ISSN 1368-2105

SPRING 2000

Problem solving
Audit works!

Learning Styles
Using video two approaches
http://www.speechmag.com

Assessments assessed
You say what you think

C L I N I C A L LY E F F E C T I V E

Team working
Best practice

How I put practice into research In My Experience

Arts therapies

My Top Resources
Velopharyngeal dysfunction

Making a difference to speech and language therapy practice

..READER OFFERS..READER OFFERS..READER OFFERS.

e v i t c e l f Re reative C king r o w d r a H nal i g i Or ergetic En ndly Frie hable c a o r p p A ghtful u o h g T n i t s e r Inte tic s i l a Re o-date t p U liable Re

Win Clicker 4
Would any of your clients benefit from computer software which allows them to write? Using Clickers facilities of symbols, pictures, photographs, colour coding, whole words, letters, and recorded or synthesised speech, you can customise the programme for individual clients (see review on p.23 for more details). Speech & Language Therapy in Practice has a copy of Clicker 4 to give away FREE to a lucky subscriber, courtesy of Crick Software. Clicker 4 is programmed in such a way that documents written with it can, if you wish, be published directly on the Internet. It normally retails at 90 including switch access. To enter, simply send your name and subscriber number / address marked Clicker 4 to Avril Nicoll, 33 Kinnear Square, Laurencekirk AB30 1UL, tel. 01561 377415, e-mail avrilnicoll@speechmag.com by 14th April, 2000. The winner will be drawn randomly from all valid entries. Before entering, please make sure you have the equipment necessary to run Clicker 4 - Windows 95/98/NT/2000; 32MB RAM; 50 MB hard disk space.
Competition rules: 1. Entrants must subscribe personally or as one of a department to Speech & Language Therapy in Practice, and only one entry per subscriber number is allowed. 2. Entries must be received by the editor on or before 14th April, 2000. 3. The winner will be randomly selected from all valid entries. 4. The winner will be notified by 21st April, 2000. 5. The winner will have access at work to suitable computer hardware.

Further information about the product from Crick Software at 35 Charter Gate, Quarry Park Close, Moulton Park, Northampton NN3 6QB, tel. 01604 671691, www.cricksoft.com

Win Pictures
Do you need clear, photocopiable, adaptable picture material? Courtesy of Black Sheep Press, Speech & Language Therapy in Practice has four sets of the companys new material for lucky readers, each worth 29, in a prize draw: Pragmatics 1 (emotions and facial expressions), Language in Pictures 9 (irregular past tenses with -ew endings) and Language in Pictures 10 (irregular past tenses with -ought endings). In the pragmatics pack, six emotions each have four linked pictures for discussion. For the irregular past tenses, each pack has thirty pages of fun and interactive worksheets aimed at children aged approximately 5 - 10 years. The words are introduced and worked on individually but the packs include a section combining the words in sentences. To enter, simply send your name and subscriber number / address marked Black Sheep Press to Avril Nicoll, 33 Kinnear Square, Laurencekirk AB30 1UL, tel. 01561 377415, e-mail avrilnicoll@speechmag.com by 14th April, 2000. The winner will be drawn randomly from all valid entries.
Competition rules: 1. Entrants must subscribe personally or as one of a department to Speech & Language Therapy in Practice, and only one entry per subscriber number is allowed. 2. Entries must be received by the editor on or before 14th April, 2000. 3. The winner will be randomly selected from all valid entries. 4. The winner will be notified by 21st April, 2000.

you. s t a e th n i z a ag The m

For the full range of Black Sheep Press material, send for a catalogue to Coast Cottage, Donna Nook, Louth, Lincs LN11 7PA, tel. 01756 791627, www.blacksheeppress.co.uk, e-mail competition@blacksheeppress.co.uk

Contents
2 News / Comment
www.speechmag.com
SPRING 2000
(publication date 28th February) ISSN 1368-2105 Published by: Avril Nicoll 33 Kinnear Square Laurencekirk AB30 1UL Tel/fax 01561 377415 e-mail: avrilnicoll@speechmag.com Production: Fiona Reid Fiona Reid Design Straitbraes Farm St. Cyrus Montrose Printing: Manor Group Ltd Unit 7, Edison Road Highfield Industrial Estate Hampden Park Eastbourne East Sussex BN23 6PT Editor: Avril Nicoll RegMRCSLT Subscriptions and advertising: Tel / fax 01561 377415 Avril Nicoll 2000 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.

Spring 2000
18 In My Experience
Both speech and language therapy and arts therapy share some fundamental aims. These include promoting skills in forming healthy relationships and interaction with others, building confidence, improving attention and allowing children to access the school curriculum. The fundamental difference is that the arts is primarily non directive, non-verbal and relationship based. Julie Ford and Jo Legum on the benefits arts therapies offer children with communication and emotional and behavioural disorders.

4 Problem solving
We noted that only 24 per cent of the referrals were also for communication assessments and advice, yet a further 65 per cent of the referrals were shown to have communication difficulties requiring speech and language therapy intervention. This implies that dysphagia has a much higher profile and that, indeed, communication impairment was taking second place in medical staffs consideration. Gill Free uses audit as a tool for change.

20 Reviews
Head and neck, child psychiatry.

8 Using video
Working with a child with severe autism in the aloof group who shows a considerable capacity for learning is challenging for all involved - because these children are not interested in the least in the help we feel we can offer, one can easily begin to feel inadequate as a therapist, a teacher, or even a parent. Beth Junor adapts to a childs individual learning style. A second article follows progress of the National Autistic Societys EarlyBird project. Jane Shields explains the importance of video as a resource for parents.

21 Assessments assessed
Published assessments and programmes are again given a rigorous evaluation by practising therapists. Find out what they really think of the PETAL, Clicker 3 and QuickFire, Earobics Pro PLUS Steps 1 and 2 and the Phonological Abilities Test.

24 How I put practice into research

Three contributions from the child language, adult learning disability and acquired neurological fields demonstrate how the profession is crossing the perceived divide between research and practice.

14 COVER STORY

12 Further Reading
Child language, adolescent psychiatry, outcome measures, aphasia, stammering, velopharyngeal dysfunction, gender dysphoria, hearing impairment, head and neck, AAC.

Team working
The users indicated they found the clinic useful and enjoyed the contact with other valve users as well as the spontaneous problem solving which takes place in the waiting room. They also commented on the benefits of meeting company representatives and discussing individual issues. Fiona Buck and a nurse colleague improve postoperative services to clients with a trache-oesophageal valve.

30 My Top Resources
During screening the childs head is held still as s/he views the 3d pictures (I have a choice of Mickey Mouse, Little Mermaid or Beauty and the Beast) and a clear image is achieved. Everyone is happy! Lindsay Thomason specialises in cleft lip and palate and neonatal feeding disorders.

Cover picture courtesy of Portsmouth Hospitals NHS Trust - see p.14.

IN FUTURE ISSUES EDUCATION VOICE BILINGUALISM STAMMERING ETHICS AAC

Speech & Language Therapy in Practice has moved.

All correspondence should now be sent to: Avril Nicoll, Speech & Language Therapy in Practice, 33 Kinnear Square, Laurencekirk, Abedeenshire, AB30 1UL tel/fax 01561 377415. For subscribers in the UK, the FREEPOST address is now Avril Nicoll, Speech & Language Therapy in Practice, FREEPOST SCO2255, LAURENCEKIRK, Aberdeenshire, AB30 1ZL. The magazines complementary internet site, speechmag, has also moved to http://www.speechmag.com e-mail avrilnicoll@speechmag.com (Mail is being re-directed from the old address and callers to the old telephone number will hear a recorded message with the new number.) Apologies for any inconvenience caused by these changes.

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2000

news

Technology praised
A charity for the combined care and education of severely disabled young people with physical disabilities has been sharing its best practice with Japanese students. The Treloar Trust in Hampshire hosted a visit by thirty social care students from Shukutoku University in Tokyo. They saw round the Lord Mayor Treloar School where over 130 young people receive live-in care, therapy, education and training in independence in a residential setting. The visitors were particularly impressed by the technology in use by residents with communication difficulties and the individual programmes. Treloar Trust: www.treloar.org.uk

Early intervention
The national educational charity for children with speech and language difficulties is embarking on an ambitious fundraising programme for early intervention. I CAN is planning a major awareness and fundraising initiative to support a 2.5 million investment in an extensive national network of Early Years provision. It hopes to David Braybrook, build on its 1998/89 success where percentage net fundraisDirector of Education, I CAN. ing costs were held but income raised increased by over 30 per cent following the appointment of a fundraising team. Supporters include grant-making trusts, national and local companies and individuals. In the next twelve months I CAN hopes to add to the Early Years services in Bournemouth, Brighton and Hove, Falkirk, Greenwich, North Tyneside, Salisbury and Worcester by opening more in North West England, Northern Ireland and Yorkshire and Humberside. I CAN provides a grant and the expertise to support setting up a nursery and running it for two years in partnership with the local education authorities and health services, who then take over responsibility. The charity has also appointed a new Director of Education. David Braybrook has an extensive background in special needs teaching and inspection. He has responsibility for the development of educational policy and practice across I CAN schools and services, including monitoring and evaluating standards of education, therapy and care. I CAN, tel. 0870 010 40 66.

Telephone update
The telephone number of the British Stammering Association is now 020 8983 1003, fax 020 8983 3591. The Helpline number stays as 0845 603 2001.

Early help for dementia

General practitioners in Scotland are being urged to promote a helpline for people with dementia and their families at an early stage. The confidential 24 hour Dementia Helpline is staffed by trained volunteers, many of whom have cared for someone with dementia themselves. Common enquiries are on how to get help, understanding the illness, treatments, maintaining independence, financial and legal matters, coping with behaviour, community care and long-stay care homes. Although there have already been over 20 000 callers, Alzheimer Scotland - Action on Dementia is concerned that too many have found out about the helpline too late. Dementia Helpline, freephone 0808 808 3000.

Finance for reading Special needs organisations with a

scheme to engage and develop readers in an imaginative and fun way could be in line for financial help. Awards totalling 100 000 are available through the BT Reading Challenge. Last years recipients included an organisation for people with moderate to severe learning disabilities which held creative writing workshops culminating in the creation of a members Poetry Wall. The closing date for entries is 7 April, 2000. Details: Kemi Onipinla or Toby Greany at the Campaign for Learning on 0171 976 2011 or 0171 930 1111, e-mail konipinla@cflearning.org.uk

Aphasia development
An NHS Trust, a University and a national charity have collaborated to offer a new style of service for people with aphasia. The Newcastle Aphasic Clinic at the University (NACU) is the only one of its kind in the North East. In addition to intensive treatment, both individual and group, the facility offers opportunities for student training and research into therapy effectiveness. NACU is funded for three years by the Tavistock Trust for Aphasia and is based in Newcastle Universitys Department of Speech. The third partner is Newcastle City Health Speech & Language Therapy Department.

Helpline number - 0808 800 3333

A helpline for people with cerebral palsy and their families and carers has been re-launched with a new number. This free-to-call confidential information and counselling service provided by the disability charity Scope is staffed by trained counsellors. The helpline has been running for 10 years and now takes around 1700 calls a month. Funded by public donations, it is open Monday to Friday from 9am-9pm and Saturday and Sunday from 2pm-6pm. Scope, tel. 0171 619 7200
Cerebral palsy helpline 0808 800 3333, e-mail cphelpline@scope.org.uk

The opening of NACU (l-r) Professor David Howard, Research Development Professor, student Hannah Cundale, Lord Tavistock and James Wright, University ViceChancellor.

SPEECH & LANGUAGE THERAPY IN PRACTICE

SPRING 2000

news & comment

Epilepsy outreach
A major research project is looking at supporting children with epilepsy in their local schools. St Piers, a non-maintained, national centre in Surrey for children and young people with epilepsy, has received National Lottery funding for two years to develop an outreach service. Having last year opened a national assessment service in partnership with Great Ormond Street Hospital for Children NHS Trust, the centre will now in addition be able to finance trips to a childs home or local school to show how recommendations can be fully implemented. A three-strong team will be recruited to provide this support for 40 children over the next two years and results will be audited and published. St Piers, tel. 01342 832243.

...comment...
Avril Nicoll, Editor

When compromise
33 Kinnear Square Laurencekirk AB30 1UL

is needed

Beth Junor describes a feeling of inadequacy in her work, a concern that anyone observing her will think she is not doing her job. Many aspects of our work - non-directive therapy, working with parents and carers, following a consultative model with teachers and nursing staff - can make us feel we are not doing enough. But, as Beth goes on to say, other professionals often feel exactly the same way and sharing this feeling of inadequacy can go a long way to overcoming it. We can often feel a fellow professional is not interested in us / doesnt give communication a high enough priority / thinks s/he is already doing everything were suggesting. If we openly acknowledge the difficulties of working in partnership and show a willingness to compromise, we start breaking down barriers. As well as a re-evaluation of what doing means in our job, we need to recognise we cannot do it all and know not just when to pass on, but to whom and how to ensure a clients needs are met. Julie Ford and Jo Legum suggest the arts therapies have much to offer our clients. Compromise can mean acceptance of the best possible in the circumstances rather than the best. Gill Free is frustrated by some of the audit results of her dysphagia service, yet recognises much progress continues to be made. Each new venture, whether a leaflet, resource pack, video, training course, project or guidelines - in this case, the establishment of Dysphagia Trained Nurses has to be seen as part of an evolving process, rather than an end in itself. Clients can give us feedback about where we need to compromise. One patient of Fiona Bucks highlights the importance of her joint clinics recognition that the NHS cannot provide everything, and the value of the decision to include companies and their products in services provided. Rationing has always been present but is only beginning to be acknowledged and discussed - we need to explore what is acceptable. Compromise is an idea running through How I put research into practice. There isnt time to keep up-to-date, so groups such as the STEP team help summarise available information....There are limits on the public purse, so we must heed the results of applied research and stop doing what doesnt work and do more of what does....Research doesnt have to be a major academic event sharing ideas through special interest groups and papers is often as valuable. One thing never compromised is this magazines commitment to keeping you up-to-date with the best practice in the real world. We continue to move away from a focus on narrow specialisms with a new device read this if... to help you decide on the basis of ethos rather than client group which articles are most relevant to your needs. And remember, youll find more on our re-designed website too.

Symbol award
Writing with Symbols 2000 is one of the 2000 most innovative products developed in Britain today. Millennium Product status has been granted to the computer program which allows a symbol to appear when you type in a word. It is used to help people access text. Widgit Software, tel. 01926 885303, www.widgit.com

tel/ansa/fax 01561 377415

e-mail
avrilnicoll@speechmag.com

Health qualifications
Two projects are aiming to help health care employers understand more about General National Vocational Qualifications. The first will help improve links between health care employers and schools and colleges, while the second will encourage the employers to offer places to young people with the qualification. Information on GNVQs from FEDA, tel. 0171 840 5360.

Aphasia aware
Local and national events are being planned to mark International Aphasia Awareness Week. In the UK, Action for Dysphasic Adults is planning an evening lecture with Dr Oliver Sacks and making packs available for people to use as the basis of a display. ADA, tel. 0171 261 9572.

SIGNALONG for adults

The SIGNALONG group is to design training courses with a more pronounced adult bias. New member of staff Sarah Bissett, a tutor for the signing system, will be using her experience in adult care when developing the training. Tel. 01634 819915/832469. The group now has a website: www.signalong.org.uk

Good health, good business

Special health and safety inspections suggest many employers, although taking action to manage health risks, are not reviewing and auditing action taken. The Health and Safety Executive is working to reduce the number of work related accidents and cases of ill health through a Good Health is Good Business campaign. For a free employers guide call 0345 181819.

SPEECH & LANGUAGE THERAPY IN PRACTICE

SPRING 2000

problem solving

When whats happening is hard to swallow...

Many speech and language therapists believe that dysphagia is swamping speech and language therapy services for people with communication impairments. But even people with dysphagia dont always get the quick, multidisciplinary response they need. Gill Free charts her hospitals progress, based around repeated audit, in addressing these problems.

Read this if you are: frustrated in multidisciplinary working concerned by dysphagias prominence interested in using audit

uring the day to day management of our dysphagia caseload, the adult speech and language therapy department was becoming increasingly frustrated and worried about the problems encountered in trying to respond to the high level of (and often inappropriate) referrals from anxious nursing and medical staff, and in ensuring that our advice was being adhered to. There was also concern about the perceived neglect to patients with communication difficulties. In an audit undertaken in 1995, and repeated in 1997, we identified several areas of concern: who refer to speech and language therapy and the appropriateness of referral how long patients were waiting for assessment compliance to advice given by speech and language therapy. We looked at 59 referrals in a nine week period in 1995 and 60 referrals in a nine week period in 1997. In 1995 only 47 per cent of referrals were initially made by medical staff (doctors) and only five per cent of these followed the correct protocols (doctor signing referral form). The Royal College of Speech and Language Therapists (RCSLT) Communicating Quality Standards (1991) stipulated that all referrals of dysphagia to speech and language therapy must be made by a doctor. We had great difficulty ensuring compliance to this. Often the doctor would automatically agree once they had been contacted to confirm the referral originally made by a nurse. Of those referred primarily by the doctor, 11 per cent were felt by us to be inappropriate for assessment. Of the remaining 53 per cent of referrals, 40 per cent were made by nursing staff and 46 per cent of these were felt to be inappropriate.

We considered patients who were too ill for assessment, unconscious or semi-conscious and those who had been referred with no neurological or structural cause, for example with diabetes, as being inappropriate. Forty two per cent of the patients referred for swallow assessment had proven to have a normal swallow when assessed by us, yet had been kept nil by mouth whilst awaiting assessment. Once we had received the referral, 75 per cent of patients were assessed on the same day, 8 per cent the next day and 16 per cent waited two or more days. We were unclear as to how long it took for us to receive the referrals. If it was the weekend, sick leave or annual leave we were not available to receive the referral and we were also aware that nurses/doctors often left referral until an appropriate time, such as a Monday morning. Doctors had only documented their intention to refer in the medical notes in seven per cent of the sample. Of this we noted 25 per cent were received by us on the same day, 31 per cent the next day, 31 per cent two days later and 15 per cent three days later. This may indicate that there is a gap between doctors deciding to refer and the actual referral being processed. As we were concerned that patients were waiting for assessment, sometimes inappropriately, and that doctors and nurses were not following our referral guidelines, a multidisciplinary working party was set up. Guidelines on the Management of Dysphagia and Nutrition After Stroke were drawn up and established (summary in figure 1). Within these guidelines a swallow screen test was included. It was advised that doctors use the test to screen for dysphagia and then as a basis for appropriate referral to speech and language therapy. The guidelines also advised on suitable nutritional management to ensure that patients were not being kept nil by mouth with-

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2000

problem solving

Any attempt to insist on doctor referral led to further delays for the patient and ill-feeling among the multidisciplinary team.

out adequate non-oral nutritional support. A summary of agreed responsibilities is in figure 1. On re-audit (1997) doctors had now increased their referral rate to 60 per cent (only 48 per cent supported by written documentation) but we were still accepting referrals from nursing staff. Any attempt to insist on doctor referral led to further delays for the patient and ill-feeling among the multidisciplinary team. The number of inappropriate referrals had reduced by 11 per cent and only 22 per cent of the assessments now showed a normal swallow. We saw 81 per cent of patients within day one and two, but there were 19 per cent waiting beyond this period. Disappointingly the doctors only used the swallow screen test for eight per cent of the referrals to speech and language therapy, and only when they knew we would not be available, for example at weekends. On one occasion the nurse then ignored the doctors advice which was based on the swallow screen test. The purpose of the swallow screen test was to enable more timely screening thereby reducing patients wait. The fact that there were still 17 per cent of inappropriate referrals means there were patients who would have benefited from being screened more quickly. They would not have required speech and language therapy input, thereby reducing our caseload.

Second place
We noted that only 24 per cent of the referrals were also for communication assessments and advice, yet a further 65 per cent of the referrals were shown to have communication difficulties requiring speech and language therapy intervention. This implies that dysphagia has a much higher profile and that, indeed, communication impairment was taking second place in medical staffs consideration.

Of the patients who had received advice and guidance from speech and language therapy as to how to manage their dysphagia - for example, not safe for oral feeding, pure, thickened liquids, posture - 54 per cent of patients had noncompliance and 36 per cent of all episodes had non-compliance (1995). There was no difference in rate of non-compliance if we reviewed the patient within two days (38 per cent) or beyond two days (35 per cent). We found, however, that non-compliance within two days of review was due to lack of knowledge about the advice or what it meant. Non-compliance on day three or more (before speech and language therapy review) was also due to active decision making by

nursing staff and occasionally doctors; where they felt that the patients may have changed in ability, advice was altered, for example to give a patient normal liquids.

Disagreement
The problem was that, in both situations, speech and language therapists mainly disagreed with the non-compliance. Workshops were organised to train the nursing staff. We found there was high attendance of staff from the care of the elderly wards but much fewer from acute wards. On re-audit in 1997 there had been a reduction in non-compliance within day one and two of advice

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2000

problem solving

Figure 1 - Summary of multidisciplinary guidelines 1. Initial assessment of the swallow is a medical responsibility. Assessment of gag reflex is not sufficient. 2. Decisions about feeding should be made at least every 72 hours and involve the patient (where possible), the family / carers and the multidisciplinary team. 3. A nutritional risk score must be completed by the named nurse on all patients within 24 hours of admission. 4. Speech and language therapists will see patients within 72 hours of receiving a referral from a doctor / dysphagia trained nurse. In the absence of a speech and language therapist, consultant review is required. 5. Defining patients who are suitable / not suitable for each alternative method of feeding is a multidisciplinary decision but responsibility for ensuring a decision is made and documented lies with the medical team: naso gastric tube feeding should be the first line of management. Regular oral hygiene is a nursing responsibility. percutaneous endoscopic gastrostomy (PEG) can be performed safely under benzodiazepine sedation and local anaesthetic in patients with recent strokes, respiratory, cardiac or other chronic illnesses who would otherwise be high anaesthetic risks. intra venous peripheral feeding (TPN) may be an option if a naso gastric tube is not being tolerated whilst waiting for a PEG. Figure 2 - Assessment Criteria for Dysphagia Trained Nurses KNOWLEDGE The DTN can 1. explain, in outline, what happens at the oral and pharyngeal stages of a normal swallow. 2. state five things that may affect a persons ability to eat or drink safely. 3. state criteria for referral to three other professionals, in relation to eating and drinking difficulties. 4. state the role and responsibilities of a DTN. SKILLS 1. Preparation of equipment. 2. Explanation of the assessment to the patient. 3. Following the assessment procedure. 4. Making and recording accurate observations. 5. Choosing appropriately when to stop assessment. 6. Writing accurate assessment summary. 7. Writing appropriate management plan. 8. Making appropriate referrals. Figure 3 - Role of Dysphagia Trained Nurse Assessment All patients with suspected feeding difficulties should be assessed using the ward dysphagia screening assessment by a dysphagia trained nurse. The purpose is to establish: a) the nature of the difficulty b) whether it can be managed by the nursing staff c) the need for referral to other disciplines. Decision Following assessment, a decision should be made: a) further assessment required b) manageable by named and suitably qualified nursing care staff c) specialist intervention required. Referral To speech and language therapy all patients with suspected problems at pharyngeal stage advice when dysphagia does not improve after one week assistance with management of any difficult case. To dietetics all patients who meet referral criteria on nutrition risk assessment all nutritionally compromised patients information on nutrition requirements and alternative methods. To physiotherapy all patients for advice on positioning a) for eating meals b) due to risk of aspiration c) due to chest infection all patients who need management of chest infection due to risk of aspiration and poor positioning. To occupational therapy All patients for whom you need any advice on managing standard cutlery getting food from plate to mouth maintenance of suitable position during eating and drinking.

nurses vary greatly in their knowledge of dysphagia and general workshops do not necessarily target all the nurses who deal with dysphagia regularly.

being given (now 17 per cent) but there was still 28 per cent of non-compliance on day three and onwards of advice being given. In this audit, we looked at reasons behind us reviewing on day three and onwards. We found 26 per cent was due to clinical need but 64 per cent should ideally have been reviewed earlier. Reasons for delay were speech and language therapists ran out of time on a given day, were not available (sick leave/annual leave) or it was the weekend. It was clear that we were prioritising for initial assessment and patients requiring review were having to wait. The swallow screen test guidelines asked that the test should be repeated every 72 hours if no speech and language therapy assessment or review was available. This only happened in nine per cent of all the cases where we did not review until day three or onwards, despite 28 per cent of these cases having non-compliance to advice due to the nursing staff feeling that the patient may have moved on and therefore needed their management altered. We felt that the doctors swallow screen test had not been used as effectively as hoped and that doctors were not complying with the referral guidelines. It is clear that nursing staff play an integral part in the day-to-day management of dysphagia. Further, it has been shown that nurses vary greatly in their knowledge of dysphagia and that general workshops do not necessarily target all the nurses who deal with dysphagia regularly.

Timely input
We have therefore developed Dysphagia Trained Nurses (DTNs). These few DTNs are trained by us to screen, instigate basic management procedures, make appropriate referral to speech and language therapy (see RCSLT Clinical Guidelines May 1998) and help oversee advice given by us. As they are ward based, they are more accessible to patients and ward staff, and therefore their input is more timely. We hoped they would be able to support and have a training role for other ward staff and carers and ensure good communication of management strategies. We also hoped this would reduce the frustrations and worries of the speech and language therapy department and enable a more complete service to people with dysphagia. In the long term, we reckoned it would free up more of the our time to concentrate on more complex dysphagia cases and to develop a better service to communication impaired clients. From a wider perspective, we hoped this development would encourage retention of experienced nursing staff and improve multidisciplinary working. Applications for DTN positions were invited from registered nurses (Grade F or above) with an interest and experience in both dysphagia and multidisciplinary working and a commitment to continued professional development. Following initial training from speech and language therapy, a practical test was carried out to ensure competency.

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2000

problem solving

NEWS...NEWS...NEWS...NEWS...
Ongoing monitoring of assessment and management forms by speech and language therapy, regular case conferences and continued training are a vital part of the DTNs development. We drew heavily on work done in other Trusts when developing our assessment criteria for DTNs (figure 2) and the role of the DTN (figure 3). We have also provided process details for dysphagia management (neurological swallowing difficulties), a ward dysphagia screening test, a bedside information chart, texture classifications of liquids and solids, an advice sheet and a patient information leaflet. Our guidelines for DTNs making management plans indicate that they should include statements on alertness, positioning, nutritional needs, food charts, alternative feeding / supplements, safe consistencies and amounts, supervision needs, special equipment needs, referrals made, advice / instructions to the patient, mouth care needs and a re-assessment date. In accordance with RCSLT guidelines, the DTNs can now refer directly to speech and language therapy. Where none is available, doctors are required to use the swallow screen test and refer to speech and language therapy if indicated. Our dysphagia nurse training was completed in March 1999. Six candidates attended and five passed. Four were ward based (three acute, one care of the elderly) and one, the nutrition nurse, had scope to visit patients wherever required. Has this made the difference we were anticipating? After six months, a small audit (19 patients) was completed. Disappointingly, only 57 per cent had their swallow screened prior to speech and language therapy assessment, 55 per cent of these by the doctor and 45 per cent by the DTN. Thirty three per cent of doctor management following the swalDo I use audit to low screen test find out whether was felt to be my perception of inappropriate, for example: what is happening patients swallow is the reality? was not safe, but doctor awaited Do I acknowledge speech and difficulties and language therapy take realistic steps assessment before considering to resolve them? non-oral feeding Do I look beyond patients swallow the speech and considered safe, but to continue language therapy nil by mouth profession for until seen by solutions to speech and language therapy. problems? All of the DTNs screening and subsequent management was felt to be appropriate. We did find however that in 40 per cent of the cases, the doctors refused to acknowledge the DTN assessment and insisted on speech and language therapy assessment prior to instigating non-oral management. Of the ones who did not have a swallow screen prior to speech and language therapy assessment, 10 per cent were appropriate to be assessed (therefore 33 per cent were inappropriate referrals!) In 15 per cent of cases there was non-compliance to the consistency advice given by either the speech and language therapist or the DTN. In each case documentation showed compliance, but observation by speech and language therapy showed non-compliance, for example, patient documented as being given thickened liquids, but a glass of unthickened juice was placed in front of them. Regrettably, compliance is still an issue for us despite joint speech and language therapy/dietitian workshops for each ward, consistency charts, patient information charts and so on. We do feel very positive about having the DTNs but this still does not wholly solve the problems. We feel more DTNs are required. Many key wards need more than one as it can be frustrating when a DTN is not on duty to assess and monitor patients. We also need to ensure that everyone is clear on the DTN role and on the effectiveness of screening. We plan to train more DTNs and to move the project onto other hospital sites. We are also considering creating a Dysphagia Trained Auxillary whose responsibility would be to oversee patients consistency/advice charts to ensure compliance, and to aid the DTN. In future, audit should focus on individual wards and care groups so that results can be used to effect a change at a more local level. Despite the slightly disappointing audit results, the DTN system on certain wards has worked exceptionally well. Gillian E Free is Chief Speech and Language Therapist with Essex and Herts Community NHS Trust. Any queries, contact Gill at Speech & Language Therapy, Addison House, Princess Alexandra Hospital, Hamstel Road, Harlow, Essex CM20 1QX, tel. 01279 698655.

Hypertension treatment
Evidence-based guidance on treatment of hypertension to prevent disease such as stroke suggests current levels of detection and treatment are low. The NHS Centre for Reviews and Dissemination is calling for further research into patient compliance. It is also interested in why half of the population with hypertension is undetected and the reasons for GPs reluctance to consider treatment at levels quoted in guidelines. Effectiveness Matters, Drug Treatment of Essential Hypertension in Older People, 4 (2), October 1999, tel. 01904 433634.

Defeating glue ear

The UKs national research charity for deaf and hearing-impaired people is stepping up its campaign for better awareness among teachers of glue ear. Defeating Deafness has called on the government to work closely with the voluntary sector and commit resources to ensure all teachers have the information they need to identify the symptoms of glue ear and take appropriate action to minimise its impact. In 1999 the charity began a study to identify children who are particularly prone to glue ear with the aim of developing a genetic-based test to find children who will suffer severe and persistent glue ear. Information leaflets for parents and teachers are available free of charge from Defeating Deafness on 020 7833 1733.

Reflections

www.autism99.org update

Acknowledgements
I would like to thank the Adult Speech and Language Therapy Department, Mary Hobday, Stroke Services Co-ordinator, Dr Ron Morgan, Care of Elderly Consultant, and Annette Harman, Nutrition Nurse, for their advice and support, Jenny Pennell for secretarial support and the Audit Department for their helpfulness.

References
College of Speech & Language Therapists. (1991) Communicating Quality : Professional Standards for Speech and Language Therapists. CSLT. Royal College of Speech & Language therapists (1996) Communicating Quality 2 : Professional Standards for Speech and Language Therapists. RCSLT. Royal College of Speech & Language Therapists (1998) Clinical Guidelines by Consensus for Speech and Language Therapists. RCSLT.

The first global disability conference on the Internet drew 34 200 visitors. The average time spent by each visitor per session viewing the autism99 event was 25 minutes and delegates were drawn from 112 countries. The most visited part was the papers, with the medical and biomedical theme proving most popular. A series of seminars is planned to build on the success of the conference, the first on prevalence. Numbers are restricted to 500 on a first come, first served basis. Seminars will take place during a 24 hour period, with interaction via bulletin boards and instant chat facilities. National Autistic Society, tel. 020 7833 2299.

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2000

using video

While the media sensationalises miracle cures and desperate parents raise funds for intensive treatments, professionals deal with the reality of trying to provide the best therapy and teaching for all individuals with autistic spectrum disorders. As Beth Junors case example of a preschool child demonstrates, we can learn much from the experiences of adults with autism if we listen to and apply what they are telling us.

In his own style

Photograph courtesy of the National Autistic Societys EarlyBird Programme.

Read this if you: have or want access to video technology recognise learning styles differ feel inadequate in your work are keen to work in partnership with parents.

n her excellent manual, Autism - An InsideOut Approach, Donna Williams suggests that one way of communicating things you think [people with autism] should know or need to know, is to make a home video of these lessons using a home-video recorder ....Lessons can make use of established interests or collections or can be used to teach spoken or written language. This is because, she suggests, video learning can be attended to without forcing acknowledgement of what is being learned in the way that interpersonal, face-to-face learning does. But can we really use video to teach the spoken word? Background details of one child on my caseload, C, are in figure 1. Cs severe impairment in social interaction certainly placed him, as a young preschooler, in Lorna Wings aloof group - he seemed cut off, in a world of his own, completely absorbed in [his] own ... activities (1996); for example, true to Lorna Wings description, in one of his first individual therapy sessions, C took my wrist without looking up at me, and pulled me to the door handle leading to the cupboard which held (as he recaIled from the previous week) all

the interesting things he wanted However, at this same time (3 years, 6 months), C very quickly learned to use proto-imperative pointing to a symbol, to obtain repetition of a favourite activity bubbles. The next week, C demonstrated spontaneous use of this newly-acquired communicative skill. The range of communicative behaviours listed in figure 1 illustrates how much C strives to reach and understand our world and its symbol systems. In his preschool year, C attended Central Regions first preschool group provision for children with autistic spectrum disorders. Cs own style of learning developed further in this setting. C made progress in social interaction and, on one occasion, offered comfort to a distressed peer. Not only did C come to display a close interest in what his peers were doing in the group, but he began to attend more closely to the adults present. By the time the summer holidays were approaching, it was apparent that C was paying close attention to the visual aspects of speech production, looking closely at the speakers lips. After his summer break, C began attending a newly set up Base at a local mainstream primary

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2000

using video

Figure 1 - Case history summary Background boy (C) - 6 years 8 months diagnosis of severe autism at chronological age 3 years 9 months living at home communicates using vocalisations, word approximations, symbols, Lightwriter (belonging to a peer), pointing and motoric communication Interventions referred to speech and language therapy service at chronological age 2 years 3 months art therapy at chronological age 4 years, 6 months attended group provision for children with autism in preschool year - interdisciplinary approach (specialist pre-five teacher, speech and language therapist, nursery nurse) now attends Base for children with severe social and communication disorders in nearby mainstream Primary School

Figure 2 - First vocabulary list hello yes Mummy no Daddy (name of sister) (name of family dog)

numbers I - 10 letters of the alphabet (Alpha to Omega cards shown) goodbye

school. Symbols were introduced to Cs classroom and the environment was arranged to maximise his learning opportunities. Mother continued to use symbols at home, and also took them with her on outings to the local shops, to provide visual explanations for C as needed.

Challenging for all

All of Cs learning takes place at his own pace, and in his own unique style. Working with a child with severe autism in the aloof group who shows a considerable capacity for learning is challenging for all involved - because these children are not interested in the least in the help we feel we can offer, one can easily begin to feel inadequate as a therapist, a teacher, or even a parent. Professionals are given a redundancy notice at the very first meeting. As therapists, because our conventional (that is, neuro-typical) methods of therapy are not applicable, we feel we are not doing as much as we could or should be doing for these childrens language and communication development. Many sessions spent in developing joint attention behaviours, playing alongside C at his chosen activity, accompanying his play with our symbols/ words/ pictures/ speech, altering the classroom environment, focusing on imitation are carried out to the accompaniment of a voice in the therapists head saying, I know this doesnt look like my job, but it is. As C seemed to observe the classroom activities and materials in a peripheral way, many sessions were spent demonstrating the speech sound system on my own, beginning with the sounds with which C was already experimenting - thankfully, C has a sympathetic teacher. An important part of our liaison was to acknowledge the sense of inadequacy engendered. Teachers, too, can feel they are not teaching. This is particularly acute when one sees how eager the child is to learn, and how much he does learn, in his own style. We were obviously the ones who were going to have to change our expectations and preconceptions, not only of this pupil, but also of ourselves and our roles.

of the world to us. This is an invaluable service to us neuro-typical people, and to the present and future generations of children with autism, if we take heed of what is said. Searching for a way to give this young boy the help which he clearly wanted but could not accept from any form of direct, confrontational-type approach, Donna Williams suggestion of video teaching must have surfaced back to consciousness. In response both to Cs continued interest in the visual aspects of speech production and to his own learning style, a video was made for therapy purposes. The vocabulary chosen had to be relevant, meaningful and reflect Cs interests. There should be some inclusion of social vocabulary. The vocabulary items chosen are in figure 2. Both the numbers and the letters of the alphabet (presented both by name of letter and phoneme) were a concession to Cs interests. The vocabulary items were written in bold black ink on large cards in both word and symbol form (for example, the name of Cs sister and the symbol for sister), so that C could see clearly what was being said. Only the word on the card was spoken, followed by a brief pause, the setting down of that card and presentation of the next. The physical setting was stark, with the video set up for filming against a plain wall, with no distracting or irrelevant background visible. Only my head and shoulders were presented. Facial expression was minimised - I smiled for hello only, for the sake of naturalism. I did not look directly into the lens while filming but focused on a spot just below the lens, not only to be non-confrontational but importantly - as with all the other measures taken - to minimise the amount of information necessary for C to process while watching. The presentation of the vocabulary items is preceded by an introduction intended for the adults living or working with C.

What do you want her to do, dance the Fandango?

Searching
Several adults with autism have done the painstaking work of explaining their experience

Control
The video was sent home, where it was received with great enthusiasm and interest on Cs part and was recognised as being excruciatingly boring

to the others in the family. (What do you want her to do, dance the Fandango? mum asked, in my defence.) C was given control over how he watched it - any number of rewindings was acceptable. The video was sent to school on the day the therapist saw C and it was set up for him, in the school context. C allowed me to sit beside him while he watched the video in a quiet room, he with the remote control again. C watched the video intently, and with obvious enjoyment He made a lot of use of the rewinding facility, and was clearly more interested in the social language than in the numbers and letters of the alphabet. C rewound to hello on eleven occasions throughout this session, vocalising the third time he watched. When he saw hello for the seventh time, he walked up to the screen and said hello intelligibly. He also frequently turned to me to request that I say some of the words live. He regularly looked at words frame by frame. After some time, he switched the room light off, thus improving the video picture quality. A fortnight later, both Cs class teacher and his Mother reported C was continuing to enjoy the video very much. He had by then said both hello and bye to mum, who was thrilled. A month after introduction, C was using very clear speech for the first two items presented on the video - hello and mummy now, too - while pointing to the screen. C did not vocalise when observing the next word presented, but rewound to this again. By this time C was shutting off the volume and fast-forwarding over the letters of the alphabet to reach z and then putting the volume on again for goodbye. C frequently watched the screen through side vision, with his head turned. C began to seem much more amenable to suggestions from me, for example he left behind a toy hed found in the viewing room, when asked (speech only) to do so. Similarly, Cs class teacher reported at this time that C would enter a message in the Lightwriter, then pass the Lightwriter on to her for her to enter something - a sign of great progress in turn-taking.

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2000

using video

Photographs courtesy of the National Autistic Societys EarlyBird Programme.

Some short phrases were filmed onto the video next, this time with Cs class teacher doing the presentation. Highly motivating requests were presented, this time the meaning depicted with real objects as well as written words on card - so that when crisps, a video or a book was requested, the desired object was then handed to the speaker. Mum reported that this section of the tape soon became a favourite. It is now apparent to us that generalisation will need to be taught, as the class teacher reports that whenever C now requests a book, he follows this by going to search only for the particular book presented in the video.

Offering hope

Social language
Using video to teach the spoken word has been very successful with this child with severe autism of the aloof group. C has shown us what is of most interest and value to him on the video and, interestingly, it is not the numbers or letters available for him elsewhere, but the social language Am I prepared to he has seen and change my heard around him but finds so difficult preconceptions to process at our about clients and speed. C has also, through his applicamy own role? tion of what he has Do I really take into learned, reminded account the interests us of the importance of incorporatand unique learning ing flexibility and styles of my clients? generalisation into Do I give sufficient our therapy and teaching. He was consideration to able to apply some teaching social phrases i m m e d i a t e l y. generalisation of However, if we skills? mean that phrases which are requests can refer to any book, any video or any drink, then we need to explicitly teach that - easier to absorb in theory than to remember in practice. Giving C a tool which is useful and satisfying as a learning aid and which takes account of his autism would also seem to have increased his trust and motivation to interact with us - now that shouldnt be surprising, should it - ?

(but not a cure)

Video can be used in different ways to benefit clients with autism and, as Jane Shields reports, is one of the main features of the National Autistic Societys EarlyBird Programme.

Reflections

Beth Junor is a speech and language therapist with Forth Valley Primary Care NHS Trust, based at the Royal Scottish National Hospital in Larbert.

References
Williams, D. (1996) Autism - An Inside-Out Approach. Jessica Kingsley Publishers. Wing, L. (1996) The Autistic Spectrum. Constable.

he National Autistic Societys EarlyBird Programme began in 1997 as a pilot project based in South Yorkshire. The NAS EarlyBird Centre has developed and evaluated a model of early intervention which works in partnership with parents, using best practice to help parents understand and manage the effects of autism on their preschool childs developing communication and behaviour. The programme offers hope (but not a cure). It gives information, explanation and practical strategies that empower parents and boost their confidence. EarlyBird presenters have experience of working with people with autism and parents trust them, knowing these professionals have

encountered similar problems and will share their experiences. While not claiming to have all the answers, they make it clear they will offer suggestions and are happy to share parents problems. EarlyBird works with a group of six families over a three month period. It appears long enough to prime the pump for parents of recently diagnosed preschool children, yet short enough for them to cope with the commitment of participating. EarlyBird helps parents at a crucial time in their childs development and should ideally be offered once the initial shock and grieving that result from diagnosis have eased. One or two carers from each family may attend - mother and father, parent and grandparent, or any combination of people closely involved in caring for the

10

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2000

using video

EarlyBird programmes on the EarlyBird Video, showing the progress that can be made during (and after) the programme. Parents comments about EarlyBirds use of video include: This is a good way of meeting other children. It also makes you more aware of how you are with your child. You are seeing things from a different angle. Fascinating to see other people working with their children. Aspects of other situations I could apply directly to our own. Very stimulating. A chance to share ideas and celebrate success. It was interesting to see how others in the group approached the tasks set and also later on how we could improve on certain things. It also gave a great boost to see the differences in the children themselves. (EarlyBird Customer Satisfaction Data, 1998; 1999) Jane Shields is Manager of the EarlyBird Centre.

preschool child. A weekly commitment is necessary, with homework.

Active role
The EarlyBird model combines the supportive group dynamic of joint parent training sessions with individualised, one-to-one support of home visits. There are eight sessions of three hours with a half-hour lunch break. The group sessions are intensive and structured, but the professionals aim for an informal atmosphere and encourage the parents to take an active role. The growth of a supportive group dynamic is promoted and parents are encouraged to problem solve together, rather than relying on the professionals. During the home visits a professional works with the parent-child dyad, helping individualise what has been learned during group training sessions and using video-feedback to help the parent(s) selfevaluate. This framework is based on that of the Hanen Program (Manolson, 1992) which helps parents of children with a variety of developmental disorders and targets communication. The Hanen Program has found it necessary to modify its programme for use with families of children with autism, and preferable to group families of children with autism/pervasive developmental disorder together. The content of the NAS EarlyBird Programme is not that of a Hanen Program. EarlyBird addresses three content strands, each of which underpins the others and helps parents maximise their childs development. Parents learn firstly to understand their childs autism: to appreciate how people with autism experience the world and how the underlying triad of social deficits

influences development, thinking and learning. Next, parents learn about communication and how best to build interaction and social communication with their child. A particularly powerful lesson has proved to be that of showing parents how to modify their own communication so as to improve their childs understanding and interaction. Thirdly, parents are helped to analyse their childs behaviour: examining underlying triggers and the possible functions of inappropriate behaviours. They learn to use structure and visual cues to prevent or minimise problem behaviour. The programme uses autism-specific materials. The eight group training sessions are supported by the EarlyBird Parent Book and visual learning is encouraged - in the parents as in their children using video, flipcharts and overhead transparencies. Video is a powerful medium and EarlyBird makes extensive use of it during group sessions and home visits. Some of the video material used is specific to the particular group, being filmed by the EarlyBird presenters during the programme. The EarlyBird Video, which supports all sessions, uses interviews with and examples of UK parents and their preschool children with autistic spectrum disorder. The programme content targets the needs of parents living with a preschool child, but covers children across the whole autistic spectrum and a resultant spread of developmental stages.

Resources
Information on training in the Hanen approach is available from Anne McDade, The Hanen Program UK / Ireland, 9 Dungoyne St, Maryhill, Glasgow G20 0BA, tel. 0141 946 5433.

EarlyBird Training
With the support of BT, the EarlyBird Centre is now offering training in the licensed use of the NAS EarlyBird Programme and its supporting materials. Teams of two (or more) professionals, who must have prior experience of working with people with autism, can complete an intensive three day training course to become licensed users. They learn how to set up and run the programme with the help of the extensive supporting materials: EarlyBird Training Manual, Video, and Parent Book. This three month early intervention programme uses the model of enhancing and developing parents skills and self-confidence. It can be run as part of a generalised service for people with autism, to complement other services or as a separate early intervention package for parents of a preschool child with a diagnosis of autistic spectrum disorder. The programme and its supporting materials can only be used by professionals who have completed an EarlyBird licensed training course and have signed a licensing agreement. Details from: The EarlyBird Centre, Manvers House, Pioneer Close, Wath-upon-Dearne, Rotherham, South Yorkshire S63 7JZ. Tel: 01709 761273 Fax: 01709 763234 Email: earlybird@dial.pipex.com The NAS would like to acknowledge BTs support of this initiative.

Not alone
Video clips also make it possible for parents to meet each others children and to share progress whilst working with the children at home. Parents report the relief of realising they are not alone. They are also encouraged by clips from previous

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2000

11

further reading

further reading further reading further reading further reading further reading

further reading...
Annual rates are Disks (for Windows 95): Printed version:

This regular feature aims to provide information about articles in other journals which may be of interest to readers. The Editor has selected these summaries from a Speech & Language Database compiled by Biomedical Research Indexing. Every article in over thirty journals is abstracted for this database, supplemented by a monthly scan of Medline to pick out relevant articles from others. To subscribe to the Index to Recent Literature on Speech & Language contact Christopher Norris, Downe, Baldersby, Thirsk, North Yorkshire YO7 4PP, tel. 01765 640283, fax 01765 640556. Institution 90 Institution 60 Individual 60 Individual 45.

Cheques are payable to Biomedical Research Indexing.

OUTCOME MEASURES
Malec, J.F. (1999) Goal attainment scaling in rehabilitation. Neuropsychol Rehabil 9 (3-4) 253-75. Applications, controversies, and statistical issues related to goal attainment scaling (GAS) in rehabilitation are examined on the basis of available literature and outcome data from a postacute brain injury rehabilitation programme. Prior studies suggest that GAS is a promising method for measuring progress toward the type of highly individualised goals that characterise rehabilitation. GAS appears useful for (1) monitoring progress in a time-limited epoch of care, (2) structuring team conferences, (3) planning and making decisions about ongoing rehabilitation, (4) ensuring concise, relevant communication to the client, significant others, referral source, and funding sources, (5) guiding the delivery of social reinforcement, and (6) evaluating the programme. In brain injury rehabilitation specifically, the highly structured, systematic, and concrete goal-setting process provided by GAS may be helpful in (7) encouraging more accurate self-awareness, and for (8) redeveloping the capacity for goal setting. In rehabilitation settings, GAS has shown superior sensitivity to change compared to other functional outcome measures, excellent interrater reliability, and satisfactory concurrent validity with other outcome measures. Concerns about the idiosyncratic nature of GAS measures may not be as pertinent in rehabilitation as in mental health. For instance, the concurrent validity of GAS in rehabilitation generally appears stronger than in mental health settings. Nonetheless, GAS is probably best employed as one facet of a comprehensive outcome measurement system that also includes standardised measures of functional outcomes. The inclusion of GAS in a comprehensive outcome measurement system is recommended by its potential benefits, particularly its responsiveness to change, and its sensitivity to the values of clients.

AAC
Light, J.C., Binger, C., Agate, T.L., Ramsay, K.N. (1998) Teaching partner-focused questions to individuals who use augmentative and alternative communication to enhance their communication competence. J Speech Lang Hear Res 41 (6) 241-55. A single-subject, multiple-probe experimental design was used to investigate the effect of instruction on the acquisition, generalisation, and long-term maintenance of partner-focused questions (ie. questions about communication partners and their experiences) by individuals who use augmentative and alternative communication (AAC). Six participants who had severe speech impairments and used AAC participated in the study; they ranged in age from 10 to 44 years, had a variety of disabilities, and used a range of AAC systems. Instruction used a least-to-most prompting hierarchy in real-world interactions and during simulations. All of the participants successfully learned to ask partner-focused questions spontaneously in social interactions; they required an average of approximately six hours of instruction (range: 3-11 hours). The participants generalised the use of partner-focused questions to new situations in the natural environment and maintained use of partnerfocused questions at least two months postinstruction; one participant required some booster instructional sessions four weeks postinstruction to maintain her long-term use of partner-focused questions. The participants all reported high levels of satisfaction with the outcomes of the instructional program, as did their facilitators. Members of the general public, blind to the goals of the study, judged the majority of the participants to be more competent communicators after instruction.

STAMMERING
Hugh-Jones, S., Smith, P.K. (1999) Self-reports of shortand long-term effects of bullying on children who stammer. Br J Educ Psychol 69 (2) 141-58. BACKGROUND: Victimisation at school may result in long-term social, emotional and psychological effects (Parker & Asher, 1987; Sharp, 1995), particularly for children with special educational needs (Whitney et al., 1994). Children who stammer may be at risk of being bullied due to their peer-relationship and verbal difficulties. AIM: This study aimed to explore the nature, frequency and causes of bullying amongst children who stammer as well as the short- and long-term effects of their victimisation. SAMPLE: The sample consisted of 276 respondents from the British Stammering Association, a national association for dysfluent people. METHOD: A retrospective analysis of school experiences related to bullying, and its effects, was conducted through both semi-structured interviews and postal questionnaires. RESULTS: A majority of respondents had experienced bullying at school, and the likelihood of being bullied was related to the reported difficulties in friendshipmaking. Nearly one-half of teachers and families were reported as not being aware of this bullying. A majority reported immediate negative personal effects of this bullying, and 46 per cent reported some long-term effects. CONCLUSION: Logistic regression analyses suggested that the severity of bullying, together with other factors such as difficulty with friendships, predicted these effects. Comment: In response to the high incidence of bullying experienced by children who stammer, a pack has been developed which aims to create a more empathetic school climate where differences are tolerated rather than assaulted.

APHASIA
Simmons-Mackie, N., Kagan, A. (1999) Communication strategies used by good versus poor speaking partners of individuals with aphasia. Aphasiology 13 (9-11) 807-20. Ten nonaphasic volunteers and 10 individuals with aphasia were assigned to dyads and videotaped in conversation. Judges ranked each volunteer in the videotaped conversations from best to worst communication partner. The two best and two worst interactions were submitted to detailed analysis using Conversation Analysis (CA) methodology. Discourse devices and resources employed by speaking partners in the dyads were identified. These included use of acknowledgements, congruent overlap, disjunct markers, accommodation, clarification sequences, and the semantics of incompetence. Results abstracted from the CA were compared to contrast discourse characteristics between the high ranked and low ranked partners. Specific strategies identified and implications for aphasia intervention are discussed.

GENDER DYSPHORIA
Gelfer, M.P. (1999) Voice treatment for the male-to-female transgendered client. Am J Speech Lang Pathol 8 (3) 201-8. Male-to-female transsexuals are sometimes a part of a speech-language pathologists voice caseload. This article is intended to provide information and a suggested treatment approach to speech-language pathologists who work with this small but fascinating population. Aspects of the transition process, interviewing strategies, selection of a target frequency, and suggested treatment techniques are presented.

12

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2000

further reading

further reading further reading further reading further reading further reading

VELOPHARYNGEAL DYSFUNCTION
de Serres, L.M., Deleyiannis, F.W., Eblen, L.E., Gruss, J.S., Richardson, M.A., Sie, K.C. (1999) Results with sphincter pharyngoplasty and pharyngeal flap. Int J Pediatr Otorhinolaryngol 48 (1) 17-25. OBJECTIVE: To evaluate speech outcomes and complications of sphincter pharyngoplasty and pharyngeal flap performed for management of velopharyngeal insufficiency (VPI). DESIGN: Case series. SETTING: Tertiary care childrens hospital. PATIENTS: All patients who underwent pharyngeal flap or sphincter pharyngoplasty from 1990 to 1995. METHODS: Perceptual speech analysis was used to assess severity of VPI, presence of nasal air emissions and quality of nasal resonance (hyper, hypo, or normal). Pre-operative measures of velopharyngeal function were based upon nasendoscopy and videofluoroscopic speech assessment. Recommendations for management were made by the attending surgeon. Complications of hyponasality and obstructive sleep symptoms (OSS) were noted. Patient characteristics were compared using univariate analysis. RESULTS: Sixteen patients underwent sphincter pharyngoplasty and 18 patients underwent superiorly based pharyngeal flap. Patients were similar in terms of lateral pharyngeal wall medial motion and palatal elevation. The groups were also similar with regard to VPI severity, though there was a trend for more severe VPI in patients undergoing sphincter pharyngoplasty than pharyngeal flap (50 vs. 33.3 per cent, respectively). Patients with pharyngoplasty had a higher rate of resolution of VPI than those who had pharyngeal flap (50 vs. 22.2 per cent, respectively), although this was not statistically significant. Post-operative hyponasality and obstructive sleep symptoms were present in both groups. However, only patients who underwent PF and had postoperative OSS had obstructive sleep apnea (OSA). CONCLUSIONS: There were no detectable anatomic differences between treatment groups implying that treatment selection during the study period was not guided by strict anatomic criteria. Sphincter pharyngoplasty may have a higher success rate with a lower risk of OSS.

HEARING IMPAIRMENT
Stephens, S.D., Jaworski, A., Lewis, P., Aslan, S. (1999) An analysis of the communication tactics used by hearing-impaired adults. Br J Audiol 33 (1) 17-27. The aim of this study was to establish whether and to what degree certain types of communication strategies (hearing tactics) used by hearing-impaired adults could be shown to co-occur, and to find out which strategies were more likely to be used in which type of communicative situations. A consecutive series of 100 patients attending an audiological rehabilitation clinic was given a questionnaire asking how often they used each of five different hearing tactics in 11 different situations. Avoidance and request for repetition were the tactics used most commonly. Pretending to hear/understand and positioning self to improve hearing were used less frequently, with interruption the least commonly used. There was some association between tactics and situations but no clear picture emerged. In a reassessment of our methodology and results, we suggest that the future research of communication strategies would benefit from a sociolinguistic approach based on the qualitative analysis of naturally occurring discourse (conversation) of hard-ofhearing people, focusing on the use of different strategies in relation to communicators goals in interaction.

ADOLESCENT PSYCHIATRY
Wasserman, G.A., Pine, D.S., Workman, S.B., Bruder, G.E. (1999) Dichotic listening deficits and the prediction of substance use in young boys. J Am Acad Child Adolesc Psychiatry 38 (8) 1032-9. OBJECTIVE: Prior studies note relationships among verbal deficits, disruptive psychopathology, and substance use. The current study examines the relationship between verbal deficits, assessed through a dichotic listening test, and childrens substance use. METHOD: A series of 87 young boys was prospectively followed over a one to two year period. A prior study in these boys noted a cross-sectional relationship between disruptive psychopathology and deficits on a dichotic consonant-vowel listening test. The current study examines the predictive relationship between this language-related deficit at one study wave and substance use assessed during a follow-up study wave. RESULTS: Reduced right ear accuracy, reflecting a deficit in left hemisphere processing ability, predicted substance use at follow-up. This association was independent of any other predictors, including cognitive or behavioral indices of substance use risk. CONCLUSIONS: A lateralised deficit in verbal processing on a dichotic listening task predicts change in substance use by follow-up. Findings are consistent with other evidence linking early childhood lateralisation abnormalities to development of disruptive psychopathology.

HEAD & NECK

Z o r m e i e r, M.M., Meleca, R.J., Simpson, M.L., Dworkin, J.P., Klein, R., Gross, M., Mathog, R.H. (1999) Botulinum toxin injection to improve tracheoesophageal speech after total laryngectomy. Otolaryngol Head Neck Surg 120 (3) 314-9. Total laryngectomy patients, after undergoing a tracheoesophageal puncture (TEP), may have poor TEP speech because of hypertonicity or spasm of the pharyngoesophageal segment (PES). Conventional treatment options include speech therapy, PES dilation, pharyngeal neurectomy, and myotomy. Botulinum toxin injection into the PES has recently been reported to be effective for this disorder. However, data accumulated were based primarily on subjective analyses. This prospective investigation used both qualitative and quantitative measures to assess the effects of videofluoroscopy-guided botulinum toxin injection on TEP voice quality in laryngectomees with PES dysfunction. Patients underwent voice analyses, tracheal air pressure measures, and barium swallows before and after botulinum toxin injection. Seven of eight patients had significant voice quality improvement, and tracheal air pressures normalized in six of eight patients after injection. Videofluoroscopic botulinum toxin injection into the PES is efficacious, safe, and costeffective and should be considered as a first-line therapy for the treatment of laryngectomees with poor quality TEP speech caused by PES dysfunction.

CHILD LANGUAGE
Oram, J., Fine, J., Okamoto, C. and Tannock, R. (1999) Assessing the language of children with attention deficit hyperactivity disorder. Am J Speech Lang Pathol 8 (1) 72-80. Attention deficit hyperactivity disorder (ADHD) involves, according to theory, an underlying impairment of executive function - the cognitively based control system that regulates behaviour. It is possible that this executive dysfunction interferes with performance on certain tasks used to identify language impairment (LI). We compared the performance of three groups of children aged 7 to 11 years: ADHD-only (n = 25), ADHD+LI (n = 28), and non-ADHD controls (n = 24), on 18 tasks within three language measures (Test of Word Finding, Rosners Auditory Analysis Test, Clinical Evaluation of Language Fundamentals-Revised). Children with ADHD-only performed like those without the disorder on most tasks examined. However, the CELF-R Formulated Sentences subtest was particularly difficult for children with ADHD-only. In-depth error analysis indicated that aspects of the executive dysfunction in ADHD such as impulsivity and pragmatic deficits may have influenced performance on this subtest. Clinical implications for testing children with ADHD are discussed.

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2000

13

cover story

medical practice with a

Good

human face
Laryngectomy patients not only have to deal with the traumas of cancer, a major operation and losing their normal voice - often there are signifcant and frightening postoperative complications which are not provided for in a systematic way. Fiona Buck describes how a joint drop-in aftercare clinic for patients with a trache-oesophageal valve is meeting this need.
Read this if you: are aware of gaps in your service need to involve company representatives want to work well with other professionals
14
SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2000

suppose that for all patients who, like me, must come to terms with living for the rest of their lives with a stoma, there must be a sense of vulnerability. The medical implications are obvious, but less so are the underlying needs for practical support and understanding. Happily, the clinic established by the team has recognised these complexities. While its primary task is medical, the clinic has travelled beyond the basics. The clinics small team has also recognised that, given the absence of NHS provision for some products, it must also act as a dispensary for stoma related products. In this role it has become a lifeline for those of us who rely on these necessities for day to day communication. Most importantly, however, the clinic has developed a unique personal touch in the treatment it offers individual patients. This marks it out as something beyond the norm, a remarkable example of good medical practice with a human face. (John Wells, November 1999). It is well known that the conversations that occur between speakers at conferences are often just as fruitful as the presentations themselves. Following such a discussion between two professionals - a speech and language therapist and a ward sister (nurse) - at a national conference in 1996, an idea developed into a practical reality. The result was a clinic set up with the aim of providing a clear focus of aftercare for patients with trache-oesophageal valves.

cover story

Case example 1
EP had a total laryngectomy and primary puncture in April 1997. Supplied with a Servox on day three and began fluids on day 10. Fistula on stoma delayed discharge but eventually home on day 16. Attended clinic in May, fitted with 2.6 duckbill, good voice and Servox returned. Attendance at June clinic to try tracheo-stomal outer valve. In July puncture re-measured to 16 Fr. 2.2. before settling to a low pressure 1.8 in September. Trained to self-manage valve in December 1997 clinic. EP now attends the clinic twice a year and visits other laryngectomees whilst they are in-patients.

Case example 2
DD had a total laryngectomy and primary puncture in March 1997. Fluids commenced day nine, modified barium swallow revealed spasm despite the myotomy; began on pure diet. Seen on ward for valve fitting although problems expected, needed to keep the puncture patent. Size 2.6, 16 Fr. low pressure valve inserted but unable to voice. Seen in April clinic during re-admission. Servox given to enable communication, commenced radiotherapy. Attended June clinic, swallowing deteriorated seen by ward dietitian and speech and language therapist. Continued problems with dysphagia, seen in November clinic and appointment arranged for DD to see consultant. Valve replacement in May 1998, also seen by consultant for management of granulation tissue and naso-gastric tube placed by nurse during clinic. Ongoing input regarding speech and swallowing as DD continues to attend clinics for support and review.

Case example 3
I had a laryngectomy on the 13th of May 1998 and spent 12 days in hospital. Once the valve was fitted I returned to work. When it started to leak, I felt nervous but able to go straight up to the hospital and have the valve attended to by the nurse and the speech and language therapist. I found out that there was a clinic set up especially for the valves. It put my mind at rest knowing that there were trained people available to deal with my problems. I know a catheter can be fitted in an emergency but you cannot speak with just that in place! The setting up of this clinic was an excellent idea and it took a big worry off my mind as it will for others. When I was discharged I was determined to lead a normal life and with the help of my family and the care from all the staff I have achieved that. BD

Complementary skills
A straw poll indicates a number of these type of clinics are run throughout the country in different combinations. They are often led by an ENT consultant and speech and language therapist or a consultant / nurse team to provide care postoperatively for laryngectomy patients with a voice prosthesis. Previously, in Portsmouth, postoperative management for patients with valves was ad hoc with no clear pathway of aftercare. The speech and language therapist working within the ENT team and the nurse, trained in ENT, shared an interest in the better management of valves. They recognised that their clinical skills were complementary and could, if more clearly targeted, enhance the quality of care for these patients. To that end it was agreed that a series of joint clinics would begin from December 1996. The aim was to provide a regular, accessible dropin centre for long-term management of patients using trache-oesophageal valves. The clinic would include teaching self-care (see case example 1), trials of new products and advice on any aspects following laryngectomy. The clinic was run on the Head and Neck Unit where the patients had had their surgery, allowing easy access to doctors for any patients needing urgent medical review or a prescription. Establishing the clinic on the ward increased the speed of response for those patients indicating any sign of recurrence or infection.

Portsmouth and South-East Hampshire has a population of 545,000. There are five full-time ENT consultants, three of whom specialise in malignancy of the head and neck. Between 12 and 15 laryngectomies are carried out each year. Patients remain in hospital for 10 to 14 days if there are no complications. All are seen by the tracheoesophageal valve staff within one week of discharge, when their later attendance at our clinic is determined. An average of 12 patients (range 919) are seen at each clinic. Patients have had either a total laryngectomy or pharyngo-laryngectomy with jejunal free flaps. Table 1 gives general information and percentages of primary and secondary procedures. The numbers exclude those laryngectomees in the area who are oesophageal or Servox speakers. Table 1: N= Total number of patients eligible to attend the clinic
Ratio male to female Age range Primary puncture Secondary puncture Number of patients (N=40) 10 : 1 35 - 82 Average age = 62 61 per cent 39 per cent

patient records are kept identifying, as a minimum, general status of the patient, valve type and dates of replacement and medication. On arrival, patients are triaged (prioritised) according to: Staff perception of the degree of problem presenting Medical /general health of patient Distress levels Extra demands, for example, radiotherapy or transport booking. Patients attend for advice and input on: a) Puncture measuring following primary/ secondary puncture b) Assessment for suitability for tracheoesophageal valve c) Valve placement/changing d) Tracheostomy management e) Stoma management f) Oral care g) Oral/skin care during and after radiotherapy h) Dysphagia i) General advice and individual problem solving j) Advice and trial of tracheostoma hands free valve k) Candida management l) Supplies

The clinic is held monthly and dates publicised one year in advance. Patients are informed of the clinic postoperatively prior to discharge. They are seen one week post-discharge and invited to attend the next appropriate clinic. Detailed

Holistic care
Working together with a common interest has been a profitable way to learn and develop skills

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2000

15

cover story

Figure 1 - Patient questionnaire

How often do you attend the clinic? Every month .................. Every other month ......... Other ...............................

Working together with a common interest has been a profitable way to learn and develop skills in the management of clients with valves.

Four times a year ...........

What do you use the clinic for? Valve fitting / changing ............................................... Supplies ................................................................. Contact with other laryngectomees ................................. Contact with company representatives ............................. Other reasons .......................................................... Support ................................................................. Information resource .................................................

Do you think the clinic should run: More frequently (twice a month) ................................... Less frequently (alternate months) ................................. As it does now (once a month) .....................................

Are there any improvements / changes you would like to see? ........................................................................... ........................................................................... Thank you.

in the management of clients with valves. The speech and language therapist and nurse share certain tasks. These procedures follow the guidelines described by Blom (1995) and include puncture measuring, valve placement and assessment and problem solving. Both members of the team bring unique skills, for example, the speech and language therapist includes the management of dysphagia (see case example 2), videofluoroscopies and assessment for secondary puncture in addition to advice and assessment of voice and speech. The nurse is specifically able to advise on wound care and dressings as well as management of the stoma. Coltart (1998) writes, The way forward lies in the multi-disciplinary teams ability to work well together to provide good holistic care for these patients. The team members have recognised that they must have core skills and, through working together, have been able to develop levels of competence which allow the service to continue when one member is absent. The clinic is run on a drop-in basis and dedicated time is given by both the speech and language therapist and the nurse for the management of these patients. Appointment times were not felt to be appropriate since it is not possible to predict when the patients will need to attend. Running the clinic on an as needs basis can lead to increased waiting times, but it allows for considerable flexibility, particularly for these patients who often live at a distance, are working or where problems have arisen unexpectedly. The speech and language therapist and the nurse

meet before the clinic to discuss specific patients and plan as far as possible for the session. Whilst flexibility can be very advantageous to patients and indeed staff, the downside of course has been that the morning clinic often extends into the afternoon. A patient questionnaire was devised as part of ongoing evaluation (figure 1), covering aspects such as perceived benefits and satisfaction levels. The users indicated they found the clinic useful (see case example 3) and enjoyed the contact with other valve users as well as the spontaneous problem solving which takes place in the waiting room. They also commented on the benefits of meeting company representatives and discussing individual issues. Monitoring the clinic is ongoing to ensure the patients receive the levels and type of service they need. Each patient has a standard file with biographical details. There is a front sheet detailing valve type and specific information re-fitting procedures - for example, patient positioning, insertion system. These files are kept in the clinic in an accessible filing cabinet.

Proactive role
The stock supply of valves is now controlled by the speech and language therapist and the correct levels of supplies have been resolved due to changes in responsibility with budgetary control. Increased experience within the clinic has led to the team taking a more proactive role in determining the timing of patients discharge and fol-

low-up. This has reduced the need for the very frequent reviews which took place in the early days of the clinics existence. Anecdotal evidence has suggested that patients discharged with a Foley catheter in the puncture are less prone to complications (puncture trauma, frequency of resizing). We now tend to discharge the patient with a larger catheter in the puncture and arrange a valve sizing ten to fourteen days after discharge to allow any postoperative swelling to reduce. Once the valve is fitted, patients are also given a catheter to take home as a safety device to ensure that, in the event of any problems, they are able to pass the catheter, thus avoiding the risk of puncture closure. One of the major consequences of the multidisciplinary approach is the raised awareness of the management of laryngectomy patients. The members of the team have given training to junior doctors, nursing staff and speech and language therapists from our own geographical area and beyond. Additionally, the clinic encourages regular and practical review of the new products available for these patients, with an increasing number of company representatives being prepared to attend and play a dynamic role within the sessions. Most of the literature on management of laryngectomy focuses on issues related to the valves, patient satisfaction and management techniques. There does not appear to be any information available covering ongoing practical care and the

16

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2000

cover story

RESOURCES...RESOURCES

Technology recognised
The computer software shortlisted for the annual BETT awards under the special educational needs category for 2000 was: Clicker 3 - Crick (winner) Inclusive Writer - Inclusive Technology Sign It - Sign Communique Writing with Symbols 2000 - Widgit Wordbar for Windows - Crick. For hardware, the list comprises AlphaSmart 2000 Infrared - Tag Developments BigMack - AbelNet (winner) JamCam - Digital Camera - Tag Developments Variable application Load Switch - Penny & Giles.

Increased experience within the clinic has led to the team taking a more proactive role in determining the timing of patients discharge and follow-up.

Scenes from the Joint Clinic courtesy of Medical Photography, Portsmouth Hospitals NHS Trust.

More voice care

An extended edition of a voice care booklet for teachers is now targeting a wider readership of professional voice users. Practical voice exercises are included. More Care for Your Voice from Voice Care Network UK, 29 Southbank Road, Kenilworth CV8 1LA. Single copy 4.50, 10 or more at 3 each, 50 or more at 2 each, inc p&p.

Reflections

effective levels of profess i o n a l involvement. Do I consult service Clements et users to find out how al (1997) found that what I am providing patients meets their needs? using tracheDo I consider the oesophageal prostheses location and were signififlexibility of a clinic cantly more satisfied from the clients with their perspective? communicaDo I use networking tion when compared to opportunities and oesophageal learn from and electroexperience to make larynx speakers. It is improvements to my important, service? therefore, that the postoperative follow-up is both as effective and as accessible as possible. Fiona Buck is a specialist speech and language therapist at Queen Alexandra Hospital in Portsmouth, working for Portsmouth Healthcare NHS Trust.

References
Blom, E.D. (1995) Tracheoesphageal Speech. Seminars in Speech and Language 16:3. 191-204. Thieme Medical Publications. Clements, K.S., Rassekh, C.H., Seikley, H., Hokanson, J.A., Calhoun, K.H. (1997) Communication after laryngectomy. An assessment of patient satisfaction. Archives of Otolaryngology - Head and Neck Surgery. 123 (5), 493-6, May. Coltart, L. (1998) Voice restoration after laryngectomy. Nursing Standard 13, 12 : 36-40, December 9.

Technology
A new series of easy-to-use computer programs is designed to help teachers with the Key Stage 1 and 2 curriculum and special needs. It includes a literacy pack covering anagrams, rhymes, matching words to meanings and opposites. DO I.T. from Topologika incorporates 16 activities across four subject areas, and includes copiable worksheets. Prices from 25. Tel. 01326 377771, www.topolgka.demon.co.uk

Further reading
Edels, Y. (1983) Laryngectomy. Diagnosis to rehabilitation. Croom Helm. Evans E (1990) Working with laryngectomees. Winslow Press. Quer, M., Burgues-Vila, J., Garcia-Crespillo, P. (1992) Primary tracheoesophageal puncture vs oesophageal speech. Arch Otolaryngol Head and Neck Surgery 118, February. Blom, E.D., Singer, M.I., Hamaker, R.C. (1998) Tracheoesophageal restoration following total laryngectomy. Singular.

Acknowledgements
Thanks to my colleagues Marion Dempster, Sister, Head and Neck Unit (until Summer 1999) and Mandy Houghton, Senior Staff Nurse, Head and Neck Unit.

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2000

17

in my experience

Embracing
Evidence suggests speech and language therapists are routinely working with children who have emotional and behavioural difficulties alongside communication impairments. Jo Legum and Julie Ford believe that, to make a significant difference, speech and language therapy alone is not effective, and involving and learning from arts therapies is essential.

the arts
C
antwell and Baker (1987) find that the ...literature strongly suggests that children with delays or disorders of development in speech and language are at risk for developing both emotional and behavioural difficulties and learning difficulties. The reason for this relationship is the subject of debate and remains unclear but, in practice, speech and language therapists are routinely faced with the challenge of children with both communication difficulties and emotional / behavioural difficulties. This affects the whole case management process from assessment, through differential diagnosis, therapy, team working and onward referral and raises questions about what the speech and language therapist can or should do on their own. The debate surrounding the use of the label emotional behavioural difficulties is vast and any terms used to describe it may be open to interpretation. But, however it is viewed, the reality is that research shows a high correlation with speech and language difficulties. For example, in 1982 Baker and Cantwell studied the prevalence of emotional behavioural difficulties in children who had speech and language impairments. The population of 291 children were selected from a community-based speech clinic. The results indicated that 44 per cent of an average speech and language therapy clinic caseload also suffered from emotional behavioural disorders. In Canada, Beitchman et al (1986) conducted an epidemiological study of 1655 school children. Of those diagnosed with speech and language difficulties, 48.7 per cent also presented with additional psychiatric disorders. Closer to home, Stevenson and Richman (1976) found that 59 per cent of the English three

Read this if: any client has emotional and behavioural difficulties you use, or want to use, non-directive approaches you could improve your onward referral patterns.

year olds with expressive language delays they studied had behavioural disturbances. Baker and Cantwells 1982 study also found a difference in prevalence according to the type of speech and language impairment. Those children presenting with pure language disorders were the most seriously at risk from emotional and behavioural disturbance at 95 per cent prevalence, whereas for children from the speech and language disordered group it was 45 per cent and for those with a pure speech disorder still lower at 29 per cent prevalence.

Decisions made easier

We are often having to deal with these children in schools or busy clinics where time is precious. For speech and language therapists not involved in well structured multidisciplinary teams, it can be difficult to liaise with other professionals. In such circumstances how do we know how to fit into the overall picture of others working in this field? At what point does the therapist decide their intervention is not an appropriate use of resources? It is important to know, as some children may need their emotional development addressed before speech and language therapy can be effective, whereas others may benefit from speech and language therapy alongside other forms of therapy. Only by having a clearly defined idea of our role in relationship to others and being committed to working in teams with other professionals will these decisions be made easier. It is also important to acknowledge that we require access to our own emotional resources to provide our energy and innovation. Yet we often fail to attend to these. Establishing practice and procedures to help therapists cope with the pressures of working within this field is essential.

18

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2000

in my experience

There may be a place for speech and language therapists to use other methods of intervention, such as play therapy, as a way for children to access more conventional approaches or, at times, even as a way of resolving some speech and language difficulties (Summers, 1998). Each therapist already has additional skills - anything from the creative arts to counselling that they draw on every day. The difficulty in incorporating this into widespread practice is that it raises two questions. Firstly, how far should we use these - often untrained - skills and, secondly, how can we ensure that we are well enough supported to use them safely and effectively? The special interest group for counselling continues to discuss these issues. Another option is to refer on to people who are working within the field of creative therapies. We have become increasingly aware of the value of this form of therapy as effective intervention for these children. The arts therapies, in a similar way to psychotherapy, help an individual to develop emotionally. Arts therapy is an umbrella term for work using any form of art with a therapeutic aim. This may include drama, puppetry, sand play, music, movement or painting. Both speech and language therapy and arts therapy share some fundamental aims. These include promoting skills in forming healthy relationships and interaction with others, building confidence, improving attention and allowing children to access the school curriculum.

some children may need their emotional development addressed before speech and language therapy can be effective, whereas others may benefit from speech and language therapy alongside other forms of therapy.

Focus on ability
The fundamental difference is that the arts is primarily non directive, non-verbal and relationship based. The advantage of this intervention with children suffering from both emotional difficulties and speech and language difficulties is two fold: it allows children to direct their own therapy and creates a channel of communication which does not depend on the verbal medium. In utilising the arts, a non-verbal medium of communicating is offered instead of relying on talking. If the child is able to decide how they communicate with the therapist then the child does not need to initially feel that they are struggling to keep up with the interaction. This immediately allows them to focus on and use something of interest to them and create an environment they are confident in. The focus is on ability not disability, creating an environment which promotes a positive experience of relationships and communication. The child can direct how they want to work, dictating what they want to communicate to the therapist - It is only because the child is treated as a communicator he becomes one (Newson

and Newson, 1979). In this way it may become clear whether factors other than speech and language difficulties are the focus of the childs anxieties and so should be addressed initially. One of the disadvantages of working in a more directive manner with these children is that, in some cases, the child will continue to sabotage therapy because their emotional needs may prevent them accepting more cognitive skills. It can be hard for therapists to find appropriate and motivating work without direction from the child. By giving the client responsibilities in the process of the therapy, they gain confidence in having control of their learning and their abilities to communicate. Children are agents of their own learning and so must be given the opportunities to make their own discoveries (Edwards and Mercier, 1989). The techniques outlined fit into the guidelines laid down by the National Curriculum Council which encourage an ethos where the client can feel able to make mistakes, be tentative and think aloud without being judged. Where their own language, way of talking (and right to be silent) are respected and where their opinions are taken seriously.

clear he had a significant communication impairment that affected his ability to interact. As his confidence grew, he was able to use the session as a safe place in which to practise and develop his speech and language skills. We need to examine our practice with children with communication difficulties and emotional behavioural difficulties more closely. It is essential that speech and language therapists receive training in the area of emotional development both at a foundation level and once qualified as part of ongoing professional development. This should involve specific training courses and access to clinical supervision. Speech and language therapists must also consider when their intervention alone is appropriate and when referral on to another profession is needed. Through our experience we can recommend arts therapies as a particular choice. Julie Ford and Jo Legum are speech and language therapists with experience in the emotional behavioural disorders field. Julie Ford is also trained as a Drama and Do I bring Movement therapist and Jo outside skills Legum has completed the first into my work year at the Institute for Arts in Therapy and Education. They and monitor would be interested in readers their feedback, particularly regarding effectiveness? more recent research findings.

Reflections:

References

Opportunity to explore

Take Sally, a child with complex needs including communication difficulties and significant mental health problems. A combined approach to therapy using role play, movement and storytelling, allowed her to express her particular frustration. Through the opportunity to explore different ways of being and behaving, Sally was also able to find strategies for communicating, resolve past issues and build new relationships. Another child, Martyn, apparently had behaviour problems and communicated very little. During speech and language therapy sessions Martyn clearly preferred to work non-verbally and enjoyed activities such as music, art and model making. It soon became

The focus is on ability not disability, creating an environment which promotes a positive experience of relationships and communication.

Baker, L. and Cantwell, D. P. (1982) Psychiatric disorder in children with different types of communication disorders. J Commun Disord 15 (2). Beitchman, J. H., Nair, R., Clegg, M., Ferguson, B. and Patel, P. G. (1986) Prevalence of psychiatric disorders in children with speech and language disorders. J Am Acad Child Psychiatry 25 (4). Cantwell, D. P. and Baker, L. (1987) Clinical significance of childhood communication disorders: perspectives from a longitudinal study. J Child Neurology 2 (4). Edwards and Mercier (1989) TALK: The Journal of the National Oracy Project. London. Newson, J. and Newson, E. (1979) The handicapped child: what is an autistic child? Nurs Times 75 (37) suppl 4-5. Stevenson, J. and Richman, N. (1976) The prevalence of language delay in a population of three-year-old children and its association with general retardation. Dev Med Child Neurol 18 (4). Summers, S. (May 1998) Playing in a world of his own. Bulletin of the Royal College of Speech & Language Therapists.

Do I see the value of building a team even in difficult circumstances? Am I aware of local resources in arts therapies and how to refer?

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2000

19

reviews & resources

e.. v.. i. e s. REVIEWS.r.. ..w ...

Useful for developing skills
HEAD AND NECK
Clinical Manual for Laryngectomy and Head / Neck Cancer Rehabilitation (2nd ed.) Janika Casper & Raymond Colton Singular ISBN 1-56593-959-X 30.00 This is a clear, well presented, easy to read manual, which takes the clinician through the diagnosis, treatment and rehabilitation of the laryngectomy patient. Chapters cover the U.S. model of medical/surgical intervention and rehabilitation describing the selection and use of artificial larynges and the development of oesophageal and trache-oesophageal voice. There is little on head and neck cancers other than those of the larynx, just a few pages in chapter seven and a whistlestop tour of the oral cavity in chapter eight. The main changes in this second edition, according to the preface, are in chapter six on surgical voice restoration (SVR); this information would be available to any clinician who has attended an advanced SVR course. The appendices have some useful information including a web site and a functional communication rating form, although no word lists for those struggling with artificial larynges and oesophageal speakers. The book is reasonably priced and would provide a useful resource for a clinician developing his or her skills in laryngectomy rehabilitation. Linda Nixon is Professional Head Speech & Language Therapist at St Marys Hospital in London.

Make sure you have a copy

CHILD PSYCHIATRY
Communication Disorders and Children with Psychiatric and Behavioural Disorders Rogers-Adkinson and Griffith Singular ISBN 1-56593-746-5 35.00 This recent American book fills a real gap in the literature. It considers theory, defining psychiatric disorders and looking at their complex relationships with communication disorders. It deals with assessment issues and how to be better at teasing out what influences what. Lastly, a third of the book is on intervention implications. Excellent reference tables range from common drug treatments, to the development of theory of mind, to clinical discourse analysis. Its a must if you work in Child Mental Health or EBD schools. If you come across some of these children in other settings make sure your department or service has a copy you can read and use for reference. Alison Wintgens is Head of Child and Adolescent Speech and Language Therapy with South West London and St Georges Mental Health NHS Trust.

RESOURCES...RESOURCES...RESOURCES...RESOURCES...RESOURCES...RESOURCES...

Autism video
A new video aims to raise awareness of the abilities and needs of people with autism. The 30 minute National Autistic Society video narrated by Nick Hornby includes contributions from four people of different ages with autism. The oldest is 49 and only discovered he had autism three years ago. The diagnosis has enabled appropriate employment support to be provided. The youngest contributor is seven, and the two young adults featured have Aspergers syndrome and are living in their own homes with round the clock supervision. The Ages of Autism, 18.49 inc. p&p, tel. 020 7903 3595.

Clicker 4 launched
A new version of the Clicker computer programme allows documents to be published directly on the Internet. Manufacturer Crick Software believes Clicker 4 is also easier to use than previous versions. Enhancements include a talking pictorial spell checker and the ability to include multimedia features such as video. Clicker 4 costs 90 for a single user. Upgrade costs are available. Tel. 01604 671691, www.cricksoft.com

Special needs website

A special needs website focuses on applications of technology for education, therapy and the arts. Based on a one day conference at the University of York, Special Needs Technology 2000, the site includes links to relevant organisations and research projects. See http://w3.to/ SpecialNeedsTechnology

Psychiatric review
A systematic review of community therapy for people with personality disorders and mentally disordered offenders includes reports on the roles of different disciplines. NHS Centre for Reviews and Dissemination Report 17, Therapeutic Community Effectiveness, 12.50, tel. 01904 433648.

BSL and careers

A DVD-ROM computer program about careers is now available with British Sign Language. Details: Careersoft, tel. 01422 330450, www.careersoft.co.uk

Bullying and stammering

The revised reprint of Bullying and the Dysfluent Child in Primary School is now available. It consists of 150 hard-card pages in a ring-folder with more than 30 photocopiable exercises. From the British Stammering Association, 27.95 inc. p&p, 15 Old Ford Road, London E2 9PJ.

Videofluoroscopy chair
A furniture designer has collaborated with speech and language therapists and doctors to develop a videofluoroscopy chair. Features include spongeable, nonslip material, braked castors, a retractable footrest and a restraining strap. Special requirements can be met. P. Towse (Cabinetmaker), tel. 01298 71262, www.ptoswecabinetmaker.co.uk

Bedside manners
An education resource pack will help health professionals improve their understanding of patient needs in a multi-cultural society. Suitable for NHS Trust training departments and universities, the resource is designed to facilitate discussion during a two hour session and make up for deficiencies in initial training. Returning Voluntary Service Overseas volunteer and former nurse Liz Smith developed the pack as part of VSOs work in the UK. Bedside Manners, 5.00 (proceeds to VSO) from Liz Smith tel. 0181 780 7312, e-mail liz.smith@vso.org.uk

Autism
A new journal is dedicated to promoting good practice with children and adults with autistic spectrum disorder. The two issues per year will cost 30 for an individual and 40 for an organisation. Good Autism Practice Journal from BILD, tel. 01562 850251, e-mail LindaAverill@bildirc.demon.co.uk

20

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2000

assessments

Readers of Speech & Language Therapy in Practice continue to put assessments and programmes to the test. How do they measure up?

Assessments assessed
Step 2 (Ages 7 - 10) Auditory memory (for digits, words, long vowels, short vowels, consonants) Segmenting (number of speech sounds/ phonemes in simple/complex syllable structures Blending (syllables into words, sounds into words) and word closure Discrimination (of vowels/consonants in nonsense syllables/words) Onset and coda (recognition of word endings/ beginnings).

Earobics Pro PLUS Steps 1 and 2 UK From Don Johnston Special Needs 18 Clarendon Court, Calver Road, Winwick Quay, Warrington WA2 8QP tel. 01925 241642. Step 1 CD 199.00 Step 2 CD 199.00 USA From Super Duper Publications www.superduperinc.com

Small steps, with plenty of practice

It would be very helpful to be able to print out the detailed menu of options for handy reference, and to use as a score-sheet for each child. (I typed my own.) A simple (child-friendly) score-sheet is automatically filled in for each child, but it is not completely clear to which skills it refers. American vowels (and some consonant distortion) can make the blending programmes difficult. Specific to Level 1 Programmes are explained and proceed too fast for the children to tune in initially. Children require good mouse skills as well as visual scanning to indicate their choices in time. They soon lose heart when they cant keep up. It is very difficult to be quick enough to press the pause button between items in a particular programme and explain to the child what is happening. Although corrections are given, it is not made clear that they actually are the corrections and not the subsequent task. Specific to Level 2 There is a significant delay between each item within one exercise, which means that one is in effect wasting time. (It would have been much more appropriate to have these delays at level 1.) Feedback on at least one of the programmes is inconsistent, which is very de-motivating. Despite the disadvantages, I intend to continue using these programmes and require more time to see how useful they will be to individual children. I also need to experiment with modifying access to them (for example controlling the mouse myself while the child points to his/her choice on the screen) to achieve success with children with a slow response-time. Jessamy Pears is a Specialist Speech & Language Therapist at Andrew Language Unit, Viewfield Lane, Selkirk TD7 4LJ. She won the Earobics CDs in the Reader Offer of the Summer 99 issue of Speech & Language Therapy in Practice.

Jessamy Pears finds children enjoy the graphics on this computer software and are curious about what they will hear next...
Earobics is an auditory development and phonics software program on two CDs, Step 1 for ages 4 7 and Step 2 for ages 7 - 10. Once I confirmed I had the necessary computer equipment and had the method of access explained to me, I was intrigued to see what I would find. I have divided the review into details about the skills covered in the program and the advantages and disadvantages I found with it.

Advantages
Both levels deal with phonological skills in a way that is fun and rewarding. Children are curious as to what they will hear next, and enjoy the graphics. The skills proceed in very small steps, with plenty of practice at each level. If a child is making errors, the programme automatically drops back to an easier level of the task being targeted which, in theory, should make failure rare. It is easy to set up a page for up to 24 different children, and to access immediately the point which they reached the previous time. The score-sheet (dataview) for therapists to use is almost too detailed - but does provide a method of checking progress if another adult has been given responsibility for carrying out the programme.

Skills covered
Step 1 (Ages 4 - 7) Auditory discrimination, auditory memory and figure-ground discrimination (using environmental sounds, one-syllable words, digits, speech sounds) Auditory discrimination (vowel pairs, CV nonsense contrasts) Rhyming (identifying the non-rhyming word, and the rhyming words) Sound-symbol correspondence, recognition of sound and position in a word Blending (words into compound words, syllables into words) Segmentation of syllables and phonemes (counting drum-beats/segmenting syllables/ phonemes in a word.)

Disadvantages
General It takes about four minutes between first switching on your computer and arriving at your chosen programme. Instructions are not slow and clear enough for the child to take in, nor is the marking system explained. Theres no way of knowing exactly which point you have reached within a particular programme, within which there may be up to 30 exercises on one aspect of phonology.

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2000

21

assessments

A good starting point

The Phonological Abilities Test Valerie Muter, Charles Hulme and Margaret Snowling The Psychological Corporation, Foots Cray High Street, Sidcup, Kent DA14 5HP tel. 0181 308 5750. 74.55
follow. The stimulus booklet is brightly coloured and clearly illustrated. The test has proved to be useful with a variety of children, two of whom are described:

Child A
Child A was originally referred for speech and language therapy at age 2;06 years with a general language delay. This problem remitted with therapeutic intervention, though a residual phonological problem remained. Mum was very concerned Child A might experience difficulties at school, so the Phonological Abilities Test was administered in an attempt to identify any potential problem areas that might interfere with the development of literacy skills. The Phonological Abilities Test profile identified some problems with word and phonemic deletion - Child A performed below the 10th percentile in both areas. This information was shared with mum and with school and programmes of work have now been started that should help to resolve these difficulties.

Tina Quinn has found this quick test useful with a variety of children for identifying areas of phonological weakness.
The Phonological Abilities Test is designed for use with children between the ages of four and seven years. Its aim is to identify children at risk of reading failure. The test can also be used as a diagnostic tool for older children to identify any areas of phonological weakness. It looks specifically at rhyme detection, rhyme production, word completion - syllables and phonemes, phoneme deletion - initial and final sounds, speech rate and letter knowledge. The test is quick and easy to administer and takes no more than thirty minutes - sometimes faster, depending on the child. The manual and the stimulus booklets are well laid out and easy to

Child B
Child B is an older child, aged nine years, who is currently place in a resourced provision for children with speech and language disorder. This child presents with a severe receptive and expressive language disorder and has thus far failed to acquire measurable literacy skills. In addition,

child B is often reluctant to cooperate in the testing situation. Again it was decided to try the Phonological Abilities Test with him to identify underlying areas of phonological weakness. Other phonological awareness assessments had been tried on previous occasions but with no success. On this occasion, child B appeared to enjoy the brightly coloured pictures and the short length of the assessment was a definite advantage. The Phonological Abilities Test profile revealed significant difficulties across all the areas examined, indeed child B failed to score on many of the subtests. This information has been shared with teachers and parents and work has been initiated in an attempt to encourage the development of these skills. There are currently several assessments on the market that allow us to measure a childs phonological awareness skills. However these tend to be more time consuming and less visually attractive. The Phonological Abilities Test will certainly remain a part of my assessment kit and I would recommend it to other speech and language therapists who are looking for a rapid assessment of phonological awareness skills. It is a good starting point for the busy clinician, though it may be necessary to look elsewhere for more detail. Tina Quinn is a specialist speech and language therapist / paediatric coordinator with Dewsbury Health Care.

PETAL: Phonological Evaluation and Transcription of Audio-Visual Language Ann Parker Winslow, Telford Road, Bicester, Oxon OX6 0TS tel. 0800 243755. 89.50

A comprehensive and valuable resource

and natural speech production. It is therefore very valuable when assessing the speech of the hearing impaired population and could also be used with adults with motor speech disorders. At first glance the PETAL appears quite daunting, with a maximum of ten stimulus books and a full booklet of assessment record forms. In reality, the administration time is 30-45 minutes; however, depending on experience, the recording and analysis of the speech sample may prove more time consuming. It was apparent that, to accurately describe the features and processes of the clients speech, a well trained ear, good phonetic transcription skills and a knowledge of how to describe and transcribe the prosodic features of speech were essential. I used this assessment to analyse the speech of a seven year old girl, LB, who was three years post cochlear implant. Having made good progress in acquiring speech and a wide range of phonemes, her speech remains very unintelligible. In the community clinic, speech assessment had been carried out using standard phonetic assessments coupled with informal observations of prosodic features of speech. I could immediately appreciate the benefits of the PETAL assessment given that it facilitated me in assessing more specifically the non-segmental features of speech. It also takes account of visual language, for example the use of signing, and factors such as body posture and tension. The nature of this assessment leads you to ask pertinent questions on all factors necessary for good speech production. It guides you in answering questions regarding variability and consistency and the contrastiveness of the system as well as the actual phonetic realisations. Having gathered a detailed analysis of LBs speech, I now could clearly identify specific processes - albeit abnormal ones - which were

Elaine McGreevy appreciates the benefits of an assessment that manages to be detailed and practical without being too lengthy.
This well packaged, in-depth, non-standardised assessment enables you to obtain a detailed description of a child or adults idiosyncratic speech production patterns. As the name suggests it allows you to investigate all areas of structured

22

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2000

assessments

producing actual contrasts and contributing to her intelligibility; I therefore ruled these out as therapy targets. I was able to indicate other appropriate processes which ought to be targeted in therapy. Having eventually completed the analysis process, I now had before me a baseline measurement of LBs complete speech system and the evidence on which to base my therapy objectives and then measure progress. In essence, PETAL assesses the clients ability to produce single syllable structure. However, part of the procedure includes a story sequence. This, as well as being used to record intonation, can be

used to make judgements about the need for more detailed assessment of syntax. LB enjoyed this assessment. However, she found some of the stimulus material slightly ambiguous. Models had to be occasionally provided for target words and hence this information had to be excluded from the analysis. In general, this comprehensive assessment is a valuable resource to have. Those working in specialist centres or schools for children or adults with hearing impairment would benefit most from having the PETAL as a resource. It provides useful headlines for report writing. It can be

administered in parts to investigate a specific group of phonemes or the prosodic features of speech. Although it contains some theory in the manual, those wishing to make the most of this assessment might find the PETAL courses helpful in providing a refresher on phonetic transcription and topics related to this assessment. I certainly would use this assessment again and would recommend it to colleagues working in school settings or units. Elaine McGreevy is a speech and language therapist with Down Lisburn Trust.

Limited only by creativity of user

Clicker 4 has now replaced Clicker 3 90 single user (including switch access), plus 10 for every additional user QuickFire (site licence included) Four levels at 30, 40, 50 and 60 Crick Software, 35 Charter Gate, Quarry Park Close, Moulton Park, Northampton NN3 6QB
with its capacity for personalisation builds the bridge from a strongly educational focus to its use within the speech and language therapy field.

Personalised
There are over 2200 graphics and a picture-asyou-type option. Graphics can be selected from the Mayer-Johnson colour PCS symbols, Rebus, Makaton or the Crick Picture Library (over 400 curriculum related pictures). Additionally, photographs or relevant pictures can be scanned in for a more personalised touch. Clicker 3 provides excellent value for money and is a must-have resource for all ages. Speech and language therapists who are just starting to get their heads around technology will find it well worth the extra money to buy some or all of the four different levels of QuickFire. The more IT-literate speech and language therapists will be able to make their own topic grids using the Clicker 3 programme alone. Pre-requisite knowledge to using this software includes: Understanding concepts of left/right for mouse control. Understanding use of save/open/new for word processor use. Use of full stop to end the sentence (to initiate speech production of the written sentence). The CD would appeal to the following range of users: Preschool and school aged pupils, and those with special needs across a wide range of ability Children with language delay or disorder People with physical disability People learning English as a foreign language Adults with a learning disability Adults following a stroke, suffering from aphasia and dyspraxia Clients following a head injury Clients with a mild to moderate visual impairment. Melissa Lombard is a senior speech and language therapist and Zoe Atkinson an instructor (Le Geyt Training Centre) with Health & Social Services, States of Jersey. * NOTE: Crick Software has asked us to point out that, with Clicker 4, the latest version of the software, this situation is now much improved as the word processing screen extends across the whole width.

Dynamic
Clicker 3 provides a good user guide, an on-screen tutorial, web-site and e-mail support as well as Clicker centres with phone and e-mail contacts. It is a very dynamic piece of software and has had many changes since emerging on the market following suggestions made by users. The setting up of Clicker 3 assumes user knowledge based on an educational background and is easily used within this environment. There are many new resources available this year designed for use with Clicker 3, for example, The Picture Dictionary which offers ideas based on the National Literacy Strategy and is also useful for all symbol users. Clicker 3 is more difficult to adapt to a speech and language therapy focus as there is limited information on how to achieve many of the ideas presented in the manual and tutorial. However QuickFire, a newly released package designed for use with Clicker 3, contains grid material specifically designed for communication work and spans four different skills levels. It contains vocabulary grids set up using specific topics such as food and drink and clothes and uses Mayer-Johnson PCS symbols. Combined with QuickFire, Clicker 3 offers so many varied facets that it is limited only by the creativity of its user! Clicker 3 includes Microsoft Speech (synthesised) with a choice of three voices, as well as having the option of recording your own voice. Whilst the pronunciation of the synthesised speech is poor, there is a facility to adjust the supra-segmental aspects of speech permanently. The word processing component scrolls up as you write. If large writing or symbols are used, the beginning part of the sentence disappears from view before speech is activated by the full stop. The end result is that you do not always have visual and auditory feedback at the same time. This can be overcome by sending the document to Writing with Symbols (Widgit) which provides a larger screen*.

Melissa Lombard and Zoe Atkinson are impressed both by the possibilities of this evolving software for all types of clients with communication difficulties and its low price.
Clicker 3 is an on-screen concept keyboard with speech, pictures and writing. An in-built word processor allows the user to write letters, words, sentences or pictures and has simultaneous speech feedback. The programme appears on-screen as boxes within a grid. The user must set up the number and dimension of cells and their subject matter. Up to 100 cells can be used and colour-coded within any grid and these can be linked to any number of grids. A basic tool bar and simple punctuation can be accessed easily on screen via a mouse. All work can be printed to hard copy. Clicker 3 has been revolutionary in the field of education because of its combination of word processing, the ability to record ones own speech, graphics and the ability to change the language of preference. It also has uses within the realm of speech and language therapy, particularly when work overlaps with education and the national curriculum, enabling speech and language therapists and teachers to work together on communication and literacy with a shared focus. It is a valuable tool for the speech and language therapist given its impressive range of symbols, graphics and voice. The flexibility of the package, together

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2000

23

how I

put practice
Read this if you want: your practice to be evidence based clients to drive research questions research and practice identified more closely together
James Law is Reader in Language and Communication Science at City University, London.

into research
Speech and language therapists want what they do to be effective - to make a

difference to the lives of their clients. They want to know optimum times for intervention, techniques that produce results and caseload organisation that makes the best use of limited time. The evidence comes from research, but researchers have a slightly different agenda and may not make practical implications transparent. Even when they do, clinicians do not always use the evidence to change practice. We hear how the profession is crossing the perceived divide between research and practice in the child language, adult learning disability and acquired neurological fields.

Cath Valentine is a Speech and Language Therapist working in Down Lisburn Health & Social Services Trust, Northern Ireland. Since July 1997, she has been collaborating on research projects with Roy McConkey, Professor in Learning Disability at the University of Ulster.

The multidisciplinary STEP team based at Glasgow Royal Infirmary comprises Peter Langhorne, Senior Lecturer in Geriatric Medicine, Lynn Legg, Research Occupational Therapist, Alex Pollock, Research Physiotherapist and Cameron Sellars, Speech and Language Therapist.

24

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2000

how I

esearch is important. It reaches a wide and influential audience and, if it addresses the appropriate questions, can lead to a dramatic change in the way people look at what they are doing and the way services are developed. Likewise the study of practice (our own and that of others) is important because it increases our understanding of the subjective elements of the clinical experience as far as both the client and the therapist are concerned. But is one inherently better, more useful than the other? The comparison is invidious because they are not discrete entities - practice over here on the left and research over here on the right. Rather there is a spectrum of interaction between the two. We should see a rainbow of research between the subjective and the objective with different methodologies answering questions at different levels. In part the criticism that practitioners sometimes level at researchers is based on the experience, possibly gleaned from an interaction with medical colleagues, that if research does not mean randomised control trials it is not research. But this is a half baked view of research. Research is only a process of addressing questions in a systematic fashion. We do it all the time in our daily lives. The main difference is that the stakes are raised when we are dealing with public money. Of course, many researchers see themselves as addressing issues which are of absolute rather than applied value and, to be fair, we should judge people by the criteria they set themselves rather than the rules we might wish they were governed by. Such research may be instructive but it is unlikely to address the question that practitioners want to answer. Yet it is careless for practitioners to criticise researchers for addressing questions that they themselves may not be interested in. Theoretical research is simply different and we should recognise that. But who is this we? I have received implicit criticism at a recent interview considering whether I should be promoted from Senior Lecturer to Reader for only publishing my work in applied journals. Just as there is a certain snobbery amongst clinicians who do not think that researchers deal with issues that are important to them, so there is a suspicion amongst the academic community about reliance on applied research for publications - the currency of the researcher. My view is there is very little in the field of social science - including much of psychology - that amounts to rocket science, and we are always in a position of weighing odds and probabilities when we are interpreting results. The hinterland between researchers and practitioners comes into focus in the work of researchers who explicitly attempt to address applied issues.

very effective 2. direct, clinician-led intervention seems to be more effective that parent-led intervention for speech difficulties but 3. indirect, parent-led intervention seems to be at least as effective as direct, therapist-led intervention for expressive language impairments. The great advantage of a systematic review is that it encourages you to look for gaps in the literature. So we know that a) the available data does not address the issue from the point of view of disadvantaged populations and b) few of the studies examine the intervention effects with just the group that we know has long term difficulties those with expressive/receptive difficulties. A recent study that I have completed - funded by the responsive funding programme of the Regional Health Authority - has begun to fill in some of these details as has the recently completed study from the Speech and Language Therapy Research Unit in Bristol under Dr Sue Roulstone. I predict that in the next ten years such focused programmes of research will have addressed many of the most pressing issues in the practice of paediatric speech and language impairments.

Good

questions, good answers

James Law sees research as a process of addressing questions in a systematic fashion. In the field of child language development, it should already be enabling clinicians to stop doing what doesnt work and do more of what does.

Reallocate funding
Should these results change practice? I am confident that, when the research is geared in this way, this should happen. If we set up studies specifically to address clinical issues it is no longer possible for clinicians to hide behind their individual cases. We need to put more funding into service provision where the research tells us we are most effective and correspondingly we need to reallocate funding from areas where the data tell us we may not be having an impact. What do we need to be looking for in good applied research? I would suggest: It has the client (rather than the theory) as the end product. The original question may have been formulated by practitioners and characteristically may have been honed by researchers. There may be theoretical implications to be drawn from the study but these are not the main thrust of the work. It is directed at influencing practice - the evidence naturally has to be weighed against political, societal and economic considerations. The interpretation also needs to be weighed up against the methodology employed. It is essential that applied research is not viewed as a byword for bad research. Likewise care has to be taken to ensure the design of the study permits the inferences that we draw from the results. Particular care has to be taken that we meet the usual standards of validity and reliability. Both practitioners and users are likely to be closely involved in the study. Necessarily the whole issue of ethical consent and active involvement of participants is one which needs to be carefully monitored. In the end it is all about being confident in the answers we draw from the research. There is no real divide between research and practice. Good questions are more likely to lead to good answers. We all want to use evidence but this requires a research literacy amongst practitioners and a clinical literacy amongst researchers. There is absolutely no reason why these should be mutually incompatible.

Bamboozled
My own area of interest has been child language development, a field where any number of different professionals have formed opinions, very few of them addressing the same questions. No wonder, then, that when we recently carried out a systematic review of the literature for the Health Technology Assessment panel of the NHS (Law et al, 1998) we started by generating nearly 10 000 papers written over the past thirty years on the subject. Fortunately we did not have to read most of them because they either did not address the questions we wanted to address or because the methodology adopted did not meet our criteria. But it is no wonder that clinicians feel so bamboozled by what they read. But what is interesting is that there is a kernel of literature that begins to address just those issues which clinicians do want to start addressing. For example we now can state that: 1. intervention for early speech and language delays can be

Reference
Law, J., Boyle, J., Harris, F., Harkness, A. and Nye, C. (1998) Screening for speech and language delay: A systematic review of the literature. Health Technology Assessment 2 (9).

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2000

25

how I

e should all be asking ourselves questions about the efficacy of our work; research is a means to test our ideas and attempt to answer these questions. Evidence based practice should be all the more effective if the quest for evidence is driven by practice in the first place. As my own experience in the adult learning disability field demonstrates, putting our practice into research need not be a major academic event. Sharing innovative ideas with colleagues through special interest group meetings or writing up a project for a peer journal can be good methods of selfevaluation and information exchange.

Extra sessions
In my Trust, a high value is placed on the importance of effective communication to the provision of person-centred services. This has led to the allocation of extra speech and language therapy sessions. I am carrying out and evaluating communication skills training for a wide range of learning disability staff: residential and day care staff, vocational trainers and professionals. The training consists of two oneday workshops and at least one follow-up session. Based on the Take Two! training package (Purcell et al, 2000) it covers: What communication involves How communication varies across contexts Which factors are likely to effect communication for people with learning disabilities How to match communication styles to the needs of any one individual (each course participant chooses a service user as a partner). Evaluation is through self-report questionnaires and checklists as well as observations of staff-service user dyads. One of the tools being used is a communication profile we have developed over the past two years. Designed to guide key people to consensus on communication issues, whenever possible involving the service user, I am finding this to be a powerful awareness-raising tool. It explores both what the individual is able to do and their communication environment. In carrying out the profile, we often uncover discrepancies in our opinions of a service users communicative competencies, providing the opportunity for discussion and resolution.

Steady shift

No assumptions
Cath Valentines search for evidence is driven by her practical experience in the adult learning disability field, including a recognition of the importance of being approachable, accessible and team oriented.

The role of the speech and language therapist within learning disability services has been shifting steadily from a focus on the intrinsic aspects of an individuals communication to the exploration and manipulation of extrinsic factors, such as the physical environment and the need for communication. This has come about through a combination of research and practical clinical experience (see, for example, van der Gaag & Dormandy, 1994). Working in adult learning disability services for the past five years, I have noticed that the ability of staff to communicate effectively with those who use their service can vary widely. In collaboration with Roy McConkey, I am therefore investigating how staff perceive both their own communication styles and the communication competencies of the people they work with. Further, we are exploring ways by which we can alter communication styles to enhance communication between staff and their service users. One of the common difficulties, which often goes unrecognised, is that staff tend to overestimate the amount of verbal language that their service users can understand. We know that people who have a learning disability are unlikely to communicate to their optimum ability unless there are factors in their environment which facilitate and maintain this for them. Arguably, the most important factors are the communication style of the person they are interacting with, their relationship with that person and the need and desire for communication within that relationship. Learning disability services often experience a high staff turnover and movement between different service locations. Communication is paramount to appropriate service provision, especially when the focus is person-centred planning, yet many service users do not appear to have consistent opportunities to communicate their perspective effectively. Can we afford to ignore this? One thing that is becoming ever more clear to me is that we should assume nothing! It is all too easy to make assumptions, not only about communication, but also about the knowledge held by staff. I often feel the need to provide explanations to staff which challenge their attitudes towards a service users behaviour. For example, when I am told someone will not co-operate, I might talk about cognitive development and comprehension difficulties. When staff comment on unintelligible speech, I inform them about phonological development and/or dyspraxia. We cannot expect people to have knowledge of the complexities of communication and the terms used to describe these unless we offer specific training. While informal on the spot training can be effective with regard to individuals, surely there is scope for more formal and wide-ranging training to raise awareness of communication issues in general? I feel this should be offered as part of an overall Disability Services training package and be based on evidence regarding best practice.

Proactive
To succeed in improving communication for our service users, we must be proactive in promoting our role as speech and language therapists. Staff and families need to know who we are and what we can realistically contribute. Taking the time to build up relationships on both a professional and personal level ensures that people see us as approachable and accessible. For me, this happens best when I am participating in real events with staff and service users. Evening Activate sessions, Christmas parties, the rehearsals and performance of a pantomime by service users in a local theatre; these are all meaningful occasions which provide the motivation, the need and the opportunity for communication for all of us. Above all there needs to be a team approach whereby the staff in any one unit are aware of the issues for providing an optimal communication environment. All staff are responsible for and capable of this. Resources should be allocated to ensure that staffing levels are appropriate and staff development and training is provided to support people in their work. A major role of the speech and language therapist is to pilot staff teams through these uncharted seas. If we are able to mark our way with the buoys of research, we should be in a position to influence others and make a real difference to the lives of the people we are working for.

References
Van der Gaag, A. & Dormandy, K. (1994) Communication and Adults with learning Disabilities. Whurr. Purcell, M., McConkey, R. & Morris, I. (2000) Staff communication with people with intellectual disabilities: the impact of a work-based training programme. Int. J. Language & Communication Disorders 35 (1).

26

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2000

how I

he Stroke Therapy Evaluation Programme (STEP) language therapy to patients with stroke creates more complex arose out of recognition of the importance of basing challenges. How does the researcher know how much clinical decisions about care of the stroke patient on treatment any one patient has received? How do they know the best available evidence from clinically relevant that all the treatments were the same? How can the effects of research. STEP comprises a multi-disciplinary team - doctor, the treatment be measured? How can a placebo treatment be speech and language therapist, physiotherapist and given? occupational therapist - and, for practical reasons, at present These problems have been well highlighted (Howard, 1986; is focusing its attention largely on Scotland. Pring, 1986) and may have turned many speech and language Evidence-based practice should be daily practice. However, therapists against randomised controlled trials, but we should it is widely recognised that time (to find and read the article) beware tossing the baby out with the bathwater. Certainly, access (to journals not held by your hospital library) and evaluating stroke rehabilitation does have difficulties, yet ability (to make informed decisions about the quality of the over 270 randomised clinical trials of stroke rehabilitation research methodology) are major barriers (Closs et al, 1998). have so far been identified by the Cochrane Stroke Group. For example, Table 1 lists just some of the journals that may Approximately 27 per cent of these are related to publish clinical trials of the effectiveness of aspects of physiotherapy; 29 per cent to occupational therapy; 26 per rehabilitation, including speech and language therapy, for cent to service organisation; and 18 per cent to speech and patients with stroke. language therapy, nursing or other issues. There is a lot of So how do we aim to tackle these barriers? The three core evidence out there. Achieving evidence-based stroke elements are: rehabilitation should be a 1. Producing systematic reviews realistic - if challenging - goal. Table 1: Journals known to publish randomised of rehabilitation treatments Indeed, systematic reviews in controlled trials relating to speech and language 2. Disseminating the results of the area of speech and language therapy for stroke relevant rehabilitation therapy for patients with stroke Aphasiology Applied Psycholinguistics research and are perhaps more widely available Archives of Neurology 3. Identifying priority areas for than systematic reviews of other Archives of Physical and Medical Rehabilitation future research into stroke areas of stroke rehabilitation. British Medical Journal rehabilitation. Speech and language therapy for British Journal of Disorders of Communication the treatment of aphasia as well British Journal of Occupational Therapy as interventions for dysphagia Brain and Language have been systematically reviewed Clinical Rehabilitation STEP is working with the and their results due to be Community Medicine Cochrane Collaboration (figure 1) published on the Cochrane Library Dysphagia to produce systematic reviews of (Greener et al, 1999; Bath et al, International Journal of Language and stroke rehabilitation treatments. Communication Disorders 1999). The STEP project has started A systematic review is a research International Journal of Rehabilitation Research a systematic review of speech and Journal of Neurology Neurosurgery and methodology with which all the language therapy interventions Psychiatry clinical trials on a clearly for dysarthria following nonJournal of Psychosomatic Research identified treatment intervention progressive brain damage, as well Journal of Speech and Hearing Disorders are identified and reviewed. A as reviews relating to areas of Journal of Speech and Hearing Research systematic review should provide concern in physiotherapy and Lancet a clear statement of the best occupational therapy. Medical Engineering and Physics available evidence relating to the We can provide support, Neurologia use of a specific treatment. The training and advice for any Neurology Cochrane Collaboration Rehabilitation Nursing therapists interested in carrying publishes all intended and (This incomplete list was drawn from the out or being involved in a database held by the Cochrane Stroke Group.) completed systematic reviews on systematic review in an area the Cochrane Library (an related to stroke rehabilitation. The Figure 1 - The Cochrane Collaboration electronic database which can be aim is that STEP can support The Cochrane Collaboration is an accessed using a CD or through the therapists working in clinical international organisation that aims to Internet). To date there have been environments to identify research help people make well-informed decisions relatively few systematic reviews of about healthcare by preparing, questions, and to carry out reviews rehabilitation treatments. But why? maintaining, and promoting the to find the best available evidence accessibility of systematic reviews of the Systematic reviews are based on the on the identified treatment area. effects of healthcare interventions. Its results of randomised controlled main work is done by Collaborative trials. When seeking evidence about Review Groups (CRGs), within which the benefits of a certain treatment, Cochrane reviews are prepared and Systematic reviews go a long way. randomised controlled trials - in maintained. The Cochrane Stroke Group However, to achieve evidence-based which the effects of a treatment have is a CRG. It registered with the Cochrane stroke rehabilitation, health care been compared to the effects of a Collaboration in August 1993 and is based professionals should keep up-to-date placebo treatment - are generally in the Department of Clinical and fully informed on all recent accepted as a gold-standard Neurosciences at the Western General relevant research findings. But they (Sackett et al, 1996). This sort of trial Hospital in Edinburgh. This group seeks to review all randomised controlled trials simply do not have enough time. is easily achievable if you are a large and controlled clinical trials of To help, STEP searches a wide drug company wishing to investigate interventions used in the prevention of variety of relevant journals on a the effects of drug x compared to a stroke, and the treatment and regular basis and identifies articles placebo. Assessing the benefits of rehabilitation of stroke patients (including relevant to stroke rehabilitation. offering early physiotherapy, subarachnoid haemorrhage). Summaries and critiques of these occupational therapy or speech and

The

burning questions
The multidisciplinary STEP team believes achieving evidence based stroke care is a realistic - if challenging goal. They explain how they are assisting practitioners by gathering evidence, making it more accessible and ensuring the priorities of clients, families and clinicians are addressed first.

1. Systematic reviews

2. Disseminating results

Left to Right: Cameron Sellars (speech and language therapist), Peter Langhorne (senior lecturer in geriatric medicine) and Alex Pollock (physiotherapist). Not pictured is Lynn Legg (occupational therapist).

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2000

27

how I

Practical points:
1. The combined evidence from research and practice leads to reallocation of funding and change in service provision. 2. A lot of evidence is already available but clinicians need training and assistance to access and apply it. 3. Useful research is all about questions - they should be systematic, relevant and prioritised. 4. Practitioners need a research literacy and researchers a clinical literacy. 5. Applied research should start and end with the client and take into account real factors such as high staff turnover and disadvantaged populations. 6. By sharing experience and ideas with colleagues through special interest groups and writing or reviewing articles, practitioners can participate in research on a small scale.

articles are published in a quarterly newsletter - the S-Files. To address critical appraisal needs, STEP a) publishes glossaries and explanations of statistical terms in an easy to access format within the newsletter. b) carries out workshops on critical appraisal. This includes small in-service type training workshops where groups of therapists can work with members of the STEP team to read and review a relevant article, and larger seminars and research workshops.

References
Bath, P.M.W., Bath, F.J., & Smithard, D.G. (1999) Interventions for dysphagia in acute stroke. Cochrane Library, Oxford, Update Software. Closs, S.J., & Lewin, B.J.P. (1998) Perceived barriers to research utilisation: a survey of four therapies. British Journal of Therapy and Rehabilitation 5(3), 151-155. Greener, J., Enderby, P., and Whurr, R. (1999) Speech and language therapy for aphasia following stroke. Cochrane Library, Oxford, Update Software. Howard, D. (1986) Beyond randomised control trials: the case for effective care studies of the effects of treatment in aphasia. British Journal of Disorders of Communication 21, 89-102. Pring, T.R. (1986) Evaluating the effects of speech therapy for aphasics: developing the single case methodology. British Journal of Disorders of Communication 21, 103-116. Sackett, D.L., Richardson, W.S., Rosenburg, W.M.C., and Haynes, R.B. (1996) Evidence-based medicine: how to practise and teach EBM. London:Churchill-Livingstone. If you wish further information on STEP, would like to become involved in a systematic review within the area of stroke rehabilitation, or would like to receive the quarterly newsletter, please contact: STEP, Academic Section of Geriatric Medicine, 3rd Floor Centre Block, Glasgow Royal Infimary, Glasgow, G4 OSF. Acknowledgements This project is funded for three years by Chest Heart and Stroke Scotland. We would like to thank the Cochrane Stroke Group for permitting us to access and publish information from their database of clinical trials.

3. Identifying priority areas

There is a lack of high quality research into stroke rehabilitation, preventing health professionals basing their treatments on evidence. Although systematic reviews are designed to produce a clear statement of the evidence for a particular treatment intervention, without the necessary clinical trials on which to base the review the conclusions that can be drawn are limited. The systematic review of aphasia therapy concluded It has not been possible... to arrive at any conclusion about the effectiveness of speech and language therapy ... However... lack of evidence of effectiveness does not mean that there is evidence of no effectiveness. (Greener et al, 1999, p.22). The need for well-designed research into all areas of stroke rehabilitation is essential. However, to help clinical practitioners achieve evidence-based practice, researchers should concentrate first on the most burning questions. STEP has carried out a research project into these as perceived by health professionals working in stroke rehabilitation. As the views of stroke patients and their carers are all too often ignored, STEP is also using a series of structured interviews to identify their burning questions. The results of both should steer academic and clinical researchers as they formulate research questions and projects.

Speech & Language Therapy in Practice

Now with new updated design and contents!
See also

Spring 2000 speechmag:

Reprinted articles Laryngectomees need all our skills (Eryl Evans, September 1989)* Developing self awareness in children (Hilary Bulman, February 1992)**

a new article on NVQ for speech and language therapy assistants If possible, we would recommend that two assistants work through NVQ together, not only from a supportive point of view, but we felt that it encouraged us to stick to deadlines we had set, as we did not want to let each other down. June Bould and Marg Hall, speech and language therapy assistants with speech and language therapist Carole Davies. (Original version published in Grapevine of the Royal College of Speech & Language Therapists.) Judith Thomas describes her resource Language and Listening Games for Small Groups. Short articles for the speechmag site are welcome.

SLTs crucial role in dysphagia clinics (Dr Myra Skipper and Professor Owen Hargie, August/September 1994)**
All from Speech Therapy in Practice* / Human Communication** , courtesy of Hexagon Publishing.

Also on the site - contents of back issues, links to other sites of practical value and information about writing for the magazine. Pay us a visit soon!

h t t p : / / w w w. s p e e c h m a g . c o m
28
SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2000

IMPORTANT NOTICE
Subscribers should contact the publisher if they have not received their magazine(s) within two weeks of the publication date, or if there are any problems with the magazine itself.Tel: 01561 377415
Speech & Language Therapy in Practice is published on the last Monday of February (Spring), May(Summer), August (Autumn) and November (Winter).

25 personal UK 21 part time (5 or fewer sessions) UK 18 students / assistants / unpaid * UK 30 Eire & Europe personal 34 overseas personal
* delete as applicable

45 authorities (single subscription) 50 other overseas authorities.

UK/Europe

Bulk orders (sent to any single work address): 2 for 52 3 for 72 4 for 88 5 or more for 20 each

Special offer for personal subscribers Introduce a colleague* to Speech & Language Therapy in Practice and you both get an extra issue - free!
The new subscriber fills up their details on the form and puts your name in the recommended by space. Once their payment has been received, they will get 5 copies for the price of 4 in their first years subscription, and you will be notified that your subscription period has been moved on by three months. So, tell all your friends the advantages of a personal subscription to Speech & Language Therapy in Practice. Remember - you will get an extra issue for every new subscriber you bring in. *Must be a NEW subscriber to the magazine.

British Aphasiology Society Therapy Symposium

EVENTS

6-7 September, 2000 Glasgow An opportunity for therapists to present new ideas and perspectives on therapy for in-depth discussion. Details: Susan Booth, tel. 0141 211 4819

Cheques payable to AVRIL NICOLL BUSINESS. OR Please debit my Visa / Mastercard / Switch card: (Card payments cannot be accepted without a signature.) Card number: Expiry date: Switch only: Issue No. OR Valid from date: NAME: RECOMMENDED BY: (if applicable) HOME ADDRESS: Signature:

AFASIC In-Service Training Courses 2000

Various dates from 3 May to 17 November Topics include functional language, secondary school implications, language and literacy, emotional and behavioural problems, selective mutism, bilingual pupils, semantic pragmatic disorder, mainstream support and dyspraxia. Details from Carol Lingwood, AFASIC Training, PO Box 2320, HOVE BN3 6RS, tel/fax 01273 381009, e-mail: carol.afasic@lingwoods.demon.co.uk

Voice Care Network UK Study Days

Anatomy & Physiology Meredith Bunch 25 March - Introductory 8 April - Follow on Riverside Centre, Teddington, Middlesex Each day costs 75. Vocal Profile Analysis Christina Shewell 26-27 June 2000 UCL 135.00 (excl. lunch) Cheques for all payable to Voice Care Network UK. Details: VCN, 28 Hanworth Road, Hampton, Middlesex TW12 3DL.

POSTCODE:

HOME TEL. WORK ADDRESS:

Parkinsons Disease Multidisciplinary Conference: Improving Participation in Life

12-13 May 2000 Posthouse Birmingham City Hotel Details from Martlet, tel 01273 686889, e-mail jo@martlet.co.uk

Estill Voice Training Systems

The Core Courses Anatomy & Physiology, Level One, Level Two Napier University, Edinburgh 14-19 April 2000 Tutors: Gillyanne Kayes and Paul Farrington Details on these and more advanced courses, including those for performers and their teachers, from EVTS (UK) Limited, c/o 59 Fearnley House, Vestry Road, London SE5 8JR, tel. 0171 703 0136.

POSTCODE:

WORK TEL. e-mail: Please note acknowledgements and renewal notices are sent automatically. Return to: Avril Nicoll, From outside the UK, Speech & Language Therapy in Practice, the address is: FREEPOST SCO2255 Avril Nicoll LAURENCEKIRK 33 Kinnear Square Aberdeenshire Laurencekirk AB30 1ZL Tel/fax 01561 377415, e-mail avrilnicoll@speechmag.com Aberdeenshire www.speechmag.com AB30 1UL
It would be very helpful if you could complete the following information:
Job title(s): Name of employer / university: Topics you would like to see covered

Contributions to Speech & Language Therapy in Practice:

Contact the Editor for more information and / or to discuss your plans. Please note: articles must be of practical use to clinicians use case examples and list useful resources length is generally around 2500 words supply copy on disk if possible keep statistical information and references to a minimum photographs and illustrations will be returned

Your personal details will only be used for the purposes of Speech & Language Therapy in Practice magazine and will not be passed to any third party.

UBSCRIPTION FORM SUBSCRIPTION FORM SUBSCRIPTION FORM SUBSCRIPTION FORM

ITCH! W S Y B MENT Y A P G TAKIN Subscription form for Speech & Language Therapy in Practice NOW PERSONAL RATES AUTHORITY/DEPARTMENTAL RATES

MY TOP RESOURCES
Lindsay Thomason
4. Detail Reflector Essential when checking for inaudible nasal emission and more effective than a dental mirror. It is made of a reflective plastic material and therefore is not as cold and hard. It is also slightly larger than many dental mirrors. When held under the nose it is easy to see when misting occurs during speech rather than as a result of breathing and the misting clears quite quickly. I bought mine from another therapist at a special interest group meeting. She had been given one when visiting in America and had then bought a bulk order from the supplier: Floxite Company Inc., 1 Lethbridge Plaza, Mahwah, N. J. 07430, USA, tel. 00 1 201 529 2019, around 2 each. 5. See-Scape. I had given up on the See-Scape as a therapy tool because it gives negative feedback when used in the traditional way. However, having recently heard an American Speech Pathologist suggest using it as an indicator of oral airflow, I decided to try it with a noncleft client who was struggling to achieve oral airflow on fricatives. It proved very effective and the child enjoyed using it. I was also able to overcome the problem of hygiene by placing a straw in the end of the plastic tube instead of the nosepiece, which is always so difficult to clean. See-Scape is available as a special order: contact Taskmaster (0116) 270 4286. 6. View-Master 3d Not a very technical piece of equipment but invaluable when one is carrying out lateral videofluoroscopy investigations for velopharyngeal function with children. An engineer from the Radiation Physics department made a bar on which the viewer is fixed and then a clamp is used to attach the bar to the side of the x-ray machine. A clip-on microphone can also be attached to the bar. During screening the childs head is held still as s/he views the 3d pictures (I have a choice of Mickey Mouse, Little Mermaid or Beauty and the Beast) and a clear image is achieved. Everyone is happy! Tyco, available from most toy shops. 7. Palate Function Diagrams (Harland & Bowden 1997) There are two diagrams of the head in crosssection with the important features (tongue, hard and soft palate, oral and nasal cavities, pharyngeal area) clearly shown. The soft palate is attached to the diagrams by a small plastic rivet so it is mobile. One diagram demonstrates a soft palate of normal length which works effectively whilst the other shows a short soft palate which is unable to form a seal with the posterior pharyngeal wall. The diagrams have limitations because they are only two dimensional but they are extremely helpful when explaining to parents how the soft palate should work and what happens if it doesnt. Available from Speech & Language Therapy Dept., Greater Manchester Cleft Team, University Dental Hospital of Manchester, Higher Cambridge St, Manchester, M15 6FH, tel. 0161 275 6795, 10 a set.

works as a specialist speech and language therapist for cleft lip and palate with Leicestershire and Rutland Healthcare NHS Trust (5 sessions) and Nottingham Community Health NHS Trust (1 session). The service to the Leicestershire Cleft Team is well established whilst in Nottingham Lindsay has been involved in setting up the specialist speech and language therapy cleft service. She also specialises in neonatal feeding disorders.
9. Mead Johnson Very Soft Bottle In my role as feeding advisor for babies with clefts my policy is to use a Mead Johnson Very Soft Bottle with an orthodontic teat. By squeezing the bottle as the baby sucks, the baby can be assisted to take a full feed without becoming overtired. Babies with cardiac or respiratory problems who have normal sucking and swallowing ability may also benefit from this assisted feeding method. A thorough feeding assessment for each baby should be done first to ensure that this recommendation is appropriate. CLAPA 0171 431 0033, 3.30 each. 10. Feeding and Swallowing Disorders in Infancy by Lynn Wolf & Robin Glass, Winslow, 51.50 This textbook is my main source of reference when I need help in assessing and managing neonates with feeding problems. It is written by two occupational therapists who have vast experience working as infant feeding specialists. The format is such that you can dip into it for information about a specific feeding problem, syndrome or feeding method without having to wade through pages of unnecessary detail before you find what you are looking for. The information given is easy to follow and practical. I keep it handy at all times and am reluctant to lend it out for very long. 8. Sound Pictures These are an excellent resource for therapy games and I have pictures acquired from various sources. However, I am looking forward to the publication in spring 2000 of a set of 30 Therapy Games produced by the cleft therapists at St Andrews Centre for Plastic Surgery in Chelmsford. The aim is to provide motivation for the child at the boring stage of speech sound work, for example at CV level. For each game there is a coloured, laminated version for use in the clinic and a photocopiable black and white version for home practice. Contact Caroline Hattee on 01245 516020. Approximate cost 65 (including postage and packaging).

1. Great Ormond Street Speech Assessment (GOS.SP .ASS) Most of my clients have cleft palate and/or velopharyngeal dysfunction so GOS.SP.ASS provides a meaningful framework on which to structure and analyse my speech assessments. I also use the assessment when giving a second opinion of clients with nasal speech to speech and language therapy colleagues. Sending a copy of my completed GOS.SP.ASS form is a useful way of feeding back findings. The quantitative rating scales for nasality and nasal airflow provide a meaningful description of speech to the cleft team plastic surgeon too. Sell, D., Harding, A., Grunwell, P. (1994) GOS.SP.ASS A Screening Assessment of Cleft Palate Speech. EJDC 29:1-15 Sell, D., Harding, A., Grunwell, P. (1999) GOS.SP.ASS 98: An Assessment for Speech Disorders Associated with Cleft Palate and/or Velopharyngeal Dysfunction (Revised). Int. J of Lang. & Comm. Disorders 34:17-33. 2. Speech Assessment GOS.SP .ASS 94 and 98 - a training video of speech characteristics This fairly new resource explains how to use the assessment and demonstrates each phonetic characteristic in detail with the relevant phonetic symbol. I have found this extremely useful as a revision tool and training aid. Colleagues in the community have appreciated the opportunity to familiarise themselves with the different features of cleft speech and they have become more skilled at interpreting the completed GOS.SP.ASS forms. Available from The Department of Medical Illustration, Great Ormond Street Hospital for Sick Children, Great Ormond Street, London, WC1N 3JH, 27.50. 3. IPA chart and additions/diacritics Although now familiar with the phonetic characteristics associated with cleft palate/ velopharyngeal dysfunction I still sometimes struggle to remember the correct phonetic symbol (for example, a uvular plosive or velar fricative). Likewise, describing the way a nonEnglish speech sound is articulated may be easy but correctly transcribing it can be a different matter (for example, a voiceless labialvelar fricative). Consequently I have a copy of the 1993 IPA chart with additions and diacritics on the wall above my desk and refer to them when necessary. The International Phonetic Association (1999) Handbook of the International Phonetic Association: A Guide to the use of the International Phonetic Alphabet. Cambridge University Press. The most recent chart is on the IPA website http://www.arts.gla.ac.uk/IPA/ipa.html