ISSN 1368-2105

Autumn 2006 Summer 2006

www.speechmag.com

AN OPEN MIND

Intelligibility testing Whats the score? The Listening Program A case example More Power to you PowerPoint as a therapy tool

Discourse on course? An expert conversation Integrity is the key RCSLT conference themes And featuring Succession planning

How I take services into the community

liveACTIVE and Windows of opportunity

PLUSWinning Ways Grey(ish) powerHeres one I made earlier and My Top Resources from Bangladesh

Reader oers
WIN React2!
Are you looking for customisable and comprehensive software for use with people with aphasia, adults and children with learning disabilities or children with a language disorder? Then this offer is for you! React2 has a planned content of around 9,000 exercises that target auditory processing, visual processing, semantics, memory / sequencing and life skills. Features include resizing, randomisation and results analysis. The activities are graded by level of difficulty and as the therapist you can set up the next session in advance. Developed by a software company in conjunction with speech and language therapy staff at NHS Borders, this package is a completely re-written and updated version of the original React program. React2 will retail at around 375 for a single user (prices for upgrades, single modules and multi-users are available) but Speech & Language Therapy in Practice has a copy to give away FREE to a lucky reader courtesy of Propeller Rehabilitation Software. For your chance to win, simply e-mail enquiries@propeller.net with your name, job title and address, and mark your entry react2 offer. The closing date for receipt of entries is 25th October 2006 and the winner will be notified by 1st November. For further information about react2 or Lexion software, or to request a free demo disk, see www.propeller.net or tel. 01896 833528. We had three great reader offers in the Summer 06 issue. The lucky winners of the NDP3 (2004) were Fiona Grayling and Fiona Fickling, while Speechmarks Communication Development Profile went to Clare Elliott, Helen Thompson and Jane Baker. Congratulations also go to Elspeth Gibb, Elise Croot and Kate Jones who won Talking Mats books, and to Jane Baker (again!) who won the Phoneme Factory software in our Spring 06 offer. Speech & Language Therapy in Practice also has a copy of the book Collaborating for Communication to give away free, courtesy of publishers Taskmaster. Written by speech and language therapist Karen Heins as a manual for schools and therapists wishing to run language groups linked to topics in the national curriculum, the book was positively reviewed on p.12 of the Summer 06 issue. It normally retails at 14.95. To enter, e-mail your details to editor avrilnicoll@speechmag.com by 25th September 2006.

Autumn06speechmag
A NEW ARTICLE ADDED TO WEBSITE - VIEW FOR FREE!
Boyes, S. (2006) Applying project management skills, Speech & Language Therapy in Practice Spring, pp. 10-12. Online at www.speechmag.com/archives/sattyboyes.pdf. If you want to find out more about some of the topics in this magazine, you may be interested in the following articles from earlier issues. Remember, if you dont have access to them, check out the abstracts on www.speechmag.com and take advantage of our article ordering service. A community focus (287) Nicoll, A. with Park, K. & Gouda, N. (2004) A midsummer nights conversation. Autumn: 8-9. (345) Baker, J. (2005) Asperations 4 u. Winter: 27-28. To subscribe to our FREE e-update Dysarthria service for readers of Speech & (006) Hewerdine, F., Jouault, R. & Moar, A. (1997) How I manage dysarthria. Summer: 17-21. Language Therapy in Practice, e-mail (161) McGrane, H. & Stansfield, J. (2001) avrilnicoll@speechmag.com. Your Strength in compromise. Autumn: 8-11. details will not be passed to any third Overseas teaching party. (012) Marshall, J. (1997) Training for Kenya Our cumulative index facility is now database-driven! This lessons for all. Autumn: 19-21. means you can search for articles from the Spring 2004 Succession planning issue by author, title or text, and we have also grouped (196) Wood, L. (2002) The right people for the job. Summer: 20-21. articles under new categories. (The index of abstracts The Listening Program from Summer 1997-Winter 2003 is still available online. (218) Treharne, D. (2002) From sceptic to convert, the objective way. Winter: 24-26. You can search it by author, category or through using the speechmag sites search facility.) When you find an abstract that inspires you, you can order a copy of the full article for a small charge via our secure server.

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contentsautumn06
24 HOW I TAKE SERVICES INTO THE COMMUNITY
Our authors show how services can move into community venues and offer flexible programmes that increase opportunities for people with communication difficulties to participate in new activities and learning.

(1) WINDOWS OF OPPORTUNITY

For people who have not grown up with Windows or Word, finding their way around a computer can be a trial and this is compounded if they have communication difficulties. Vicky Styles, Sarah Woodward and Alex Davies explain why and how they set up an intensive group in a community setting to ensure their clients could make the most of the opportunities offered by computer literacy.

(2) liveACTIVE
Cover photo of Amanda with speech and language therapist Judy Goodfellow by Paul Reid.

The logistics of offering a therapy-led activity club in a sports centre for adults with learning disabilities might seem daunting but Judy Goodfellow finds with teamwork, enthusiasm and ongoing audit and adaptation, the practical benefits can be huge.

AUTUMN 06 (publication date 28/08/06) ISSN 1368-2105

INSIDE COVER READER OFFERS, AUTUMN 06 SPEECHMAG

Win react2 (see also book offers on inside cover, p.16 and p.18).

17 MORE POWER TO YOU

The result [of my phonology assessment] is a child who interacts with the computer as they click on the buttons to advance the slides and generate the sound, and who laughs and provides a pretty good sample of spontaneous speech as they explore the cartoons. We usually associate the Microsoft Corporations PowerPoint software with presentations at conferences, but Elizabeth McBarnet finds it invaluable as a therapy and assessment tool.

4 LISTEN AND LEARN

Published by: Avril Nicoll 33 Kinnear Square Laurencekirk AB30 1UL Tel/fax 01561 377415 e-mail: avrilnicoll@speechmag.com Design & Production: Fiona Reid Fiona Reid Design Straitbraes Farm St. Cyrus Montrose Angus Website design and maintenance: Nick Bowles Webcraft UK Ltd www.webcraft.co.uk Printing: Manor Creative 7 & 8, Edison Road Eastbourne East Sussex BN23 6PT Editor: Avril Nicoll, Speech and Language Therapist in my experience, most children with autism spectrum disorder exhibit some form of auditory processing disorder It therefore makes sense to consider including auditory stimulation as part of a childs treatment plan. Donna McCollum was sufficiently impressed by her training in The Listening Program to try it out with Aodhan, a 7 year old boy with a diagnosis of autism.

18 REVIEWS
Education, stammering, transsexual clients, eating and drinking, voice, ColorCards, students, voice for teachers, emotional intelligence, self-esteem, low-tech AAC.

7 INTELLIGIBILITY: WHATS THE SCORE?

speakers read or repeat a list of words randomly selected from items composed of (near) minimally differing sets of words. The number of words recognised by a listener is taken as a measure of severity of any intelligibility problem. Improving intelligibility is an important goal for many of our clients, notably those with dysarthria. But do we know enough about diagnostic intelligibility tests to use them effectively? Jennifer Vigouroux and Nick Miller investigate.

20 CONFERENCE CALLS INTEGRITY IS THE KEY

To my knowledge this is the first time a service user has been asked to participate in a Royal College conference, and the response from delegates suggests it is worth exploring different ways of doing this again in the future so that it impacts positively on practice and on the service user(s) concerned. Editor Avril Nicoll reflects on some key themes from the Royal College of Speech & Language Therapists conference Realising the Vision.

10 DISCOURSE ON COURSE?
In the past we have probably underestimated how hard it is to change communication behaviour at conversational levelYet change at the conversational level of interaction is vital for therapy to make a difference in that individuals life and the lives of his family and friends. In late 2004 the Stirling Discourse Colloquium considered current and future approaches to the analysis and treatment of disordered communicative interaction. We eavesdrop on a discussion among the main participants: Linda Armstrong, Suzanne Beeke, Steven Bloch, Richard Body, Marian Brady, Chris Code, Caroline Davidson, Ruth Herbert, Simon Horton, Catherine Mackenzie, Catherine Niven and Mick Perkins.

22 WINNING WAYS GREY(ISH) POWER

When new ideas come up it is easy to be cynical and dismissive but an open mind will see the development of an old idea and learn how to adapt it. Things do come round again - think of music and fashion - but there is generally a slightly different aspect which makes it more accessible to the following generation. How do you stay motivated when you have given many years to the profession? Life coach Jo Middlemiss considers why maturity can be empowering and something for us all to celebrate.

13 HERES ONE I MADE EARLIER

Alison Roberts with more low-cost therapy activities: Lucky dip reporting game and All about me boxes. Subscriptions and advertising: Tel / fax 01561 377415 Avril Nicoll 2006 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.

14 FEATURE SUCCESSION PLANNING

it is incumbent on individual speech and language therapists, departments and NHS Trusts to think creatively to ensure that potential students have the opportunity to access as much information as possible before they make important career choices. Editor Avril Nicoll asks what we can do to ensure the next generation of therapists are the right people to take the profession forward.

BACK COVER MY TOP RESOURCES

The speech and language therapy course cannot operate without volunteer speech and language therapists coming out here to teach and share their experience and specialist skills with the students. We are always looking for peoplewho would be as proud as we are to take an active part in the creation of speech and language therapy as a profession in Bangladesh. Amy Jensen on her top resources as a volunteer speech and language therapist working and teaching students on the first speech and language therapy degree course in Bangladesh.

IN FUTURE ISSUESTRAINING...TECHNOLOGY...APHASIA...STUDENTS...VOICE...PAEDIATRIC GROUPS

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2006

NEWS

Professorship for Jannet Wright

Jannet Wright has been appointed Professor of Speech and Language Therapy at De Montfort University. On making the move from University College London to Leicester, Jannet said, I look forward to building on the Universitys commitment to professional education and practice-based research. The speech and language therapy divisions specialist expertise and strong links with employers has earned it an excellent reputation among practitioners.

Fresh look at SEN

The Education and Skills Select Committee Inquiry Report into Special Educational Needs has now been published, and is awaiting the governments response. The report calls for a completely fresh look at SEN (p.108), with a clear strategy which nonetheless allows for local flexibility, along with better training, early intervention and partnership working. A radical review of statementing is also recommended, with particular emphasis on the need to ensure the fundamental problems in the statementing process that prevent funding from following the child should be resolved as a matter of urgency (p.117). The uncertainty over inclusion is considered, with the committee believing that a range of educational provision to meet individual needs is desirable. The committee took evidence from a number of agencies including I CAN, the National Autistic Society, the Downs Syndrome Association, Afasic and the Royal College of Speech & Language Therapists, and issues around speech and language therapy provision were highlighted time and again. Commenting on the report, I CANs chief executive Virginia Beardshaw warned; Recommendations like these have been made many times before. I CAN will not be satisfied until we see government action that brings with it real change. It is unacceptable that children with severe communication difficulties and their parents are still experiencing a postcode lottery when it comes to effective early intervention and provision. The report is available at www.parliament.uk/edskills/

Speech and language therapist is new president

Speech and language therapist Dr Anna van der Gaag, the new president of the Health Professions Council, says she is proud to be part of the regulatory reform process. Anna has been a member of HPC since 2002 and, prior to her election as president, chaired the Communications Committee and was a member of the Education and Training Committee. Annas extensive experience covers clinical work, university teaching, management and research across the UK. At a national level she has been involved in evaluations of professional competence and the role of support workers, developing professional standards, clinical audit tools, organisational reviews, measuring the effectiveness of interventions, and patient and public involvement. She has also served on a variety of national and international committees. www.hpc-uk.org

Advert e-kit for registrants

If you want to ensure people can confirm you are registered with the Health Professions Council, you can use an e-kit to download a logo for use on any publicity material from websites to stationery. www.hpc-uk.org/ registrants/advertekit/

Resources on TAP

Travel fellowship call

Applications for a Winston Churchill Memorial Trust Fellowship 2007 have to be in by 19 October 2006. Fellowships are available to British Citizens who wish to acquire knowledge and experience abroad that will be of benefit to their community and the UK when they return. Application categories include Special Educational Needs, Science and Technology and Multicultural Relationships in British Society. www.wcmt.org.uk

The photo shows the launch of I CANs Parent Point website (www.talkingpoint. org.uk/parentpoint), part of the Talking Point venture. Parent Point includes ideas and resources for families of children with a communication disability. It has 10 advisory partners: ACE Centres, British Stammering Association, Contact a family, The Down Syndrome Educational Trust, Dyslexia Action, The National Autistic Society, The National Childminding Association (NCMA), The Royal College of Speech and Language Therapists, StartHere and Talk to Your Baby. The Talking Point site also now includes Talking Links (www.talkingpoint.org. uk/talkinglinks), a database searchable by postcode to find out local speech and language, education and voluntary sector services to support children with communication difficulties. I CAN is inviting parents and professionals to answer an online poll to determine whether there should be more information available to parents about typical communication development during the early years see www.ican.org.uk.

Speech and language therapists and language and communication teachers in Tower Hamlets who have set up a website to share practical activities would welcome participation from across the UK. The Targets and Activities Project (TAP) site includes freely available activities sheets for working with children at different levels and across a variety of curriculum and skill areas. They are intended for use by education staff such as learning support assistants who have had guidance from appropriate specialists. The site uses P-scales (differentiated performance criteria and outline attainment for pupils working below level 1 of the national curriculum) and the lower levels from the national curriculum to organise the documents which are produced in a standardised format. Complementary resources such as game boards or visual timetables can also be shared. www.commtap.org

The 4Rs welcomed

Approval for drinks

SLO pre-thickened cold drinks have been awarded ACBS (Advisory Committee on Borderline Substances) approval and will appear in the September drugs tariff. The ACBS is responsible for advising GPs on the circumstances in which it would be reasonable to prescribe particular non-medicinal products, particularly foodstuffs that are specially formulated to to be suitable for use by people with given medical conditions. It is an advisory, non-departmental public body that is non-statutory and UK wide. Supplier Mathew Done says that although the SLO hot drinks were well received, the committee felt they didnt justify the extra expense to the NHS that might be caused by their prescription. The hot drinks are available for direct purchase, tel. 08452 22 22 05. www.slodrinks.com

I CAN has welcomed the 4Rs Commission on primary education announced by the Liberal Democrats as it gives the charity the opportunity to share the knowledge and expertise gained from successfully developing services which support childrens communication, and our proposed solutions for change. The party is looking for some big thinking on primary education, including speaking and listening skills which they describe as the 4th R, aRticulation. It explains, Too many children arent arriving at school with the vocabulary and the ability to speak in sentences that allows them to pick up where the governments literacy strategy begins were missing a step. Giving young children the language skills they need to express themselves helps them learn, improves behaviour and imbues them with confidence. To participate in the process, visit www.4rs.org.uk.

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2006

NEWS AND COMMENT

Aphasia award

comment

Eirian Jones, retired head of speech and language therapy at Addenbrookes Hospital, Cambridge, has become the first recipient of the Robin Tavistock Award. The award will be given annually to a person or group making a significant contribution in the field of aphasia. The Tavistock Trust for Aphasia which is presenting the award was founded by the late Robin Tavistock the 14th Duke of Bedford. He received intensive speech and language therapy from Eirian for aphasia following a brain haemorrhage. Eirian was well-known as a clinician, researcher and lecturer and a former chair of the then College of Speech Therapists. The Trust praised her distinctive insightful, intuitive, intellectual and effective approach to therapy for language impairments. www.aphasiatavistocktrust.org

An open mind
Ashley sat at the table in disappointment because they were going to the tuna sandwich factory. She was disappointed because she didnt like tuna sandwiches. Our 6 year old wrote a book today called Ashley tries a tuna sandwich. The 10 chapters include discussions about such crucial matters as the precise ages of Ashleys relatives, the revelation that her dad is cutting down trees in Poland, and a spelling of dual carriageway that had us in stitches, but the message of his story is clear enough. When presented with something you are unsure of, keep an open mind and find out as much as you can about it because you might be pleasantly surprised. Thats certainly what Donna McCollum discovered (p.4) when she went on The Listening Program course. Although such approaches have their critics and she herself was sceptical, what Donna heard made sense in relation to her clients. She is now testing it out, and monitoring and sharing the results. Asking questions and taking nothing for granted is an essential part of an open mind. Jennifer Vigouroux and Nick Miller (p.7) took this approach to their research into the scoring of diagnostic intelligibility tests, and the results have clear implications for clinical practice. Jo Middlemiss (p.22) suggests an open mind and a closed mouth is one of the ways we carry on learning and enabling others to learn, no matter how long we have been in the profession. Combining enthusiasm with experience is her solution to keeping things fresh, as was shown by key speakers at the Royal College of Speech & Language Therapists conference (p. 20). Our feature on succession planning (p.14) however reinforces the need for us all to play our part in promoting the profession so we can open the minds of potential recruits to the possibility of a career in speech and language therapy. Being open minded isnt easy though. When we find something we believe works, or is right, or feels comfortable, it is tempting to stick with it. The expert conversation involving Marian Brady and colleagues (p.10) shows why it is worth persevering with integrating new ideas with old practice. Not only does it keep you fresh, it also allows you to offer more evidence-based and individualised therapy. New ideas to integrate include the opportunities offered by technology. Elizabeth McBarnet (p.17) makes imaginative use of PowerPoint software, while Vicky Styles, Sarah Woodward and Alex Davies (p.24) have designed a course to enable their clients to use computers to perform simple functions. Amy Jensens top resources from Bangladesh (back page) demonstrate that being open minded entails making an effort to understand where other people are coming from, and why they might not be on your wavelength. Here in the UK, Judy Goodfellow and colleagues (p.26) realised that staff caring for adults with learning disabilities often focus on an activity rather than a process. This realisation enabled them to give staff the time and support they needed to adjust their ideas. For lunch tuna sandwiches! Ashley ate them. They are LOVELY thanks mum! THE END

A key intervention
The newly published NICE (National Institute for Health and Clinical Excellence) guideline on Parkinsons Disease includes speech and language therapy as a key intervention. It says that speech and language therapists should give particular consideration to: improvement of vocal loudness and pitch range, including programmes such as Lee Silverman Voice Treatment; teaching strategies to optimise speech intelligibility; and maintaining an effective means of communication throughout the course of the disease, including use of assistive technologies. Therapists should also support the safety and efficiency of swallowing and minimise the risk of aspiration. The guideline also states that the evidence to support the use of speech and language therapy in Parkinsons Disease is limited, but that patients feel it is effective. It recommends a pragmatic trial to compare standard NHS speech and language therapy with no treatment. The Parkinsons Disease Society has welcomed the guideline but called for the government to take action now to make its recommendations a reality. www.nice.org.uk www.parkinsons.org.uk

Art in health gives fuller voice

A specialist arts in health consultant has suggested that a project for people in Surrey with dysphasia has potential for countywide, regional and national and international benefit. In a mapping report, Derek Freeman has highlighted work at the purpose built Dyscover centre for further investment and development. The charity offers support and opportunities to people with dysphasia, including a creative writing group led by poet Wendy French that also involves music and drama. While Freeman notes the congenial space and the special and distinctive value of the group to its members, he goes further in suggesting that What is going on here in essence is no less than the facilitation of a new artistic language. He adds that this language belongs to people with dysphasia and gives them fuller voice. Among the reports recommendations are ways in which such projects can have built into them a commitment to spreading the word. New Body Languages: the emergence of participatory arts in health is available at www.mole-valley.gov.uk/index.cfm?articleid=3059. www.dyscover.org.uk

Dysphagia quality improvement

Speech and language therapist Dr Maxine Power has been awarded a Health Foundation Quality Improvement Fellowship to improve care for people with dysphagia following a stroke. The Senior Research Fellow at Salford Royal Hospitals NHS Trust will spend twelve months based at the Institute for Healthcare Improvement in the USA and will study on the clinical effectiveness programme at the Harvard University School of Public Health. Maxine plans to develop, pilot and evaluate the impact of a specialist, 24-hour dysphagia team which will rapidly provide ward-based assessment and treatment of patients including the early administration of artificial feeding. Through the scheme, The Health Foundation hopes to develop a group of senior clinical leaders with the experience, skills and enthusiasm to lead quality improvement in the NHS at the highest levels. Applications are now open for 2007-8 and the deadline is 9 November 2006. See www.health.org.uk for details.

Avril Nicoll, Editor 33 Kinnear Square, Laurencekirk AB30 1UL tel/ansa/fax 01561 377415 e-mail avrilnicoll@speechmag.com

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2006

CASE EXAMPLE

One of the greatest challenges facing speech and language therapists is choosing among the many treatment options that are now available. Which one is most appropriate for a child and will produce the most benefit? When talking about children with an autism spectrum disorder there is no easy answer, as each child is unique and treatment programs need to be individualised. However, in my experience, most children with autism spectrum disorder exhibit some form of auditory processing disorder. Doman (2005) says that, indeed, auditory processing problems are recognised today as the primary sensory impairment in children diagnosed with an autism spectrum disorder. It therefore makes sense to consider including auditory stimulation as part of a childs treatment plan. So what might tell us that a child has a difficulty with auditory processing? If they are over-responsive to auditory input, they may feel they are being continually overpowered by sound and try to counteract this by covering their ears or avoiding the sound. Doman (2005) also sets out five areas where individuals with autism spectrum disorder commonly experience difficulties if they have auditory processing dysfunction: 1. Auditory attention the ability to attend, focus or listen 2. Filtering extraneous sound being able to tune out irrelevant sounds in order to concentrate 3. Sound discrimination ranging from basic phoneme discrimination, to being able to distinguish change in voice tone so that they understand the emotional meaning being conveyed in language 4. Temporal processing perceiving the timing of rapidly changing sounds 5. Auditory sequential memory. These impairments affect behaviour and communication abilities as well as listening skills. Alexander Doman (2005) says, The primary objective of any auditory stimulation method is to reorganise and normalise the auditory system so that the full spectrum of sound is processed without distortion. Doman is the founder and president of the company Advanced Brain Technologies which has developed a treatment tool called The Listening Program. Following my training as an Authorised Provider in 2004 I did a Certification Exam to qualify me as a Certified Provider.

READ THIS IF YOU WANT TO HEAR ABOUT AUDITORY PROCESSING DIFFICULTIES AN AUDITORY STIMULATION TOOL A CLIENTS PROGRESS

Initially sceptical about the value of music-based listening tools in helping children with auditory processing difficulties, Donna McCollum was sufficiently impressed by her training in The Listening Program to try it out with Aodhan, a 7 year old boy with a diagnosis of autism.
zine suggests there has been a rapid increase in its application with children on the autism spectrum. This is due in part to its perceived positive impact on engagement, emergent skills, sensory integration and auditory processing, and reduced sound sensitivity. The Listening Program consists of an extensive series of high quality audio CDs that integrate specially produced acoustic music, primarily classical, with innovative sound processing techniques. To create a permanent change in the brain, the sensory stimulation must be delivered with sufficient frequency, intensity and duration. This stimulation allows the brain to process sound without distortion,

Listen
so that it can better perform the auditory skills needed to effectively listen, learn and communicate. All music is spectrally analysed to confirm frequency spectrum. The music is listened to through high quality headphones. A minimum of 40-60 hours is recommended for initial gains to be achieved. Standard Listening Schedules and Variations of 20 hour cycles encompass daily (5 days per week, 2 days off ) listening of 1530 minutes over a course of 816 weeks. Preparatory listening of 210 minutes daily can be done with sensitive listeners prior to beginning a Standard Schedule. The Listening Program can be self-administered under the monitoring and consultation of a trained Authorised Provider. The Listening Program Classic Kit includes eight CDs, TLP 1 TLP 8. There are additional Specialised CDs, not part of the kit, that focus on different frequency zones including Sensory Integration (SI) 0 750 Hz, Speech and Language (SL) 750 4000 Hz, and High Spectrum (HS) 3500 Hz and above. The identification of these frequency zones is attributable to Dr Alfred Tomatis, with each zone corresponding to different areas of human brain and body function. So Zone One (SI) is related to balance, rhythm, coordination, muscle tone, body awareness, sense of direction, laterality and right/left

Logical
The Listening Program (TLP) is a Music-Based Auditory Stimulation method, designed to build the auditory skills a child needs to effectively process sensory information. I was initially very sceptical of the whole concept of using music to aid communication skills, but the course was presented in such a logical fashion that it captured my interest. Since The Listening Program first became available in 1999, the number of case studies in its Provider maga-

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2006

Picture posed by a model.

CASE EXAMPLE

Figure 1 Assessment scores (NB Two different versions of the CELF used) A. 6;3 years, CELF-R B. 7;3 years, CELF-R UK3 Subtests Linguistic concepts Sentence structure Oral directions RECEPTIVE LANGUAGE SCORE Word structure Formulated sentences Recalling sentences EXPRESSIVE LANGUAGE SCORE TOTAL LANGUAGE SCORE Standard Percentile Score Rank 6 8 10 87 8 6 8 82 83 9 25 50 19 25 9 25 12 13 Subtests Sentence structure Concepts and directions Word classes RECEPTIVE LANGUAGE SCORE Word structure Formulated sentences Recalling sentences EXPRESSIVE LANGUAGE SCORE TOTAL LANGUAGE SCORE Standard Percentile Score Rank 11 8 10 97 10 11 9 101 99 63 25 50 42 50 63 37 53 47

Figure 2 Assessment using The Listening Program Pre- and Post- Listening Checklists The following skills went from always to rarely: oversensitivity to certain sounds difficulty in sound discrimination confusing similar sounding words becomes sleepy when listening to speakers or reading. The following skills went from often to rarely: tires easily difficulty hearing low male voices difficulty hearing high female voices sings out of tune difficulty relating isolated facts stumbles on words. The following went from sometimes to rarely: uses a flat and monotonous voice quality difficulty with reading aloud poor spelling.

There are four most commonly reported benefits cited by Doman & Lockhart Lawrence (2003). Firstly, the area of increasing engagement is enhanced. Use of The Listening Program can improve self-image, reduce tactile defensiveness and lead to a better sense of the body in space. The autistic child subsequently initiates more physical contact, responds better to others, and increases attention span and eye contact. Secondly, sound stimulation helps facilitate better integration and organisation in the sensory and motor systems, leading to a faster acquisition of skills. The third benefit is in the improvement of rate and accuracy of sound perception. As the brain develops this skill, it has a direct effect on the development of auditory processing and receptive language skills. Doman & Lockhart Lawrence also claim that the use of The Listening Program reduces hypersensitivity to sound, as it provides sound stimulation that helps the nervous system to modulate sensory input more efficiently. This often results in a reduction in abnormal sensory perception, especially with sound. The autistic child is thus more comfortable in their environment as they dont have to deal with unwanted sounds any more.

Add to understanding
Conscious that music-based listening approaches are regarded with suspicion by some, I was keen to introduce The Listening Program in a way that would bear scrutiny and add to our understanding of its potential value as one tool for children with auditory processing difficulties. Here, I would like to describe its impact on Aodhan, a 7 year old boy with a diagnosis of autism. Aodhan was referred to the speech and language service when he was 3 years old. Following assessment, he was offered a place in a joint speech and language / occupational therapy group intervention which he attended for 12 sessions. He presented with severely delayed receptive and expressive language skills, poor social interactional skills, auditory hypersensitivities, together with echolalia and numerous other difficulties related to auditory processing and sensory integration dysfunction. His occupational therapist was unable to complete a formal standardised assessment at this stage due to Aodhans highly distractible attention skills. Delayed gross and fine motor skills and visual perceptual skills were identified by clinical observations. Lateral dominance was not established. Aodhan was subsequently diagnosed as having an autism spectrum disorder when he was 4 years old, and received a Statement of Special Educational Needs. He attended a second speech and language / occupational therapy group for a further 12 sessions, followed by two blocks of individual therapy. Whilst excellent progress had been made in all areas of speech and language on formal assessment, two main areas of deficit were identified when Aodhan was 6 years old. Aodhan still found it very difficult to remain focused on a task, particularly if it was auditory in nature. He also
SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2006

and learn
discrimination. Zone Two (SL), which targets mid and higher frequency sounds, is related to memory, concentration, attention, speech, language and vocal control. Zone Three (HS), which targets higher frequency sounds, is associated with the development of energy, intuition, ideas, creativity and auditory cohesion.

Interrelated and interdependent

The three zones are inextricably linked; the first lays a foundation, the second builds on that foundation and the third is supported by the first and second. This concept lends weight to the view that lower level brain organisation supports higher level functions with all brain organisation being interrelated and interdependent (Ayres, 1979). Doman & Lockhart Lawrence (2003, p.1) have written about the benefits they have found in using The Listening Program in the treatment of autism, in particular, acknowledging the link between autism and auditory processing: The vestibulocochlear system informs us of sound, movement and orientation of space. The cochlear portion of the system turns sound or vibration into electrochemical messages that are relayed throughout the central nervous system and is critical to auditory

processing. The vestibular portion serves to provide stabilization, influences attention and arousal, posture, movement, thus being critical to sensorimotor integration. It is the integration of our senses that allows us to understand what we are experiencing in our world. So it makes sense that a program that would stimulate and help to integrate the cochlear and vestibular systems might be very helpful for the autistic child. They continue (p.2): Listening to the CDs in The Listening Program literally exercises and tones tiny muscles in the middle ear called the tensor tympani and stapedius muscles. Exercising these two muscles improves their tone, thus making them more responsive to their task of directing the middle ear bones and eardrum. This helps them to amplify soft sounds and protect the inner ear from damaging harsh or loud noise. The Listening Program was designed to help balance and restore our ability to listen to and process sounds across the full auditory spectrum, from 2020,000 Hz. The brain receives especially rich auditory stimulation, and because of its ability to change with stimulation, its ability to process sound improves.

CASE EXAMPLE

resources
Learning options
A new Australian book for parents explains the perspective of two trained teachers who believe that good nutrition and a range of approaches such as neuro-developmental therapy, sound therapy and chiropractic can be beneficial for children with a range of difficulties. Learning Options: choices for struggling students, see www.learningoptions.net.au.

Best treatments
The British Medical Journal offers a free, independent, one-stop health website which includes medical information on more than 120 different conditions. Current evidence on medical research, symptoms, treatments and questions to ask the doctor are covered. www.besttreatments.co.uk/btuk/home.jsp

still had some abnormal responses to sensory input. To address these two issues I agreed with his parents that we would embark on The Listening Program. I assessed Aodhan using the CELF-R (figure 1, p.5), and completed The Listening Program pre-listening checklist. Aodhan began his personalised Listening Program with preparatory listening, with the Sensory Integration Classic CD followed by the Sensory Integration Kids CD. He then continued through the 16 weeks (15 minutes twice a day) of the Classic Kit, and continued to complete three cycles of listening. Listening was carried out under the supervision of his mother at home. No other therapy intervention was offered while Aodhan was using The Listening Program. Aodhan was then assessed on the updated CELF-R UK3 (figure 1, p.5), and The Listening Program post-listening checklist was completed.

Voice mentoring
Vocal Process, a training resource for vocal practitioners, is experimenting with personal mentoring over the internet and telephone for people who cannot easily get to London. Further information from gunvor@vocalprocess.co.uk

Aodhans greatest improvements are his selfregulation skills, his ability to concentrate, and his reduced hypersensitivity to noise. He initiates conversation readily, he asks more questions and isnt satisfied readily, he will analyse comments and then asks something more. (Aodhans parents)
Aodhans greatest improvements are his self-regulation skills, his ability to concentrate, and his reduced hypersensitivity to noise. Since Aodhan is so receptive to listening, we agreed that he should start using the Level One kit after a four week break. At the time of writing he has nearly completed one cycle of this.

Dyslexia programme
Nessy is a computer learning programme to help with reading, writing and spelling. Specifically developed for children with dyslexia, the programme has found favour more generally in schools in East Renfrewshire and Conwy. Demo available at www.nessy.co.uk

humour. Expressively they were aware of increase in communication, vocabulary, sentence structure and initiating verbal participation (bear in mind Aodhan was not receiving any other speech and language therapy intervention). Aodhan was also less restless, and showed increased sense of rhythm and a decrease in sound sensitivity. An increase in attention and organisational skills has undoubtedly contributed to his overall progress. Aodhans dedicated parents feel that he made excellent progress during the year of listening to three cycles of The Listening Program: He initiates conversation readily, he asks more questions and isnt satisfied readily, he will analyse comments and then asks something more. His mother has been amazed by the difference in his musical awareness: He will sing along to music on the radio, and not only the melody. He will tap out rhythms and again not the most obvious one. One of the proudest moments for his parents was when Aodhan was given a role in the school Christmas concert. Although Communicating Quality 3 guidance does not currently include individuals with an auditory processing disorder (RCSLT, p.312), it does state that, for people with autism spectrum disorder, speech and language therapy value is to provide an environment which maximises opportunities for individuals to develop their receptive and expressive communication skills (p. 267-268). It is clear to me that Aodhan has benefited immensely from The Listening Program and that further work with the program will help maintain his gain and assist with continued positive change.

References
Ayres, J. (1979) Sensory Integration and the Child. Los Angeles: Western Psychological Services. Doman, G.A. (2005) Unlocking potential, Autism-Aspergers Digest, Nov Dec, pp.18-25. Available at: http://www. advancedbrain.com/pdf/Unlocking_Potential.pdf (Accessed: 21 June 2006). Doman, G.A. & Lockhart Lawrence, D. (2003) Using The Listening Program in the treatment of autism, AutismAspergers Digest, May June. Available at: http://www. advancedbrain.com/pdf/7_Article_Using_TLP_Autism. pdf (Accessed: 21 June 2006). RCSLT (2006) Communicating Quality 3. London: Royal College of Speech & Language Therapists.

DDA duties
The Department for Education and Skills has issued guidance on the implementation of the Disability Discrimination Act in schools and early years settings to help them understand their duties and increase access. www.teachernet.gov.uk/wholeschool.sen

Increased attention
Aodhan has responded extremely well to The Listening Program. In addition to his communication skills development, he has developed in other areas. While participating in The Listening Program he was not involved in any specific activities to improve his motor skills. However, he was formally reassessed by the occupational therapist recently and has been discharged from this service as skills are now developing well. Aodhans gross and fine motor skills are now more refined, lateral dominance is now established and his visual perceptual skills are above average. The occupational therapist felt that many of these skills improved as a direct result of Aodhans increased attention. When completing the Observations Checklist of The Listening Program, Aodhans parents noted an increase in eye contact, independence, flexibility and sense of

PMLD curriculum
A Childrens Trust special school has produced a school curriculum for children and young people with profound and multiple learning difficulties. A Curriculum for Learning focuses on those with a developmental age of up to 12 months, covering sensory cognitive, communication, social, motor and life skills in an integrated 24 hour educational framework. www.thechildrenstrust.org.uk

Resources
Doman, G.A. (2003) Pre-post Listening checklist in The Classic Kit Guidebook, The Listening Programme , Advanced Brain Technologies LLC. Doman, G.A. (2003) Observations Checklist in The Classic Kit Guidebook, The Listening Programme , Advanced Brain Technologies LLC. Semel, E.M., Wiig, E.H. & Secord, W. (1987) Clinical Evaluation of Language Fundamentals Revised (CELF-R). San Antonio, TX: The Psychological Corporation. Semel, E.M., Wiig, E.H. & Secord, W. (2000) Clinical Evaluation of Language Fundamentals 3UK. London: SLTP The Psychological Corporation.

Basic skills
The Basic Skills Agency has a new range of resources, Raising Expectations, to support practitioners in helping teenage parents and parents-to-be to improve their reading, writing and maths in four different contexts: health matters; parenting; house and home life; and schools, college and work. The agency also producesTalk to Me!speaking and listening materials for parents and teachers of 4-5 year olds to support the transition from early years to primary school. www.basic-skills.co.uk More resources on p.9

REFLECTIONS DO I RECOGNISE AUDITORY PROCESSING ISSUES AND CONSIDER HOW TO ADDRESS THEM? DO I OFFER PARENTS AND CARERS A SUFFICIENT LEVEL OF DETAIL TO HELP THEM NOTICE CHANGE? DO I MAKE THE MOST OF OPPORTUNITIES TO WORK IN PARTNERSHIP WITH OCCUPATIONAL THERAPISTS?

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2006

ASSESSMENT

Intelligibility: whats the score?

Improving intelligibility is an important goal for many of our clients, notably those with dysarthria. The associated assessment and therapy usually involves sets of minimally different words. But do we know enough about the scoring and interpretation of such tools to use them effectively? Jennifer Vigouroux and Nick Miller investigate.

harting changes in intelligibility is an integral part of clinical work, particularly for clients who have dysarthria. In a typical word recognition test, or more valid diagnostic intelligibility test (Yorkston & Beukelman, 1981; Kent et al., 1989; Weismer & Martin, 1992; Kent et al., 1994; Wilcox & Morris, 1999), speakers read or repeat a list of words randomly selected from items composed of (near) minimally differing sets of words (see examples in next paragraph). The number of words recognised by a listener is taken as a measure of severity of any intelligibility problem. In diagnostic intelligibility tests, scrutinising the pattern of mishearings gives valuable insights into the nature of the underlying disorder and targets for therapy. There are two broad approaches to scoring such tests: 1. Open format scoring Here, listeners write on a blank sheet the word they think they heard. 2. Closed format scoring For each item the listener is presented with a selection of words, one of which is the target and the others (near) minimally differing foils. For example, the targets for three items from the test we used for this study were keep, wad and fat. For each item listeners had to circle which word they think they heard from a choice respectively of: cup, coop, keep, cape, cope, carp (looking at vowel variation); what, wad, watch, watts, one, was (tapping word final tongue tip sounds); bat, pat, fat, vat, mat, hat (assessing ability to make word initial labial distinctions). But do these two methods lead to equivalent scores - or are they qualitatively different tests with differing strengths? Searching the literature does not turn up many suggestions. Yorkston & Beukelman (1978, 1980) found scores

elicited from the open format were significantly lower than scores from the closed format. Despite differences in intelligibility scores, however, both versions still ranked dysarthric speakers similarly. Both assessment formats have therefore been referred to as equally reliable and applicable methods of evaluation. Kent et al. (1989) refer to differences between open vs closed scoring as a negligible concern (p.492). Yorkston & Beukelman (1981) acknowledged the potential score difference by specifying that (p.6) once selected, subsequent re-administrations should utilise the same judging format.

READ THIS IF YOU WANT ASSESSMENT AND THERAPY TOOLS THAT ARE OF FUNCTIONAL RELEVANCE PROMOTE AND REFLECT CHANGE CAN BE TAILORED TO AN INDIVIDUALS CLINICAL NEED
inconsistencies between the scoring methods, it would have implications for diagnostic accuracy, outcome measures in therapy and prioritisation of treatment. What would be useful to know is exactly how great a discrepancy arises in scores between the two formats; is the gap between them systematic (so predictable across different speakers), or inconsistent? Another issue concerns which scoring procedure is more predictive of performance in spontaneous speech? To find some answers, we recorded twenty-seven people, age 62-83 years (mean 72 years), with varying severity of Parkinsons disease. They read sixty items from a diagnostic intelligibility test which we had devised (based on Yorkston & Beukelman, 1981 but adjusted to the local accent of the area where the speakers came from). They also described how to make a cup of tea. Two groups of everyday listeners (with no experience of dysarthric speech or Parkinsons disease), ranging in age from 18-76 years, listened to the same set of recordings. Each speaker was scored by three different listeners in each format; each listener heard five different speakers. Thirty one listeners scored in a closed format that is, they ticked the word they heard from a choice of twelve (near) minimally distinguished words (target and 11 foils). Examples from the score sheet appear in table 1. Thirty other listeners had just a blank piece of paper
SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2006

If it were established that there are inconsistencies between the scoring methods, it would have implications for diagnostic accuracy, outcome measures in therapy and prioritisation of treatment. Question marks
However, there are enough question marks over earlier studies to justify looking again. For instance, earlier studies used small numbers of speakers, of a wide range of intelligibility level, and listening was done by a limited number of trained speech and language therapists or student speech and language therapists, not carers or everyday listeners. If it were established that there are

ASSESSMENT

to write answers down (open format). They all heard an excerpt from the cup of tea passage and rated on a five point scale how disordered / natural the speech sounded. The total words correctly identified by the three listeners were averaged to derive an intelligibility score per speaker. Mean disordered scores were calculated in the same way.
Table 1 Sample items from the closed format scoring version of the diagnostic intelligibility test cub cape one watts mat vat store snore coop heap fall was cat what draw score cup cop what wad hat heart flair sore carp hub wash want fat tat floor chore keep cap waltz warn pat bat four spore sheep hoop wool watch gnat sat poor nor

We found a difference in scores derived from the two formats (see summary in table 2). The differences are statistically significant (t (26) = 7.10 p< 0.001), however such a divergence would not matter too much if change were systematic and people were ordered the same in severity by both versions. Looking at individual speakers, though, there was not a consistent variation. For example speakers 6, 9, 12, and 17 in the closed test obtained mean 54, 54, 53, and 55 points respectively. In the open test they ranged from mean 35 (speaker 12) to 52 (speaker 17). Speaker 22 scored almost identically in both test formats; speaker 29 achieved higher in the open than the closed version.

Table 2 Mean intelligibility raw scores from the open and closed format diagnostic intelligibility test Scoring No. format Closed 27 Open 27 Mean Median Standard Range (out of 60) deviation 47.85 34.86 50.3 37.3 9.88 13.41 15-59 0.33- 54.97

How did results in the different formats fare in relation to the disordered ratings made on the basis of the cup of tea description? Intelligibility rankings from the open and closed listener formats were compared to the disordered ratings. There was an almost significant relationship of intelligibility-rating scale scores only in the open format ratings so indicating that scores from the open version came closest to reflecting listeners impressions of levels of severity from spontaneous speech. All this tells us that significantly lower intelligibility scores are obtained using an open format. That agrees with Yorkston & Beukelman (1978, 1980) but, contrary to Kent et al. (1989), the difference was not negligible, and in contrast to Yorkston and others conclusions the difference is not neatly systematic. So why did we get such different outcomes? a) We used a large sample of everyday naive listeners with mixed ages, not either two experienced speech and language therapists (Yorkston & Beukelman, 1980) or a group of young speech and language therapy students (Yorkston & Beukelman, 1978). It is known that both age and experience of dysarthric speech can exercise an influence on intelligibility scores (Tjaden & Liss, 1995; Dagenais et al. 1998, 1999; Garcia & Hayden, 1999). b) We employed a larger sample of speakers, all with the same aetiology. Yorkston & Beukelman (1978, 1980) used small samples (9-12 speakers) with varying aetiologies. c) Also, the fact that Yorkston & Beukelman (1978, 1980) used their small sample with a broad range of intelligibility severities may have guaranteed close correspondence between open and closed format diagnostic intelligibility tests for the purpose of ranking speaker impairment. If there are sufficiently large gaps of ability between subjects, subtle differences between test formats or listener effects are not revealed. In this study, participants clustered at the moderate-mild end. d) Our word sets were also more tightly controlled for minimal differences. This may have made the listening task harder for our listeners (especially as they were people unused to hearing dysarthric speech).

ity, loudness, not articulation. To gain a fuller picture of changes, these voice and prosodic features need to be assessed too. This point has further consequences. Closed format is better where small differences are to be gauged in relatively severely impaired speakers, whilst the open format version is more sensitive to impairment and differences in mildly affected speakers. The issue is neatly illustrated with pre and post therapy intelligibility assessments we conducted with people not associated with this study. Both John and Jean had dysarthria following stroke.

It is important to control for those who do the scoring of the tests.

John was severely affected. Therapy subjectively appeared to have made some progress. Yet a colleague who was not familiar with him, scoring the test from audiorecordings using an open format, revealed no progress. However, when matched listeners repeated the task with the target and foils before them, clear improvement from pre to post therapy was shown. Jean demonstrated the opposite. She had a relatively mild intelligibility problem, which nevertheless disturbed her greatly. For that reason we had worked hard on speech. Closed class scoring revealed little benefit from our collective efforts. Using open class scoring a definite step forwards from pre to post therapy emerged.

Clinical practice
So, whats the score for intelligibility testing? As regards clinical practice we suggest the following: 1. Scores across closed and open formats are not equivalent. Thus, to compare across speakers or in one speaker over time, one must compare using the same format. Using open scoring on one occasion and closed on another will not deliver a valid measure of change. 2. The strengths of the two approaches lie in different directions. Where a speaker is severely affected, then closed format scoring will provide a more sensitive measure. Conversely, where intelligibility is relatively mildly impaired, the more sensitive measure will be open format scoring. When it comes to associations with overall speech naturalness the indication is that open format scores correspond more closely. This may be a function of using relatively unimpaired intelligibility speakers here. We still have to confirm whether this would be true for severely affected speakers. 3. The study also confirms that it is important to control for who does the scoring of the tests. Everyday listeners may rate differently to clinicians; people used to hearing dysarthric speech rate differently to those unfamiliar with it. Hence experience, age and familiarity need to be carefully controlled across time to establish reliable readings of change in intelligibility. Jennifer Vigouroux is a speech and language therapist at Newcastle General Hospital and Dr Nick Miller a senior lecturer based in Speech and language sciences, George VI Building, University of Newcastle, Newcastle-upon-Tyne NE1 7RU, tel. 0191 222 5603, e-mail Nicholas.Miller@ncl.ac.uk.

Large discrepancies
We ranked individuals by score in each format. This revealed some large discrepancies. Over half the people were ranked more than five positions from their position in the other test, with speaker 29 in the extreme case ranked 5th for severity in the open test and 22nd in the closed test. Even when we tried to group people together into severity bands of mild-moderate-severe, only 7 fell in the same scoring band across formats. Some of the discrepancy might have led back to having different groups of people rate the recordings, so we removed listeners from the equation if they looked like they sometimes produced a score that was out on a limb compared to the other people scoring a given test. This improved the correspondence between open and closed rankings, but still did not resolve the inconsistencies in rankings, and made no difference to the relative mean scores across conditions.

If there are sufficiently large gaps of ability between subjects, subtle differences between test formats or listener effects are not revealed.
From our study, it seems open format scoring tallies closer to overall intelligibility rating of spontaneous speech. Closer scrutiny of the figures uncovered some more lessons in relation to this. The correspondence was stronger for more severely impaired speakers, and not so much for those mildly affected. This hypothesis is supported by Dagenais et al. (1998, 1999) who found intelligibility correlated with naturalness for moderately (1999) but not mildly (1998) impaired dysarthric speakers. Yorkston & Beukelman (1981) also argued that closed format tests do not consistently identify mildly impaired speakers. The reason doubtless relates to if articulation is not significantly distorted, what identifies these speakers as impaired are aspects of speaking rate, voice qual-

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ASSESSMENT / RESOURCES

Acknowledgments
This research was supported in part through a grant from the Parkinsons Disease Society, GB. Grateful thanks also to the speakers and listeners who volunteered to be part of this study.

resources
One stop shop
OATS (Open Source Assistive Technology Software) is the first free online one stop shop of open source software that enables those with disabilities to access computers. Developed by a consortium headed by the ACE Centre, the resource also provides a forum for developers to interact with users and even customise software in response to individual quests, which can then in the open source spirit be made available to others. www.oatsoft.org/

Contact a Family
Contact a Family has produced several new / updated items including: A checklist of the most common benefits and other help which may be available to the parents of a disabled child www.cafamily.org.uk/Checklist.pdf Reaching out to Disabled Parents www.cafamily.org.uk/GAPDisabledParents.pdf Reaching out to Fathers www.cafamily.org.uk/GAPFathers.pdf Reaching out to Black and Minority Ethnic Parents www.cafamily.org.uk/GAPBME.pdf Health Professionals Support Pack www.cafamily.org.uk/HealthSupportPack.pdf Concerned about your child? to encourage parents who are worried about their childs development to seek medical advice. www.cafamily.org.uk/paptinfo.html

References
Dagenais, P., Watts, C. & Garcia, J. (1998) Acceptability and intelligibility of mildly impaired dysarthric speech by different listeners, in Cannito, M., Yorkston, K. & Beukelman, D, (eds.) Neuromotor Speech Disorders: Nature, Assessment and Management. Baltimore: Brookes, pp. 229-240. Dagenais, P., Watts, C., Turnage, L. & Kennedy, M. (1999) Intelligibility and acceptability of moderately dysarthric speech by three types of listeners, Journal of Medical Speech and Language Pathology, 2, pp. 91-96. Garcia, J. & Hayden, M. (1999) Young and older listener understanding of a person with severe dysarthria, Journal of Medical Speech and Language Pathology, 7, pp. 109-112. Kent, R., Weismer, G., Kent, J. & Rosenbek J. (1989) Toward phonetic intelligibility testing in dysarthria, Journal of Speech and Hearing Disorders, 54, pp. 482-499. Kent, R., Miolo, G. & Bloedel, S. (1994) Intelligibility of childrens speech: a review of evaluation procedures, American Journal Speech Language Pathology (May), pp. 81-93. Tjaden, K. & Liss, J. (1995) The role of listener familiarity in the perception of dysarthric speech, Clinical Linguistics and Phonetics, 9, pp. 139-154. Weismer, G. & Martin, R. (1992) Acoustic and perceptual approaches to the study of intelligibility, in Kent, R.D. (ed.) Intelligibility in Speech Disorders. Philadelphia: John Benjamins, pp. 67-118. Wilcox, K. & Morris, S. (1999) Childrens speech intelligibility measure. San Antonio: Psychological Corporation. Yorkston, K. & Beukelman, D. (1978) A comparison of techniques for measuring intelligibility of dysarthric speech, Journal of Communication Disorders, 11, pp. 499512. Yorkston, K. & Beukelman, D. (1980) A clinician-judged technique for quantifying dysarthric speech based on single-word intelligibility, Journal of Communication Disorders, 13, pp. 15-31. Yorkston, K. & Beukelman, D. (1981) Assessment of Intelligibility of Dysarthric Speech, Tigard: CC Publications. SLTP

Guidelines
The Scottish Intercollegiate Guidelines Network (SIGN) will be publishing guidelines on head and neck cancer and autism spectrum disorders this year. For updates on progress see www.sign. ac.uk/guidelines.

Regulation
A new leaflet from the UKs 13 health and social care regulatory bodies including the Health Professions Council (HPC) lists which body is responsible for monitoring each profession and gives their contact details. It also explains what regulation means. Who regulates health and social care professionals? from www.hpc-uk.org (available in large print and 12 languages)

Altered Images: Becoming parents of our disabled children.

A parent-led self-help group in North Yorkshire has produced a collection of writing about being and becoming parents of disabled children. 12.99, e-mail post@ryedalespecialfamilies.fsnet.co.uk.

React2
The first version of React2 software for people with aphasia or other language disorders will be available from October. Purchasers will get an automatic upgrade to version 2 in early 2007, which will have over 9000 exercises. New features include randomised exercises, full screen presentation and increased settings controls. There are five modules: auditory processing, visual processing, semantics, memory / sequencing, and life skills. Single user prices vary from 50-95 per module to around 375 for a full clinical user. Upgrade costs for users of React and multiple user licences are also available. www.propeller.net

Waving not drowning

Working Families, which campaigns for a better balance between home and work for all families, has produced a new guide for working parents of disabled children based on interviews with parents who already successfully combine working and caring. The organisations Children with Disabilities project helps parents of disabled children who are working or would like to work, and has a parents newsletter Waving not drowning. Leaflets aimed at helping social workers and health visitors understand the needs of working carers may also be of interest to speech and language therapists. Make it work for you is 5.50 (post free) for parents and 15.50 for others. www.workingfamilies.org.uk

Photosymbols 2
This CD of photographic images for making easyto-read information has been redesigned to include over 800 new images, most suggested by version 1 users. The models reflect a more diverse range of people and over 2000 images are included. There have also been technical improvements which will make the software easier to access and install than before and all images will be supplied at a resolution suitable for commercial print jobs. www.worth1000words.org.uk

Food Talks
Scope Early Years has developed a pack to promote inclusion for children with eating difficulties. Training has also been developed to accompany the pack. For more details contact Scope Early Years Coordinator Jackie Logue on 01933 625284. Food Talks, 15 inc. p&p, tel. Maria Linehan on 01233 840764.

REFLECTIONS DO I RELY ON MY OWN JUDGEMENT OF A CLIENTS INTELLIGIBILITY OR DO I ALSO INVOLVE NAVE LISTENERS? DO I CUSTOMISE SPEECH-RELATED ASSESSMENT AND THERAPY TO TAKE ACCOUNT OF A CLIENTS ACCENT? DO I SELECT ASSESSMENTS TO ENABLE DIAGNOSTIC ACCURACY, OUTCOME MEASUREMENT AND PRIORITISATION?

WhisperPhone
The hands-free WhisperPhone aims to help people focus on and hear their own speech sounds louder and more clearly. The manufacturer reports positive feedback from speech language pathologists relating to users with a variety of communication needs. www.whisperphone.com

CAMH guide
The British Medical Associations board of science has produced a report on Child And Adolescent Mental Health A Guide For Healthcare Professionals. Download free at www.bma.org.uk/ap.nsf/Content/ Childadolescentmentalhealth

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2006

THERAPY DIRECTION

Discourse on co
In late 2004 the Stirling Discourse Colloquium considered current and future approaches to the analysis and treatment of disordered communicative interaction. While some of its individual papers are to feature in a special issue of Aphasiology, we have the opportunity to eavesdrop on a discussion among the main participants: Linda Armstrong, Suzanne Beeke, Steven Bloch, Richard Body, Marian Brady, Chris Code, Caroline Davidson, Ruth Herbert, Simon Horton, Catherine Mackenzie, Catherine Niven and Mick Perkins...

READ THIS IF YOU ARE LOOKING AT DISCOURSE AND WANT TO FEEL MORE CONFIDENT IN WHAT YOU ARE DOING CHOOSE THE RIGHT ANALYSIS TOOL AT THE RIGHT TIME GET THE MOST OUT OF CLINICAL CONVERSATIONS

Picture of Stirling Castle from VisitScotland / Scottish Viewpoint. See www.visitscotland.com.

uantitative and qualitative approaches to analysis of a communicative interaction are seen as opposite ends of a continuum. This continuum stretches from highly structured sampling to unstructured naturalistic real-life interactions measurable and quantifiable approaches to the narrative description of discourse features group to individual level data broad brush to very fine-grained analysis. While some entrenched radicals probably remain uninterested in alternative approaches, most individuals are more flexible, as both analysis tools do a particular job. The analysis approach should be dictated by the information you seek to collect and the function the results will have. If you want to compare an individuals performance to that of a wider population of people you need to analyse the data in a quantitative manner. If you want to explore an individuals performance within a peer conversation then you will use a qualitative method. It is possible that different clinicians naturally ask different questions. Having a predisposition may lead us to think that one of these approaches would be more or less informative than the other, which in turn would have a greater or lesser influence on the clinical intervention. Unless a clinician is comfortable with a given approach, the results and the utilisation of the analysis may be limited. Normal conversations are complex so analysis will be based on messy data. Some researchers have begun to look at co-construction but we have yet to develop an understanding of how normal conversations really work. There is a myriad of subtle and hidden activity that conversational partners do or achieve through their talk of which we have only just begun to become aware, for example in turn-taking negotiation or making a complaint. We should also consider the possibility that a disordered pattern of discourse features is only a symptom caused by an underlying impairment. Perkins (2005) has highlighted the possibility that pragmatic impairment may be a compensatory adaptation. In the past, we have focused on treating symptoms but consideration should also be given to the impairment(s) within a broader context. In addition, it is important to consider the limiting constraints of existing cognitive resources, ageing and any brain damage that may moderate our expectations of change in the clients communicative behaviour.

Joint responsibility
A key benefit of a qualitative approach is that it forces us to consider the joint responsibility of both the communicatively impaired individual and their conversational partner. Communication impairment affects both individuals talk and has an impact on the nature of the communicative interaction. In some cases communicative partners collaborate to achieve a successful interaction. The communicatively-able

10

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THERAPY DIRECTION

urse?
participant may use positively adaptive supportive techniques, for example collaborative repair, which enable a communicatively impaired individual to make a greater contribution. In Perkins et al. (1999), one researchers contribution to an interaction altered between a group of people with non-fluent aphasia and a group with fluent aphasia. A computer program automatically identified and quantified a set of linguistic and discourse features in a transcribed corpus of conversational data. The researcher was consistent on some measures of conversational interaction, but not on others. It is likely that they adjusted their contribution, when required, to compensate within the interaction for communicating with individuals with different communicative abilities. Alternatively, the compensatory behaviour employed by a communicatively competent speaker may be maladaptive, for example the use of testing within the conversation. This type of behaviour is not conversational, introduces an institutional flavour to the interaction and may reflect the conversational partners subtext in entering into the conversation. Similarly, the experience or familiarity of the non-communicatively impaired conversational partner may also be factors. For example, Herbert (unpublished research) observed that an agrammatic speaker had two very different conversations depending on her conversational partner. While interacting with her daughter she was required to produce very little in terms of lexical content but in conversation about holidays with a speech and language therapy student (whose approach was highly interrogative) the clients contribution consisted primarily of nouns. The topic of conversation may also have been an influencing factor, as was the students role and lack of experience as a therapist. In unpublished work by Perkins, speech and language therapy students and their supervisors were asked to record themselves communicating with a client with the purpose of identifying what makes the difference between a student and an experienced therapist. Students exhibited two main types of communicative contribution. They were observed to be either too controlling or too accommodating. In contrast, the experienced supervisors struck a very fine balance between these two approaches. Differences in the perceived competence of augmentative aid users communicating with different communicative partners have also been anecdotally reported (Robillard, 1999). Exploration of these issues is difficult because of the range of familiarity and experience of communication partners as well as the additional factors that may also influence conversational interaction, for example the conversational partners gender, age, education and the context of the interaction. and attitudes. Recent work suggests that speech and language therapist-client talk is somewhere between institutional and peer interaction (Lindsay & Wilkinson, 1999). It is possible that speech and language therapy education and expertise permits clinicians to encourage somewhere near normal conversations in a clinical context. While conversation within such a context is not representative of any or all other types of communicative interaction, it is representative of a clinical conversation, and such settings could provide an ideal context for sampling material in a consistent manner across time. The approach to sampling a communicative interaction can range from naturalistic to highly controlled and structured. A naturalistic sample might be a random sample of completely unstructured conversation between two peers and enables us to say something about how the people interact in the real world. A highly deal of caution is required in interpreting such data as it requires an appreciation of the sampling technique and some assumption of the degree to which the results are of relevance to another environment or setting. In light of these factors, it is vital that collected samples (and any contextualising details) are made available so that claims made from the results can be perceived by others.

Fundamental
The analysis approach chosen by a clinician should 1. provide information about what is important within the communicative interaction 2. aid diagnosis 3. inform effective therapy (which will in turn have a positive impact on the clients communication) and 4. measure change over time. If an analysis of the use of discourse features during an interaction is to be used for diagnostic purposes then we need to know what the range of non-brain damaged communicative behaviour is on such a measure. This becomes essential when we are faced with an individual who may exhibit very subtle communicative problems, for example as a result of early Alzheimers disease or right hemisphere brain damage. Here the clinician must decide whether what they are listening to is within the range of normal communicative behaviour or not. The higher the language demand, the more blurred the distinction between a communicative pattern that is normal and one that is abnormal. (We all know someone whose normal communication could be described as impaired by a speech and language therapist!) Caution should be employed when analysing a sample as the extent to which we are informed of the participants communicative history may subconsciously influence the extent to which we observe evidence of disordered communicative interaction. In Mackenzie et al. (1999) and Brady et al. (in press) an expectation that verbosity would be associated with right hemisphere brain damage was challenged when the most verbose individuals (as per word count) were in the non-brain-damaged groups. In such situations it is essential to have a general framework of normal conversational behaviour from which to objectively appraise subtle deficits. To make an unblinded differential diagnosis of such subtle deficits on the basis of a qualitative description of a sample alone is very difficult, if not foolhardy. Speech and language therapists are experts in discourse and conversational analysis and their knowledge - which may be informally acquired over time - should not be underestimated. However, it is vital that they examine not only their clients contribution to a communicative interaction but also the communicative partners (in some cases their own) communicative behaviour. Transcribed data or video- or audio-recorded feedback can be used to alert the communicative partners to various features of the interaction. Some might question the
SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2006

Transcribed data or videoor audio-recorded feedback can be used to alert the communicative partners to various features of the interaction
structured task might be the controlled elicitation of a procedural sample from a person with a communicative impairment with minimal contribution from the communicative partner. Such a sample will provide little information of relevance to the individuals performance within a naturalistic conversation but allows some comparisons to be made over time and across individuals. The purpose of the two approaches to sampling differs, but with each we need to acknowledge how close the collected sample is to what is real. We no longer have the perception that what is observed in one type of discourse holds good for other genres. Individuals communicative interactions are likely to differ across contexts. For example, one clients narrative sample may provide information of relevance to their conversational interactions but for another the narrative sample will have elicited data that is primarily sentential and bears little resemblance to their conversation. Other task-related factors should also be considered. For example, we know that a clients age and educational background have an impact on their performance on a picture description task (Mackenzie et al., in press). Performance on such formal tasks may be related to an individuals confidence in a test situation. On the other hand, some semi-structured elicitation cues can easily be introduced within a therapeutic conversation (for example Tell me about your family). These are rarely perceived by the client as a formal task and are thus less likely to provoke a confidence crisis. A great

Therapist-client talk
Interactions in a therapy setting are typically exchanges of information while interactions seen in less formal settings are characterised by an exchange of opinions

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value of identifying features that are only evident at a detailed transcription level, arguing that appropriateness is probably best perceived by the communicative partner within the context. There is now some indication that the expert therapist as an observer of a live or recorded interaction has the skills to note the use of such features without the need for in-depth transcription (Armstrong et al., in press). One of the difficulties with qualitative approaches is the vast range of discourse features that can be considered. As the body of literature builds, however, that information will in turn direct clinical focus towards features of note within an interaction. And as our knowledge increases through in-depth methods of descriptive analysis, this should feed into new clinically feasible approaches. While many therapists do not feel they have time to undertake the detailed transcription required for qualitative approaches to analysis and some lack confidence in the use of discourse terminology (turn-taking, repair, coherence), most seem keen to intervene at the practical level of discourse features within conversational interaction. There appear to be different perceptions as to how long qualitative analysis takes, but a means of making this rich source of information more accessible in clinical settings would be welcome. Communicative sequences are multi-layered and any proposed analysis tool for routine clinical use would need to provide more than superficial information. Clinicians require a tool that not only identifies the use of disordered features but also allows some description or explanation of how the participants are dealing with the features to inform an appropriate intervention. A first step may be to develop tools that work at a superficial level. Categorical counts sensitive to change at a conversational level or frameworks to allow the analysis of communicative interaction in an objective and efficient way are two possible starting points. Some advances towards this goal have already been made (Lock et al., 2001).

from family members are also likely to be relevant. In the past we have probably underestimated how hard it is to change communication behaviour at conversational level, perceiving that successful therapeutic interventions targeted at word or sentence level would automatically - or with a little support - be generalised to conversational level. But some features of conversational interaction are probably not under our conscious control - and individuals without a communicative impairment have difficulty changing their communication style! Yet we continue to expect that people (in some cases with associated brain damage) will change their communication behaviour with very little effort. Despite huge therapeutic effort amongst some (for example, individuals with traumatic brain injury), conversations can still go wrong in context and this may indicate that deficits at other cognitive levels also require attention.

If the therapeutic focus is to shift towards conversational level interventions then a change in clients perception of therapy and what it has to offer is required.
Yet change at the conversational level of interaction is vital for therapy to make a difference in that individuals life and the lives of his family and friends. If the therapeutic focus is to shift towards conversational level interventions then a change in clients perception of therapy and what it has to offer is required. Speech and language therapy students at the University of East Anglia (in collaboration with Connect) have become conversational partners for people with aphasia, yet some of the people with aphasia have found the concept of someone coming just to have a conversation with them challenging.

Evidence
The link between quantitative approaches to assessment and impairment-based therapy has been well documented. Formal quantitative approaches provide concrete evidence that therapy is efficacious and this evidence is accessible to (and increasingly sought by) clinicians, clients, family members, managers and policy makers. The link between qualitative approaches to analysis and therapeutic intervention however has not been adequately demonstrated and should be urgently addressed. For example, a substantial amount of work has been carried out training conversational partners and, while we can say their conversation is better, we should be able to prove it. Quantification provides evidence of effectiveness in a way a single case study will never do. However, we also know that the effectiveness of therapy is related to the impact of the intervention on the quality of the individuals daily communicative life. Quantifying change on selected outcomes using valid and reliable assessment tools of communicative improvement may be complemented using other qualitative approaches. For example, psychosocial indicators of whether the client with traumatic head injury is able to develop friendships, avoid confrontations or is confident enough to participate socially (for example, go to the pub) are all valid indicators of change. Reports of improvement

Ownership
Clinicians have a responsibility to choose the best approach to intervention for a particular client and their family - and that may not always be at conversational level. Developments in therapeutic interventions have progressively evolved towards focusing on both the client and the conversational partner within an interactional setting. However, this (by design) takes the focus away from the person with aphasia. We need to acknowledge that people have different learning styles and some people with aphasia actually enjoy the more formal, quantitative approaches to assessment as well as impairment-based therapy. They find they can explore the full extent of their language disorder and develop an understanding of what they can and cannot do. They can regain a sense of control over their impaired communication from insights gained through testing and a sense of achievement from successfully completed tasks. Although aphasia affects all the communicative participants within an interaction, the person with the impairment retains ownership. Therapeutic intervention increasingly includes working with communication partners (usually family members and friends). This development is no doubt a reflection of the difficulty many client groups have in independently

changing their communication patterns. It is well recognised that small therapist-enacted changes to the communicative context, such as getting a partner to make greater use of pauses, can suddenly make a person with communication impairment seem much more competent by allowing them to contribute to the interaction. In the past there was a perception that a conversational partner pushing for or encouraging a better response was a positive thing. Education on the nature of the communication deficit and suggestions for successful management strategies for certain communication habits can take some of the pressure off communication partners without them feeling the need to produce a painful emulation of therapy. Some partners (and clients) can have significant insight into how they are coping with the communication impairment and the strategies that they are using to overcome them, yet we should be cautious of putting the onus of successful communication solely on them. It would be useful to be aware of the limits of possible change not only for the communicatively-impaired individual but also the extent to which a communication partner, for example the elderly spouse of an individual post-stroke, can be trained to change their conversational style and improve their communicative support. Different approaches are likely to be required for different client groups. For example, there may be some scope in the consideration of hard-line behaviour modification, pharmacological co-interventions and social decision making models when working with individuals with traumatic brain injury. Such approaches are however unlikely to be appropriate when working with individuals with aphasia. With the possibility of subtle interactional impairments merely being a symptom of (or an adaptation to) a non-linguistic underlying cause, speech and language therapists are increasingly working collaboratively with other professionals. While an interest in conversation level impairment and intervention is appropriate, it should not be to the exclusion of other approaches. Interventions based on cognitive neuropsychology have proved to be effective (as measured by increased test scores) but the therapeutic community appears to have become disinterested. Efforts should be made to understand whether interventions demonstrated to be effective are also effective at conversational levels. For example, we should consider to what extent improvements in word finding can be understood within the context of everyday communicative interactions. It is crucial to consider what happens outside the clinic and about how the individual lives with the communication impairment. We talk about living with dysarthria or living with aphasia and look at communicative impairment in an adaptive way. However, the infrastructure and technology that is required to help people to live with their communication impairment is as yet unavailable and so to some extent therapy - and more disappointingly the individual - is still constrained within a deficit model.

Stories of success
Clinicians have many stories of both success and failure. Analysis is mainly deficit and impairment focused, with little consideration given to how therapy works and, when it does work, why. We should pay more attention to our success stories by considering the circumstances in which the intervention proved to be beneficial. While

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HERES ONE I MADE EARLIER...

qualitative approaches to analysis provide many ideas for conversational level interventions, we also need to work at translating those into successful therapy. Where success has been achieved then we must communicate this to others to enable the ongoing development of our interventions. If there is evidence of effectiveness then clinicians can justify spending time on analysis that will inform effective interventions. Together, quantitative and qualitative approaches to analysis add to the potential richness of data collected. We look forward to these two approaches evolving towards a single analysis methodology that represents combined elements, thus allowing a quantification of the use of discourse features. Address for correspondence: Marian Brady, Nursing, Midwifery and Allied Health Professions Research Unit, Buchanan House, Glasgow Caledonian University, Cowcaddens Road, Glasgow G4 0BA.

Heres one I made earlier...

ALISON ROBERTS WITH MORE LOW-COST, FLEXIBLE THERAPY SUGGESTIONS SUITABLE FOR A VARIETY OF CLIENT GROUPS.

I. LUCKY DIP REPORTING GAME

This game helps to develop lateral thinking and narrative skills in fairly able clients. The idea is for the clients to become Reporters, who provide a main idea, and then give a few details to go with a newspaper headline that they have picked out of a container. Playing this game also provides an opportunity for you to suggest that keeping up-todate with and being able to talk about real news can be a good conversation skill. MATERIALS Plenty of headlines cut out of newspapers - vague themes are best, rather than headlines that restrict the reporter to one particular story Some sort of container such as a basket, hat, or bag Small envelopes BRAWN Place each headline in an envelope. This is preferable to just putting them straight into the container, because otherwise you risk them getting ripped. Also, in this way, the headline can be kept private to the reporter, avoiding others chipping in. IN PRACTICE Clients are asked to pick out an envelope, look at the headline, and then provide a short report to follow it. Request that they keep the headline to themselves until they have a rough idea of their report. Suggest that they then read out their headline, and follow it with a main theme, then two to three details. Its good if you go first to demonstrate. Lets say the headline reads: Phew! What a scorcher! You could give a main theme: Temperatures reached 35 degrees centigrade in Gloucestershire today, then supply three details: Farmer John Smith had to keep his cattle indoors today to stop them getting heatstroke. He put the hoses on to spray them. He blamed global warming for this problem. Reward clients for reports of the right length. Those who tend to ramble will benefit from having to be short and to-the-point, whilst your clients who tend to offer one word as a response must elaborate a bit.

II. ALL ABOUT ME BOXES

This is a self-awareness activity. It is best done over several sessions, taking time to complete the boxes to a good finish and talk them through. You can carry out this activity with just one client, or in a group. A word of warning: this activity should be carried out in a light-hearted atmosphere - you are not trying to be a psychotherapist. My advice is to make one about yourself before the session, which you are prepared to open to reveal the contents, but state clearly that they will not have to reveal the contents of their boxes to others if they do not wish to. MATERIALS Small (about 6cms x 6cms x 2 cms) plaincoloured cardboard boxes available from craft shops. The best sorts have a frame within the lid. If you really cannot run to that expense, then the small individual cereal boxes sold in packs are a good substitute, but you will need to paint them white before decorating, and make a neat opening at one end. A photo of your client Felt-tip pens Small pieces of paper or card Sticky tape IN PRACTICE (I) The outside of the box is decorated with the felt tips, and with words to show the world what this person is good at, or likes to do, and should include their name. This part is open for others to inspect. Inside the box your client will place the small pieces of paper or card with words to describe their secrets, fears, disappointments, dreams, etc. It is important for the clients to be sure that the boxes are kept in a secure place, and that you will not look inside without their permission. When they have completely finished making the boxes they may like to seal them with sticky tape. If your client is happy to do so, they will stick their photo on the lid of the box, within the frame. IN PRACTICE (II) This is good for the group setting. Begin the writing of the cards for inside the box with some less sensitive topics, for example preferences (favoured holiday resorts; music; types of food), or aspects of the clients biographies (birthday;place where their childhood was spent; schooling). Pool all of the cards, and take turns to pick one out and guess who wrote it, before placing it in its owners box.

Acknowledgement
We would like to thank Dr. Ellen Townend and Elizabeth Stirrat for transcription of the discussion sessions.

References
Armstrong, L., Brady, M., Mackenzie, C. & Norrie, J. (in press) Transcription-less analysis of aphasic discourse: a clinicians dream or a possibility?, Aphasiology. Brady, M., Armstrong L. & Mackenzie, C. (in press) Change over time in linguistic abilities in people with right hemisphere brain damage? Journal of Neurolinguistics. Lindsay, J. & Wilkinson, R. (1999) Repair sequences in aphasic talk: a comparison of aphasic-speech and language therapist and aphasic-spouse conversations, Aphasiology, 13, pp. 305-326. Lock, S., Wilkinson, R. & Bryan, K. (2001) Supporting Partners of People with Aphasia with Relationships and Conversation (SPPARC). Bicester: Speechmark Publishing. Mackenzie, C., Begg, T., Lees, K.R. & Brady, M. (1999) The communication effects of right brain damage on the very old and the not so old, Journal of Neurolinguistics, 12, pp. 79-93. Mackenzie, C., Brady, M., Norrie, J. & Poedjianto, N. (in press) Picture description in neurologically normal adults: concepts and topic coherence, Aphasiology. Perkins, M.R. (2005) Pragmatic ability and disability as emergent phenomena, Clinical Linguistics and Phonetics 19, pp. 367-377. Perkins, M.R., Catizone, R., Peers, I., & Wilks, Y. (1999) Clinical computational corpus linguistics: a case study, in B. Maassen & P. Groenen (eds.) Pathologies of Speech and Language: Advances in Clinical Phonetics and Linguistics (pp. 269-274). London: Whurr. Robillard, A. (1999) Meaning of a Disability the Lived Experience of Paralysis. Philadelphia: Temple University Press. SLTP REFLECTIONS DO I HAVE REALISTIC EXPECTATIONS OF HOW MUCH A COMMUNICATIVE PARTNER CAN ADAPT THEIR COMMUNICATION? DO I HAVE A FLEXIBLE APPROACH TO THE DIRECTION OF THERAPY THAT TAKES INTO ACCOUNT THE LEARNING STYLE AND WISHES OF THE INDIVIDUAL CLIENT? DO I PARTICIPATE IN EVENTS THAT GIVE CLINICIANS, RESEARCHERS AND ACADEMICS TIME TO PAUSE AND REFLECT TOGETHER?

Alison Roberts is a speech and language therapist at Ruskin Mill Further Education College in Nailsworth, Gloucestershire.

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Leaving school at 17, Im not convinced I had a clear idea why I had chosen speech and language therapy. I wanted to study for a job rather than a degree, was interested in communication and was keen to do something that would make a difference. I was lucky it was right for me and has given me opportunities to develop other interests too. But, in a profession beset by recruitment and retention problems (RCSLT, 2005), what are the costs to individuals, universities, services and society when we miss people who would have been an asset or take on those whose talents lie elsewhere? Jane Rawlings, an independent therapist in the Leicester area, is concerned that universities and services dont have sufficiently joined up thinking. CREST (the Committee for Research and Education in Speech and Language Therapy, which represents all the UK courses) apparently agreed some years ago that it was not essential for potential students to have observed therapy sessions. However, when a friend of her daughters was accepted on a speech and language therapy course on this condition, the local trust couldnt offer observation sessions as they didnt have enough therapists. Luckily Jane stepped in, and the girl proved to be an ideal candidate: She was very enthusiastic, completed my observation questionnaire well, asked lots of pertinent questions and was accepted onto the course. What worries me is what would have happened if I hadnt taken her? We nearly missed this one. Jane feels strongly that hands-on time is usually when people really know if this is a career for them: If we want decent therapists, we need to be prepared to give people opportunities to see what it is really like. She suggests a more flexible system with some out-of-the-box thinking could produce results. For example, independent therapists could be paid to do sessions at a university clinic, perhaps with people on NHS waiting lists, specifically to give potential applicants work experience.

Succession planning
Many people take up careers without properly understanding what is involved. Consequently they find that their chosen field, selected on inadequate information, is not for them (Rt. Hon. Lord Ashley of Stoke, in Wright & Kersner, 2004, p.ii). Editor Avril Nicoll asks what we can do to ensure the next generation of therapists are the right people to take the profession forward.
The Dudley department also offers careers talks. Clare has found this works particularly well in conjunction with a newly qualified therapist who has up-to-date information about being a student. An additional benefit for staff development is that everyone gets confidence from realising how much we do in explaining it to others. Speech and language therapist Samera Mian agrees that small things such as offering careers talks can make a big difference. Having qualified 2 years ago, the invitation to talk to 30 pupils at her old school came as a pleasant surprise. Samera had attended an independent girls school in Manchester where it was unheard of to do a vocational degree, and even to go to a Metropolitan University. She came across the profession by accident but was unable to access any information via her school and was discouraged from applying. The request for the careers talk came about because current pupils saw her profile and wanted to hear more. But Samera is concerned that people dont understand how difficult and demanding the job is, and how academic. A colleague was asked, Did you have to go to evening classes to do that? Even Sameras sister, a medical student, said during a discussion, Im really surprised you know that but I dont really know what you do. I supposed you just help people with their talking. important than the white participants. In contrast, the white female participants rated being part of a team as more important (p.89). However, the researchers stressed that, [While] career choice is influenced by a variety of factors including aspirations, academic performance, gender and cultural backgroundwithout some knowledge of speech and language therapy, they cannot consider it as a career (p.92). They recommended that undergraduate students could be paid for visiting schools and colleges to talk about their chosen profession to pupils and their parents as personal contact is more effective than print. They also suggest we should raise awareness of the degree requirement and the professions scientific and evidence-based nature. In writing A Career in Speech and Language Therapy, Jannet Wright and Myra Kersner were keen to ensure potential applicants got a flavour of the complexities of the job as what makes it appear easy is the therapists mastery of the required individual skills and knowledge, and their mastery of the ability to process their thoughts and actions simultaneously, at speedif you decide this is the career for you, you will need to study hard (2004, p.3). I asked Myra what had prompted the book. She says they had become frustrated by the number of times people asked at University College London admissions, What can we read to find out more? The book is based on anecdotal evidence of what students have said to us over the years: We didnt realise, You said ___ but we didnt believe . It therefore emphasises the hard work, the academic standards, the busyness and variety of the job, the admin, and the need to work with individuals and groups. It also outlines the different roles we undertake: professional; therapeutic; teaching; facilitating; assessment; team member; counselling; training; advo-

Keep it local
Since Clare Grennan and Jane Rogers wrote about offering work experience placements in Dudley (2005), several departments who do not have such schemes have directed people to Dudley. One enthusiast was even prepared to travel and stay in a hotel for the duration of the five day placement, but Clare says they have to keep it local. While this is partly due to the high demand for places, Clare believes we all have a duty to be proactive in this way, and she hopes other departments will take the idea and run with it. In Dudley the first five pupils to contact the department are given the places. So that the experience is rewarding for staff as well as pupils, they have to have a serious interest in a career in speech and language therapy. Three years into the scheme, Clare says there have been fantastic candidates whose log books are reflective, and who have come back for advice on applying to courses.

Personal contact
As a British Muslim, Samera was interested in the findings of Greenwood et al. (2006) about perceptions of the profession among school pupils. They suggested that female minority ethnic students regarded such factors as having a high salary, a prestigious career, following a profession, a scientific career, being their own boss and parental approval of their course as significantly more

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FEATURE

[While] career choice is influenced by a variety of factors including aspirations, academic performance, gender and cultural backgroundwithout some knowledge of speech and language therapy, they cannot consider it as a career (Greenwood et al., 2006, p.92). conclusions but there is nothing which obviously differentiates these intakes from interviewed intakes. She explains that to be offered a place candidates instead have to show that they have knowledge of communication disorders and the role of the speech and language therapist, emphasising, it is not logging that you have certain experiences which matters, but rather showing what you have gained from these. The university plays its part by offering comprehensive information on its website and an open day with a talk on speech and language therapy and the course. This is followed up by a specific session for applicants with talks from paediatric and adult therapists, videos and information about what makes a good application. The third stage is an information session about the course for those to whom offers have been made and their families. Catherine concludes, At this point I can see no good reason to return to the traditional interview process. In contrast, speech and language therapy hopeful Lindsey Kent was invited to an interview at City University. An introductory talk included reassurance that the process had been designed to assess how well applicants felt they would cope with the course and how suited they were to speech and language therapy. Lindsey says the panel composition of an academic and a practising therapist made for an interesting interview dynamic. Lindsey was successful and is eagerly anticipating starting her postgraduate degree in September. With a degree in Comparative American Studies and now working in Spain as an English as a second language teacher, it was a conversation with her sister about what kind of work might suit her personality and interests that got her thinking about speech and language therapy.

Illustration by Graeme Howard

cacy; administrative and time management. Like Jane and Clare, Myra believes it is incumbent on individual speech and language therapists, departments and NHS Trusts to think creatively to ensure that potential students have the opportunity to access as much information as possible before they make important career choices. She suggests that therapists can point enquirers in the direction of the book and books by people with communication impairments, offer open days, make videos and generally talk to people about their work. She also says it is important to encourage potential applicants to do work in a voluntary or paid capacity that will give them as much contact as possible with people with communication impairment as, There is always going to be some element of being unprepared for the actual feel of working with people in a clinic. Occasionally people are misguided about their own interpersonal skills but more often they realise themselves it is not the right course for them.

A recognisable face
Speech and language therapy student Andrew Lawtie had extensive previous experience in health and care settings and argues they are fertile recruiting grounds for people suited to a career in speech and language therapy if they are exposed to the role. Andrew first decided to look into speech and language therapy when he was a care assistant at a residential school for children with special needs and saw a therapist working with children with autism and AAC needs. Having gained experience as a speech and language therapy assistant, Andrew was knocked backed by universities on academic grounds, so instead enrolled in a degree in childrens nursing. He says, Working as a childrens nurse I could see that

the profile of speech and language therapy within the medical setting is not that great. A therapist came in and did a lot to make herself a more conspicuous part of the team a lot of credit goes to her for becoming a recognisable face, and there was a noticeable change in awareness of the profession. Although Andrew enjoyed nursing he still hankered after a career in speech and language therapy. He wanted a more specialised role, with more autonomy, where he would feel more valued. Andrews experience enabled him to go directly into second year at De Montfort University. While the course is meeting his expectations in terms of clinical placements, the academic demands have been higher than he expected and he would have appreciated more timely feedback to boost his confidence. Andrew was offered a place on five out of the six courses he applied for. He expressed surprise that some universities offered places without an interview, as he wonders how suitability can be assessed through a written application. I asked Catherine Mackenzie, course director of the BSc Speech & Language Pathology at the University of Strathclyde, about the thinking behind this, and if it is proving to be a successful strategy. She explained that an interview used to be a Royal College of Speech & Language Therapists requirement, but that courses had raised concerns about the costs to the applicant and staff time; the difficulty ensuring objectivity; and the fact that all courses had examples of people who had passed an interview but were later seen as unsuitable. Although a few courses still interview, RCSLT has removed its requirement for a trial period of five years. Catherine says, We now have three years of intake without routine interviews, and this year we have interviewed no-one. This is too few on which to base

While Lindsey began her hunt for information on www.rcslt. org, personal contact with several speech and language therapists gave the most useful and honest perspectives
Lindseys sister is an occupational therapist and her mum is training to be an occupational therapist following many years experience as an assistant. To Lindsey this was important as they know her capabilities, strengths and motivators, and also offered her an interesting perspective. It seems this is not an unusual scenario; Greenwood et al. (2006, p.84) found that school pupils with relatives in a health-related job were significantly more likely to consider speech and language therapy [as a career] than those without such relatives.

Useful and honest

While Lindsey began her hunt for information on the Royal College of Speech and Language Therapists website (www.rcslt.org), she also benefited from graduate information websites like www.prospects.ac.uk, a web
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FEATURE

forum for prospective healthcare profession students www.admissionsforum.co.uk/ and the NHS website. Personal contact with several speech and language therapists however gave the most useful and honest perspectives, both positive and negative. Lindsey says, the more I researched, the more interested I became in the job. There seemed to be plenty of room for personal development, further training and research opportunities. The job would be varied and it would combine my love of language and communication by enabling me to facilitate the language and communication skills of others. Lindsey read Crystal & Varley (1998) and set about getting some practical experience, spending a day observing and talking with a therapist at a rehabilitation clinic in Aberdeen. She found it was particularly difficult to secure observation days in London, although some hospitals run open days, and became a little downhearted, as I thought perhaps I wouldnt have done enough to show how passionate I was, or to demonstrate that I was already beginning to develop useful skills. However, clearly City University agreed with one of her friends who said, Lindsey, this is a career which makes perfect sense for you. While we can wish Lindsey, Andrew and every other student all the best, we might also reflect on the reasons why we chose speech and language therapy and what more we can do to ensure that our successors are equipped to take the profession forward. As Clare Grennan says, I really think its worthwhile because it is amazing how much people dont know about what we do. Its a really interesting job, I love it to bits.
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Acknowledgements
Many thanks to Clare Grennan, Lindsey Kent, Myra Kersner, Andrew Lawtie, Catherine Mackenzie, Samera Mian and Jane Rawlings for their infectious enthusiasm.

References
Crystal, D. & Varley, R. (1998) Introduction to Language Pathology. London: Whurr. Greenwood, N., Wright, J.A. & Bithell, C. (2006) Perceptions of speech and language therapy amongst UK school and college students: implications for re-

cruitment, International Journal of Language and Communication Disorders 41(1), pp. 83-94. Grennan, C. & Rogers, J. (2005) All in a days work, Speech & Language Therapy in Practice Winter, pp. 4-6. RCSLT (2005) Annual Report 2004-2005. London: Royal College of Speech & Language Therapists. Wright, J. & Kersner, M. (2004) A Career in Speech and Language Therapy. London: Metacom Education. SLTP

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Myra Kersner and Jannet Wright are offering Speech & Language Therapy in Practice readers a 1.00 discount per order for a limited period. To qualify, print off the order form at http://metacomeducation.tripod.com, quote SLTB1, and ensure your order with payment is with publishers Metacom Education by 25th September 2006.

SLTP

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CREATIVE SHORTS

owerPoint software comes as part of the Microsoft Office package. First launched in 1994, it has become the most common tool for presenters at conferences. Where people formerly used a flipchart and pen, or an overhead projector and transparencies to write key points, with PowerPoint you save a slide presentation which can include text, cartoons, photographs, colour, movement and sound effects. Its use and abuse in presentations is a topic of debate (see for example http://joycevalenza.com/powerptart.html, accessed 11 June 2006), particularly in terms of the effect it can have on a speakers interaction with their audience. In its favour, though, is that it can lead the speaker to present their information in an organised and clear way and it is easily updated or amended for different purposes. As a visual tool, it can also help the people looking at it to focus on and retain the information. Used judiciously, the variety of sound and visual effects can grab attention. Because of these features, I find PowerPoint particularly useful for bringing therapy and assessment activities to life.

1. Phonology assessment
My phonology assessment is not standardised, and I change and improve it from time to time, but it is a lot of fun for the children. Each slide contains a target picture which I have chosen to be clear and unambiguous. I use photographs which I have taken myself or downloaded from the internet (Google images or Microsoft), also cartoons and animations which are carefully selected for their humour. Some have accompanying sound effects such as a tiger roaring or a cat meowing. These provide motivation to name the pictures and rewards for speaking. The result is a child who interacts with the computer as they click on the buttons to advance the slides and generate the sound, and who laughs and provides a pretty good sample of spontaneous speech as they explore the cartoons.

We usually associate the Microsoft Corporations PowerPoint software with presentations at conferences, but Elizabeth McBarnet finds it invaluable as a therapy and assessment tool.
One of Elizabeth McBarnets own therapy pictures

2. Therapy activities
In phonology work, the picture comes up on the computer screen, the child names it and I ensure the appropriate sound symbol zooms / flies / whizzes in to reinforce the correct production. For example, when I am working with a child on s clusters, a picture of a key appears on screen. The child calls Sammy Snake by saying /s/ and pressing the arrow on the keyboard. Sammy Snake then crawls onto the screen, in front of the key. The child says /s-ki/, presses the button and an arrow points to an animation of a boy skiing. Snails can crawl in, tops can spin or teddies boomerang. The motivation this produces is amazing, and varying the method of entry and exit of the picture means the child is fascinated to see the next slide and hardly realises how much they are talking about it. Children who can read can have a picture / cartoon appearing followed by the target word as reinforcement. I find PowerPoint particularly effective for verbs as I can include animations so that the action is really action! I have also used this method with people with mild to severe aphasia. Sentence completion is fun when the first part of the sentence appears and the client clicks to bring the rest up on the screen after saying it and clicking on the button. This can give a sense of control and independence to people who have lost so much. Naming activities with big, bright and realistic pictures are enjoyable and infinitely adaptable.

More Power to you

3. Making the slideshows
To produce slideshows for assessment or therapy, you will need a computer with PowerPoint software (or other presentation software), internet access, a digital camera and a scanner. 1. Identify the clients interests and therapy targets and find suitable graphics, ensuring there are no copyright issues. 2. Open a new PowerPoint slideshow. 3. Download the pictures you have chosen from the internet, or scan and save them to your computer, and paste them on to the relevant PowerPoint slides. 4. Use the custom animation tool to arrange order of appearance and method of entry / exit of the pictures. 5. Add sound if required (downloadable from Microsoft online, www.microsoft.com). It takes me hours and hours to create these programmes but once they are made I can reuse and adapt them for each individual I see. Everybody gets therapy tailored to their interests and needs. One little boy who was working on /s/ wanted me to include the SpongeBob SquarePants character, so we went online immediately and found a picture that we could download to include in the set. These were printed and he took them home to practise. PowerPoint programmes can then be copied on to a disk or a CD and handed or e-mailed to clients if they have their own computer and compatible software. Elizabeth McBarnet is an independent speech and language therapist working with children and adults in Ballyclare, County Antrim.

Resource
PowerPoint software is a brand product of the Microsoft Corporation, www.microsoft.com/powerpoint/. SLTP
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REVIEWS

reviews
EDUCATION (1)
Class Talk Rosemary Sage Network Educational Press Ltd ISBN 1-85539-061-2 17.95 in a Language Base there are a range of activities I will be able to dip into to help students access key subjects. Katie Davies is a speech and language therapist working in a Junior Language Unit for Bournemouth PCT.

Good value for money

An interesting, enjoyable read, primarily aimed at teachers, though also providing useful pointers for therapists devising communication strategies for individual children, and the rationale behind these. The author flags up the change in the childs role at school entry: from prolific speaker to passive listener. She considers this a problem for children, as taking an active role in conversation is essential for effective learning. Within this ambitious work is a section on how stages of brain development and knowledge about hemispheric dominance bring about different learning styles, which teachers need to consider when planning lessons. A wideranging chapter on non-verbal language even includes a welcome feature on vocal hygiene for teachers. Throughout the book are common-sense teaching tips, such as .. help students visualise ideas, to help thinking and communication (p107). Appendices include communication skills checklists and some excellent ideas for group games. Good value for money. Sally Gray is a speech and language therapist working in Forth Valley.

TRANSSEXUAL CLIENTS
Voice and communication Therapy for the Transgender/Transsexual Client Richard K. Adler, Sandy Hirsch & Michelle Mordaunt Plural Publishing Inc ISBN 1 59756 012 X 55.00

knowledge and expertise in this highly complex field. It will quench the thirst of therapists embarking on this area with clear presentation and sound practical advice from assessment to management, whilst whetting the appetite of more experienced clinicians to review their practice and consider the challenges of ethical issues. This resource has appendices with material for training and is good value for money. Valerie Moffat is head of speech and language therapy at Chailey Heritage Clinical Services in East Sussex.

contact details for further information. Jaclyn Dallas, speech and language therapist, is now working with adults at Stracathro Hospital, Brechin, but was until recently a paediatric therapist in Dundee.

VOICE
Singing and Teaching Singing Janice L Chapman Plural Publishing Inc ISBN 1-59756-015-4 25.00

A pleasure to read
This book was most enjoyable, informative and a pleasure to read. I learned a lot about singing, but realised I could relate to it easily, as Janice Chapmans teachings and techniques are similar to those I already use with clients. Janices approach is connecting with the primal self and emotional expression. She uses some ideas from Estill and Accent methods, as she feels the singer needs to relate the sensation in the vocal apparatus to the sound produced. There are five other contributors. They all add a different and informative perspective on singing. I would recommend this book to all voice specialist speech and language therapists and anyone else who may be interested. Considering the wealth of information in the book and the appendix of exercises it is good value for money. Linda Collier is a specialist speech and language therapist working with people with voice disorder in the NHS for Basildon PCT and in independent practice. Speech & Language Therapy in Practice has a copy of Singing and Teaching Singing to give away FREE to a lucky reader, courtesy of Plural Publishing. For your chance to win, e-mail editor avrilnicoll@ speechmag.com by 25th September 2006.

A limited approach
This book provides an overview of the complex range of issues involved when working with transgender clients. Its main context is the North American health system and culture, which does rather restrict its relevance, and it is not always an easy read. Explanations and treatment suggestions in sections such as pitch and intonation appear complicated, and use a limited approach without reference to various other widely-used techniques. There is no mention of phonosurgery for male-to-female clients, or the role of speech and language therapists in supporting it, a significant omission in a comprehensive clinical guide. However, there are useful suggestions and tools for assessment and goalsetting in some aspects of therapy, and an accompanying CD illustrates some before and afters in male-to-female speech samples. Linda Preston is principal speech and language therapist at the Royal Sussex County Hospital, Brighton, working with people with voice disorders and head and neck cancer.

STAMMERING
GUIDE to good practice when working with pupils who stammer in secondary schools (CD ROM) GUIDE to good practice when working with pupils who stammer in primary schools (CD ROM) ENGLISH oral work from S1 to S4 (CD ROM) British Stammering Association 12.99 each inc. VAT

Many useful strategies

These CD ROMs present basic information regarding the management of children who stammer for teachers and speech and language therapists. They will give teachers and other staff a wider understanding of the issues surrounding stammering and its management. The information provided could also be used valuably in training for students of speech and language therapy and education to provide a basic knowledge of the issues and what can be done to help. In schools, we are encouraged to help the children take ownership of their own learning and increase their awareness of their difficulties and what they can do to help themselves. The third CD is the ideal learning tool for secondary school aged pupils who stammer. It gives many useful strategies that pupils can use themselves to be successful in English oral coursework. These are useful resources for therapists dealing with this client group, and provide invaluable printable materials for teachers and parents. For newly qualified therapists this resource is very useful, but perhaps for more experienced therapists the CDs may be less so. Menus are easy to navigate, and the British Stammering Association has given comprehensive

EDUCATION (2)
Lend Us Your Ears Rosemary Sage Network Educational Press Ltd ISBN 1-85539-137-6 16.95

Activities to dip into

This book focuses on improving listening in the classroom, by considering it a thinking activity and using information about how the brain functions. This is explained in an informative, easy-toread manner and provides a way of explaining to colleagues in education the importance of speaking and listening in the curriculum. The book is aimed at clinicians working in education and has practical examples of developing listening, understanding and writing related to the curriculum; although many would only be relevant if you are working in the classroom. As the emphasis of the book is for use in schools, I dont think it would offer much to busy speech and language therapists working in clinics, but working

EATING AND DRINKING

Eating & Drinking Difficulties in Children: A Guide for Practitioners April Winstock Speechmark ISBN 0 86388 426 1 39.95

SELF-ESTEEM
The Adventures of Little Tin Tortoise Deborah Plummer Jessica Kingsley ISBN 1 84310 406 7 17.99

Sound advice
A comprehensive and practical guide primarily written for speech and language therapists, but also providing a teaching resource for other professionals, families and carers. The manual is well researched with excellent references to other sources and brings together

Easy to use
This is an accessible resource, useful for anyone working with young children who could benefit from developing their narrative and emotional literacy skills. Theres some theoretical background

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about the importance of self-esteem; noone can learn without confidence. There are also some interesting ideas about story rituals and the suggestion that you shouldnt be rigid about the listening behaviour you expect. I also like the idea that too much exploration and analysis of a story can destroy it (remember English literature at school?) Then theres a story in seven parts, each with worksheets covering different themes such as emotion management and social problem solving. The story tellers notes make these easy to use. Melanie Cross is a speech and language therapist who works with children who have social, emotional and behavioural disorders.

STUDENTS
Anatomy and Physiology Study Guide for Speech and Hearing William R. Culbertson, Stephanie S. Cotton & Dennis C. Tanner Plural Publishing ISBN 1 59756 026 X 18.00

couples meeting, dating and having sex. The cards use lifelike, computergenerated illustrations and include people of all ages and also from a range of ethnic backgrounds. We used the cards with young adults with moderate learning difficulties and additional communication impairment. In general, they were motivated by using the cards and found it easy to tell what the images depicted. Some of the clients found the content of some of the cards difficult / uncomfortable but all indicated that they felt the cards helped in discussing the issues. These cards are a useful tool for discussing all aspects of personal relationships. They are particularly relevant for adolescents and adults with learning disability or autistic spectrum disorders. Vanessa Osborne is lead therapist/senior speech and language therapist at St. Marys College, St. Marys Wrestwood Childrens Trust, Bexhill on sea, East Sussex.

EMOTIONAL INTELLIGENCE
Becoming Emotionally Intelligent Catherine Corrie Network Educational Press ISBN 1-85539-069-8 17.95

A practical resource
This book helps you understand what emotional intelligence means. Directed at class teachers, it is useful for anyone working in educational settings. It is easy to read. The principles surrounding emotional intelligence are explained well. The practical exercises can be adapted for staff training, and the activities in the last four chapters are useful for circle time / social communication groups. I enjoyed the book because it challenges you. It makes you analyse your emotions / actions and reflect on how these impact on the children you work with, and your colleagues! The supporting quotes were great. A practical resource, of most benefit to those involved in collaborative work in schools. Lorraine Thomas is a speech and language therapist working in a Language Resource Base within a mainstream school in Camden.

Concise tool
This relatively easy to read study guide has 7 units, each well laid out into a synopsis (concise and covering most of the relevant vocabulary and facts); objectives and study guide; study outline; and self-test. Obviously written for American students, but still relevant to the UK. The illustrations are well drawn, but label lines are lost in dark areas and at least one feature is mislabelled. By completing the study outline from course notes and textbooks, the student could produce a reference tool for their early working life. However, they may feel that 18 would be better spent on a basic textbook and making a DIY study guide. A useful tool if youre a student with spare funds! Erica Ford is a senior speech and language therapist working in Swindon specialising in the speech and language needs of children with Down Syndrome.

VOICE FOR TEACHERS

Can you hear me at the back? A Handbook on voice for all who teach. Caroline Cornish BiVocal Press, 8 Woodhill View, Honiton, Devon EX14 2GH, www.bivocalpress.co.uk ISBN 0 9526458 1 5 9.50 + p&p

physical well-being. It is suggested that a video recording is made at the same time to focus on non-verbal interaction and to look at the processes involved in decision making, and that a photograph of the completed mat is made to record the choices made. This can be used as a starting point for continuing the conversation at a later stage or, if consent has been given, to inform others of the decisions made. It is a pity that the authors felt it inappropriate to produce a video for the alternative methods of eating and drinking package, instead suggesting this particular tool should be used by clinicians experienced in Talking Mats. A CD Rom would also be a preferred format. Notwithstanding these two minor quibbles, these tools enhance meaningful communication through the use of a visual framework. If you are not familiar with the concept, I suggest you access www.talkingmats.com to discover more. Elsje Prins is a specialist speech and language therapist, clinical lead neurology, with Harrogate and District Foundation Trust. (3) Talking Mats and learning disability AAC Research Unit, University of Stirling ISBN 1 85769 215 2 69.95 (inc. VAT)

Meaningful and fun

Rightly pitched as a resource to enhance communication, this low-tech AAC package includes a video specific to learning disabilities which is unchanged from the previous version (2002) but adequately demonstrates application of this technique. A revised booklet describes the use of Talking Mats across a wide range of situations and service user populations as well as all the necessary practicalities. In addition, two ready made symbol packs function as a starter pack. This resource is pertinent to all therapists and students, whatever their knowledge of AAC, although general experience of any one population and specific experience of using these techniques would be essential in applying Talking Mats effectively. It is fun to use and meaningful for both therapists and service users. The pack is an excellent resource for training others in adapting their own communication style and promoting inclusion. A must for every speech and language therapy department, despite being a little on the expensive side. Dr Cath Valentine is team leader, speech and language therapy in learning disability services, Down Lisburn Trust, Northern Ireland.

User-friendly and memorable

If I were to be marooned on a desert island this would be my choice of book. It is a good read well written, amusingly illustrated, and a very useful source for those wishing to make themselves heard, an advantage should there be any passing ships! My copy of the original is well thumbed, so Im very grateful that Caroline Cornish has produced a revised edition. Now with a spiral bound laminated cover in A5 size, it is even more user-friendly. Caroline is a fine teacher who has managed to commit to paper her vast experience of how to encourage people to explore the potential of the human voice. Practical exercises and visual images reinforce the fun that Caroline brings to her teaching. A memorable book to dip into or read from cover to cover whatever your method, you will find on every page just the help you are seeking. Olwyn Jack MA LTCL Hon TCL is a voice teacher and a tutor with the Voice Care Network UK.

LOW-TECH AAC
(1) Talking Mats and Frail Older People AAC Research Unit, University of Stirling ISBN 1 85769 216 0 69.95 (2) Talking Mats and Alternative Methods of Eating and Drinking AAC Research Unit, University of Stirling ISBN 1 85769 217 9 69.95

Welcome new packages

It is almost 10 years since Talking Mats was developed by Joan Murphy as a low-tech communication aid. Since then it has been expanded and researched, and has established a large international following. These two welcome new packages consist of Talking Mats: A Resource to Enhance Communication, sets of wellselected picture symbols, a short leaflet and, in the case of the frail older people package, a helpful video. These packages assist people with communication disorders in making informed life choices and expressing their feelings about complex issues regarding their social, psychological and

COLORCARDS
Colorcards Personal Relationships 48 cards and instruction booklet Speechmark ISBN 0 86388 559 4 26.95+VAT

Helped in discussing issues

These cards picture a variety of relationship types including parents and families, professional, friendships and

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CONFERENCE CALLS

Conference calls:
The I CAN contingent from left: Mary Hartshorne, Rachel Brown, Kate Freeman, Jenny McConnell. (Missing from the picture is Lesley Culling.)

THE 5TH ROYAL COLLEGE OF SPEECH & LANGUAGE THERAPISTS CONFERENCE REALISING THE VISION RAN FROM 10-12 MAY 2006 AT THE UNIVERSITY OF ULSTER, JORDANSTOWN, NORTHERN IRELAND. THERE WERE 5 KEYNOTE ADDRESSES, 16 PARALLEL SESSIONS AND 66 POSTER PRESENTATIONS. RCSLT PLANS TO MAKE SOME OF THE CONFERENCE MATERIAL AVAILABLE ON ITS WEBSITE WWW.RCSLT.ORG AND THERE WILL BE A SPECIAL EDITION OF THE INTERNATIONAL JOURNAL OF LANGUAGE AND COMMUNICATION DISORDERS. THE CONFERENCE ALSO SAW THE LAUNCH OF COMMUNICATING QUALITY 3, RCSLTS UPDATED GUIDANCE ON BEST PRACTICE IN SERVICE ORGANISATION AND PROVISION.

Integrity is the key

Editor Avril Nicoll reflects on some key themes from the Royal College of Speech & Language Therapists conference Realising the Vision.
A. THE CONTEXT Professor Pam Enderby is living proof of her own pronouncement that you can never get bored with speech and language therapy. One of the foremost ambassadors for the profession, she argues that, rather than being put off by the push for an evidence informed approach, we should be excited by the opportunity for clients to benefit more from our service. Specifically, Pam says it is essential that we increase our knowledge about the size and needs of the populations we work with and that we select the right type of therapy and are clear about its aims. We also have to make sure that the available evidence actually impacts on our practice. In spite of a significant increase in the number of speech and language therapists there are - and will always be pressures. We need to look at where therapy is offered, to whom it is offered, when and how much. (While the 6 week block and the 6 month review are commonplace, these choices have no evidence behind them.) In the future, Pam anticipates we will be looking at more opportunities for independent practice and more funding through insurance, a greater skill mix, more patient choice and expectation and greater regulation and bureaucracy. She says integrity is the key to moving forward as a caring profession with a scientific base, without letting one polarise the other. Recommended action: 1. Where there is evidence, use it. 2. Where there is evidence of no benefit, dont do it. 3. Where there is no evidence, be creative and gather evidence and research. 4. Be less precious and more confident about what you promise - and about what you dont need to provide. 5. Where appropriate, be more open to enabling other professionals to take responsibility (eg. screening). 6. Go at least once a year to a multidisciplinary conference, and seek opportunities for cross-fertilisation of ideas and evidence from other disciplines. 7. Share single case studies with colleagues. Another champion of the profession, Professor Sue Roulstone, says this combination of different angles and knowledge bases is one of the things that drew her into the profession in the first place. Agreeing that our decisions should be increasingly open to being challenged, she chose to focus on the ongoing and inevitable need for prioritisation. Interestingly, she argued that our fears about service users behaving like consumers are not borne out by the reality and that problems arise when they perceive we are covert and inexplicit about our prioritisation. Exploring the factors that influence our professional judgement and decisions, she suggests we aim for the middle ground between intuition and analysis where possible. B. BEING HEARD Sue Roulstone noted that the presentation by Clem Stewart with speech and language therapist Rosalind Gray Rogers made a significant contribution to our listening and the mood of the conference. Clement Stewart had a stroke when he was 37 years old. Twenty two years later, he agreed to talk to the conference about his experience of aphasia and speech and language therapy. To my knowledge this is the first time a service user has been asked to participate in a Royal College conference, and the response from delegates suggests it is worth exploring different ways of doing this again in the future so that it impacts positively on practice and on the service user(s) concerned. Clem emphasised the importance of speech and language therapists to him, of their ability to listen and thereby reduce his explosive feeling, and of their role in stimulating laughter. He says speech and language therapists cannot have a frosted face. He saw impairment based therapy as necessary but humdrum, and liked the way that group therapy made him feel his ideas

At the conference gala dinner from left: Evelyn New, Noreen Murphy, Oriana Morrison-Clarke, Sarah Nash, Sally Murray and Jenny Moultrie.

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CONFERENCE CALLS

were not wasted. He feels very strongly that as a profession it is essential we have face-to-face and telephone contact with spouses and families, who know pre-stroke strengths and interests that can be built on - and that we remember to enquire how they are. Asked Where are you now?, Clem replied It is 22 years to stand up and talk to you with my wordsPast and future tense is there, but living the present tense is vital for meIf I can prepare this talk to you, I am mentally strong. I asked several delegates what impact this session had on them and what it will mean for their practice: I am a researcher at the moment, but starting a postgraduate speech and language therapy course this year, so this was my first contact with a person with aphasia. It was good inspirational really to hear about the qualities needed in students, and what students need to think about. I definitely feel I am suited. Ive been involved in so many conversations about the academic side of the work and evidence based practice that it has really made a difference to me to get a personal point of view this is the reason were doing it. Amy Riddett, prospective student Since Clems talk Ive discussed with colleagues and friends the way he focused on being able to laugh, and we all agree that it really helps to be cheery. Its nice to know that that first impression of a smile really does make a difference. Its also good to know that people do continue to go to different kinds of therapy even years after their stroke, and that 6 week blocks over the first year are not the end. Its lovely to hear good things about speech and language therapists and to know youre doing a good job. Victoria Young, speech and language therapist Its good to know that we are appreciated if we put the personality in and give people the motivation they need. We really noticed when he said you should ask family members - How are YOU? - and it was clear to us how important it is to involve the family. The whole relationship is so important, and we really agree that you get the work done when you have the greatest fun with a client. Sinead Fox and Katherine McBride, students We need to see people as individuals. And just because we might not think we should provide any more therapy doesnt mean we shouldnt if a person is so motivated. Sarah Heneker, speech and language therapist He expressed enormous frustration and sense of loss the battle of every day - really articulately. You do see it in kids too, but they dont know its loss. We dont talk enough as therapists with people about the emotional stuff , perhaps assuming someone else is doing it. On a practical level it maybe comes down to the time issue as were always constrained. Maggie Vance, speech and language therapist It really made us wonder how universities can accept speech and language therapy students without doing face-to-face interviews. How can you sense that warmth through an application form? We were interested to hear about the range of therapy Clem had had over the 22 years, and it reminded us that as therapists we sometimes lose sight of the functional things among all the nouns and verbs.

We have never been as affected by a presentation from a service user. He had clearly put in a lot of preparation, and we really heard his need for professionals to ask his wife How are YOU? because she misses his verbal attentions. We enjoyed the humour about him sharing homework with his grandson. Its really powerful when someone tells their story with all its deep-seated emotion and says they are glad to be alive. Libby Downie and Katy Creaney, speech and language therapists C. LEARNING Universities have seen an increase in speech and language therapy students in recent years, with a resulting pressure on placements. Parallel session 2 included an opportunity to hear how educators are rising to the challenge and, in the process, benefiting service users. Linda Collier and Karen Sage at the University of Manchester advocate a conversational partner role for 1st year students. The students have had taster sessions with three local aphasia support groups, and people with aphasia have welcomed the opportunity to evaluate their conversations and suggest ways they could improve. Volunteers are given gift tokens and some people with aphasia have gone on to become involved in research. The project has highlighted at an early stage people who are not suited to the speech and language therapy course. The success of

disorders. The videos, medical history and assessment data were used with groups of students to see how they reached a diagnosis, and the issues arising are forming the basis of learning resources for the next phase of the project. For example, students find it difficult to reach a diagnostic conclusion, so videos will be made of people doing this. What surprised me was the difficulty that the researchers had in recruiting students to take part in the project, as it sounds like an opportunity many therapists would jump at! Similarly, final year students involved in Claire Parker and Karen Sages problem-based learning project to prepare them for working with people with aphasia viewed it as an added extra at a time when they were preoccupied with final exams. Third years were more positive about the workshops which used videos as triggers to work through the problem of identification, assessment and management of the clients communication impairment, identifying group learning objectives and researching these through student-directed independent learning followed by feedback. D. ONES TO WATCH (i) User involvement The profession appears to have mixed views on the value, priority and extent to which we should be embracing the user involvement agenda. Sharon Symon cautioned that, while many allied health professionals think they do involve users in decision-making about their care, it is still very therapist-led and the majority of users are not aware they have any other options. Some researchers are focusing on ways of gathering users views about their communication difficulties and their therapy, others on methods of helping service users get their voices heard. Others have gone further and are involving users in the planning and delivery of services. Sharon Symons enthusiasm is clear: I just really look forward to going on being involved in it. (ii) Ethos Mary Wickenden is an anthropologist as well as a speech and language therapist. In talking about the views of parents of disabled children in Mumbai, she raised interesting points for reflection on the whole focus of speech and language therapy and research. Do we follow the expert style (do this); the transplant style (do this because) or the empowerment style (this or that what do you think?) Do we make enough use of narrative interviews where the storyteller decides what to tell and chooses the emphasis? Do we understand that, while impairments are universal, disability varies because it is a construct? Do we draw sufficiently on anthropological research methods such as ethnography? (iii) Economic evaluation Anna van der Gaag says as a profession we are uncomfortable with economic evaluation discussions because our education didnt cover it and it doesnt fit with our values. But the reality is that there are costs in delivering a service, costs to society and costs to individuals, and all these need to be taken into account. By engaging with health economists we will be more able to influence the debate in the direction of cost utility analysis, which adds a quality of life dimension and includes outcome data. SLTP

Go at least once a year to a multidisciplinary conference, and seek opportunities for crossfertilisation of ideas and evidence from other disciplines.
the venture means it has been extended to Sure Start and involvement with making communication passports with adults with learning disabilities. Students at the University of East Anglia are now trained as conversation partners to do outreach visits for 1 hour a week over 6 months as a clinical placement. Simon Horton and Sally McVicker explained how the partnership with Connect developed, and how the impact on clients of Connects Conversation Partners Outreach Project is subject to ongoing evaluation. They said it is particularly strongly felt by service users as an opportunity to talk and to become more confident. Students are offered tutorials, video feedback and informal phone and e-mail support, and people with aphasia are also involved in their training. Issues that have arisen include communication strategies; topic management; using and accessing resources; coping with emotions; roles and boundaries; and ending the placement - all relevant to life as a therapist. Students also need to develop clinical reasoning skills. Kirsten Hoben described how the University of Sheffield is using PATSy (the Patient Assessment and Training System) which offers access to real data on 20 adults with acquired disorders and 3 children with developmental

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WINNING WAYS

he theme for this article was generated by a few calls over the months from therapists who have been in the profession for many years. They have been very motivated in the past, and wish to stay motivated, but without change and innovation how do you stay motivated? How do you keep the enthusiasm necessary to do a good, professional and fulfilling job right up until you retire and move on to the next stage in your life? As I was pulling my ideas together, I found a great little book of quotations on the joys of being senior. Age doesnt matter unless youre a cheese is a trifle cheesey, but it has some apt quotes. From Elizabeth Kubler-Ross, that great expert on death and dying, Our only purpose in life is growth, there are no accidents (p.146). From Albert Einstein, Do not grow old no matter how long you live. Never cease to stand like curious children before the great mystery into which we were born (p. 303). And finally from Norman Vincent Peel, Live your life and forget your age (p. 125). No one can doubt that the profession has changed hugely over the last few decades. The professional standing and status of therapists, the academic and accountability standards expected, not to mention societys expectations and the sheer volume of work. Is it any wonder that some degree of burnout and disillusionment appears?

Grey(ish) power
How do you stay motivated when you have given many years to the profession? Life coach Jo Middlemiss considers why maturity can be empowering and something for us all to celebrate.
READ THIS IF YOU FEEL YOUR MOTIVATION FLAGGING THINK YOUNGER PEOPLE HAVE MORE TO OFFER WANT TO VALUE ENTHUSIASM AND EXPERIENCE
was all mine, as she cared nothing for fashion, had quite a few chin hairs, wore very thick stockings even in the summer and smoked like a steam train! But all of the younger teachers knew that we were walking on holy ground. I once mentioned to her that it was a bit of a poor deal for the children who got a brand new chick like me for a year rather than her. She was so encouraging and said she thought that the children would gain as much from my enthusiasm as they would from her experience. about their practice. And, while Jenny delighted in the enthusiasm of younger therapists, so full of new ideas, she also noticed a degree of condescension towards those who had been in practice over an extended period. When I asked Jenny what kept her motivated she made several clear points: 1. She welcomed new ideas and techniques 2. She had a thirst for new client skills 3. She loved working with others who were willing to learn 4. She loved working with positive and motivated people. There are developments in the profession which Jenny welcomes, especially in the area of professional reviews and appraisals. She feels that, when these are well used, they provide an opportunity for learning and goal setting. But she has noticed that some of her colleagues are terrified of appraisals and so tend to be very defensive when the time comes for review. This of course is understandable but again the young can lead the way as they expect it and are used to it and therefore do not feel threatened by it.

Open mind
When new ideas come up it is easy to be cynical and dismissive but an open mind will see the development of an old idea and learn how to adapt it. Things do come round again - think of music and fashion - but there is generally a slightly different aspect which makes it more accessible to the following generation. Also, a closed mouth and an open mind actually allow people to make mistakes - and mistakes have to be made if any learning is going to take place. When I asked Jenny, What are the main challenges facing speech and language therapists? she responded with: paperwork isolation dealing in a multidisciplinary team differing ideologies in the profession organisational issues tedium. This was a good, honest list. These are the places where our attitudinal keys awareness, appreciation, abundance, affirmation, authenticity come in. How can we make sure that our needs within the workplace are being met when these challenges are ongoing? I offered Jenny this slightly different take on an individuals basic human needs. We all have need of: 1. certainty 2. variety 3. personal significance 4. connectedness 5. growth 6. contribution.

a closed mouth and an open mind actually allow people to make mistakes - and mistakes have to be made if any learning is going to take place.
However, I have been thinking about those professions where longevity is considered a positive advantage. Now, while age isnt a badge of honour in itself, just think of the times when you would actually prefer to see someone who looks as though they have a plentiful amount of experience. If you went to see an eye surgeon, would you like to be his first patient? My brother is a cardiologist, and I know that his patients are reassured by his grey head. When I was a young teacher, my mentor was a woman who had been teaching for 40 years. I was in awe of her. No child ever left her room as a non-reader but she wanted to know about our young trendy gimmicks just to see if she still had something to learn. In truth the learning

Enthusiasm combined with experience

In retrospect I realise that the answer lies somewhere in the middle. The aim is enthusiasm combined with experience. Staying fresh over the years. Embracing new skills but building on the years and years of experience accrued by long-term practitioners. Jenny booked a session because she wanted to talk over this very thing. She had been a therapist for over 25 years and had never taken a career break. She had a range of skills in the profession and had gone on to take some advanced qualifications. Her question was How do you stay motivated especially in the face of the negativity of other senior colleagues? She had observed that several older therapists were very set in their ways, resistant to change and defensive

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Figure 1 Six basic human needs TASK: CERTAINTY / 10 Ideas to increase this: UNCERTAINTY/VARIETY / 10 Ideas to increase this:

news extra
Next steps for older people
Age Concern has welcomed the government report Next Steps in Implementing the National Service Framework for Older People, but called for the recommendations to be funded and put into practice as soon as possible. The ten programmes of activity identified include steps to ensure that older people receive any assistance they need with eating and drinking and to support stroke survivors as they transfer from hospital to home and with long-term services. The importance of healthy ageing and independence, well-being and choice are also emphasised, prompting Age Concern to note that, While younger generations are increasingly encouraged to lead healthier lifestyles, the health needs of older people have been routinely overlooked. We support any action to tackle barriers, such as poor health awareness and access to leisure facilities. A new ambition for old age: Next steps in implementing the National Framework for Older People by Professor Ian Philp is available to download at www.dh.gov.uk.

SIGNIFICANCE / 10 Ideas to increase this:

CONNECTEDNESS / 10 Ideas to increase this:

GROWTH / 10 Ideas to increase this:

CONTRIBUTION / 10 Ideas to increase this:

If we make sure that all these needs are met, we will feel like happy and fulfilled people. Take any task you like and another task you loathe. Give yourself a score out of 10 in each box as to how much of it you have. You will soon discover why you love / loathe that task. For me throwing a dinner party scores high but ironing scores very low. However, if I insert some distraction into ironing - like listening to a play or watching an old movie - I can make the most of it. If you take this idea into the workplace (figure 1) it can help to pep things up when tasks become repetitive and tedious, as they do in any job. Difference of opinion and style can always be resolved if people are upfront and open and stay in an adult state. We all know that it is impossible to change other people although it is hard to put into practice. Time and time

again we must learn that we can only change ourselves - but in changing ourselves, the world seems to change. If we want changes in our lives, we have to make the changes. It may be changes in style, shape, situation or attitude. We can choose the easy route or the hard one - but choose we must. According to baby boomer journalist Rosie Boycott, her generation has every intention of living up to this challenge. Coughlan (2004) quotes her as saying, I dont want to give up that sense of being involved in things to do with change. I think well have an exciting old age. It will be something that will be rather thrilling, it will shake up a lot of governments. It is possible to stay motivated when you have given many years to the profession - and maturity can be empowering. Mahatma Ghandi said frequently, Be the change you want to see. I conclude with reference to a little book I dip into often, The Power of the Subconscious Mind by Dr Joseph Murphy. The language is archaic, and he does quote the Bible fairly often, but the underlying message is the same: Patience, kindness, love, good will, joy, happiness, wisdom and understanding are all qualities that can never grow old. Cultivate them and express them, and remain young in mind and body. (p. 223)

User involvement makes a difference

Therapists who want to promote user involvement may be interested in an award winning scheme where young people brought up in care contributed to teaching social work students. The School of Applied Social Studies at The Robert Gordon University in Aberdeen won a Care Accolades 2006 under the category Involvement of people who use services in any aspect of the organisations work. Lecturer Jeremy Miller said, We have been working with a service user group of young people brought up in care who delivered a session on the ideal social-worker to first year students as part of a module on social work roles and tasks. Everyone found the session to be of immense value, and as a result we are keen to develop further opportunities for the young people to contribute to teaching the social work students. Continuing the theme, a research project in Manchester schools is claiming striking improvements in attendance, behaviour and attainment by allowing pupils to have a say in how their schools are run. Developed in conjunction with the University of Manchester, the Manchester Inclusion Standard uses the views of children and young people as a stimulus for school and staff development. A spokesman said, Our evidence supports the view that the views of pupils can provide a powerful lever for change.

References
Coughlan, S. (2004) The rise of grey power, BBC News Online. Available at: http://news.bbc.co.uk/1/hi/magazine/3550079.stm (Accessed: 23 June 2006). Murphy, J. (1988) The Power of your Sub-conscious Mind. New York: Simon & Schuster. Petras, K. & Petras, R. (2002) Age doesnt matter unless youre a cheese. New York: Workman Publishing. SLTP

Jo Middlemiss is a qualified Life Coach with a background in education and relationship counselling, tel. 01356 648329, www.dreamzwork.co.uk. Jo offers readers a complimentary half-hour telephone coaching session (for the cost only of your call). Jo would especially like to hear from readers who are going through a major change such as coping with being a student, starting a first job, promotion or returning to work after a career break. The detail of your call will be entirely confidential and, while it will inform Winning Ways, no personal or identifying details will be given.

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HOW I

HOW I TAKE SERVICES INT

COMMUNICATING QUALITY 3 (RCSLT, 2006) STATES THAT SPEECH AND LANGUAGE THERAPY INTERVENTION IS LIKELY TO INCLUDE WORK TO ENSURE THAT COMMUNICATIONDISORDERS DO NOT PRECLUDE OPPORTUNITIES FOR SELF-DETERMINATION, FULFILMENT AND PARTICIPATION IN COMMUNITY LIFE (p. 100). OUR TWO CONTRIBUTIONS SHOW HOW SERVICES CAN MOVE INTO COMMUNITY VENUES AND OFFER FLEXIBLE PROGRAMMES THAT INCREASE OPPORTUNITIES FOR PEOPLE WITH COMMUNICATION DIFFICULTIES TO PARTICIPATE IN NEW ACTIVITIES AND LEARNING.
Reference RCSLT (2006) Communicating Quality 3. London: Royal College of Speech & Language Therapists.

HOW I (1): ADULT ACQUIRED

Windows of opportunity
FOR PEOPLE WHO HAVE NOT GROWN UP WITH WINDOWS OR WORD, FINDING THEIR WAY AROUND A COMPUTER CAN BE A TRIAL AND THIS IS COMPOUNDED IF THEY HAVE COMMUNICATION DIFFICULTIES. VICKY STYLES, SARAH WOODWARD AND ALEX DAVIES EXPLAIN WHY AND HOW THEY SET UP AN INTENSIVE GROUP IN A COMMUNITY SETTING TO ENSURE THEIR CLIENTS COULD MAKE THE MOST OF THE OPPORTUNITIES OFFERED BY COMPUTER LITERACY.

INTO THE COMMUNITY (1) ADULT ACQUIRED WINDOWS OF OPPORTUNITY INTO THE COMMUNITY (2) ADULT LEARNING DISABILITY liveACTIVE

ur Computer Assessment and Training Service (CATS) was established five years ago. It provides assessment, support and advice to clients and healthcare professionals living in the southwest region and beyond. The service offered covers computer access and software options (for therapy, skill building and recreational purposes) for individuals with communication difficulties. Over the years, it has become apparent from work with local clients that assessment and advice are not always enough, and that they often require assistance above and beyond the remit of our service. For a lot of the clients we see, finding appropriate software and hardware solutions is the tip of the iceberg. In addition, they need help to find their way around their computers, to open and shut down documents, create and save documents, navigate through pop-up menus and generally build their confidence in operating a personal computer (PC). For some of them, seeing us in the assessment centre is the first time they have ever used a computer. A few hours input from us is not enough and their local speech and language therapist cannot justify spending their dedicated speech and language therapy sessions undertaking this kind of work. A number of our clients have investigated accessing free information technology courses provided through local libraries and further education colleges. However, these courses are often inaccessible for people with communication difficulties, as the style of delivery and materials used are not aphasia-friendly. Our clients described problems with the language used by the tutors, and the rate at which they run through topics. It quickly became apparent that a group would be a good way for us to target a larger number of people with similar needs who did not have a background of using computers. In the past, the service had offered consecutive weekly computer groups. Each session lasted two hours and ran once a week for 10 weeks. However, the feedback from group members showed that they had found it difficult to retain the newly learnt information from one session to the next. We therefore decided to devise and trial an intensive group course targeting basic computer skills. Group members were recruited via local speech and language therapists. In total there were five members, four of whom had aphasia and one who had Parkinsons

READ THIS IF YOUR CLIENTS WANT TO LEARN TO USE COMPUTERS LOCAL COURSES ARE NOT SUFFICIENTLY ACCESSIBLE YOU HAVE LIMITED TIME TO OFFER THE SUPPORT NEEDED Disease. We had planned to run a group for no more than six participants due to staffing levels and equipment resources. A pre-requisite for inclusion on the course was that each group member had to have their own computer at home so they could consolidate skills learnt.

Orientation
We started with an informal orientation session designed for members to get to know one another, so that introductions did not eat into group time. Each group member was asked to bring photographs or information about their interests and hobbies which could be shared with the rest of the group. This information was used to tailor activities and tasks to include each individuals particular interests, for example copying and pasting photographs of favourite football teams; opening and closing documents about popular rock bands. Although this involved a lot of extra preparatory work, including finding additional materials from the internet and saving them onto disk, the clients definitely appreciated it and so their motivation increased. Once the exercises were produced, these were saved to disk so that the clients could complete their homework tasks. During the orientation session, each group member completed a pre-course pictorial rating scale describing their current computer skills (figure 1). The results of this survey revealed that all members found basic computer operations confusing. We arranged five practical sessions on Monday, Tuesday, Wednesday, Friday and Monday at the local community hospital. Group members were asked to complete tasks during their Thursday rest day, aimed at revising the content of the course so far. Each session ran for two hours in the morning. Each group member had a laptop to work on. We originally planned to run the course via a PowerPoint projector, so that group members could copy the screen step-bystep. After a couple of attempts, we abandoned this method because the majority of group members found it too difficult to shift their attention from the projected image to

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TO THE COMMUNITY
their own computer. Thereafter, each session started with an introductory talk and then group members continued with their own tasks individually. The members would ask for assistance when they needed help. The group therefore ended up being much more like an individual training session with more than one client present.

Aphasia-friendly
Each group member was provided with an aphasiafriendly folder of instructions at the beginning of the course. These handouts were designed around the research findings of Cottrell and Davies (2004) on how to produce aphasia-friendly resources: 1. A small amount of information appeared on each screen. 2. Font size 18 was used throughout the document. 3. Pictures were used wherever possible, for example left click was presented as:

4. Screen shots were used each step of the way, to allow members to compare how the operations looked on screen. The handouts were referred to throughout the sessions. Group members worked independently on the tasks during the sessions, and were encouraged to refer to the handout before asking for assistance. We hoped this would allow them to replicate the tasks independently at home. To achieve our overall aim of building up group members confidence in using computers, we targeted: 1. Opening documents Word and photographs 2. Closing documents 3. Saving Word documents and photographs 4. Shutting down the computer 5. Cutting and pasting items. Table 1 shows the targets for each session. During a final session, each group member was asked to complete a picture based feedback sheet, although one participant was unable to attend that day due to illness. The remainder of the session focused on the group members coming together to participate in a recreational team activity. With such small numbers the results (table 2) are not entirely clear-cut, but they illustrated that all group members found the group enjoyable and that the majority of members would welcome the opportunity to do a further course. The feedback also suggests that the majority of members considered the course to be pitched at the right level and all members found the computer group interesting. We therefore feel that running a similar course would be highly appropriate. Although on the whole the course ran very smoothly, a number of issues arose which we would need to bear in mind in the future: 1. Running the course away from our clinical base causes a few problems, for example not having all our resources to hand. 2. Given the post-course feedback, we feel that future courses should continue to be run with one patient per computer, with the option for them to share if they prefer. 3. Difficulties co-ordinating hospital transport causes problems for the clients and impacts on staff time. On

two occasions one therapist had to wait with a patient for two hours until the hospital transport arrived. 4. Including group members who need assistance with toileting removes a speech and language therapist from the course. 5. Because PowerPoint was not successful, we would need to decide how best to disseminate information to the group as a whole. 6. Part-time speech and language therapists have difficulties committing time to an intensive course. 7. There are difficulties in planning such a group as each member learns skills at different rates. 8. We need to have at least two members of staff per five members to run the group. In the future we could consider involving speech and language therapy assistants, students or volunteers, or maybe even approach a local college to set up a partnership for running the course. 9. Each group member needs a large workstation to site their computer, adaptive mouse and the handout in a suitable position. These workstations also need to be accessible for wheelchair users.

Figure 1 Pre-course rating scale

Invaluable resource
However, as a direct result of planning and implementing this course, our service now has an invaluable resource in the handouts we prepared. Since the course, we have provided many other clients with copies of these handouts and they too have found them useful. Making the handouts highlighted just how many steps are involved in completing the simple tasks we were teaching. There are many ways to successfully complete the tasks, but equally just as many hurdles that may cause difficulties. The pre-course rating scales showed that some clients had little insight into their own computing skills. For example, one member rated himself as highly confident in all operations which the course planned to cover. However, throughout the course he asked for considerable help and was clearly under confident in all four areas. In future we would want to actually observe patients operating a computer as well as asking them to rate their own ability. Our course improved all group members confidence in basic PC operations. By the end every member was considerably more autonomous in using their computer and both members and their partners reported that these skills were carried over to the home environment.

Table 1 Session targets 1 Opening Documents Closing Documents Shutting Down the PC Saving Documents Cutting and Pasting Items Table 2 Post-course feedback
Member 1 Member 2 Member 3 Member 4

Did you enjoy the group? yes Would you do another? yes Was the group more fun than previous PC groups? yes Did you like working alone? yes/no What should be the maximum number of people in the group? 3 How easy was the course? right level How interesting was the course? v. int

yes yes yes yes

yes no no no 2

yes yes yes yes 1

No response

right level right level easy

v. int

int

v. int

REFLECTIONS DO I OFFER TRAINING TO ENABLE CLIENTS TO MAKE THE MOST OF NEW TECHNOLOGY? DO I MAKE THERAPY MORE MOTIVATING BY PERSONALISING IT TO A CLIENTS INTERESTS? DO I STRUCTURE COURSES TO GIVE SUFFICIENT OPPORTUNITY FOR REPETITION AND PRACTICE?

Resources
The Windows XP operating system, and Word and PowerPoint software are all brand products of the Microsoft Corporation, www.microsoft.com.

Reference
Cottrell, S. & Davies, A (2004) Supporting conversation, providing information, Bulletin of the Royal College of Speech & Language Therapists 630 (October), pp. 12-13.

Vicky Styles (pictured above left) and Sarah Woodward (above middle) are speech and language therapists at the Computer Assessment and Training Service, Communication Aids Centre, Frenchay Hospital, Bristol, BS16 1SE, www.cacfrenchay.nhs.uk/res_enable.htm, e-mail Sarah.Woodward@nbt.nhs.uk. Alex Davies (above right) is a community speech and language therapist based at Cossham Hospital.

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HOW I / COVER STORY

HOW I (2): ADULTS WITH LEARNING DISABILITIES

liveACTIVE

THE LOGISTICS OF OFFERING A THERAPY-LED ACTIVITY CLUB IN A SPORTS CENTRE TO ADULTS WITH LEARNING DISABILITIES MIGHT SEEM DAUNTING BUT JUDY GOODFELLOW FINDS WITH TEAMWORK, ENTHUSIASM AND ONGOING AUDIT AND ADAPTATION, THE PRACTICAL BENEFITS CAN BE HUGE. Our general aims were to: 1. Offer a range of appropriate therapeutic activities to adults with a learning disability who want to access community based facilities. 2. Allow carers to gain experience and confidence in using different therapeutic activities with their service user. 3. Provide a service to those who are socially isolated and / or struggle to access mainstream activities. 4. Promote individual choice making in a user-friendly way. 5. Provide a symbolised environment to promote as much independence within the building as possible. 6. Provide an opportunity for service users to gain socially from mixing with other service users. 7. Centralise therapists so clients can access us more effectively (less travel time, with group work opportunities).

ecent legislation (Scottish Executive, 2000) emphasises our clients accessing local facilities and having as much choice as possible over what happens in their lives. In late 2003 our Allied Health Professions team discussed the possibility of a therapy-led activity club in our local sports centre. The drive was led by my physiotherapy colleague who had been involved in something similar in Yorkshire. This, however, was to be much more multidisciplinary. Bells Sports Centre in Perth had a quiet day most Mondays and agreed to give us the space, although there would be a charge to each client (1.60 for the morning or afternoon; 3.20 all day). We initially agreed a five week trial, to continue if successful. READ THIS IF YOU WANT TO WORK MORE CLOSELY AS A MULTIDISCIPLINARY TEAM WIDEN THE USE OF SYMBOLS PROMOTE HEALTH, INCLUDING COMMUNICATION

8. Collect data for analysis for clinical effectiveness purposes. (We involved Tayside Audit Resource for Primary Care.) The team carried out PR Roadshows in Day Centres, Residential Homes and other community settings to publicise the day, and we also raised awareness within the area care management and community nursing teams. The clients had to get a liveACTIVE leisure card (available through Perth & Kinross Leisure at no cost), and had to register with us in case they were not already known to our service. The original timings (figure 1) have remained as they fit in with other day care provision. Examples of available activities are in figure 2.

Choice
As each service user came through the main door, there were symbolised activity sheets to assist them to sign-up to their choice of sessions. When we first started, there was an A4 sheet per activity. So if there were 4 activities per session, there could be 16 sheets of paper for people to negotiate. We expected carers to assist service users in their choice making for sessions and sign their names beside those activities chosen. This part of the day was a time-consuming and frustrating bottle-neck and staff were very keen to get past here and into the first session, which usually started late. Following the five week trial, the

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Photo by Paul Reid - a liveACTIVE Makaton group

HOW I / COVER STORY

team met to evaluate how the liveACTIVE day was progressing. There were the inevitable teething problems but generally numbers were good. On average over the first five weeks, we had 65.4 places taken up by service users each Monday, with 16-30 people attending. We can now accommodate 30-40 people per session allowing for 120150 places to be taken up during the day. The sign-in procedure needed looked at; some names were signed in and clients did not turn up. Others were concerned that places for afternoon sessions had been filled up first thing in the morning, unfair if you only arrived at lunch time. As we progressed into the more permanent block, we produced a newsletter for all liveACTIVE therapy club members and their carers, available to pick up on Mondays at the sports centre. We thanked everyone for their support but also highlighted some of the issues. We now produce two newsletters a year, and this has become one of the speech and language therapists roles.

Exciting
From a speech and language therapy perspective, the liveACTIVE therapy club is a very exciting project as it addresses so many choice making and community access issues. We are active in producing symbolised material, for example a sheet to explain the benefits of the walking group, and to ensure clients come prepared with appropriate clothing. As far as the therapy-led activities go, we started with a Hot Gossip in Perth group focusing on symbols to assist communication. We were the only profession to invite people to our group as we felt very strongly that we could not run a group each week supporting their communication if we did not
Figure 1 Timings Session 1 Session 2 Lunch Session 3 Session 4 10.30 am 11.15 am 12 noon 1.00 pm 1.00 pm 1.45 2.30 pm (45 minutes) (45 minutes) (45 minutes) (45 minutes)

know who was coming. Numbers reduced as the service users wanted to try other activities, so Hot Gossip stopped during 2004. We started up a Chat Room for less structured discussion to provide a forum for those who lacked the confidence to be heard in a more vocal group. Those who came enjoyed it, but it was poorly attended, and there were other perhaps more appealing sessions available. I was happy that our therapeutic group activity reduced to Makaton as I was struggling to justify my involvement with some of the service users coming into the Chat Room. Many were perfectly able to voice their opinions and just seemed to enjoy the time and attention they received whilst speaking and listening within a supportive setting. The Makaton group is still drop-in and is not a static group of individuals (see figure 3), but is attended by some who are currently on our caseload and others who wish to learn Makaton to communicate better with their friends. For those on our caseload, the Makaton Group cannot alone ever fully address their therapeutic need. It is, however, an excellent focus; and social contact at appropriate language and symbol / signing levels is often what is missed out of our service users busy, timetabled lives. Another speech and language therapy focus is promoting independence within the sports centre as soon as a service user walks through the front doors. In early 2005 we introduced symbol timetables but many staff said their clients did not require these, although we felt a significant number - perhaps 75 per cent - would benefit. Ultimately we were proved to be right. Our A4 sized symbol signage with yellow arrows has been in evidence from the start (figure 4). Symbols are put up on each liveACTIVE morning, strategically placed
Figure 3 Makaton group attendance Period Average service users per week January March 2005 6.25 April June 2005 7.11 August December 2005 10.38

around the centre to lead to each group location, toilets, changing area and to the reception desk where the service users show their cards and pay. Many people still simply follow on and need to be reminded to look at their timetables and find the right group, but a great deal more navigate themselves very effectively around their day as a result of their timetables. This process began late in 2005. My speech and language therapy colleague Leona Tulloch and I decided to take the bull by the horns and risk the sub-zero temperatures of the unheated foyer, manning the signingin tables to ensure choices were made (figure 5) and timetables issued where necessary. As we suspected, staff members bringing groups in from centres had, for ease, written a list of who was doing what and when. We got brave and questioned this while also regularly asking the service users what they were going to do today and showing them the symbol choice. The responses were often different from the staff lists so we were able to make up timetables for each individual as he or she came through the door. Figure 4 Symbol signage

Figure 5 Session choices

Figure 2 Activities Racquet sports Yoga Football extremely popular Makaton Hockey Athletics adapted to suit the group Boccia a soft ball bowling game for two teams Curling - with the sport so huge in Perth, our physiotherapy colleagues have a curling set that can be used on hard floors. Its much warmer this way!

Races adapted to suit the group

Tai Chi

Rebound Therapy trampolining for those with disabilities Body Awareness an occupational therapyled group of music and movement

Parachute physiotherapy activity for movement and exercise with lots of fun (eg. trying to keep a balloon on top of a parachute)

Jabadao music and movement focusing on the many aspects of non-verbal communication through dance

Walking group makes use of the grounds around the sports centre

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HOW I / COVER STORY

Figure 6 Feedback Having been involved with this group since they started, I have definitely noticed development in adults coming along. One area that stands out is the payment at Reception which has become so much easier because the adults have learnt to become confident and independentwe can enjoy a wee bit of banter with them as this is no longer a stressful occasion for them. Matt Brand is a manager at Bells Sports Centre, Perth The Makaton session at liveACTIVE gives the perfect opportunity for service users to be listened to. There is the news time when the service users tell the group of happy times / sad times / holidays etc. You see everyone bursting to tell you how their week has been, but yet they wait until it is their turn. They just love to be listened to and having this time means a lot. Tracey Hudson is a speech and language therapy support worker. Unfortunately we are unable to offer more activities due to limited multidisciplinary staff involvement. It started off with more of a multidisciplinary feel than it has now. This is, however, a very worthwhile initiative which allows adults with learning disabilities to benefit both physically and socially in a community setting with others in their peer group. A team member

The liveACTIVE walking group We are in regular contact with Perth & Kinross Leisure management with a view to involving more sports centre staff and fewer therapists. Leona and I held a well-received training day on communication for sports centre front line staff reception, catering and management. There are likely to be a few projects on the tail of this, as staff from Bells Sports Centre proposed more permanent signage, while other centres felt the work done in Bells should be replicated in the others. They would like symbol resource books for keeping at the reception desks for the use of customers with communication difficulties. This would be for showing the options available as well as the costs. Sports coaches will be attending training in the next few months and hopefully will be keen to become more involved in the therapy sessions and in time may take over some of the running of sessions to make them more available mainstream. The first step is for the sports centre to support the current sessions with the therapists, sharing ideas and expertise in both directions. Ultimately many of the sessions could and should be available without as much therapeutic intervention, for the general public - which of course includes our service users. Judy Goodfellow is a specialist speech and language therapist working in the Perth and Kinross area for NHS Tayside, Birch Avenue Centre, 55 Birch Avenue, Scone PH2 6LE, tel. 01738 555419, e-mail jgoodfellow@nhs.net.

Focus on process
This process took forever, with often a frustrated staff member champing at the bit to get into the first session with their service users. This was when it became so obvious to us how staff focus exclusively on the activity rather than the process. While physiotherapy or occupational therapy-led activity is a very important part of the day, the team had to keep emphasising that this process was just as important. Having stood our ground, in early 2006 we had one staff member from a centre asking for copies of all the symbols so they could assist the service users to make up their own timetables before they came out to liveACTIVE. We felt we had made a major breakthrough. From our humble beginnings of, Do you think Jane might use a symbol timetable?, we now have only around five people who dont want them. Two of the resource centres have taken on the choice-making discussions with their clients so that they arrive with timetables already made up. On occasions these need to be altered at the sign-in stage if activities have been changed or cancelled due to staff absence or other reasons. We have found that clients are very adaptable as we can provide symbols to support this type of explanation. They are encouraged to choose a different activity and given a replacement symbol. We have many allied health profession staff groups (usually physiotherapy-led as ours has been) visiting our liveACTIVE therapy day in action to get ideas for setting up their own local version. Our audit cycle continues with symbolised questionnaires for our service users. We ask about the general day but also about individual sessions. A carer questionnaire goes out too and, as we aim to involve carers in the therapeutic activities, we need to get feedback both from their point of view and as to how they feel their service user(s) is benefiting. General feedback also suggests we are going in the right direction (figure 6).

Acknowledgements
Thank you to all the liveACTIVE Therapy Team (past and present members) without whom this exciting initiative would never have been born: Angela McManus, Karin Young (now Taylor), Alison MacIntyre, Leona Tulloch, Tracey Hudson, Julie Millar, Susan Wallace, Ruth Adamson and Sheila Frenz. Thanks also to Gill McShea, Physical Activity Officer for Perth & Kinross Leisure, frontline staff in Bells Sport Centre, Dave Angus, volunteer walk leader and the service users themselves who have all embraced this project. Last but not least, thanks to Carole Sutherland and Bernie Brophy-Arnott of the speech and language therapy department for their support.

References
Scottish Executive (2000) The same as you? A review of services for people with learning disabilities. Available at: http://www.scotland.gov.uk/ldsr/docs/tsay-00.asp (Accessed: SLTP 27 June 2006).

REFLECTIONS DO I TAKE ACCOUNT OF LEGISLATION AND POLITICAL PRIORITIES WHEN CONSIDERING SERVICE PROVISION? DO I TAKE ADVICE TO ENSURE ONGOING AUDIT IS USEFUL? DO I UNDERSTAND THAT CHANGE EVOLVES AND SOMETIMES I JUST NEED TO GIVE PEOPLE MORE TIME TO SEE THE NEED FOR IT?

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5 September or 19 October 2006 Assessing and Promoting Effective Communication (APEC2) For speech and language therapists in special education. Rugby 115 www.apectraining.co.uk, tel. 01788 576488 or e-mail gillian@apectraining. co.uk 21 September 2006 Parkinsons Disease Society conference New Horizons Improving care and support for people with Parkinsons disease London Book online at www.mahealthcareevents.co.uk/1096a.html or call the Credit Card Booking Hotline on 01722 716007. Bursaries may be available e-mail pvirdee@parkinsons.org.uk. 21-22 September 2006 2nd International Brain Injury Conference Salisbury 149 + VAT (profits to Headway) Tel. Andrew Norman on 01722 742066, e-mail anorman@glensidemanor. co.uk 26-29 September 2006 Johansen Sound Therapy Training Course South Queensferry, by Edinburgh 400 (inc. lunch) Dr Kjeld Johansen Tel. Camilla Leslie on 0131 337 5427 or e-mail camilla.leslie@ johansensoundtherapy.com 12 October 2006 Talk To Your Baby conference Working Together to Get Talking London 200 www.literacytrust.org.uk/talktoyourbaby/conf2006.html 7 November 2006 Practical Solutions to Support Communication 16th Annual Augmentative Communication in Practice: Scotland Study Day Stirling www.acipscotland.org.uk 29 November 2006 I CAN conference Linking language and literacy London 130 (Booking by 1 October 99) www.ican.org.uk 7-8 December 2006 1st UK Stroke Forum Conference Harrogate 210 for RCSLT members www.ukstrokeforum.org 2728 March 2007 or 1011 July 2007 Developing communication through music Nottingham 130 (1 day), 260 (2 days) Wendy Prevezer I CAN Training, tel. 0845 2254073, e-mail training@ican.org.uk 2-5 April 2007 Afasic Fourth International Symposium Understanding developmental disorders: From theory to practice University of Warwick www.afasic.org.uk Connect training events for everyone working in stroke services are run regularly in London. Details at www.ukconnect.org CALL Centre courses include Getting to Grips with Boardmaker 5, Clicker 5 and Interactive Whiteboards. Details at www.callcentrescotland.org.uk/training

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MY TOP RESOURCES
4. MY OLD UNI NOTES AND LECTURES As an afterthought I brought my old university notes with me, and Im so glad I did, as theyve been invaluable in planning lectures. Can you imagine trying to teach cognitive neuropsychological models of language processing with no notes? (Thank you, Tim Pring! www.city.ac.uk/lcs/biographys/tpring.html) The course is organised along Western lines, and although therapy is a Western concept we try to tailor case examples, tutorials and classes to the local culture. However students find talking to the clients about prognosis and recovery very difficult, because of peoples very different attitudes to sickness in Bangladesh. Many Muslims see recovery, or lack of it, as down to Allahs will alone. The students have also reported that to discuss prognoses may be seen as disrespectful. In spite of this it is interesting to see that similar challenges (implementing AAC, getting people to do their dysarthria exercises, people with a stammer desperate for a cure) exist, and also to see that people do benefit from therapy in such a completely different culture. 5. DONATED BOOKS AND JOURNALS We rely almost completely on donated books and journals and because of this many of the books available to the students are quite outdated. There is a real lack of up-to-date resources, particularly adult-based books. Some therapists have kindly donated some of their backdated journals, but we do not receive these regularly. Speech Pathology Australia delivers its quarterly publications free of charge to our library, as does Speech and Language Therapy in Practice. Thank you! www.speechpathologyaustralia.org.au www.speechmag.com 6. DONATED ASSESSMENTS We have been donated a number of assessments and therapy materials from British therapists. Most of the assessments are of course culturally inappropriate for Bangladesh where many people have not seen a burger, a bathtub or a carton of milk. The context can be explained to the students and the donated assessments serve as models for them to compile new culturally appropriate home-made assessment materials. These include: Pictures of local food such as curry, rice, vegetables and fresh fish as many of the food pictures we received are not suitable, including sandwiches, salads and ice cream cones. The simple toys that children in Bangladesh use for play, such as different sized boxes, and wheels, as many children just dont know how to play with sophisticated toys. Actions such as walking, drinking (not alcohol) and cycling, but not children skipping and playing tennis, or people eating with knives and forks. People pictured in appropriate clothing. We have to be sensitive about what is regarded as a state of undress, including shorts, particularly on women. Although the majority of the people know how Westerners dress, it may be offensive to present this in assessment material, and children may be bamboozled. Interestingly, we have particular difficulty assessing swallowing, as it is hard to get hold of modified consistency foods and fluids. The thickest fluid we have come up with is mango juice, which is readily available. 7. RESOURCES IN BENGALI Speech and language therapy is an established profession in India. Bengali is spoken in Calcutta, close to the border with Bangladesh, and here weve managed to find some great resources, including the Picture Test of Receptive Language, a Bengali language assessment which is standardised on Bengali speaking children in India. Kaul, S. & Bose, S. (2003) Picture Test of Receptive Language (Bengali), Calcutta, Indian Institute of Cerebral Palsy, www.iicpindia.com/ All India Institute of Speech and Hearing, www.mylibnet.org/aiish.html 8. BENGALI PHRASE BOOK Although English is Bangladeshs second language, widely used in business and education, Ive found it really helpful to be able to speak some Bengali. Any attempts are warmly received and I take a total communication approach to my interactions! This usually breaks any ice and gives people a laugh at my expense (Bangladeshis have a great slapstick sense of humour). Speaking Bengali - albeit more like a curious form of Benglish at times - has opened up all sorts of opportunities to me that I wouldnt have experienced had I been unable to communicate with the local people. If you want to find out more, the book Brick Lane by Monica Ali (Pub. Black Swan, 2004) about a Bangladeshi person in London is great, as are the following websites: www.banglapedia.org www.virtualbangladesh.com www.cia.gov/cia/publications/factbook/geos/ bg.html www.bangladesh.com 9. APPROPRIATE CLOTHING As Bangladesh is predominantly an Islamic country, women are expected to dress modestly, and cover their bodies. I wear a salwar kameez, which was introduced in Bangladesh by the occupying Pakistanis before the War of Independence in 1971. It consists of a long tunic, trousers and an orna, which is a long, broad scarf worn to cover the chest. On special occasions, I wear a sari, which is so glamorous, but hard work to put on! www.shijucreation.com/wearingasari.htm 10. OTHER VOLUNTEERS The speech and language therapy course cannot operate without volunteer speech and language therapists coming out here to teach and share their experience and specialist skills with the students. It may be possible for the Centre for the Rehabilitation of the Paralysed to assist any prospective longer-term volunteers to access funding. We are always looking for people who would be interested in visiting this beautiful and vibrant country, and who would be as proud as we are to take an active part in the creation of speech and language therapy as a profession in Bangladesh. If you would like to know more about volunteering, contact volunteers@crp-bangladesh.org or Cristy Gaskill at cristy@crp-bangladesh.org.

AT THE TIME OF WRITING AMY JENSEN WAS A VOLUNTEER SPEECH AND LANGUAGE THERAPIST WORKING AND TEACHING STUDENTS AT THE CENTRE FOR THE REHABILITATION OF THE PARALYSED, A CHARITABLE INSTITUTION IN SAVAR, DHAKA, BANGLADESH. THE COURSE IS A FOUR YEAR BSc HONS AFFILIATED TO UNIVERSITY COLLEGE LONDON AND IN THE PROCESS OF AFFILIATION WITH DHAKA UNIVERSITY. AMY SAYS, I HAVE THE PRIVILEGE OF TEACHING BANGLADESHS FIRST EVER SPEECH AND LANGUAGE THERAPY STUDENTS, NOW IN THEIR SECOND YEAR. AS THERE ARE NO QUALIFIED LOCAL SPEECH AND LANGUAGE THERAPISTS, THE COURSE CURRENTLY RELIES ON VOLUNTEERS FROM ABROAD TO TEACH THE STUDENTS.

1. MY STUDENTS The students, who helped me to compile this top ten, are my most important resources. As well as all the student responsibilities they have, they act as my interpreters during therapy sessions and even in matters unrelated to speech and language therapy. They are my advisers on the local customs and culture - for example they warned me to stop using the thumbs up sign as it is offensive in Bangladesh. In addition to this they create culturally appropriate resources, using Western assessments and therapy materials as examples. These five men and seven women are the most committed students I have encountered, and passionate advocates for the profession. 2. THE CENTRE FOR THE REHABILITATION OF THE PARALYSED The Centre for the Rehabilitation of the Paralysed is a spinal injuries rehabilitation centre. This charitable institution set up the Bangladeshi Health Professions Institute where the teaching of speech and language therapy, physiotherapy and occupational therapy takes place. The Centre is committed to developing speech and language therapy as a brand new profession in Bangladesh. It provides the clients for our students to observe and treat under supervision, and placements in its mother and child unit, its neurology outpatients department, and its school for children with special needs. www.crp-bangladesh.org 3. INTERNET Access to the internet is elusive because of frequent, prolonged power cuts and painfully slow connections, but it has proved essential to gather the information I need to plan lectures and tutorials. With one slow computer for all the students, their access to the net is even more limited than mine (female students are allowed four opportunities to leave campus per month and, unsurprisingly, choose not to spend that precious time in an internet shop). When I can, I use the internet to send begging letters to long suffering ex-colleagues for donations, and as a lifeline to family and friends.