELECTING THE CONTENT OF ACCESSIBLE MATERIALS? DO I CREATE AN ATMOSPHERE WHERE PEOPLE FEEL COMFORTABLE WITH MAKING MISTAKES AND LEARNING FROM THEM? DO I ENSURE TRAINING HAS SUFFICIENT ELEMENTS OF FUN, FAMILIARITY AND NEW IDEAS?

Resources

10

SPEECH & LANGUAGE THERAPY IN PRACTICE spring 2009

Heres one I made earlier

Heres one I made earlier...

Friendship Bands

Alison Roberts has two low cost, flexible therapy suggestions to promote friendship.

This is a good way to bond and promote trust between a group of children or teenagers. They will be proud of the finished, personalised article, which they are making as a gift to another group member, so the social skills of giving and receiving are also practised. Girls are really keen on these items, but boys are fine with them too. This method is an adaptation of the complex knotted variety. MATERIALS Narrow white cotton tape (the narrowest you can find) Thick soft wool in many colours Red and black biros (or colours to suit) Scissors String PREPARATION a) The clients need to choose their four favourite colours of wool and cut off lengths of about 50 cms. They also need the same length of cotton tape. b) On the tape they write their own name in red biro and the other group members names in black. They will need to repeat the writing several times to fill the whole length. The superior version repeats this process on the other side of the tape, because as the band is made the tape will tend to fold in on itself, partly hiding some of the writing. c) Now they pass their tape and chosen wools to another person in the group this is the bit about trusting the potential friend. IN PRACTICE 1. The band is formed by plaiting. Use the tape as one of the three components and two pairs of wool lengths for the other parts. A loop is needed at one end of the band to form one half of the fastening when the band is worn, so tie this in at the beginning, poke some string through the loop, and use this to attach that end to the back of a chair to make the plaiting process much easier. Plait the three components together, stopping short of the end. (Some of the clients, especially the boys, may have no idea of how to plait, and dyspraxic clients may find it quite difficult. My advice is to let them do it themselves, taking their time over it, and give a little help here and there. The finished article must look good, otherwise the point about trusting others will be lost, so help out if you see a potential fashion disaster forming. If they find the plaiting really too difficult, another method would be to twist the lengths together tightly, so that they will double back on themselves and hold when the lengths are folded in half.) 2. Untie the string at the end of the band to free it from the chair, and measure around the wearers wrist. Make a knot at the end of the wrist measurement, and another one at the end of the whole thing, leaving a fringe at the end. 3. You should now have the following formation on each band: - a loop - a knot - a length of plait or twist to fit round the wrist - another knot - a free length of wools and tape - another knot - and a fringe. 4. Now the band is given back to the person who chose the colours and wrote their name in red on the tape. You may like to use this opportunity to encourage the clients to practise their presenting and receiving skills, maybe slightly exaggerating the thank you, and adding compliments. 5. To wear the band you push the fringe and free lengths through the loop, and tie off gently, using a knot that can easily be undone. Each client now has a personalised band, with the names of all group members on it, so they will find it easier to remember everyones names.

Fields of interest

A practical way of registering the interests and hobbies of clients in a college or school, so that they can meet others with similar ideas and potentially form new friendships. The clients names should be put on the register if they are happy to let people know that they have a genuine interest in an area already listed, or if they would like to start a new one. They should be prepared to accept that they might be unique in their interest. The clients will also learn the meaning of the expression field of interest. It is nice if the fields can be wall mounted but, if this is not possible, they could be in a notebook or file. MATERIALS The largest post-it notes you can get, or if you have a notice board or wall space you can pin or blu-tac ordinary paper up (green is the ideal colour if you can get it, as it is more field-like) A sheet of flip-chart paper to attach the fields to, and headed with the title Fields of Interest (or just Our Interests if you prefer) I have also found a plastic pocketed wall hanging for displaying postcards (obtainable from Habitat) more expensive, but neater and easier to move - you just buy blank postcards to put in the pockets. IN PRACTICE 1. Ask clients about their interests, and start a few of the lists, heading each post-it note with the name of the interest, fascination, or hobby. This could be anything from basketball to cookery, or a particular brand of music. If you are working with people on the Autism Spectrum be prepared for some unusual interests such as disposal skip firms, train timetables or a fondness for collecting electrical plugs. 2. Encourage the next group of clients to spend time thinking about the fields of interests sheets, and let them add their names or start new fields. 3. Once you have a pair or more of people with a shared interest you may find that they already know each other but had not discovered the similar interest. However, they may need to be introduced for the first time. 4. It will be up to the clients to decide how to proceed, for example whether they would like to have a trip together to an electrical supplier. It may be enough for them just to know that they are not alone in their unusual fascination or, on the other hand, that so far they are the one and only waste skip enthusiast.

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Clinical decisions

If at first you dont succeed

Liz Ackroyd undertakes a two part reflection on the variety of tools and techniques used over 12 months with a client with severe oropharyngeal dysphagia, and considers why they may or may not have contributed to what on first sight is very limited progress.
raditionally my role in the management of dysphagia on our rehabilitation unit has been a very familiar one: assess; diagnose; alter texture and, if appropriate, try compensatory techniques. This article describes the journey a client with severe oropharyngeal dysphagia and I took when traditional intervention did not work. I was very aware that this relatively young man and his family were faced with a devastating situation. Over the many months of my involvement, I used a variety of methods and tools to try to assist. While these are explained in more detail in part 2 of this article at www. speechmag.com/Members/, I will concentrate here on the clinical picture.

Part 1: When traditional techniques are not enough

READ THIS IF YOU ARE INTERESTED IN INTERVENTIONS THAT ARE NOT SUCCESSFUL BIOFEEDBACK TECHNIQUES A HYPOTHESISLED APPROACH

My client whom well call David - is a 46 year old male. He presented to his GP with a swollen tongue and choking on his food in January 2007. He subsequently deteriorated and was diagnosed with basilar meningitis and a left medullary infarct. He also suffered a cardiac arrest and was then intubated and tracheostomised on 28 January 2007. He was de-cannulated in May 2007. An ENT review at this time revealed good vocal cord mobility bilaterally, minimal hypopharyngeal secretions, and a normal larynx with reduced laryngeal and pharyngeal sensation on the left. David received regular speech and language therapy whilst in the acute hospital. Icing and compensations were trialled but his swallow remained unsafe for oral intake. In June 2007, David was transferred to the neurological rehabilitation unit. When I first saw him, clinical presentation included: damage to cranial nerves VII, IX, X, XI, XII dysarthria dysphonia (falsetto voice) poor lip seal inadequate nasopharyngeal closure

David

no laryngeal or hyoid movement residue in pharynx poor sensation unaware of bolus in pharynx ineffective cough poor secretion management frequently expectorating into a tissue left sided facial palsy (Sunnybrook Facial Grading System (Ross et al., 1996) score 4/100 ) upper limb ataxia loss of sensation poor proprioception adiadochokinesis (motor incoordination associated with cerebellar damage) poor fine motor control in his hands. The cerebellar signs were more apparent below the head and neck. David presented with a dysarthria but this was not an ataxic type. The overriding feature was his highpitched, strained / strangled voice. His speech was highly unintelligible except to very familiar listeners.

4. The lack of hyoid movement negatively impacted on the ability of the larynx to elevate and excurse. 5. Poor sensory feedback from the lips and cheeks, oral cavity and pharynx resulted in poor awareness of the bolus and the resulting blueprint provided by the medulla was ineffective. David had a dense lower motor neurone left sided facial palsy with mass over-activity on the right. The facial palsy had a significant impact on the intelligibility of his speech and his ability to achieve lip seal. As Trophic Electrical Stimulation aims to prevent or reverse changes associated with muscle atrophy, I used a Neuro4 trophic electrical stimulator twice daily with David in one hour blocks. I also introduced a variety of tools and resistive exercises to try to improve tongue movement and encourage better lip seal, and tried a number of compensatory strategies. The Trophic Electrical Stimulation (TES) and numerous oro-motor exercises trialled with David had a positive effect on the symmetry of his face at rest, the most notable difference being a reduction in the over-activity of the right side of his face. As therapeutic tools (FaceFormer; facialflex) encouraged David to rely too heavily on his stronger side to perform the activities required, they were discontinued. This overactivity on one side without initiating activity on the other could indicate that the muscles targeted were not in an adequate condition to respond to the active exercises and were therefore introduced too soon. David is however pleased with the improvement in his facial musculature and continues to use the TES with a view to reintroducing gentle exercises when the condition of his musculature has improved sufficiently.

Positive effect

I administered the Jays Observational Assessment of Dysphagia in Adults (Hibberd & Taylor, 2005) on admission. This guides the clinician through the process from referral to suggested treatment. The sections include case history taking, oro-motor abilities and clinical swallow assessments. It allows the clinician to take a hypothesis-led approach to the assessment and treatment of dysphagia. The hypotheses I formulated were: 1. Poor lip seal prevented the pressure being maintained to allow anterior-posterior transfer of the bolus cohesively. 2. Reduced rate, range, strength and co-ordination of the tongue muscles resulted in poor oral control of the bolus. 3. The suprahyoid muscles responsible for hyoid excursion and elevation were weak.

Hypothesis-led

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clinical decisions
I used the Sunnybrook Facial Grading system to provide a baseline and regular outcome measure for the use of TES and oro-motor exercises. The system provides a composite score of facial symmetry through a calculation which takes into account the symmetry of voluntary movement, resting symmetry and synkinesis of each movement (degree of involuntary contraction as a result of the nerve failing to switch off). A composite score of 100 indicates normal facial symmetry. Davids overall score increased gradually from 4/100 to 30/100 (25 July 31 December 2007). As the growth rate of a damaged nerve is approximately 1mm a day, this therefore appears to be an excellent outcome. The improved symmetry due to reduction in over-activity had a huge impact on his appearance at rest. The most notable change in active movement was closure of his eyelid rather than movement of lips. There was limited change in the scores for the other muscles targeted. There were flickers of movement of the risorious on the second set of measurements and during other sessions but these were not seen on the occasions the grading system was used. We used photographs to measure efficacy. The combination of TES and oro-motor exercises was the most likely explanation for the marked improvement in Davids lip seal following therapy. But, while lip seal was now functional for swallow, there was no improvement in Davids dysphagia, and the resistive tongue exercises had had no impact on elevation and excursion of the larynx. I gave David specific targets which were reviewed on a fortnightly basis to establish the efficacy of the sEMG. The first treatment goals were: 1. To reduce the length of time between introduction of the bolus and swallow initiation to 35 seconds per trial (baseline = 40 seconds). I delivered 2.5 mls of water via a syringe to the area just behind his lower front teeth. 2. To increase the amplitude of the peak of muscle activity to 75 micro volts on at least one swallow each session. The maximum peak at baseline was 50 micro volts. 3. To increase Davids level of satisfaction / enjoyment of swallow trials. This was measured using a self-rating scale, with 0% being unbearable and 100% being very enjoyable. 4. To decrease perceived level of struggle. A self-rating scale was given to David with 0% extremely difficult and 100% effortless. Initiation of the swallow sequence occurred within 10 seconds of the introduction of the bolus on each swallow attempt. As this improvement was noted from the first therapeutic use of the sEMG, it calls into question the validity of my baseline measure. Following four weeks of therapeutic input of one hour daily there was no change in the level of struggle David perceived with each swallow trial. The level of satisfaction David felt was variable throughout the therapeutic period but ranged between 40-60%. There were no occasions when the amplitude reached 75 micro volts. There was no increase in the differential between resting state and the amplitude during swallow attempts. The number of swallows trialled per session varied dependent on the level of fatigue and force and duration of coughing to clear the bolus, but the average was four. There were clinical signs of aspiration and / or penetration on each of the swallow trials using sEMG over the eight-week period. There is no easy access to objective measure of swallow within the rehabilitation unit and so there was no repeated FEES (Fibreoptic Endoscopic Evaluation of Swallowing) or videofluoroscopy. David continued to have a very productive cough which was more evident during swallow trials. He expectorated the bolus (and secretions) into a tissue. His management of secretions did not respond to any of the medical intervention (for example Hyoscine) and continued to be a cause of great embarrassment to him. He developed a chest infection but the team did not consider this to be aspiration. In light of his continued difficulties and lack of progress despite intensive intervention, continuing with sEMG was not appropriate. The key to the success of sEMG is the person engaging in specific behaviours to modify the usually unfelt and involuntary physiological process (Barofsky, 1995). I was aware that David was very passive during the entire rehabilitation process. The impact of this passivity on the outcome is unclear but it may partially explain the lack of success. There are no norms available for amplitude of EMG signal. The literature suggests a statistically significant difference between normals due to the differing amount of subcutaneous tissue each individual has and therefore it is not possible to state what amplitude is required for a safe and effective swallow. On reflection, utilising amplitude as a goal was an erroneous measure as the placement of electrodes is not an exact science (Steele, 2004). The EMG signal provides information to the client on their performance during that one session and is therefore not sensitive to how effective therapy has been. If David had been able to use a manoeuvre successfully following the implementation of sEMG, this would have indicated its effectiveness as a clinical tool. It was unclear which muscles were being measured during the therapy. sEMG proved to be an imprecise measurement of muscle function in the pharynx. There is no definitive answer within the literature as to whether this is important in the use of sEMG with clients with dysphagia, particularly when using it as an assessment tool. However I felt that this lack of precision had a knock-on effect on my ability to set realistic goals with David. The severe nature of Davids swallowing disorder, such that there was minimal laryngeal elevation at six months and again at twelve months after intensive rehabilitation, may indicate that the damage to the cranial nerves was too severe to make a perceptible change in the safety or effectiveness of his swallow. There are a number of reports of success with sEMG and dysphagia many months or years post-onset, and it is possible that this intervention was too early for him. David and his family reported that they had not been satisfied with the level of speech and language therapy input he had received and did not feel that I had tried hard enough. Working on the rehabilitation unit can be challenging due to peoples high levels of expectation and, when no change occurs, it is difficult for clients and their relatives to accept. However, I also wonder if there is anything else I should have tried. David has been referred for further intervention as an outpatient. There is, as yet, no change in his ability to manage his secretions or eat and drink. The lack of progress made with the traditional approach to dysphagia therapy with this client led me to undertake a thorough literature search to find a possible solution. The process of the development of the equipment and its use with the client has been invaluable and has added to my skills and those of the rest of the speech and language therapy team.

I undertook a literature review to see what other techniques might be utilised, and this raised the possibility of the muscle biofeedback tool called surface electromyography (sEMG). Clinical surface Electromyography (sEMG) biofeedback has been extensively utilised in other realms of physical rehabilitation and has proven clinical efficacy for a variety of disorders (Huckabee & Pelletier, 2003). In recent years interest in the application of sEMG in dysphagia rehabilitation has increased markedly. Using it during swallow can not only provide information on the timing and relative amplitude of selected muscle contraction patterns during swallowing, but it is also noninvasive, reliable, relatively inexpensive and easily learned by clinicians (Crary et al., 2004). It provides general information regarding the duration and amplitude of muscle activity during swallow which is displayed on a computer screen and provides immediate feedback to the patient. It provides instantaneous, performance-contingent feedback regarding the function of a physiological or psychophysiological system. It is an extension of the patients or clinicians senses (Kasman, 1994, p.67). In the neurogenic population there may be impaired proprioception and sensation and thus providing visible feedback may augment these systems. This was certainly the case with David.

Possibility

Unchanged

There was no perceptible improvement in effectiveness or safety of Davids swallow despite six months of speech and language therapy intervention. Laryngeal movement remained minimal. His performance on the Jays Observational Assessment of Dysphagia in Adults was unchanged from admission.

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CLINICAL DECISIONS

Critical Friends pilot

Following a suggestion from readers that Speech & Language Therapy in Practice should pilot a form of supportive peer review, two volunteers responded to a request for a retrospective critical friends appraisal of About a Boy by speech and language therapist Helen Francis and occupational therapist Joanna Lloyd.
This article appeared in our Autumn 08 issue (pp.12-14) and is now freely available at www. speechmag.com/Resources/Reprints. It tells the story of Mark John (14) who had profound and multiple learning difficulties, sensory defensiveness and severe communication difficulties. He was offered a collaborative Individualised Sensory Environment (ISE) programme with sensory integration techniques. The article explains how this opened the door to him reaching his potential. Deborah Green is principal speech and language therapist with Richmond Learning Disability Service, and Nicola Hayton is a speech and language therapist working with young adults with learning difficulties for the Together Trust in Stockport. Deborah commented that the article is a reminder of the excellent principles and practicalities of ISE which in my experience has inexplicably gone slightly out of fashion. She particularly liked the clear evidence the article provided of the effectiveness of cross discipline working and of highly structured action planning with clearly identified goals and measurable outcomes. The inclusion of information about a well designed and clinically valuable tool for recording observations was also welcome, and Deborah appreciated the opportunity to see how specific therapeutic interventions over the long-term had a positive outcome on the clients general communicative skills. She added that the challenge for readers is to find ways of replicating this work if they practice in less structured environments, or lack opportunities to offer joint, long-term input. Nicola Hayton also found it an inspiring article, which was interesting and relevant to her area of practice. It was particularly welcome as she feels there is so little written about and published in this field. Although it was very sad, it was good to hear that people make a great effort to reach out to and support the potential of a young person with such profound and complex learning and physical disabilities. Nicola shared the article with her occupational therapy colleagues who, like her, found it supportive of the work they already do. For Nicola time is however the major limitation for this kind of practice. If you would like to comment on any article as part of the critical friends pilot, please contact editor Avril Nicoll, e-mail avrilnicoll@speechmag.com for more information.

A large number of questions are left unanswered. There is limited evidence as to which particular client groups benefit from sEMG in the rehabilitation of their swallow and a paucity of information regarding those for whom it has been unsuccessful. Is some degree of laryngeal elevation and swallow sequence necessary before commencing sEMG? There is no clear protocol for the timing and frequency of use of this method of dysphagia treatment. It is also unclear how quickly results would be seen if this technique was beneficial to the client. The published research suggests that improvements are rapid and that oral intake should be recommenced in week one if possible. Are there client groups who need a much longer period of input to improve their swallow? We continue to use sEMG on the unit, and are evaluating further its efficacy as a therapeutic SLTP tool for neurological dysphagia. Liz Ackroyd is a speech and language therapist with South Birmingham Primary Care Trust, email Elizabeth.Ackroyd@sbpct.nhs.uk. Part 2 of this article (Tools of the trade) is at www.speechmag.com/Members/.

Unanswered questions

Crary, M.A., Carnaby, G.D, Groher, M.E & Helseth, M.A. (2004) Functional Benefits of Dysphagia Therapy Using Adjunctive sEMG Biofeedback, Dysphagia 19, pp.160-164. Hibberd, J & Taylor, J (2005) Jays Observational Assessment of Dysphagia in Adults. Quest Training UK: www.quest-training.com. Huckabee, M.L & Pelletier, C.A. (2003) Management of Adult Neurogenic Dysphagia. New York: Thompson. Kasman, G.S. (1994) Surface EMG recording technique: A primer Physical Therapy Products Vol. 5(4) p.67. Ross, B.G., Fradet, G. & Nedzelski, J.M. (1996) Development of a sensitive clinical facial grading system, Otolaryngol Head Neck Surg 114, pp.380-386. Steele, C. (2004) Treating Dysphagia with sEMG Biofeedback, The ASHA Leader, p.2,23. Available at: http://www.asha.org/about/publications/ leader-online/archives/2004/040720/040720d. htm (Accessed 19 January 2009). REFLECTIONS DO I HAVE A REALISTIC EXPECTATION OF HOW PROGRESS MAY BE INFLUENCED BY UNDERLYING PATHOLOGY? DO I CONSULT THE LITERATURE AND COLLEAGUES TO DISCOVER NEW TREATMENT METHODS? DO I BEAR IN MIND THAT THE TIMING OF INTERVENTION CAN BE AS SIGNIFICANT AS THE QUALITY? What do you find helpful in long-term rehabilitation? Let us know via the Spring 09 forum at http://members.speechmag. com/forum/.

Acknowledgements References

Thank you to my client for allowing me to share this information and to my colleagues for their support.

Barofsky, I. (1995) Surface Electromyographic Biofeedback and the Patient with Dysphagia: Clinical Opportunities and Research Questions, Dysphagia 10, pp.19-21.

CRITICAL FRIENDS This article has been considered by Penny Gravill, specialist speech and language therapist at Aberdeen Royal Infirmary and The Lindens Clinic, Aberdeen. Penny says: It has been a pleasure to see such innovative and dedicated reflections of work. I think however that Liz is too hard on herself as she did a great deal. As she says, regrowth of a damaged nerve is 1mm a day and, in the time that she was recording change, there was noticeable and charted improvement. The imbalance and over-dominance of the undamaged side has to be reversed as well as the atrophy of the damaged side in order to restore the muscle tissue to optimum physiological condition. This takes time; improvement is over years not months in many more severe cases. Only when this has been achieved can movement patterns be encouraged. In Davids case, it wasnt only an isolated nerve pathology but complex and severe damage involving several nerves and parts of the brain itself, so a quick result was improbable and what was achieved over the months of treatment may well be the stepping stones to further recovery. It sounds as if Liz had a lot of pressure on her from relatives to get results. However, medullary involvement can be slow - and may not recover at all. It is important that a poor prognosis is discussed with patients and relatives, to educate them about the slowness of recovery and to use any positive signs of progress, however small, as the groundwork for working on other goals. It is also important to be aware that the principle of biofeedback cannot be fulfilled without full patient participation, so this clients passivity throughout the rehabilitation process seems significant. I have clients particularly elderly ones who cannot cope with sEMG, so it is not a useful tool for them. It is worth noting that the research literature uses very cognitively able and motivated patients. See Gravill, P. (2007) Face value, Speech & Language Therapy in Practice Summer, pp.20-21. Now available at www.speechmag.com/Members/.

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audit

A lot of hot air?

In spite of academic controversy and a lack of evidence of effectiveness, non-speech oral motor and respiratory exercises are commonly included in therapy programmes. Deirdre Cosgrave, with the support of Jill Titterington, conducts a preliminary audit in a language unit to see if sucking and blowing games can improve phonology in children with moderate phonological / articulation difficulties.
L-R Deirdre and Jill ll pupils attending the language unit where Deirdre works have a specific language disorder. Some of them also have a phonological disorder with a motor component, which we refer to here as phonological / articulation difficulties. We decided to conduct a preliminary audit of current practice to see if there was a significant association between improvement in sucking and blowing ability and phonological skills in these children. The results give indications for the direction of future research and we draw tentative conclusions for practice. A. RATIONALE Many speech and language therapists have been trained in and use non-speech oral motor and respiratory exercises in their treatment of a wide range of speech sound difficulties in children (Lof & Watson, 2008). However, there has been a great deal of vocal academic discussion around the value of such exercises for the treatment of speech sound difficulties (see for example Bowen, 2005; Clark, 2003) and the consensus is that there is little - if any - good quality research to support their use. Furthermore, the theoretical underpinnings of such an approach for treating speech sound difficulties are far from sound (Clark, 2003). Indeed, the collective opinion of authors contributing to a recent clinical forum into oral motor exercises for the treatment of speech sound difficulties in children suggests that this treatment should be viewed as experimental and, as such, should only be carried out on children with the informed consent of their parents / carers (Powell, 2008a; Ruscello, 2008; Lof & Watson, 2008; Lass & Pannbacker, 2008; Powell, 2008b). Despite this, oral motor therapy (with an emphasis on sucking and blowing) has become a popular supplement to treatment for many speech and language therapists in their approach to children with speech sound difficulties. This is not an unusual state of affairs; Joffe & Pring (2008) looked at current practice in the treatment of children with speech sound problems throughout the UK and READ THIS IF YOU WANT TO KNOW WHAT IS WORKING BACK UP PRACTICE WITH EVIDENCE PROMOTE CLINICAL / ACADEMIC COLLABORATION

found that clinicians tended not to be influenced by the current evidence-base in their choice of therapeutic intervention. Indeed Lof & Watson (2008) found that, out of 537 speech and language pathologists surveyed across America, 85 per cent used non-speech oral motor exercises as part of their treatment regimen for children with speech sound difficulties. As Bowen (2005) emphasises, the glossy advertising, fun toys and passionate self-report of trainers in the area of oral motor therapy for speech sound disorder easily convince the speech and language therapist to at least try this approach out. Research into the treatment of mild to moderate speech sound delay shows that a range of therapeutic approaches do work (Gierut, 2001; 1998; Joffe & Serry, 2004). However, it seems that as speech sound delay becomes more severe and disordered things are not quite so straightforward. Recent research suggests that the heterogeneous nature of more severe speech sound problems means that some therapy approaches may be more effective than others depending on the underlying levels of breakdown (Stackhouse & Wells, 1997; Dodd & Bradford, 2000; Dodd et al., 2004). As a consequence of this, busy speech and language therapists often adopt an eclectic approach to the treatment of these more complex speech sound difficulties. The toolbox of therapeutic interventions is often a mixture of approaches that are both evidence-based (such as minimal pairs therapy) and non-evidence-based (for example, oral motor therapy) (Joffe & Pring, 2008). Our audit therefore looks at current practice in a language unit for children with specific language disorder. We investigated the association or otherwise between suck / swallow / breathe ability and speech sound skills for a group of children presenting with moderate phonological / articulation disorder. B. METHOD 1) Participants There are four classes in the Language Unit, each consisting of 10 children and serviced

by 1.3 speech and language therapy wholetime equivalents. We selected children with phonological / articulation disorder from primary one and two (n = 12, age range = 57 years). They all had some degree of difficulty with sucking and blowing activities but only one had had previous therapy involving sucking and blowing exercises. 2) Procedure a) Assessment of phonology The class teachers assessed the degree of phonological impairment using six different levels from very severe (0) to age appropriate speech (5) adapted from the outcomes measurement drawn up by Enderby et al. (1998) (see table 1).
Table 1 Severity ratings for participants phonological impairments (0 = severe, 5 = age appropriate) Participant A B C D E F G H I J K L Severity Rating 1 1 3 2 2 4 2 3 4 4 2 3

Based on Fletchers (1972) criteria for diadokinetic rates, none of the children were able to sequence speech sounds within the age ranges expected. These results indicate that all participants had a degree of oral motor sequencing problems (although three of them had a relatively mild score on the severity rating scale). b) Assessment of sucking and blowing abilities Deirdre made informal pre-treatment measurements of each childs sucking and blowing abilities (table 2, p.16). They involved the following: i. Length of time (in seconds) taken to suck

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AUDiT
up and transfer 5 cardboard circles from one plate to another (2 cms in diameter and mm thick). ii. Length of time (in seconds) taken to suck up and transfer 5 Maltesers from one plate to another. iii. The amount of yoghurt (petit Filous) sucked up a straw 70 cms long and cm wide within 60 seconds. iv. The distance (in cms) a dart was blown from a blo-dart (3 cms in diameter and 50 cms in length). it is important to note that iiii all look at the strength and sustainability of sucking while iv looks at blowing / forced expiration. c) Treatment provided Treatment involved training and practice on all the skills assessed using a range of sucking and blowing activities and oral motor toys (whistle stop Therapy resources). Deirdre carried out these activities once a day, three days a week over a six month period in the school setting. The aim of this therapy was to increase the strength and sustainability of sucking and blowing. According to the rationale provided for this approach, this aims to increase the physiological / respiratory support and sensorimotor planning and programming necessary for speech resulting in improved intelligibility (van der walt, 2006). Additionally, Deirdre invited the parents of the children to attend a teaching / advice session on the use of sucking and blowing techniques for developing strength and range of movement in oral musculature. she demonstrated a range of activities using a variety of blowing toys (whistles, blo-darts, straws, kazoos) and sucking games. she gave a list of the types of toys and objects useful for developing these skills to each parent and actively encouraged them to practise these activities as often as they could during the week at home. This audit did not evaluate the extent to which the sucking and blowing activities were carried out at home, which would be useful to consider in future investigations. The children also all received a typical direct eclectic speech and language therapy approach towards phonological treatment which included minimal pairs work and auditory training (Joffe & pring, 2008). This was provided within 1:1 therapy sessions and class group sessions two to three
Figure 1 Length of time taken to suck up and transfer 5 cardboard circles
120 100
pre-treatment post-treatment

Table 2 Informal pre-treatment sucking and blowing measures Participant Sucking cardboard Sucking Maltesers (secs) circles (secs) Pre Post Pre Post A 66 14 100 29 B 33 12 100 42 C 31 12 100 60 D 100 15 100 23 E 34 18 100 100 F 100 100 100 100 G 16 15 100 100 H 18 10 60 100 I 100 12 100 27 J 31 21 100 60 K 21 12 100 60 L 18 16 100 100 Sucking yoghurt (cms) Pre 35 15 18 21 64 17 85 79 51 43 30 19 Post 30 22 35 48 55 37 170 100 60 38 37 130 Blowing distance (cms) Pre Post 100 125 75 150 0 150 100 125 100 175 0 200 150 200 200 200 100 150 150 200 0 175 0 200

Note. For cardboard circle and Malteser sucking we allocated a value of 100 seconds to those children who were unable to attempt the task. Table 3 Comparison of means for pre and post-treatment measures p-values obtained from Wilcoxon Signed Ranks Test (2-tailed) Severity rating for phonological impairment .02 p < .05 Sucking cardboard circles .003 Sucking Maltesers .03 Sucking yoghurt .02 Blowing blo-dart .003

times a week. Deirdre repeated the same measures noted above (both phonological severity ratings and informal sucking and blowing tasks) at the end of the therapy period. C. RESULTS statistical comparison of means (wilcoxon signed ranks Test) of pre and post-treatment measures showed that there was a significant improvement in all measures after therapy, including the severity rating of the phonological impairment (table 3). Figures 1 to 4 show the pre and post-treatment scores for each sucking and blowing measure. The length of time taken to suck the target for cardboard circles and Maltesers got less as children got better at the skill, while the distance of yoghurt sucked and the length the dart could be blown increased. These results suggest that therapy for the sucking and blowing tasks improves performance on these skills. They also show that severity of phonological impairment decreased signifiFigure 2 Length of time taken to suck up and transfer 5 Maltesers
120 100
pre-treatment post-treatment

cantly within the pre to post-treatment periods. it is important to keep in mind that these children all received a more direct eclectic approach to the treatment of their phonological difficulties alongside the sucking / blowing exercises. To see if there was an association between any of the sucking and blowing activities and improved phonology, we ran spearmans correlations between the five variables outlined in table 3. A significant association was found between the severity rating for phonological impairment and the distance of blowing the blo-dart [p = .04], but not for any of the other variables (which all involved sucking activities). There was a degree of variability in improvement made on the blo-dart blowing task which ranged from no improvement (by one child who had received therapy for sucking and blowing previously and who produced a blowing performance of 200 cms for both pre- and post-tests) to an improvement of 200 cms by two children who were unable to blow the blo-dart for the baseline measure at all. when we re-ran spearmans correlations excluding the outlier who scored 200 cms pre and post
Figure 3 The amount of yoghurt sucked up a straw within 60 seconds
200 180 160 140 120 100 80 60 40 20

Amount of yogurt in cms

Time taken in seconds

80 60 40 20 0

80 60 40 20 0

Note. A value of 100 seconds was allocated to those children who were unable to attempt the task.

A B C D e F g H i J K L participants

A B C D e F g H i J K L participants

Note. A value of 100 seconds was allocated to those children who were unable to attempt the task.

A B C D e F g H i J K L participants pre-treatment post-treatment

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AUDiT
treatment, a decrease in significance to [p = .08] was found. This is still a trend in the same direction, but indicates that this association needs further investigation with larger numbers and a more homogeneous group. D. ANALYSIS As a small scale, preliminary audit there are many limitations which must be noted. This was an audit of current practice rather than a research study so there was no control group. All the children receiving therapy for phonological impairment were included and therefore heterogeneity of the condition was not controlled by inclusion / exclusion criteria. The additional direct phonological therapy provided will have influenced improvement in phonological impairment. Limitations not directly associated with this study being an audit rather than research are that there were very small numbers which reduced the power of the findings, and also there was notable variability in performance on the informal measures used to assess sucking and blowing ability. This variability may have been related to the nature of the informal assessments used and it would be important to evaluate how to measure these skills more accurately in future studies. Variability may also have been due to the heterogeneous nature of the group and this would also need to be controlled for in future studies. Despite this, the audit has provided some interesting preliminary findings. notably there was a significant improvement in all the measures post-treatment. while we know that conventional direct therapy for phonological impairment works, and this may explain the decrease in phonological severity noted, the finding showing a significant association (or at the least a trend in that direction) between improvement in blowing ability and phonological skills is interesting. This clearly warrants further investigation through a research study using larger numbers, a more homogeneous group, more accurate blowing measures, and control group/s. This link between blowing and phonological severity may indicate that some children with phonological impairment have problems with control of expiration associated with their difficulties. while keeping the limitations in mind, it is possible to draw some tentative conclusions for clinical practice. The use of sucking and blowing exercises
Figure 4 The distance a dart was blown from a blo-dart
250 200

to support the direct treatment of phonological difficulties should be treated with caution. sucking exercises in particular should be considered very carefully in relation to each childs specific needs before incorporating them into therapy plans. On the other hand, developing blowing skills, in particular focusing on improving the force of exhalation and the ability to grade airflow, may be helpful for some children. Activities such as blow football, blo-darts and those that encourage prolonged production of sounds such as /s/, /z/ or /a/ could improve respiratory support for speech and possibly help children with phonological impairment improve their ability to grade airflow for speech production although, of course, the value of blowing exercises for improving phonological difficulties will need to be corroborated by conclusive, well-developed research.

Deirdre Cosgrave is a speech and language therapist with Western Health and Social Services Trust in Derry, e-mail deirdre.cosgrave@gmail.com. Dr. Jill Titterington is an associate lecturer in speech and language therapy at the University of Ulster, Jordanstown, e-mail j.titterington@ulster.ac.uk. Acknowledgements Thanks to the children, their parents and their teachers from woodlands Language Unit in Derry who participated in this audit. Thanks also for the support of Una isdell, the speech and Language Therapy Team Leader in western Health and social Care Trust for facilitating this project. SLTP reFLeCTiOns DO i see THe VALUe OF OBTAining sUperVisiOn AnD sUppOrT FOr CArrYing OUT AUDiT? DO i Use AUDiT TO eXAMine MY prACTiCe AnD iDenTiFY CLiniCAL reseArCH QUesTiOns? DO i eXpLAin TO CLienTs wHen AnD wHY i AM Using THerApY THAT is eXperiMenTAL?

150

100 50

References Bowen, C. (2005)what is the evidence for.? Oral motor therapy, Acquiring knowledge in speech, language and hearing 7(3), pp.144-147. Clark, H.M. (2003) neuromuscular treatments for speech and swallowing: A tutorial, American Journal of Speech-Language Pathology 12(4), pp.400-415. what have you learnt about your practice Dodd, B. & Bradford, A. (2000) A comparison from audit? Let us know via the spring of three therapy methods for children with 09 forum at http://members.speechmag. different types of developmental phonological com/forum/. disorder, International Journal of Communication Disorders 35(2), pp.189-209. Dodd, B., Crosbie, s. & Holm, A. (2004) Core Vocabulary: Intervention for children with inconsistent speech disorder. Australia: perinatal research Centre. enderby, p., John, A., sloane, M. & petherhem, B. (1998) Therapy Outcomes: Speech Language Pathology. London: singular publishing group. Fletcher, s.g. (1972) Time-by-count Measurement of Diadokinetic rate, Journal of Speech and Hearing Research 15, pp.763-770. gierut, J.A. (2001) Complexity in phonological Treatment: Clinical Factors, Language, Speech & Hearing Services in Schools 32(4), pp.229-241. gierut, J.A. (1998) Treatment efficacy: Functional phonological disorders in children, Journal of Speech, Language, and Hearing Research 41(1), pp.s85-s100. Joffe, V. & pring, T. (2008)Children with phonological problems: a survey of clinical practice, International Journal of Language & Communication Disorders 43(2), pp.154-164. Joffe, B. & serry, T. (2004)The evidence base for the treatment of articulation and phonological disorders in children, in reilly, s., Douglas, J. & Oates, J. (eds.) Evidence based practice in speech pathology. London: whurr publishers, pp.258-285. Lass, n.J. & pannbacker, M. (2008) The application of evidence-based practice to nonspeech oral motor treatments, Language, Speech & Hearing Services in Schools 39(2), pp.408-421. Lof, g.L. & watson, M.M. (2008) A nationwide survey of nonspeech oral motor exercise use: implications for evidence-based practice, Language, Speech & Hearing Services in Schools 39(2), pp.392-407. powell, T.w. (2008a) The use of non-speech oral motor treatments for developmental speech sound production disorders: interventions and interactions, Language, Speech & Hearing Services in Schools 39(2), pp.374-379. powell, T.w. (2008b) An integrated evaluation of nonspeech oral motor treatments, Language, Speech & Hearing Services in Schools 39(2), pp.422-427. ruscello, D.M. (2008) nonspeech oral motor treatment issues related to children with developmental speech sound disorders, Language, Speech & Hearing Services in Schools 39(2), pp.380-391. stackhouse, J. & wells, B. (1997) Childrens Speech and Literacy Difficulties 1: A Pyscholinguistic Framework. London: whurr. van der walt, C. (2006) Oral-Sensory-Motor & Respiratory Experiences. 2 Day workshop. Centre for CpD for Allied Health professsions, Clady Villa, Knockbracken Healthcare park, Belfast, n.ireland, 19-20 June. Resources / Maltesers, www.maltesers.com petit Filous, www.petitfilous.co.uk Toys used for the sucking and blowing activities were obtained from the whistle stop Therapy resources starter kit (15 per pack), 7 Almshouse, st Monmouth, Monmouthshire np25 3De, e-mail joanna.collins3@btinernet.com.
SPEECH & LANGUAGE THERAPY IN PRACTICE spring 2009

A B C D e F g H i J K L participants pre-treatment post-treatment

Distance blown in cms

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in brief

In Brief is supported by

Speed of sound
Lynn Griffiths explains a child-friendly visual representation of speed / pace of speech. Aim: To encourage a child to speak at a reasonable pace. Materials: A3 sheet of paper and crayons. Activity:
Explain: Sometimes you talk too fast for me to understand what you say. We are going to draw a picture so you can talk at a slower speed. Ask child to think of something they can draw to show speed. Go with the childs likes What about a train / plane / horse? Divide A3 into thirds. We are going to draw the same picture 3 times. Ask: How are we going to show how fast they are going? They might draw speed lines out the back of the train or a horse walking / trotting / galloping. Then say Lets put some numbers on here to say how fast they are going. What would be the fastest / slowest number? What number would be a good in-between number? They might need help to get a realistic in-between number (which is the important number). Then demonstrate talking at the fastest, slowest and in-between speeds. Children love this because its funny. Encourage the child to practise each speed. Find a nursery rhyme that they know and ask them to repeat it. Praise for remembering it and then practise it at the different speeds. Always finish on the target in-between speed. Photocopy their picture or make similar on computer, laminate it and give to all involved with explanation on how to use it (put tick above in-between number). Use it during sessions as a flashcard reminder to develop selfmonitoring / correction. For ownership the child needs to decide content of the picture. Numbers can go into the thousands; you just allocate the pace of speech to each number. Although there is no visual resemblance to my original sources of inspiration, I had two starting points: 1. The idea for rate / volume / fluency / clarity / intonation came from Talkabout (A social communication skills package) by Alex Kelly (p.48). Its format is cartoon drawings and writing - you discuss components of speech / conversation and write down how you think you cope with them using a smiley chart. 2. The idea of scaling came from Solution Focused Brief Therapy. As they were, both of these were too abstract for my client group to understand, so they morphed into a more child-friendly presentation. Lynn Griffiths is an independent speech and language therapist in Northampton.

In Brief is a new section of Speech & Language Therapy in Practice for 2009 suggested by readers to showcase short, practical ideas. One lucky contributor in each issue will receive 50 in vouchers from Speechmark, a company which publishes a wide range of practical resources for health and education professionals working with people of all ages (visit www.speechmark. net for more information). Brief items (250-500 words) may include therapy or assessment tips or a description of a resource you have developed. It may also be a reflection on the best piece of advice I have been given, or the things I wish theyd told me at University. Although what you write will be substantially your own work, please acknowledge any influences. E-mail your entries to avrilnicoll@speechmag.com.

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SPEECH & LANGUAGE THERAPY IN PRACTICE spring 2009

WINNING WAYS

A timely consideration
A survey sent out to a sample of Speech & Language Therapy in Practice readers included an open question about which concerns they would most like life coach Jo Middlemiss to address. Winning Ways 2009 is based on their responses, beginning with four Ms to help us stand the test of time.
esponses to the survey of readers show you are concerned about your work / life balance, coping with stress and pressure and most of all - managing your time. Many readers mentioned the stresses of juggling all of lifes concerns like an expert - or not so expert circus act. We so often choose this metaphor or the metaphor of spinning plates, an equally stressful, panicky and anxiety-laden way to look at things. I imagine that many of you have attended time management workshops or read books or magazine tips to bring time under command. My grandmother, who lived with us until her death at 99, always referred to time as The Enemy. She certainly had enough of it to consider, and I wonder how much of her view I subconsciously imbibed. Then there was my fathers constant cry, Procrastination is the thief of time!

READ THIS IF YOU WANT CALMER THOUGHTS ELASTICITY OF TIME TO BE IN CHARGE OF YOUR DAY

not in charge of me. While you will never be in charge of time because it doesnt really exist, a shift of perception causes a shift in thinking. You are the puppeteer and not the puppet. 4. Minimisation People with panic in their heart are often exaggerating or catastrophising a situation, but that process can be reversed. On your computer you can minimise a document that you are not working on. Itll wait until you bring it back into play. So minimise the things you cant get to. They wont get lost or forgotten. When you can get back to them, put them back up on a full screen and take action.

A different angle

I wonder what you happen if you considered time from a different angle? Despite our clocks, calendars and deadlines, time is actually an illusion. It is simply a way that man devised in an attempt to regulate life. We are all familiar with a two week holiday seeming like a day, or looking for a lost child when five minutes seems like a lifetime. Or a pregnancy feels like an age and a childhood goes by in a flash. My point is that the way we see the problem very often is the problem. If our life is visualised like spinning plates, it will seem frantic. If, on the other hand, we see it as a game of billiards, it instantly feels calmer, still and rescue-able. The balls will wait until we choose to make the move. If we make a mistake they will only fall into a pocket. They wont roll away into oblivion. It might help to consider one or more of these four Ms: 1. Meditation Meditation may seem to many people like a waste of time if they see it as sitting doing nothing with an empty mind. But it is very far from that. When you start your day with even a tiny bit of meditation, time takes on an elastic quality. Because you have started your day with this small attempt at mind resting, I guarantee you will start to think about time differently. That time will be even more effective if you spend part of your stillness visualising the day going well, according to plan, and with some time left over for you.

This poem (author unknown) is said to be an adaptation of an old Irish prayer. It puts time into a different perspective. Nothing is so important that your mental and physical health should suffer. A broken you is no help to any situation. Balance and perspective, and peace of mind and body, are all essential for you to be an effective and professional member of society. 2. Mediation The first person to mediate with is yourself: your need to take on too much, your ability to use time in a wasteful way and your ability to beat yourself up for not keeping up with the job. After the conversation with yourself, you need to have conversations with the people who attempt to solve their time problems with your life. You can learn to say no with firmness, sweetness and genuineness. And you can be effective without being a people pleaser. 3. Manipulation This is a thought I havent picked up from books or other people, so I am running it by you as an experiment. Clients have said to me that their days would be great if things they werent expecting didnt suddenly come in and take over. What if we play a secret game of manipulation of our 24 hours? Three goes into twenty four eight times. Think of the day in eighths. Every day only plan to use seven eighths and keep back one eighth as a spare bit. A bit just for you, or for those unexpected things that suddenly need attention. Speak to yourself in a way that gives you a feeling of authority: The hours of this day are mine to allocate. I am in charge of my day. The day is Take time to work, It is the price of success. Take time to meditate, It is the source of power. Take time to play, It is the secret of eternal youth. Take time to read, It is the way to knowledge. Take time to be friendly, It is the road to happiness. Take time to laugh, It is the music of the soul. And take time to love and to be loved.

Perspective

Jo Middlemiss is a qualified Life Coach who offers readers a confidential complimentary half hour coaching session (for the cost only of your call), tel. 01356 648329. Her book with CD What should I tell you? A Mothers final words to her infant son is now available.

SPEECH & LANGUAGE THERAPY IN PRACTICE spring 2009

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THIS HOUSE BELIEVES

OUR NEW SERIES AIMS TO DEVELOP YOUR SKILLS FOR CRITICAL APPRAISAL MAKING DECISIONS EVIDENCE BASED PRACTICE

This House Belie

The Proposition case: Botox makes sense
Adductor spasmodic dysphonia is a focal laryngeal dystonia that adversely effects the normal contraction of muscles used to adduct (close) the vocal folds (Baylor et al., 2007; Hogikyan et al., 2001; Wingate et al., 2005). The abnormal contraction causes excessive spasms that lead to voice stoppages and / or a strained-strangled vocal quality (Hogikyan et al., 2001; Wingate et al., 2005). The cause of adductor spasmodic dysphonia remains unknown; although it is widely accepted to be neurological, some authors believe that there may be emotional factors involved (Anari et al., 2007). People with the condition have reported adverse effects on job performance and reduced social interactions (Baylor et al., 2007; Wingate et al., 2005). Use of botulinum toxin injection is generally regarded as the primary pharmacological treatment. Botulinum toxin, a neurotoxic protein, blocks the release of acetylcholine, which subsequently paralyses the muscles near the injection site (Anari et al., 2007). Although numerous studies have supported the efficacy of such treatment, concerns regarding the methodological quality of these studies and potential for harmful side effects are only recently being debated in the literature. Speech and language therapists are frequently involved in the care of people with adductor spasmodic dysphonia. Should clinicians advise and encourage these clients to receive botulinum toxin injections? Localised injection of botulinum toxin causes temporary chemical denervation of the injected laryngeal muscle (Wingate et al. 2005). Dysphonic symptoms such as hoarseness, strain and breathiness may be improved due to the reduction of laryngeal spasm (Baylor et al., 2007). Symptom relief can provide improvement in quality of life for people with adductor spasmodic dysphonia according to the World Health Organisation model. The World Health Organisation encourages evaluation from the perspective of the person with the disability in order to understand issues related to social participation and quality of life (Baylor et al., 2007). People with adductor spasmodic dysphonia report adverse effects on social interactions and job performance. Qualitative methods evaluating the use of Botox (Botox; Allergen, Inc., Irvine, CA) injections on clients psychosocial well-being allow for a patientauthentic view in the context of their daily lives (Baylor et al., 2007). Baylor and colleagues (2007) interviewed 6 adults receiving Botox injections on a long-term basis. All 6 reported improvement in voice quality after receiving injections, including some

Kendrea Focht and Paula Leslie debate the motion that speech and language therapy clinicians should advise clients with adductor spasmodic dysphonia to receive botulinum toxin injections.
This House Believes explained
In her teaching, Paula Leslie uses a debating idea from the British Medical Journal to get her students to critically review a controversial subject. By understanding the strengths and weaknesses of the arguments on both sides, the students are better prepared to develop their own views. Students are strictly limited in word count and number of references to foster concise and relevant writing. Their work is now being adapted for Speech & Language Therapy in Practice. The debating format means: the Proposition is required to prove its case, while the Opposition aims to show why the Proposition is wrong either side can interrupt with a point of information while the other side is speaking our authors reach a conclusion based on the evidence and readers can continue the floor debate at the forum: http://members.speechmag.com/ forum/.

Defining the topic

who reported that their voice had returned to normal during the time the treatment was maximally effective. Some also reported improved participation within social and community activities but details on exactly how many were not reported. POINT OF INFORMATION: Although the interviews were guided around three general questions regarding their experience with Botox injections, it is unclear how many interviewers were involved. The authors also did not disclose how the interviews were verified to determine if phenomenological guidelines for conducting qualitative research were followed.

Overwhelmingly positive

Symptom relief

Nonetheless, this is one of the few studies that attempted to understand the impact of Botox intervention on quality of life. The results were overwhelmingly positive. Hogikyan and colleagues (2001) also examined the effects on quality of life. Twentyseven clients completed the Voice-Related Quality of Life Measure (V-RQOL) (Hogikyan & Sethuraman, 1999) prior to their first Botox injection and were then reassessed 6-8 weeks later. This cycle was repeated prospectively for each subsequent injection during an 18month period (Hogikyan et al., 2001). V-RQOL is a validated and reliable self-reported measure that has been shown to be responsive to change in a variety of populations, although Hogikyan and colleagues never mentioned whether the V-RQOL had been validated on people with adductor spasmodic dysphonia. The researchers found that, prior to injection, V-RQOL scores were significantly lower then the published normative data (approximately 70 points) (Hogikyan et al., 2001). Participants scores significantly improved from pre-treatment to post-treatment for each subsequent injection, although the magnitude of the treatment effect was significantly less after the second injection.

Summing up the case for the proposition

Kendrea

Paula

Kendrea L. Focht is a clinical fellow in the medical speech-language pathology clinical doctoral program at the University of Pittsburgh, USA, e-mail klf59+@pitt.edu. Paula Leslie is Associate Professor, Communication Science and Disorders at the University of Pittsburgh, USA, e-mail pleslie@pitt. edu. Paula is also a specialist advisor in swallowing disorders for the Royal College of Speech & Language Therapists.

In conclusion, the studies reviewed have shown significant and dramatic improvements on participants quality of life after receiving Botox injections. As clinicians, we have an obligation to encourage botulinum toxin injections so that our clients can improve their social participation and overall quality of life.

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SPEECH & LANGUAGE THERAPY IN PRACTICE spring 2009

THIS HOUSE BELIEVES

eves in Botox
Clinicians should not advise people with adductor spasmodic dysphonia to receive botulinum toxin injections. Botulinum toxin injections offer the possibility (not a guarantee) for temporary improvement. There have been some concerns with introducing a toxin into a clients body. Those who have received injections report post treatment symptoms such as swallowing difficulties, inability to speak, swelling / soreness at the injection site, breathy vocal quality, burning sensation, and irritation (Fisher et al., 1998; Galardi et al., 2001). Clinicians need to be aware of the harmful side effects of botulinum toxin, especially when the failure rate of treatment is one in three (Galardi et al., 2001).

The Opposition case: insufficient evidence

Placebo effect
As discussed, studies have demonstrated improvement in patients scores on the V-RQOL after receiving Botox injections. The question remains whether the improvement in scores indicates treatment success or a placebo effect. Anari et al. (2007) examined 38 people with adductor spasmodic dysphonia to compare Voice Handicap Index (Jacobson et al., 1997) scores across three points in time: immediately prior to injection (baseline), one day post-injection and two weeks post-injection. The investigators found that most of the changes in the scores occurred between the baseline and one day post-injection. Statistically significant changes included the total and emotional domains. Since the neurotoxic effect is expected to take 2-3 days to be noticeable, the investigators offered three explanations for their results: the toxin may take effect more quickly than previously reported, the toxin may have a strong placebo effect, and / or the effects of the toxin are not real. POINT OF INFORMATION: Limitations of the study include clients who already have had injections (and thus have some prior notion that it is successful) and inclusion of a small number with abductortype spasmodic dysphonia.

Judgement:

The motion is carried

Botulinum toxin injection is currently considered the gold standard for treatment of adductor spasmodic dysphonia. On the evidence presented, we recommend that clinicians continue to offer Botox injections to people with the condition. However, clinicians also have a responsibility to discuss both the benefits and risks associated with receiving Botox injections. This includes possible side-effects, variation in success with each injection and reported failure rates. Such discussion encourages the informed consent process for people undergoing the procedure. Unrealistic expectations on behalf of the client can also be addressed at this time.
Anari, S., Carding, P., Hawthorne, M., Deakin, J., & Drinnan, M. (2007) Nonpharmacological effects of botulinum toxin on the life quality of patients with spasmodic dysphonia, Laryngoscope, 117, pp.1888-1892. Baylor, C., Yorkston, K., Eadie, T., & Maronian, N. (2007) The psychosocial consequences of BOTOX injections for spasmodic dysphonia: a qualitative study of patients experiences, Journal of Voice, 21, pp.231-247. Fisher, K., Giddens, C., & Gray, S. (1998) Does botulinum toxin injections alter laryngeal secretions and mucociliary transport? Journal of Voice, 12, pp.389-410. Galardi, G., Guerriero, R., Amadio, S., Leocani, L., Teggi, R., Melloni, G., & Comi, G. (2001) Sporadic failure of botulinum toxin treatment in usually responsive patients with adductor spasmodic dysphonia, Neurological Sciences, 22, pp.303-306. Hogikyan, N., & Sethuraman, G. (1999) Validation of an instrument to measure voice-related quality of life (V-RQOL), Journal of Voice, 13, pp.557-569. Hogikyan, N., Wodchis, W., Spak, C., & Kileny, P. (2001)Longitudinal effects of botulinum toxin injections on voice-related quality of life (V-RQOL) for patients with adductory spasmodic dysphonia, Journal of Voice, 15, pp.576-586. Jacobson, B.H., Johnson, A., Grywalski., C., Silbergleit, A., Jacobson, G., Benninger, M.S. & Newman, C.W. (1997) The Voice Handicap Index (VHI): development and validation, American Journal of Speech-Language Pathology, 6, pp.66-70. Truong D., Rontal M., Rolnick M., Aronson A., & Mistura K. (1991) Double blind controlled study of botulinum toxin in adductor spasmodic dysphonia, The Laryngoscope Journal, 101, pp.630-634. Watts, C., Nye, C., & Whurr, R. (2006) Botulinum toxin for treating spasmodic dysphonia (laryngeal dystonia): a systematic Cochrane review, Clinical rehabilitation, 20, pp.112-122. Wingate, J., Ruddy, B., Lundy, D., Lehman, J., Casiano, R., Collins, S., Woodson, G. & Sapienza, C. (2005) Voice handicap index results for older patients with adductor spasmodic Dysphonia, Journal SLTP of Voice, 19, pp.124-131.

Side effects

Laryngeal tissues receive autonomic innervation which is thought to control muscle tone, laryngeal blood flow and regulation of secretions (Fisher et al., 1998). Botox injections may alter the secretions near the larynx and result in client discomfort. Fisher and colleagues (1998) retrospectively examined 26 people with adductor spasmodic dysphonia one or more weeks after injection. Prior to injection there were no reports of symptoms relating to autonomic failure to maintain balance of secretions. Within one hour of injection, and lasting over a week, 14 per cent of participants reported symptoms possibly due to altered balance of secretions such as irritation, thick mucus and swallowing difficulties. Botox may exacerbate the effects of xerostomia (dry mouth) due to side-effects from medication or disease. POINT OF INFORMATION: As the study was retrospective, the researchers were unable to determine whether or not there was a direct link between the symptoms and altered laryngeal secretions. Subsequent botulinum toxin injections do not always give the same results concerning the degree and extent of efficacy, time needed to achieve maximum results, and occurrence of side effects (Galardi et al., 2001). Galardi and colleagues (2001) examined the failure rates of 15 people with adductor spasmodic dysphonia given either Botox or Dysport (Ipsen, Milan, Italy) injections over the course of three years (total of 148 injections). Failure rates were 26 per cent and 30 per cent for Dysport and Botox respectively. This difference in failure rates between the two types of injection was not statistically significant (Galardi et al., 2001). Response failure was found to be unpredictable and a client with success after one injection may have a failure after the next one. POINT OF INFORMATION: The study was retrospective and the success against failure rate was judged by the participants during a telephone interview (Galardi et al., 2001).

Lack of evidence

The opposition point here is that there is a lack of evidence that Botox really works. Watts et al. (2006) attempted a systematic Cochrane review examining the efficacy of botulinum toxin injections for treatment of spasmodic dysphonia. Only one study (Truong et al., 1991) met the inclusion criteria, which included a treatment / no treatment comparison. POINT OF INFORMATION: Readers should note that Truong et al. (1991) was a double-blind, placebo-controlled study. It compared saline versus Botox and showed improvement in both acoustical measurements and patient self-assessment in people receiving the Botox injections. Effect sizes were calculated and demonstrated a significant improvement in fundamental frequency (pitch), pitch range and clinicians overall rating of severity.

References

Treatment failure

Summing up the opposition case

In summary there is a lack of supporting evidence from sound methodological studies and the possibility that reported improvement may be the result of a placebo effect. Clinicians cannot draw conclusions regarding the efficacy of botulinum toxin as a treatment for people with adductor spasmodic dysphonia.

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reviews

reviews
A way to reflect

CHILDREN AND FAMILIES

Disability and Impairment: Working with Children and Families Peter Burke Jessica Kingsley 18.99 ISBN 9781843103967

at different points of their recovery to see how they were doing. At times the DVD was difficult to understand, partly due to the fast talking and also the strong Scottish accents! We valued that the film was presented by people with aphasia and that they were speaking from personal experience.

This book is written for social workers but would prepare less experienced speech and language therapists for common issues faced by families. Experienced therapists could read it as a way to reflect on their caseload. The authors interest in families results from his experience of having disabled children. Based on his research, he views assessing the needs of the whole family as the best way to support disabled children. He examines the impact of disability on families, particularly siblings being stigmatised. Some helpful ideas about how to gain childrens views are provided. Importance is given to gaining these views as a way to promote selfadvocacy. The author views support groups as often the only forum for disabled children and their siblings to express their thoughts about disability. It would be useful reading for speech and language therapists who are planning to set one up. Abigail Mance is a speech and language therapist in London.

View from speech and language therapist

As a clinician, I felt that the film was an excellent starting point in sharing experiences of living with aphasia, and it worked particularly well in a group setting. The DVD goes on to discuss the art project specific to the Tayside group which, whilst interesting, was of less relevance to a nationwide audience. Experiences were shared on camera in a very honest way and this realism facilitated open discussion very well, eliminating the need for me to lead or pre-empt in any way. The only slight difficulty I had was being able to find a DVD player within the NHS clinic!

a convincing, highly readable and practical account of the rationale and the methodology. The appealingly short chapters conclude with practical exercises and suggestions for application to the clinical setting and to us as individuals. I particularly liked the chapters on The Symptom As Solution, Eliciting Quality Data (through questioning) and Avoiding Compassion Fatigue. Some bizarre use of punctuation was mildly distracting. If you want to transform your working experience, return to the philosophy of client-centred intervention, be inspired in your interactions AND achieve the outcomes that would normally appear beyond your reach read this book! Jo Mather is a specialist speech and language therapist in voice disorders and head / neck cancer, Staffordshire and a certified NLP practitioner.

LEARNING PREFERENCES

Overall

Aphasia can we talk about it? DVD Tayside Speakeasy Group Tayside Healthcare Arts Trust 5 donation (cheques payable to TAYSIDE HEALTHCARE ARTS TRUST, sent to Chris Kelly, ST/ART Project Coordinator, THAT, Trust Offices, Royal Dundee Liff Hospital, Dundee DD2 5NF)

APHASIA

We all felt that the DVD is a very useful resource to raise awareness of aphasia, to help people talk about aphasia, and as a training tool. It is suitable to show to members of the public, families, students and health professionals. For a 5 donation, this is extremely good value. Neil Henderson, Christina El-Jamal, and Margaret Mallinson are people with aphasia who have attended an aphasia group at the Assessment and Rehabilitation Centre, Sheffield. Dianne Webster is a specialist speech and language therapist in Sheffield Primary Care Trust.

Reaching and Teaching the Child with Autism Spectrum Disorder - Using Learning Preferences and Strengths Heather MacKenzie Jessica Kingsley 15.99 ISBN 978-1-84310-623-4

LANGUAGE FOR HEALTH

Aphasiacan we talk about it? is a DVD written, developed and presented by people with aphasia. Members of the Tayside Speakeasy group share their experiences of living with aphasia on film. We viewed the DVD as a group of people with aphasia and a speech and language therapist.

Excellent starting point

Magic in Practice Introducing Medical NLP: The Art and Science of Language in Healing and Health Garner Thomson with Dr Khalid Khan Hammersmith Press ISBN 9781905140190 24.99

Refreshing and uplifting

View from people with aphasia

As individuals with aphasia, we could relate to the stories being told, and found it helpful to know that other people have gone through the same thing. The film acknowledged that everyone is different, and as a group was a useful starting point to share thoughts and spark new ideas. Seeing people with aphasia talking openly gave us confidence to think about the future. Headings were used successfully to break up the film and help highlight the topic. We felt it would also be useful to show on film individuals

At a time when the emphasis of healthcare seems to be on targets and standardising interventions, this provides a brilliantly refreshing and uplifting antidote; it seeks to place the client and their uniqueness at the core of any therapeutic intervention once more. As such, it is valuable to all therapists at any stage of their clinical experience. The authors present a three part holistic consultation process that takes account of the clients unique map of the world and taps into the resources that exist within the clientpractitioner relationship with the objective of achieving change. Essentially, they urge us to be mindful that the way we think and the language we use influences our health, wellbeing and clinical effectiveness. They present

This book is intended for parents, teachers, therapists and support workers. An experienced Canadian therapist, the author has developed a model which aims to stimulate different ways of thinking about Autism Spectrum Disorder. Her belief is that the child wants to learn so this approach considers learning preferences and strengths rather than deficits. The model provides a comprehensive framework for understanding and dealing more effectively with children with autism to allow them to develop lifelong independent living. Research has shown many such children present with a specific Introvert personality type and, using her profile, this gives insight into the childs perspective and behaviour which informs planning of the intervention programme. Much of the book focuses on the programme structure, content and processes that honour the childs learning preferences and strengths but which also gives scope to challenge and develop the childs Extrovert side. Important concepts from TEACCH have been extended and incorporated, so the practical strategies suited to 2-12 year olds will act as a refresher for more experienced practitioners but will be very useful for those new to the field. Easy to read, practical and informative - a good resource to share with education colleagues when collaboratively planning and implementing teaching and learning programmes. Seonaid Workman is a specialist speech and language therapist working in Dundee.

A good resource to share

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reviews

Understanding motor skills in children with Dyspraxia, ADHD, Autism and other learning disabilities - A Guide to Improving Coordination Lisa A Kurtz Jessica Kingsley 12.99 ISBN 9781843108658

COORDINATION

STAMMERING

Stammering Advice for all ages Rene Byrne & Louise Wright Sheldon Press ISBN 9781847090201 8.99

Practical help

With so much practical advice this book offers value for money. Suitable for those working with children with coordination problems in multidisciplinary settings and accessible to parents too. Its arranged in a logical, clear way with an excellent contents page and glossary. Part 1 Understanding the nature of motor skills is theory based and concise. Part 2 does just as it says, offering Practical strategies and activities for home and school. The activities recognise different learning styles and are clearly described. The tables in each chapter are particularly helpful. The appendix on tests and assessment tools includes age ranges, testing times and a summary of each test. My only criticism is an American bias; the chapter on finding professional help could have been improved by editing for the British market. I would recommend reading the whole book then dipping into it when strategies are needed or for reference. Finding what is wanted should prove quick and easy. Julie Guilliatt is an assistant practitioner (speech and language therapy) for North Lincs PCT.

Finding what is wanted

This is a simple, comprehensive book that is good value for money. It provides practical help for people who stammer and a resource for the specialist therapist to lend out. It also covers enough basic reference information to be a good starting point for students and non-specialist therapists. Topics covered include deciding whether the childs hesitant speech is a stammer, descriptions of various therapies and self-help exercises for adults. Additionally activities provided could be used as part of therapy sessions and homework. A good index makes it easy to find relevant information. However we found the early chapters of the book difficult to read due to complex sentences and not enough illustrations. Later sections are well presented and have many practical exercises to support information provided. My parent also found the accounts of children / adults feelings particularly helpful. Julie Roach is a specialist speech and language therapist with Warwickshire NHS, now specialising in preschool including dysfluency. She reviewed this book with the parent of two clients who were on her school age caseload at the time.

addresses and websites. I would certainly recommend this book to parents and newly qualified therapists as a quick, accessible guide to development as well as for practical ideas and an insight into the main concerns of parents. Rachel Shearer is a mother of three young children and works as a speech and language therapist at York Child Development Centre as well as with adults with learning disabilities.

EMOTIONAL ISSUES

Feeling Like Crap Young people and the meaning of self-esteem Nick Luxmoore Jessica Kingsley 13.99 ISBN 9781843106821

Enlightening

This book describes individual and group work done by a counsellor with young people in schools and with young asylum seekers. I found it a really easy, enjoyable read with lots of interesting case studies used to illustrate the theory. It had some good ideas for working with groups, and the section on the impact of your physical surroundings on how both individuals and teams function was also quite enlightening. This would be a useful resource for therapists working with young people with self-esteem or other emotional issues. Helen Wilson is a developing specialist speech and language therapist paediatric fluency, Knowsley PCT.

Making Sense of Childrens Thinking and Behaviour A Step-by-Step Tool for Understanding Children with NLD, Aspergers, HFA, PDD-NOS and other Neurological Differences Leslie Holzhauser-Peters and Leslie True Jessica Kingsley 13.99 ISBN 9781843108887

BEHAVIOUR

SPECIAL NEEDS

Small Steps Forward using games and activities to help your pre-school child with special needs (2nd Edition) Sarah Newman Jessica Kingsley 13.99

STUDENTS

Sourcebook for Student Placements Clare Attrill, Lucy Bolster, Helen McDonald & Isabel OLeary STASS ISBN 9781874534471 44.00

This book gives clear examples of the areas of difficulty experienced by children with autistic features. Some of the examples would form valuable additions to training being run in this area. The authors Systematic Tool to Analyze Thinking could be easily implemented by speech and language therapists and mainstream school staff in regular contact with the children. It promotes the benefits of thinking about the thought processes that drive the childrens actions. Consideration of the impact of your responses to the behaviour is also encouraged. I enjoyed this book because it is easy to dip in and out of, and provides good value for money. Lorraine Haynes (nee Thomas) is a speech and language therapist working in Language Resource Bases in Camden.

Easily implemented

This book is an accessible resource written by a parent, for parents with children with special needs. It gives a clear and accurate description of the progression of normal development (without age norms), divided into six areas: cognitive, language, physical, sensory, social and emotional. Practical activities are described for specific skills in each of these areas and the activities are easy to carry out, using resources you would find around the home, or linked to everyday routines. The communication ideas are consistent with what speech and language therapists would advise and it gives good summaries of specific approaches such as signing. The book also includes useful chapters on how to survive coming to terms with having a child with special needs, as well as other issues important to parents of any young child sleep, toileting and behaviour. It describes the roles of professionals who may be involved with the child as well as a useful resource section including books,

Accessible guide

This sourcebook was difficult to track down once it left my desk, highlighting its appeal. Experienced clinicians in adult or child practice found a cornucopia of useful materials inside. Its crammed full of photocopiable worksheets and examples of other resources. Pre-placement information, how to write case-notes, summaries of Royal College of Speech & Language Therapists Guidelines, client and student observation sheets and also rainy day learning activities such as What makes a speech and language therapist a professional? and Making a differential diagnosis are all included. My only question, why hard copy and not CD-ROM? Specific local information could have been cut and pasted into it. Realistically priced, busy work-based educators will find this a real boon. Josie Roy is a speech and language therapist / clinical educator in NHS Lothian and currently on secondment to Newcastle University.

A real boon

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reviews / resources

DEMENTIA

Contented Dementia Oliver James Vermillion ISBN 9780091901806

17.99

In his book, Oliver James offers a thorough description of Specialised Early Care for Alzheimers (SPECAL), developed by Penny Garner. The book is predominantly written for carers, though James also recommends it as a good source of advice for professionals and those caring for people with dementia in nursing homes. The book describes the SPECAL approach in a very readable form. It details communication techniques designed to access and utilise happy memories to engender positive feelings of wellbeing in the present time. It guides the reader through communication and validation techniques aimed at diffusing stress and anxiety in the person with dementia, and maintaining good communicative relationships between those with dementia and their carers. The book provides a comprehensive model for carers to follow throughout the course of the dementia. Carers are encouraged to develop a team of family, friends and neighbours to provide them with support and respite. Detailed advice is given on training this support network to provide seamless care using the SPECAL model. The book also encourages carers to plan ahead for the future, providing guidelines to ease the transition from home to nursing home, as the dementia progresses. The book will prove a useful and easily digested resource for carers and, though simplistic, will provide a valuable addition to the clinicians toolkit. Yvonne Bramham is a specialist speech and language therapist eldercare, Cornwall and Isles of Scilly PCT.

A comprehensive model

to an undergraduate speech and language therapy degree course, interlinking modules of study into a cohesive whole. It would also be an accessible reference resource for practising therapists. Kathy Jones-Williams is a third year speech and language therapy student at UWIC in Cardiff, South Wales.

resources
Adam and Eve it
Keith Parks new book of Bible Stories in Cockney Rhyming Slang uses rhythm and rhyme to enable everyone to access stories from the Bible regardless of their level of literacy. www.jkp.com

CHILDRENS BOOK

Maybe Colours Matthew Bennet Young, illustrated by Diana Laitinen Compton Press ISBN 9870955920301 9.98 NB This is a childrens book, not a clinical text.

New CASP

The CASP (Communication Assessment Profile) by Anna van der Gaag has an updated layout and design including images in full colour and on CD ROM. 145.00 + 8.50 p&p, www.speechprofiles.co.uk

Stimulate dialogue

Taking a stand

Beautifully written, almost a poem, this book achieves the authors aim: to stimulate a dialogue about colours. Suitable from age 4 to adult, it provides a springboard for discussion and encourages communication. Initially, it may appeal more to adults than children but, used as a basis for discussion, it provides striking material from which to trigger imagination. It may help children struggling with abstract concepts, such as those with autism, to visualise colour qualities. Illustrations are interesting, but not so strong they prevent readers visualising for themselves. Not so much a bedtime story, nor an essential book, but a lovely one to look at, re-read and discuss. Anna Abrahams is a newly qualified practitioner working at a Key Stage 2 autism provision in a mainstream school; she is also the parent of a 5 and a 7 year old.

Stuttering Stan Takes a Stand is a storybook about a squirrel who is teased by other animals because he stammers. Target reading age range 6-10 years. www.cincinnatichildrens.org/svc/alpha/s/ speech/products/stuttering-stan.htm

Career update

The second edition (revised and updated) of A Career in Speech & Language Therapy by Jannet Wright and Myra Kersner is now available. 19.95, http://metacomeducation.tripod.com

Voice Catcher

The Voice Care Network UK has published an anthology of poems, prose and drama on the voice. 10 + p&p, www.voicecare.org.uk

ABA

Bullying advice

PSYCHOLOGY

Understanding Applied Behaviour Analysis: An Introduction to ABA for Parents, Teachers, and Other Professionals Albert J. Kearney Jessica Kingsley 12.99 ISBN 9781943108603

Contact a Family and Parentline Plus have produced a 15 page guide to dealing with bullying for families of disabled children. www.cafamily.org.uk/pdfs/bullying.pdf

Online learning

The Psychology of language. From data to theory (3rd edn) Trevor A. Harley Psychology Press ISBN 9781841693828 27.50

Point of reference

Intellectually engaging

This textbook assumes little prior knowledge but delivers information with an intellectually engaging style and pace. Highly readable, it has a very clear layout with a summary, questions and further suggested reading at the end of each chapter. Key terms are highlighted and explained throughout. It is comprehensive, covering all aspects of psycholinguistics from language development, literacy, linguistics, and speech processes to neuropsychology, cognitive models and the breakdown of speech and language processes. As such it is an excellent companion

This book aims to explain the enormous amount of terminology associated with Applied Behaviour Analysis as well as some of the commonly used procedures and programmes. Readers new to the subject may find this book a little overwhelming as it does not offer a how to guide as suggested by the title (An Introduction). It does provide a useful point of reference to parents and professionals currently learning about Applied Behavioural Analysis or implementing and supporting ABA programmes, who wish to refresh or clarify their knowledge of specific points. As a book to dip into rather than read cover to cover, the terminology is well organised and clearly explained via a wide range of practical examples and everyday scenarios. Shelley-Ann Epstein is a speech and language therapist with Stockport Primary Care Trust.

ALISON (Advance Learning Interactive Systems Online) offers free online learning to individuals in essential workplace skills areas including touch typing and desktop ergonomics. http://alison.com/

Voice DVD

Constriction and Release the Techniques is a voice DVD by Gillyanne Kayes, author of Singing and the Actor. www.vocalprocess.co.uk

Point of Care

The Kings Fund report Seeing the Person in the Patient suggests what can be done to transform patients experience of care in hospital. www.kingsfund.org.uk/publications/the_ kings_fund_publications/the_point_of_care. html

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SPEECH & LANGUAGE THERAPY IN PRACTICE spring 2009

resources
ADVERTISEMENT

Special Needs tips

Anyone contributing an original tip for the not-for-profit publication Special Needs Handbook will receive a free copy. e-mail helen@specialneedshandbook.com

Primal Pictures Interactive 3D Head & Neck Anatomy CD-ROM software has won an international education award. www.primalpictures.com

Head and neck

BLASTis nationally recognised as good practice in developing speech, language and communication skills in Early Years children. Following a successful roll-out to a number of local authority areas, BLAST packs and training are now available to all. Please visit the website or email us to find out more. Our train the trainers programme will allow you to roll out BLAST into all early years settings in your area quickly and easily. We can also provide training for small groups to become registered users. Training can be tailoredfor you- wed be delighted to hear from you and develop a package that meets your needs. BLAST supports the EYFS curriculum, links in with phase one of Letters and Sounds and can be used to develop early years professional skills as part of the ECAT initiative. It has proved successful in providing a universal input and has been effective in supporting children whilst they are on a waiting list for SLT input. info@blastprogramme.co.uk www.blastprogramme.co.uk

Vision care

The National Deaf Childrens Society and Sense have based Quality standards in vision care for deaf children and young people: Guidelines for professionals on advice from experts. www.ndcs.org.uk / www.sense.org.uk

Lost Without Words

Fragile X

A number of Fragile X Society articles are now freely available as pdfs on its website, including one on speech and language difficulties by Catherine Taylor. www.fragilex.org.uk

Communication training

Speech and language therapists Louise Wright and Anne Ayre, known for their innovative work with people who stammer, have started a company offering bespoke training on communication issues. www.talkcoach.co.uk

Glue ear

Ear infections and glue ear in children A guide for families is a new leaflet from Deafness Research UK. E-mail info@deafnessresearch.org.uk

Reading for Life

The National Literacy Trust and partners are campaigning to improve the life opportunities through reading of people in most need. www.readingforlife.org.uk/

The right care

Help the Aged, Counsel and Care and Carers UK have a campaign website to find the right solution for social care in England. www.rightcare.org.uk/Home

SPEECH & LANGUAGE THERAPY IN PRACTICE spring 2009

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ADVERTISEMENT

The Lost Without Words campaign now has videos from stroke survivors with aphasia on the Stroke Association website. www.stroke.org.uk/campaigns/priority_ campaigns/lost_without_words/watch_the_ films/film.html

HOw i pUT LeArning inTO prACTiCe (1)

How I put learning into practice (1):

View f

when Dawn Leoni accepted a post working with adults in north west wales, she also took on learning a whole new language. Here, at the foothills of her journey into bilingualism through immersion in welsh, she pauses to reflect on her new insights into the experience of clients with communication difficulties and how we can best support their rehabilitation. How i put learning into practice (2) will be in the summer 09 issue.

ver half of the population served by north west wales nHs trust uses welsh in their daily life (figure 1). when i was offered the opportunity to work for the speech and language therapy service, i was excited and a little overwhelmed by the prospect of learning welsh with a view to providing bilingual therapy. prior to commencing my clinical duties, i was supported to attend a 10 week intensive welsh course (Hughes, 1999). During the course, i gained some insight into how it may feel for many of our clients who are struggling to communicate effectively with limited speech and language. Throughout the process i have made a personal journey through what could be likened to a number of different speech and language therapy diagnoses. i have also made discoveries regarding speech and language learning which have altered my working practice. 1. Relating to a suddenly acquired diagnosis During the first days of the course, my head was a maelstrom and the welsh speaking world seemed a deeply confusing and scary place. Despite the course beginning with very

simple, short sentences, it was an incredible mental effort to try to work out what was being said. This impacted on all aspects of my life, leaving me feeling physically and emotionally fatigued. 2. Relating to aphasia The effort of trying to hear the new sounds of the unfamiliar language - and then attempting to map them onto my phonological knowledge - was incredible. i understood then the importance of repetitive listening, and being provided with an opportunity to look closely at the speakers face whilst they spoke. still now, i struggle to understand as effectively when speakers are looking away, or over lunch when they are chewing an apple. i required full, multimodality input in order to lay down the new language. i found that my comprehension - and later my recall of words and sentence structures - improved considerably when i was able to hear the target, watch the speaker, and see the target in written form. The ability to copy out new vocabulary and sentences also appeared to play a part in the learning and storing of the new targets.

i learned the imreAD THis iF YOU portance of errorless Are inTeresTeD learning (see Fillin ingham et al., 2005), eXperienTiAL rather than trial and LeArning error. i found that, if BiLingUALisM i had the opportu iDenTiTY issUes nity to say, to hear or to write a word or phrase in an incorrect form, then it would seem to stick in my language system, and it took extra effort to convert it back to the correct target. The try to work it out approach did not work effectively for me. As the literature on language learning suggests, my comprehension of the welsh language is far ahead of my expressive language. The most disabling and frustrating feature of my welsh learning is my relative lack of ability to respond to people in welsh; this has been the issue that most makes me empathise with my clients. i now well and truly understand the tip of the tongue phenomenon. i continually find myself stopped, mid conversation, with my mouth open whilst my cognitive processes are stretched to their maximum searching for a word. Like people with anomia, i am often

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SPEECH & LANGUAGE THERAPY IN PRACTICE spring 2009

HOW I PUT LEARNING INTO PRACTICE (1)

from a Welsh mountain

Figure 1 Use of the Welsh language in NW Wales NHS Trust areas Gwynedd Anglesey Conwy % of population able to speak Welsh 69% 60% 29%
(Welsh Language Board, 2003: based on 2001 census data)

Figure 2 Learning points 1. Do not underestimate the level of information processing that takes place in a conversation, particularly for those with restricted speech and or language. 2. Be aware of, acknowledge, and educate others about the impact of a speech and language impairment on all aspects of a clients daily life. 3. Remember the importance of providing time for clients to respond, and follow their lead before jumping in to help. 4. Suggest the use of mnemonics where possible. 5. Encourage the client to use gesture whilst repeating a target, as this may form a prompt in functional conversation. 6. Provide therapy incorporating all word classes, including specific work for those words which are less readily visualised. 7. Repetition is vital in assisting comprehension, and allowing the opportunity for a correct template to be stored and recalled. 8. Consider using the errorless learning approach. 9. Ensure the client is able to watch your face whilst you are modelling speech and language. Consider the impact of visuoperceptual impairments on their ability to do this, and possible impact on auditory comprehension. 10. Facilitate multimodality input and output. 11. Incorporate tasks which require less apparently active processing in therapy, such as copying and listening to background language on audio media. 12. Offer therapy in groups if you can, to enable psychological adjustments, confidence and self-esteem to develop.

% of population who live in homes where Welsh is the only language spoken
(The Welsh Language Board, 2004)

53%

42%

17%

able to describe features of the word such as how long it is or what letter it starts with, and may be able to start the word off, but require help from my listener to provide the full target. I have found that using personal mnemonics has helped, although this can add to the time element of the search for the word. Also, attaching a mime to some action words does seem to trigger word production, as if the motor pattern of the limbs or the visualisation provides the cue. One of the more difficult word groups I have found is prepositions. Because they are abstract words which have poor imagability, I have found them incredibly difficult to learn, and have therefore realised just how disabling it is to try and communicate an idea without full access to this word group. I cannot recall any therapy I have carried out with adults which has focused on prepositions, and I wonder now whether it may have been of benefit in some cases? 3. Relating to dyspraxia The Welsh language uses some vowel and consonant phonemes which do not appear in the English phonology. Initially I was tonguetied when confronted with words using voiceless velar, and bilateral alveolar fricatives, and unfamiliar vowels. I was experiencing the classic features of verbal dyspraxia; groping for sounds, producing words with phonemes in the wrong places, and being unable to coordinate my mouth to form the sounds of the words. Extraordinarily, with careful watching, listening, and repetition, my mouth quickly became accustomed to the new shapes and movements being demanded of it, and new motor sequences appeared to be laid down. 4. Identity issues Our therapy often involves enabling clients such as those who stammer to consider their identities as people with a non-standard communication style, and encouraging them to move out from the therapy room into real life, functional situations. In the same way, I found myself facing the fear and the reluctance of using Welsh outside the safety of the classroom. The first tentative approaches to

colleagues, taxi drivers and shop staff - and the impact of their responses towards me - were significant in my being able to see myself as a Welsh speaker. I felt I was undergoing a process of reconstruction of my own communicative identity, and found that having the support, friendship and camaraderie of my class peers was invaluable in this process. 5. Subliminal language processing As my course went on, other interesting phenomena began to occur in my existence as a new language learner. I would wake in the middle of the night, with random Welsh words or phrases stuck in my head. Mostly, I wouldnt know what they meant, but would recognise that I had heard them before. This seemed to indicate that, even when asleep, my brain continued to process the new language at a subconscious level. I wonder to what extent this happens with our clients? This has led me to reconsider the benefits of recording vocabulary and sentences onto audio media to enable people to play them in the background. A summary of my learning points is in figure 2. My journey has provided me with insights and empathy that I hope will enable me to work more effectively with my clients, whether through the modality of Welsh or English. It has also highlighted the importance of providing input to our clients through their first language, as I now understand the challenges of re-learning a language through the modality of a second language. There will certainly be challenges ahead in my work as therapist with a bilingual caseload, but I hope that the

ability to develop my Welsh language alongside my clients will allow a partnership approach to develop. I am most grateful for the opportunity to have undergone such intensive language learning, and for the impact it has had on my practice. Dawn Leoni is a speech and language therapist with North West Wales NHS Trust, e-mail dawn. leoni@nww-tr.wales.nhs.uk. References Fillingham, J.K., Sage, K. & Ralph, M.A. (2005) Treatment of anomia using errorless versus errorful learning: are frontal executive skills and feedback important?, International Journal of Language and Communication Disorders 40(4), pp.505-23. Hughes, E . (1999) Cwrs Wlpan y Gogledd. School of lifelong Learning, Bangor University, www.bangor. ac.uk. Welsh Language Board (2003) 2001 Census - Main Statistics about Welsh. Cardiff: Welsh Language Board. Available at: http://www.bwrdd-yr-iaith. org.uk (Accessed 12 January 2009). Welsh Language Board (2004) 2001 Census: Linguistic Composition of Waless households. Available at: http://www.bwrdd-yr-iaith.org.uk (Accessed 12 January 2009). Recommended reading Missel, A. (2000) Welsh in the Health Service: The scope, Nature and Adequacy of Welsh Language Provision in the National Health Service in Wales. Cardiff: Welsh Language Board. Available at: http://www.byig-wlb. org.uk/english/publications/publications/222.pdf SLTP (Accessed 14 January 2009).

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software

The shape of things to come?

Editor Avril Nicoll meets the directors of Propeller Rehabilitation Software to find out what the future holds for clients and therapists.
magine a world where your clients therapy is integrated with support for with everyday living. Therapy is provided remotely via a completely customised device which is only as large as your client needs, and they control the device with their retina or hand gestures. With the forward thinking evident on my visit to Propeller Rehabilitation Software, this scenario is not as far in the future as we might think. Development Director Dean Turnbull believes we are limited by technology rather than creativity. Generalist market developments such as the iPOD touch and the Wii controller give an insight into the kind of interfaces that may become possible - and lightning processing speeds will be offered when subatomic computing becomes a reality. As a small company specialising in rehabilitation software with an emphasis on the speech and language therapy market, Propeller has to strike a fine balance between promoting what people can realistically make use of now and planning for the customer of the future. This has been recognised by Scottish Enterprise, which has awarded it status as a growth company. By providing a whole service including support and marketing rather than simply distribution, Dean and Managing Director Gordon Russell hope they will encourage more therapists and clients to understand the potential and feel confident about using technology.

Software solutions
With computer software becoming ever more sophisticated and accessible for therapy, our in-depth reviews will help you decide whats hot and whats not.
NARRATIVE Story Teller 7-12 Marshal Anderson Topologika Software, www.topologika.com Home edition 26.08; Single user licence 49.00

Propellers niche development started in 1998 with its React software for people with aphasia developed by therapists in the Borders. The portfolio now includes REACT2, lingWAVES TheraVox for voice therapy and Say it Works, a life skills and social issues CD Picture Library. Further development is planned through expansion of the levels within React and a re-write of Lexilogic literacy software to make it customisable with digital photos. Work is ongoing with speech and language therapists in Scotland, Ireland, England and America to ensure that all development is client focused and evidence based. The most recent example of such collaboration is SWORD, a therapy program developed by Professor Rosemary Varley and Dr Sandra Whiteside at the University of Sheffield for people with speech apraxia following a stroke. Propeller has been awarded world wide marketing rights for the SWORD program. Since 1998, the portability and security of software has evolved considerably, from disks to CDs and now the Dinkey Dongle, which fits in a USB port and doesnt need to be installed on a hard drive. As Gordon Russell says, Its just a tool. If we focus on whats needed and constantly adapt the technology, thats the way to success. Theres no point if it just does what paper and a pen can do. Further information about Propeller Rehabilitation Software is at www.propeller.net.

Motivating and useful

CORRECTION Ann Nordberg: An apology

Editor Avril Nicoll would like to apologise for her major proofing error which led to three figures in an article in the Winter 08 issue being muddled up after the article had been signed off by the main author Ann Nordberg. This has been corrected on the electronic record and a replacement page is available in the Extras section of www.speechmag.com/ Members. The figures are shown here in their correct order. Nordberg, A., Berg, E., Carlsson, G. & Lohmander, A. (2008) Moving forward with EPG , Speech & Language Therapy in Practice Winter, pp.22-26.
Figure 5 Bjorn saying Swedish word /to:/ before EPG therapy

Figure 6 Bjorn saying Swedish word /to:/ after EPG therapy

Story Teller is a software programme that enables children to create oral stories which are recorded onto computer and then played back. There is a bank of over 4,000 pictures - including characters, settings and action pictures - organised into 27 themes such as adventure, jungle and the Romans. The child clicks on each picture they want to talk about and tells the story into a microphone. The story can also be played back slowly so that the child can type it onto the screen. In the set-up you decide how long the story will last and how many pictures there are to choose from on each page. Story Teller is very motivating. The pictures are appealing with a mixture of real-life photographs, cartoon characters and line drawings. It is a good way of developing childrens creativity as it gives them visual ideas for who, where and what happens but also encourages them to link their ideas. There is a never ending supply of pictures but you can also add your own. The ending pictures (such as a sad face to represent a sad ending) are confusing, as the children tended to talk about the face instead of ending their story. The children I used this with were really engaged and loved hearing their stories played back. It is user-friendly so once children are confident with it they can use it independently. This is a useful, good value, individual or small group resource for therapists working in schools, which could be used as part of a narrative group or literacy lesson. To get the full benefit from Story Teller it needs to be used alongside a structured narrative framework so that the child develops a more in-depth understanding of how to create a story. Katie Spear is a specialist speech and language therapist working in a key stage 2 Language Base within a mainstream school in Christchurch, Dorset.

Figure 7 Adult target of Swedish word /to:/

28

SPEECH & LANGUAGE THERAPY IN PRACTICE spring 2009

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Our Top Resources

l-r Jodie McCord, Eryl Evans, Ruth Best with workstations (no.8)

l-r Sister Taylor and Angela

ERYL EVANS, JODIE MCCORD AND RUTH BEST ARE SPECIALIST SPEECH AND LANGUAGE THERAPISTS WORKING IN ENT AND HEAD AND NECK CANCER. ERYL AND JODIE WORK WITH PEOPLE WITH VOICE DISORDERS AND THOSE WITH HEAD AND NECK CANCER, WHEREAS RUTH IS THE FIRST MACMILLAN SPEECH AND LANGUAGE THERAPIST APPOINTED IN WALES, AND WORKS IN HEAD AND NECK CANCER ONCOLOGY. THEY ARE BASED AT SINGLETON HOSPITAL, SWANSEA, PART OF THE ABERTAWE BRO MORGANNWG UNIVERSITY NHS TRUST, PROVIDING SERVICES FOR SOUTH WEST WALES. THEY ARE ACTIVE MEMBERS OF THE MULTIDISCIPLINARY TEAMS WORKING IN THESE AREAS.
1. Angela, our Secretary Angela types, takes messages, files, and generally organises us. We simply couldnt do our jobs without her. Within the hospital there are also a number of other friendly hospital administration staff who facilitate us booking our patients in for reviews in all clinics, including short notice access to casualty clinics, and joint appointments with medical colleagues even if the clinics are full! 2. Each other This is perhaps our most valuable asset. Working as a small specialist team enables us to work closely alongside each other, supporting and learning with and from each other. It is a particular luxury for Eryl after years of working in isolation. 3. Enthusiastic medical colleagues Our enthusiastic medical colleagues are focused not only on achieving a cure, but also upon functional outcomes. Within our head and neck cancer multidisciplinary team, we work with both ENT surgeons and oncologists who are keen and willing to work collaboratively. We also value highly our specialist radiologists who provide us with an endless stream of education within the multidisciplinary team setting. Anatomical models (Adam 4. Rouilly) We find anatomical models simply invaluable for teaching and providing informative counselling to patients and relatives. We can no longer count the number of times a patient has said things like, Now are you talking about the little flap you showed me on the model (in reference to the epiglottis). Anatomical models are well worth the relatively high cost, being robust and well constructed. We use the larynx model (ref. ML11) and head and neck model (ref. MN6) daily. www.adam-rouilly.co.uk 5. Cancerbackup / Macmillan Cancer Support booklets We find these booklets provide balanced and accurate information, which supports the education provided by members of our multidisciplinary team when discussing diagnosis and treatment options. Many patients report using these for finding answers to those questions they think of in the middle of the night. Thanks to Cancerbackup merging recently with Macmillan, their booklets are now available to all free of charge. www.cancerbackup.org.uk 6. Portable clinic trolley Our trolley is a plastic six drawer unit on castors that is full of all the bits and pieces needed in a head and neck cancer clinic voice prostheses, HMEs (humidification and moisture exchange devices for tracheostomy tubes), tubes, headlights, brushes and adhesives. It is easy to negotiate down the corridors, and saves our feet running back to the speech and language therapy department for crucial pieces of equipment. www.littlewoods.com 7. PC with internet connection and EndNote From one shared computer to needing one PC per person, the technological revolution has transformed the amount of information required and available. There are excellent anatomical CD ROMs such as Interactive Head & Neck (www.primalpictures.com) available, as well as DVDs and a wealth of internet sites for teaching and continuing professional development resources. EndNote bibliographic software creates bibliographies and citations and organises references and images in a database, making it quick and easy to insert references into reports, articles and other documents (www. adeptscience.co.uk). We use a shared network drive which enables shared access to resources across the wider speech and language therapy department, and when working in different clinical areas. Access to radiology images on the digital Picture Archival and Communication System (PACS) is also invaluable. 8. Our KayPENTAX stacks Suddenly we are in the 21st century after two extremely generous donations! Our KayPENTAX Digital Video Stroboscopy and Digital Swallowing Workstations have made a dramatic difference to the quality of the assessment and therapy that we can provide to both our voice and swallowing patients. This equipment enables us to perform high quality instrumental assessments and incorporate biofeedback into our therapy programmes. Feedback from patients thus far has been very positive indeed. www.kaypentax.com/Product%20Info/ Strobe%20Systems/9295.htm www.kaypentax.com/Product%20Info/7200/7200. htm 9. Sister Janet Taylor Our outpatient department ENT sister unfortunately retires in April 2009, and we are missing her already! She has been instrumental in ensuring that we have shared resources with ENT allowing us access to use of clinical examination rooms, equipment, instruments and nursing support for difficult voice prosthesis changes. What will we do without her? 10. A great patient group who constantly surprise us with their ability to cope with the unthinkable. They make us laugh with their stories, and sad with their losses. Without them, our working lives would be considerably more demanding and definitely less entertaining.