Speech & Language Therapy in Practice, Autumn 1999

ISSN (online) 2045-6174 www.speechmag.
com

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A lucky Speech & Language Therap in
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of practical and accessible resources for
language, education, health, rehabilita
tion, ercJerly care, therapy and all aspects
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Just look at what you will
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FCTP (Functional Communication
Therapy Planner), VASES (Visual
Analogue Self-Esteem Scale),
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Companion, BASOLL (Behavi oura l
Assessment Scale of Later Life),
Working With Dement ia, Person
Centred Dementia Care, Validati on -
The Feil Method, Wandering,
Aggressi on, Screaming & Shouting,
Incontinence, Problem Behavi ou r,
Realit y Orientation, Reminiscence:
Social Care, Treasured Memories,
Memory Games for Groups,
Groupwork for Elderly People.
There are also ten runner-up prizes of a
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To enter, all you have to do is name your
favourite item from the Winslow 1999
catalogue, with a brief sentence explain
ing why you like it. The winner will be
drawn randomly from all valid entries.
Mark your entry 'Speech & Language
Therapy in Practice / Winslow draw'
and send it to Jane Lindsay,
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Oxon OX6 OTS, e-m ail janel@winslow-press.co.uk
by 30th September, 1999.
Competition rules:
1. En trants must subscribe personally or as one of a department to
Speech &Language Therapy in Practice. and only one entry is allowed per
subscriber number.
2. Entrants must work at least some of the time with elderly people.
3. Entries must be received by Winslow on or before 30th September, 1999.
4. The winner will be randomly selected from all valid entries.
5. The winn er will be notified by 6th October, 1999 .
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Speech &Language Therapy in Practice by a date agreed with the editor.
For a FREE copy of the Winslow catalogue,
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SUMMER 99 READER
OFFERS
The winner of the Earobics Pro PLUS Step 1 and Step 2 software is
Jessamy Pears, Selkirk, who will review it in a later issue. The two CDs
f or this auditory training program were provided by Don Johnston
Special Needs and Super Duper Publicat ions. The seven real words
usi ng the letters of the words ear could have included: ear, a, er, re,
are, rare, rarer, rear, rearer, area, err, era, ere and arrear.
Veronica Larki n is going to be busy reading the 100 of books from
Singular Publishing.
Winslow have announced the five winners of their new publicati on,
Autism: a social skills approach for children and adolescents by
aureen Aarons and Tessa Gittens. They are M. Swindells,
Bi rmi ngham, Miss C. Ward, Exeter, Anna Bovoli , Greece, Mrs Stevens,
Lancashire and Julie Hunt, Eal ing.
lang learn Communications had so many entries they decided to offer
two copies of t heir photocopiable resource Rhyme Time instead of one .
The winners are Katharine Howard in Exteter and Chris Brebner in
Singapore.
Congratulations to all winners and good luck to everyone entering t he
Aut umn 99 reader offer.
lEW FROM WINTER 98
Gentle, interesting, challenging, fun
REACT - Interactive Speech and Language Therapy CD-ROM
Propeller Multimedia Ltd.
28 Queen Margaret Close
Edinburgh EH10 7EE
Complete Version 425
Patients require lots of repetitive practice? Limited t ime to produce var
Ied t herapy t asks? Fed up with dog-eared worksheets? Want reall y easy
to use software that's gentle on you and patients but also interesting,
chall enging and fun? Yes? Then REACT is f or you with the added ben
efits of sound and video used in innovative ways.
Sel ect f rom 146 exercises wi thin auditory processing; visual matching;
reading comprehension; semantics; sentence processing; spelli ng; time
and money. The bulk of the material Is for severe to moderate aphasi a
(but of relevance t o other t ypes of communicat ion disorder) and wi ll
al so interest psychology and occupational therapy in the areas of
a ention, speed, problem solving and memory. Choose an input
method t o suit the patient's ability and preference (for example touch
screen, mouse or tracker ball). Independently or with minimal gui d
ance, your patient can complet e exercises, receiving clear feedback and
assist ance after three failures. When f inished, patients can check their
score (very satisfying!) Details of score and speed are maintained auto
maticall y for therapy records.
On the down si de the occasional graphic is difficult to interp ret or you
might quibble with t he grading of a task (fairly insignificant wi th 1700
items). You cannot al ter t he configuration of an exercise (but I did
want a si mple to use package). Expensive, yes, as is other aphasia soft
are. l ower cost versi ons wi th fewer opti ons are avail able.
Comparing price agai nst quality, quant ity and frequency of use, t his is
vorth pushing the boat out for.
Laorag Hunter is speech and language therapist at the Centre for Brain
Injury Rehabilitation for Tayside Primary Care Trust.
ISSN (online) 2045-6174 www.speechmag.com
www.speechmag.com
AUTUMN 1999
(publication date 31st August)
ISSN 1368-2105
Published by:
Avril Nicoll
33 Kinnear Square
Laurencekirk
AB301UL
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 1999
Contents of Speech & Language
Therapy in Practice reflect the views
of the individual authors and not
necessarily the views of the publish
er. Publication of advertisements is
not an endorsement of the adver
tiser or product or service offered.
Any contributions may also appear
on the magazine's Internet site.
Cover picture: Intensive
group therapy - see page
16. .
Contents
2 News / Comment
4 Outcome
measures
" It is vital that this process is not carried out
in an atmosphere of justification for clinical
decisions, but in the spirit of comparing
practice, exploring different approaches and
learning from variance factors. "
Jenny Hunt
and Alyson
Slater on
their team's
progress in
using outcome
measures.
Autumn 1999
*
116 COVER STORY
Intensive group therapy
"We see two major benefits of group therapy:
Structured therapy for language and social skills is
delivered in the context of familiar social activities - team
games, play, construction activities. This increases each child's
ability and opportunity to generalise the skills learnt.
Course design can enable children to recognise their
progress and to gain confidence and motivation from
succeeding at activities with other children. This often
contrasts with their experience at school. "
Liz Spooner and Sally Hewison report on their successful
group for children with autism.
20 In My Experience
"My personal and professional experience is that
7 Assessments assessed
strongly held views of specialists who spend their
Published assessments and programmes are given
lives pursuing rather narrow fields of impairment
a rigorous evaluation by practising therapists. Find
focused study and practice place serious constraints
out what they really think of The Apraxia Profile,
on listening to stories about the breadth of a life
the Tinnitus Questionnaire, Hear-Say and the
lived with that same impairment. "
Cooper Assessment for Stuttering Syndromes
Do we really listen to our clients) Carole Pound
Children's version.
finds we have much to learn.
22 Further Reading
10 Working
Floating-harbor syndrome, stammering, virtual
training, conversation, voice, learning disability.
with carers
" The idea of introducing a
range of approaches is 23 How I manage oraL
cancer
based on my experience
" ... it is crucial for speCialists and non-specialists
feel obliged to correct their
that many carers naturally
alike to have an appreciation of what is required
relative irrespective of at the pre-operative, post-operative and - in some
whether it is in their relative's
cases - terminal stages, and to work together to
best interests. "
provide the best possible service. "
Standards, team working and palliative care.
extent do carers of
individuals with dementia benefit from 30 My Top Resources
communication advice and training? "I was given an aged laptop PC ...1realise how much I
have come to rely on it and am eagerly awaiting its all
14 Reviews singing and dancing replacement. "
Colin Barnes asks, to what
ALD, stammering, dysphagia, voice, brain injury, Susan Hamrouge works with children and adults
neurology, Parkinson's, phonology, counselling. with a heari ng impairment.
WINTER 99 will be published on 29th November, 1999
IN FUTURE ISSUES
ethics' stammering adolescents' more assessments' bilingualism. learning disability. aphasia voice
Speech &. Language Therapy in Pradice has moved.
All correspondence should now be sent to: Avril Nicoll, 5peech & Language Therapy in Practice, 33 Kinnear Square,
laurencekirk AB30 1Ul tellfax 01561 377415. For subscribers in the UK, the FREEPOST address is now Avril NicolL 5peed1 &
Language Therapy in Practice, FREEP05T 5C02255, LAURENCEKIRK, Aberdeenshire, AB30 1ZL.
The magazine's complementary internet site. speechmag, has also moved to http://www.speechmag.com e-mail avrilnitoll@speedwnag.am
(Mail is being re-directed from the old addre55 and callers to the old telephone number will hear a recorded mess.age WI th the new
number.) ApologIes for any inconvenience caused by these changes_
SPEECH & LANGUAGE THERAPY IN PRACTICE AU TUMN 1999
I
news
Dental health
Speech and language therapists, dental staff and the Makaton
Vocabulary Development Project have produced a book to help people
with learning disabilities visit the dentist.
Homefirst Community Trust staff in Northern Ireland were alerted to the
need for such a resource by learning disabled people and carers. Dental
health among children and adults with a learning disability is worse than
that found in the general population and, if they cannot cope with dental
care, they have to receive treatment under general anaesthetic or sedation.
The book uses a combination of simple sentences, colour photographs,
symbols and signs to help carers explain what happens during a visit to the
dentist, including simple procedures such as fillings and extractions. The
authors hope the book will help improve attendance, confidence, under
standing and dental health among people with learning disabilities.
u
]:
.... y"O
1\
@

You nct'd your I("elh
Health
discrimination
The Down's Syndrome Association
has launched a campaign to end
discrimination demonstrated by
some health professionals against
people with Down's syndrome.
This follows a survey which
established that 28 per cent of
respondents had experienced
discrimination - overt or
unconscious - by health
professionals. Examples included
'Going to the Dentist' is 20 plus 2.50 p&p, tel. 01266635213. glasses and hearing aids not
being prescribed and, in one case,
pain relief not being
BAS administered after an operation
The national interest group formed in I brain injured people has opened in because "They don't feel pain, do young
1987 to increase the understanding Cheltenham. they?"
of aphasia has produced a publicity The Centre for Acquired Brain Injury Rehabilitation is the only facility in the While the main thrust of the
leaflet to encourage new members. UK to offer residential care and further education to newly brain injured 'Health Alert' campaign is to
Membership of the British people exclusively in the 16-25 year age group. In addition to speech and lan improve screening for heart
Aphasiology Society is open to all guage and other therapies, students will have access to an on-site sports cen defects in babies with Down's
professionals interested in the study tre, swimming pool, theatre and information technology. syndrome, there are plans for a
of aphasia. Benefits include confer In the UK, 135,000 people suffer from the long-term effects of severe brain nationwide training programme
ences, study days, reduced journal damage caused by head injury. The 15-29 age group are at highest risk of sus for all health professionals and
subscriptions and a research data taining a brain injury, along with the over 75s. Males in the younger group guidelines for staff breaking the
base. are four to five times more at risk than females. Each year, 10000 people will news to new parents.
Copies from Jo Robson, suffer moderate brain damage and will still have physical or psychological Down's Syndrome Association,
tel. 0171 477 8000 ext 4668, problems after five years. A further 11 600 will receive severe brain injuries of tel. 0181 6824001.
e-mail J.Robson@city.ac.uk which only about 15 per cent will return to work within five years.
Stroke latest
The Stroke Association has condemned variation
in access to and use of stroke services as unac
ceptable and requiring urgent action.
Its national survey of stroke services Stroke Care
- A Matter of Chance sought information from
consultants and commissioners and confirmed
piece-meal services and a lack of integration.
Although interdisciplinary teams including
speech and language therapists seem to be
available, consultants expressed concern at the
amount of time they have for patients.
The report concludes that up to 50 per cent of
stroke patients are not getting the best treat
ment available, that is, via admission to a stroke
unit. Better collection of statistics and stronger
medical leadership are also required.
Following publication of the report, a profile
raising postcard has been produced by the
Stroke Association . The five silhouettes repre
sent the five people who die every day because
they do not have access to organised stroke care.
For copies of the postcard, tel. 0845 3033100.
Scholarships awarded
Two speech and language
therapists have been
assisted with further
study by awards from the
HSA Healthcare
Charitable Trust.
The photo includes award
presenters Lawrence
Dallaglio and Tessa
Sanderson and recipients
Tessa Ackerman from
Leeds and Yvette
Crompton from London.
The scholarship is to assist
them with study for fur
ther degrees.
Evidence-based rehabilitation
A team including a speech and language therapist is aiming to encourage evidence
based stroke rehabilitation in a three year project.
The Stroke Therapy Evaluation Programme (STEP), funded by Chest Heart and Stroke Scotland, plans to
produce systematic reviews of rehabilitation treatments, disseminate research results and identify pri
ority areas for future research.
Readers who wish further information on STEp, who would like to become involved in a systematic
review within the area of stroke rehabilitation, or who would like to receive a quarterly newsletter
should contact STEP, Academic Section of Geriatric Medicine, 3rd Floor Centre Block, Glasgow Royal
Infirmary, Glasgow G4 OSF.
SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 1999 2
Changes at ADA
Action for Dysphasic Adults has appointed its first Chief
Executive to develop the organisation and raise public
awareness of the needs of people with dysphasia.
Anne Keatley-Clarke joins ADA from Colon Cancer
Concern. She is also a non-executive director of a
health authority. Horrified to learn that 200 000 peo
ple in the UK have dysphasia, her priority is to use her
PR and marketing skills to develop awareness and
push dysphasia further up the healthcare agenda.
Ruth Coles is stepping aside as Director, as manage
ment issues have taken up an ever-increasing amount
of her time, and will continue to work for ADA to
develop new initiatives and international projects.
ADA, tel. 0171 261 9572
Awards for children
Nominations for the Millenium
of AchievemenFM Child
their
awards are invited for individ
uals or groups of children.
Children who help others by
everyday tasks, cope
well with illness or disability,
excel with fund-raising initia
tives or show outstanding
devotion to friends and fam
ilies in times of need are all
eligible. The nominees must
be under 16 years old at the
closing date of 12
November 1999.
The photo shows John
who was born with cere
bral palsy. He received a
Liberator AphaTalker fol
lowing a Child of
Achievement Grant.
Details:
www.childofachievement.co.uk. or
nomination forms from C&A stores.
Millenium status
A software product for people with reading and
w riting difficulties has received an award for inno
vation.
The Design Council's Millenium Product status has
been given to textHELP! , a Windows based tool
which offers speech feedback, an advanced spelling
engine and customised word prediction.
textHELP' Systems Ltd, tel. 01849428105.
Centre commended
A national centre for children with epilepsy and
other special ' needs has been highly graded in an
inspection by the Further Education Funding Council.
The St Piers Centre in Surrey received high praise for
its work in practical, vocational areas with students
with very severe or profound learning difficulties
where the aim is to help them make sense of the
world. Practical recommendations from the team of
inspectors will lead to further improvements, for
example more flexibility in daytime routines and bet
ter links between residential and daytime services.
St Piers, tel. 01342 832243.
news & comment
... comment. ..
Avril Nicoll,
Editor
33 Kinnear Square
Laurencekirk
AB30 1 UL
tel/ansa/fax 01561
377415
e-mail
avrilnicoll@speechmag.com
Morelhaste, d
ess spee
As speech and language therapists in a technological age, we are faced daily
with high expectations of instant solut ions from clients, carers, colleagues
and, indeed, ourselves. Time and again in this issue it is clear we must hold
out against this force. Fiona Robinson's sentence in How I manage oral cancer
about "the processes by which patients travel through this stage in their
lives" applies to any of our clients and emphasises the idea of a journey
rather than a quick fix. Jane Machin's experience suggests this will be
smoother if supported by professionals all working together. To reinforce this,
we are delighted to have Dr Susan Salt giving us the benefit of her
experience of palliative care work.
Sue Hamrouge's top resources include an assessment which takes time and
ideally involves further training but provides very detailed and important
information to make therapy more effective. Our new series on assessing
assessments and programmes aims to assist readers in deciding which
resources are worth investing time and money in.
A gradual, long-term approach has ensured Jenny Hunt and Alyson Slater's
team are finding outcome measures invaluable in their drive to improve
clinical effectiveness, rather than having wasted their time with a rushed,
half-baked plan which looks good in a glossy annual report but ends up
gathering dust on the shelf and making no difference to everyday practice.
Ensuring staff have 'ownership' of a process such as outcome measures is not
easy for managers because it presents real problems and anomalies that have
to be addressed. Carole Pound's powerful arguments in favour of improving
listening skills apply to our clinical work with clients and carers, to
multidisciplinary teams and to managers. The 'golden evidence' she believes
we will find by listening to unique narratives will be worth the wait because
our work will be more relevant and effective.
Making advice for carers relevant and effective has been exercising Colin
Barnes as he develops his ideas for best practice in working with people with
dementia. The idea that we may actually be increasing carers' 'burden' is an
exacting one - it is tempting, as a speech and language therapist aware of all
the changes that" would improve communication, to throw all this knowledge
at parents I carers at once. But, perhaps particularly where carers are looking
for more and more from us, we often need to draw back and encourage a
longer-term view.
Careful planning of an intensive group for autism, including working closely
with parents, paid dividends for Liz Spooner and Sally Hewison. Although the
group itself only lasted a week, observable progress was made by the chi ldren
and the parents were won over by the advantages of group work compared
with their previous view that individual therapy is always best.
Outcome measures, standards, best practice, clinical effectiveness - all ords
which can turn off the most dedicated speech and language therapist ' hen
delivered in a stuffy, non-specific, irrelevant, sound bite fash ion. But all ords
that come to life when applied over time with real people.
outcomes
rom start
to outcome
e on
Jenny Hunt and Alyson Slater's team have been working with and refining outcome
measures since 1995. They tell us why they are positively excited by the potential
benefits they offer.
_11111_ he need for outcome measures with
in the speech and language therapy
profession has been recognised for
many years now, with the work
done by Professor Pam Enderby in
particular of paramount impor
tance. For the first time, there was a way of mea
suring our work which went beyond basic number
crunching and moved away from the restrictive
medical model of diagnosis -> treat
ment -> cure. We all knew our
involvement could have real effects;
now we could measure them.
The introduction of outcome mea
sures to our speech and language
therapy team was a gradual process,
and for twelve months the measures
were carried out in retrospect on cur
rent cases. This enabled therapists to
develop confidence in implementing
outcome measures and standardisa
tion across the District. In addition, in
service training was carried out on
setting aims of intervention to ensure
We all knew
our
involvement
could have
real effects;
now we
could
measure
them.
S.M .A.R.T. objectives (that is, ones that are
Spedfic, Measurable, Achievable, Realistic and
Timely).
Our outcome measures were initiated 'live' on 1 st
September, 1996. For each clie nt, therapists could
have numerous short-term aims running concur
rently, sequentially or overlapping.
Safe environments
It was essential that therapists 'owned' the out
come measures, so regular peer reviews were set
up to evaluate their use and to maintain District-
wide agreement on scoring. Since therapists
unhappy or unsure about the outcome measures
would not produce reliable measures, it was
imperative that peer reviews were 'safe' environ
ments. Any difficulties, queries or concerns could
be shared with the team and treated seriously by
colleagues. Solutions could then be agreed and
implemented by the whole team . Difficulties thus
addressed include:
a) Problems in scoring short-term aims, par
ticularly for client groups where therapeutic
involvement could be long term, for exam
ple language group work. In response to
this, the short term aims scoring was
replaced by achieved / not achieved.
b) Learning and / or physical disabilities
and autism were also considered prob
lematic where the focus of input was on
the carers and the environment of the
client, such as through ENABLE.
Therapists felt better able to set objec
tives and measure success of intervention
when health benefits were identified (for
example Informing, Supporting,
Modifying, Maintenance) and included in the
patient information on case notes.
c) For people with Motor Neurone Disease, ther
apists felt it was virtually impossible to set target
dates for short-term aims. This is one difficulty we
are still trying to resolve.
d) Transsexuals are another client group present
ing problems for ratings. As the communication
of a transsexual is not in itself disordered, the
impairment rating was not appropriate. The
team decision was therefore that we should not
have an impairment rating, but should rate the
appropriacy of voice on the disability and handi
cap dysphonia scales.
e) A recurring problem has been the pressure ther
apists put on themselves to be perfect, and a lot of
time has been spent stressing that it is alright not
to achieve an aim or predicted outcome.
f) It became apparent that a range of diagnostic
terms was used within the team, often influenced
by the year of qualification of the therapist. The
service therefore used peer review to agree on
diagnostic terminology (figures 1 and 2). This dis
pensed with such permutations as "mild phono
logical delay" and "immature speech".
External influences
Along with the evolution of the outcome mea
sures within the team, other external influences
began to make themselves felt. We became
increasingly aware of the need for evidence
based practice and clinical effectiveness, which is
culminating in the setting up of the National
Institute for Clinical Excellence (NICE). At the
same time, the nursing process of care pathways
was being introduced to community health care.
The Macmillan nurse in the Trust responsible for
this initiative agreed to do in-service training on
care pathways to the team.
It was apparent that care pathways were more
appropriate for multi-disciplinary teams and
needed to be developed by all involved, not led
by one discipline. Although we felt care path
ways were not a priority for us, the whole team
welcomed the idea of variance factors (figure 3)
as a useful tool to add to outcome measures
where aims were not achieved. Variance factors
helped to ease the perceived problem of 'perfect
outcomes
Cigure 1. Diagnoses for Adults with Acquired Disorder
Dysfluency Dysarthria I Anarthria
Articulation Disorder Dysphasia I Aphasia
Hyperkinetic Dysphonia Dyspraxia I Apraxia
Organic Dysphonia Cognitive Communication Disorder
Psychogenic I Functional Dysphonia Dysphagia
Differential Diagnosis Unconfirmed N.A.D. (Nothing Abnormal Detected)
Figure 2. Diagnoses for Under-16's and Adults with Congenital Disabilities
Language - expression (delay I disorder)
- comprehension (delay I disorder)
- functional use (delay I disorder)
- social communication disorder
"Speech" - phonology (delay I disorder)
- articulation (delay I disorder)
- verbal dyspraxia
- resonance (hyper I hyponasality, nasal escape, etc.)
- lateral 151
- interdental lsi
- dysarthria
Dysfluency - developmental
- non-developmental
Voice - dysphonia
- aphonia
Age appropriate speech and I or language.
predictions' and also enabled us to look at why
certain interventions might not have worked.
The most recent change in the format of our out
come measures arose from the realisation that
collating the information was a time-consuming
process, time busy therapists could ill-afford. The
team therefore developed diagnosis codes (figure
4). Using this system, a clerk could, for example,
select all outcome measures relating to children
with a moderate phonological disorder, 'PSB3' (for
paediatric, speech, disorder, impairment rating 3)
without knowing any professional terminology.
The outcome measures themselves provide mea
surable evidence that therapy has affected
change, clear indications of whether or not objec
tives have been achieved and reasons for objec
tives not being achieved . They also give us infor
mation on how objectives have been achieved,
for example, frequency of therapy, group versus
individual therapy and number of appointments.
Exploring approaches
In addition, by identifying particular case notes
within a set via the Master Patient Index (MPI)
number, different therapeutic approaches can be
compared a ~ d trends in service delivery mapped.
It is vital that this process is not carried out in an
atmosphere of justification for clinical decisions,
but in the spirit of comparing practice, exploring
different approaches and learning from variance
factors. For example, why do PSB3 children have
more group therapy than individual in one clinic
compared to another? And how does this affect
th e total number of appointments needed to
achieve the same outcome? The (for now) final
ersion of our outcomes form is in Figure 5.
Figure 3.
A
B
C
Di
Dii
E
F
G
Figure 4.
PNtIx:
Variance Factors
Environmental, Emotional, Social
Medical
Attendance
Carer Compliance
Client Compliance
Service Availability
Additional Impairments (Cognition I Memory)
Inappropriate Aim
Coding for Diagnoses - Outcome Measures
A =Adult P = Paediatric L = Learning I Physical
Disability
F = Fluency L =Language
5C =Social Communication FU = Functional Use
sw ... Dysphagia 5 =Speech
VoIce
Followed by either A = delay or B = disorder
51d11x: Impairment number rating
Figure 5 Sample form
SPEECH AND LANGUAGE THERAPY SERVICE
CLINICAL EVALUATION US1NG WHO
NAME:
DIAGNOSIS:
CODE:
LONG TERM AIM(S):
START DATE:
DISCHARGE DATE:
NO. SESSIONS OFFERED:
NO. ATTENDED:
- ENDERBY
MPI:
START PREDICTED OUTCOME
IMPAIRMENT
DISABILITY
HANDICAP
DISTRESS
AIM(S) ACHIEVED:
VARIANCE FACTOR
YESI NO AGREEMENT
SHORT TERM AIM 1:
START DATE:
VARIANCE FACTOR(S):
TARGET DATE:
NO. ATTENDED:
ACHIEVED: YIN
ADVICE [ ) INDIV. [ I GROUP [ )
SHORT TERM AIM 2:
START DATE:
VARIANCE FACTOR(S):
TARGET DATE:
NO. ATTENDED:
ACHIEVED: YIN
ADVICE [ ) INDIV. [ ) GROUP [ )
(Continues up to short term aim 7)
VARIANCE FACTORS:
A
B
C
Di
Dii
E
F
G
ENVIRONMENTAL, EMOTIONAL, SOCIAL
MEDICAL
ATTENDANCE
CARER COMPLIANCE
CLIENT COMPLIANCE
SERVICE AVAILABILITY
ADDITIONAL IMPAIRMENTS (COGNITION I MEMORY)
INAPPROPRIATE AIM
Figure 6
Sample graph
outcomes
10
9
8
7
6
5
4
3
2
1
O ~ ~ ~ ~ ~ - - ~ ~ - - ~ J
2 3
PSA2 PSA3 PSA4
speech and language
therapy team.
.... Figure 6 shows a sam
ple graph demonstrat
ing that the average
number of appoint
ments needed for chil
dren with phonologi cal
delay correlates with
the severity of the
delay. Figure 7 is one
example of the out
comes form in use for a
fairly straightforward
Different options for
collating and
companng
information seem
endless, and the
ability to prove our
effectiveness will
be useful
Figure 7 Sample completed form
SPEECH AND LANGUAGE THERAPY SERVICE
CLINICAL EVALUATION USING WHO - ENDERBY
NAME: R.A. MPI:
DIAGNOSIS: Phonological Delay
CODE: P5A4
LONG TERM AIM(S):
Phonology in line with general al1i1ities.
START DATE: 9.10.96 IMPAIRMENT
DISCHARGE DATE: 3/11/97 DISABILITY
NO. SESSIONS OFFERED 11 HANDICAP
NO. ATTENDED: 9 DISTRESS
AIM(S) ACHIEVED:
@NO AGREEMENT
VARIANCE FACTOR
SHORT TERM AIM 1:
To Estal1lish K In all positions in the word
START PREDICTED OUTCOME
4 5 5
4.5 5 5
3.5 5 5
5 5 5
:3
phonology case. Suitable points for discussion in This happens in some instances but is not yet gen
peer review might include the need for direct clin eral pract ice.
ical work versus advice. The development and evolution of outcome mea
Although our data is not yet statistically signifi- sures has been a long and occasionally painful
START DATE: 9.10.96 TARGET DATE: Jan '97 ACHIEVED: 0N
VARIANCE FACTOR(S):
NO. SESSIONS OffERED: 2 NO. ATTENDED: 2 ADVICE. {.II INDIV. [ I GROUP [
SHORT TERM AIM 2:
To estal1l1sh 5 In word initial position in the word
START DATE: 22.01.97 TARGET DATE: April '97 ACHIEVED:
VARIANCE FACTOR(S):
NO. SESSIONS OFFERED: 6NO. ATTENDED: 4 ADVICE [ I INDIV. [.I] GROUP [
VARIANCE FACTORS.:
A ENVIRONMENTAL, EMOTIONAL, SOCIAL
B MEDICAL
C ATTENDANCE
Di CARER COMPLIANCE
Dii CLIENT COMPLIANCE
E SERVICE AVAILABILITY
F ADDITIONAL IMPAIRMENTS (COGNITION 1 MEMORY)
G INAPPROPRIATE AIM
cant, we are tremendously excited by the
possibilities for the outcome measures.
Different options for collating and com
paring information seem endless, and
the ability to prove our effectiveness will
be useful in presenting our service to
Primary Care Groups. Resources can also
be targeted on interventions proving
most successful. A further development
could be the involvement of carers /
clients in setting objectives and evaluat
ing whether or not they are achieved.
process, but there is a real sense of pride in what
we have achieved.
Alyson Slater and Jenny Hunt are speech and lan
guage therapy managers for the newly merged
Bedfordshire and Luton Community NHS Trust.
This article is written on behalf of all the speech
and language therapists in the former South
Bedfordshire Trust, past and present.
References
ENABLE (1990), Lucy Hurst-Brown and Alison
Keens.
Enderby, P. and John, A. (1997) Therapy Outcome
Measures - Speech and Language Therapy.
Singular.
SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 1999
I
0
6
resources
sessmen s
assesse
In response to requests from readers, Speech & Language Therapy in Practice introduces a
new series to find out if, when it comes to published assessments and programmes, the
marketing speak matches the practical reality.
Struc ure for
The Apraxia Profile
Lori Hickman
Communication Skill Builders
(from The Psychological
Corporation)
47.00
Maggie Hardwick's clients were,
on the whole, responsive to the
demands of this profile.
The Apraxia Profile was devised for the American
market as a descript ive assessment tool for chil
dren. It identifies and describes the apraxic com
ponent of children's speech and consists of a slim
manual and two types of record form to assess
both pre-school and school-age children.
The Profi Ie brings together many of the necessary
diagnostic and management tools in a portable
package. It can be used as a screening assessment
or, with more time available, as a probing tool. It
can also be used for monitoring as speech
improves. Intervention strategies are formed on
the bases of intelligibility, mean length of utter
ance, listener response and communicative impact.
It is divided into three parts - the oral assessment,
a phonological record and a dyspraxia features
check I ist:
o The oral assessment is similar to that which a
therapist would usually administer if there were
an informal indication of dyspraxia. Tasks range
from imitation of single movements or phonemes
to imitation of multiple movement or phoneme
sequences (particularly helpful for highl ighting
difficulties).
o The phonological record calls for transcription
of imitated and spontaneous words and sen
t ences, with recitation of well-known nursery
rhymes. It highlights distortion of phonemes,
prosodic features, rate variations, inconsistencies
assessment
technique
in errors and - a major feature of developmental
verbal dyspraxia - reduced intelligibility as the
utterance demands increase. The record of con
nected speech allows for scoring of mean length
of utterance and helps to create a picture of over
all intelligibility and therefore functional commu
nication. It also documents syntact ical and mor
phological errors.
o The third section is the checklist of dyspraxic fea
tures which results in a score of the percentage of
the ten characteristics most commonly associated
with verbal dyspraxia. The f inal Summary Page will
then indicate the intelligibility level and how much
of that is influenced by the dyspraxic component.
I was helped to evaluate this assessment by several
chi ldren from both age groups and, on the whole,
found them responsive to its demands. The test of
oral movements and phoneme sequences appeared
to be tedious for the younger children who often
have no idea of what they are trying to achieve, but
they appeared to enjoy the nursery rhyme recita
tion and to be unpressurised by the word imitation.
The assessment was generally UK friendly but there
was the occasional lurking transatlant ic confusion.
'Bozo' I thought to be better omitted completel y
but it did cause some hilarity in the explaining.
Adjustment
It took some adjustment to evaluate the phono
logical errors in the suggested way but I found
that taking some time at the end to use a colour
coding system made it very easy to see types of
errors at a glance.
It is debatable whether this particular tool
improves the therapist 's diagnost ic capability but
it would give structure to the assessment tech
nique of a recently qual ified therapist or those
who work only occasionall y with this client group.
It would be useful for school screening or as a pro
tocol in a busy NHS clinic where therapy may have
to be prioritised according to severity of disorder.
One of my initial mistakes was to apply the school
age assessment automatically to the over 5s when,
in fact, some of the speech imitation tasks were
beyond the capability of young language disor
dered children. It was often more helpful to use
the pre-school assessment for those up to 8 years.
I liked the assessment and found that it addressed,
in one package, all the features that I would nor
mally have assessed using several different means.
I found the dyspra xia features checklist particular
ly useful in making a differential diagnosis. T is
spectrum disorder has recently had considerabl e
media attention but general lay understanding is
still often confused and inaccurate. To this end he
checklist can be completed toget her with the par
ent and is helpful for opening a discussion and
directing explanation. It also f ocused my attention
on the relevant points and helped e ta e
clear decisions about onward ef erral.
A final point; as a sole independent erap
a personal beady eye on he equipment bu get, I
felt it to be reasonably priced.
Compact, comprehensive and good value -0( money_
Maggie Hardwick is a i depe dent speech a d
language therapist in Hertfordshire. ~
resources
Pinpointing concerns
Tinnitus Questionnaire
The Psychological
Corporation Ltd
69.50+VAT
R.S. Hallam
... Is tinnitus relevant to your practice?
If so, Liz Stott believes you will
find this questionnaire useful.
The Tinnitus questionnaire was developed during
a programme of psychological research into
methods of alleviating the aggravation, annoy
ance and emotional distress that tinnitus may
cause. It is used primarily by psychologists work
ing in the field of tinnitus and / or deafness with
the aim of providing a quick assessment of the
chief psychological effects of this condition. It
reportedly enjoys international status.
The users' manual is well written, non-intimidating
and simple to follow. It provides a comprehensive
background as to the origins of the questionnaire
and its aims and outlines how to administer and
score the results with details of the standardisa
tion. Chapter 2 of the manual provides a review of
research relating to dimensions of tinnitus distress
and their validity which makes interesting reading.
The questionnaire comprises 52 questions which
HEAR-SAY
Kathryn Gander and
Gill Close
STASS Publications,
70.00
Sam Dales is impressed by the
flexibility of this new programme
for yrDung deaf and language
delayed children.
Hear-Say is a useful and practical resource for any
therapist working with young deaf children or,
indeed, children with restricted language skills.
The pack consists of six coloured story books and a
resource book containing a language programme
and listening profile. The story books are nicely illus
trated and enjoyable to the child. They can be used
with prelingual children but can easily be adapted
to meet the linguistic level of the older child.
at a
gIa n ce
are standardised on a clinical population of med
ical outpatients. It is quick and easy to administer
with the subject responding to a statement as
True, Partly True or Not True. Likewise, it is simple
to score and interpret. The responses are scored 2,
1,0 with the higher score indicating a complaint.
There are five dimensions of tinnitus complaint mea
sured which are listed as the following subscales:
1. Emotional Distress
2. Auditory Perceptual Difficulties
3. Intrusiveness
4. Sleep Disturbance
5. Somatic Complaints.
A score is obtained for every subscale in order to
establish the level of complaint, if any, in each
area. It enables a clinician to pinpoint at a glance
a particular area of concern for the subject.
Working in the field of cochlear implants with pro
foundly deafened adults I did not find this ques
tionnaire useful, as many of the questions were not
applicable and a little insensitive for a profoundly
deaf individual. However, for clinicians working
Practical, well-presented,
value for
money
The photocopiable language material provides a
practical language programme and activities which
are used in conjunction with the books. The activi
ties themselves are well-known and original ideas
for developing language up to a three word level.
By photocopying the pictures, you can access ideas
and activities quickly but still produce something
that is user-friendly and looks professional. There
are also photocopiable record sheets to map the
child's progress, a useful and simple measure of
clinical effectiveness or for preparing an Individual
Education Plan (IEP). The listening profile provides
an informal assessment which is easy to follow.
Although the authors describe this approach as "by
with mild to moderate hearing losses it helps quan
tify the degree of distress tinnitus may be causing a
client. It is one of the few instruments available
which can measure specifically the effects tinnitus is
having on an individual. It may well be a useful tool
for pre-post outcome measures for those working
with tinnitus and is already widely used as a
research instrument as it has psychometric proper
ties. For those not working specifically with tinnitus
it could be used as a screening tool - it may be that
therapy in a different area indirectly influences the
level of tinnitus distress a client experiences.
On a practical level, the questionnaire is expensive
to purchase and difficult to photocopy if results
required duplication. If a clinician is working with
the intervention of tinnitus then this is a useful
questionnaire to have - if tinnitus is not relevant
to an individual's practice then I do not recom
mend purchasing it.
Liz Stott is a Specialist Speech & Language Therapist
on the UCL Cochlear Implant Programme at the Royal
National Throat Nose and Ear Hospital, London.
no means new or original", I have found it to be a
valuable clinical tool enabling me to approach listen
ing work with my young deaf children in a more
organised and systematic way. As the materials used
for both the language programme and listening pro
file are similar, it allows language activities to be car
ried out simultaneously with sound recognition work.
Overall, the children enjoyed the story books and the
activities provided a good stimulus for a range of
teaching objectives. This is a valuable clinical tool
which is practical, well-presented and value for money.
Sam Dales is a speech and language therapist
working with pre-school and school-aged hearing
impaired children for Bro Morgannwg NHS Trust.
SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 1999
.,---
8
resources
-
Restrictin
CASS-C (Cooper Assessment
for Stuttering Syndromes
Children's version)
Cooper and Cooper 1995
The Psychological Corporation
12700+VAT
Sara Gourlay had high hopes of
this programme but ended up
disappointed.
This is a computer programme designed to allow
speech and language therapists to complete a flu
ency assessment of a child's speech, aged 3 - 13
years, whilst simultaneously preparing an assess
ment analysis and report. It is important to note
t hat your computer must be IBM compatible and
have 1MB of hard disk space. A printer is neces
sary if you wish hard copies for your records or for
using as part of a report.
What high hopes had I as I set out to use this pro
gramme
l
A means of recording information and
compiling a report all at the same time - a busy
clinician's dream
l
The first thing to note is that this
is an American protocol that has not been adapt
ed for English use. However, this is not too much
of a problem provided you are careful to edit obvi
ous vocabulary differences such as mom for mum
and don't mind the mild irritation of not having
enough space for a full telephone number if you
live outside London or fitting complicated country
addresses into boxes entitled "city" (American)
that clearly don't mean "city" (English translation).
The next issue is whether you can place your com
puter in such a way that you can comfortably
in terview and use the protocol without causing
disruption. The child I used this with was very
keen to see what was on the screen and - as this is
not always appropriate - it proved a challenge.
The idea of being able to produce a report without
doing any extra work greatly appealed to me.
However, it does presuppose that everything you
"ish to include in your report is included in the pro-
an not
much fun
tocol. Sadly, this is not the case. The report CASS-C
drew up was a comment on fluency only and did
not give me a rounded picture of the client. For
example, there is no mention of case history detail s
other than those relating to fluency history and
hearing and speech and language development are
not mentioned. Further, there is no reference to
current speech and language skills, other than those
that relate directly to the stammer, such as the
effect of dysfluency on prosody. Assessment advice
from other sources such as the Michael Palin Centre
in London are certainly more comprehensive.
The protocol gives a comprehensive picture of the
child's dysfluency in terms of chronicity prediction,
parental and teacher observations and an assess
ment of the child's fluency based on various output
tasks using a mUltiple choice approach. It took me
about an hour to administer, although that does
not allow for the extra time taken to persuade the
four year old I was working with that "it won't take
much longer" - somehow he didn't seem convinced.
I can't imagine a three year old lasting beyond the
first minute. I missed the flexibility of adding com
ments after each section where the choices may not
have adequately described observations made. Ilike
to tape a session that can be structured to meet the
needs of the individual child. I found the fixed for
document. However all the issues raised are vital for
consideration and, if nothing else, serve as a
reminder of the required breadth of fluency assess
ment. The tabulated report allowed easy comparison
of parents' and teachers' views of the dysfluency with
that of my own and the child's. It also encouraged me
to look more carefully at any discrepancies in per
ception of the dysfluency and to take these into
account when planning my management.
The report can be presented in its entirety or as a
summary. It is a tabulation of the collected data. I did
not find this of much use for the sort of report I tend
to write. It did not include enough information
about the whole chil d, and was something I might
consider for an appendix, although I'm not sure I
would want the parents 0" a child that has severe
fluency problems to see such a negative document.
I am grateful to CASS-C for reminding me of the
factors I need to take into account when assessing
fluency disorders but will not be using it regular
ly, as my caseload tends to be three to five year
olds for whom this assessment is too cumbersome,
inflexible and for whom a lot of the affective and
cognitive line of questioning is inappropriate and
could be tapped in other ways.
Sara Gourlay is a speech and language therapist at
University College London. 0
mat too restricting and not much fun.
Reminder
As is often the case with assessments, I came away
feeling that it had not served the bottom end of its
age range particularly well. I could imagine children
of 7-13 years understanding the line of questioning
more readily as well as having more insight into the
issues, therefore providing a more useful assessment
Orders for The Psychological Corporation on
tel. 0181 3085750 and for STASS Publications
on 01661 822316.
Under scrutiny in the Winter 99 issue are the
Dysphagia Evaluation Protocol, Assessing and
Teaching Phonological Knowledge and the
Burns Brief Inventory of Communication and
Cognition.
RSOURCS...RSOURCS...RSOURCS...R S O U R C S . ~ . R S O U R C S ...RSOURCS...
Voice leaflets
The Voice Care
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Signing
SIGNALONG's latest publications include
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The Stroke Association
Network (UK) is pro The manufacturers of the DynaVox 'This is Me', three sets of loose leaf pages, dupli has produced a ne'
ducing new leaflets, and DynaMyte dynamic display
cated with and without symbols, to help the devel leafl et ' Kno" he "m
'More Care for Your
speech aids have launched environ
opment of early reading skills ing signs' or distr"
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mental control systems, which can
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Young Voice', for older
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a manual of signs to match the word recogni health cemres.
people. Details: David Morgan or Paul tion lists issued by the DfEE for primary pu pils. Available singly or
Details from Roz Comins, Asher, Sunrise Medical Ltd, tel. Details tel. 07634879975. For development ana packs o 50, eL Q1604
tel. 07926864000.
07384446789.
training enquiries, tel. 07634832469. 623934_
dementia
Dementia care:
Speech and language
therapists are increasingly
involved in the management
of people with dementia, often
working with carers rather
than directly with the affected
individual. But what do these
carers think about what we
have to say? Does it make any
difference to the person with
dementia? And what
constitutes 'best practice'?
Colin Barnes investigates.
See our FREE
competition for 400
worth of Winslow
resources for working
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insights,
practicalities
and change
n common with the growing number of
speech and language therapists involved in
the care of people with dementia, my role is
based around the assessment of communi
cation and memory or feeding and swallow
ing difficulties. It also entails running group
or individual therapy programmes for people
with dementia and / or their carers to maintain
experience and skills of communication and
memory.
At the first national meeting of speech and lan
guage therapists working in old age psychiatry in
October 1997, 14 of the 17 people there reported
offering some communication advice and training
to carers. A review of the literature identifies a
small number of studies in which carers have
reported that communication advice and training
is useful, though none of these studies have given
specific reasons why.
To find out more - and to explore implications for
our practice - I carried out a local study designed
to consider the question" To what extent do car
ers of individuals with dementia benefit from
communication advice and training'"
Initially, six individuals with mild to moderate
dementia determined using the ABeD Assessment
(Bayles and Tomoeda, 1993) were seen for a com
munication and memory assessment. I then con
tacted their carers and visited them at home with
in four weeks. For this study, the term 'carer'
referred to immediate family members directly
involved in caring on a day to day basis and
included one husband, three wives and two
daughters. During this visit carers were provided
with:
1. the opportunity to talk about communication
difficulties being experienced
2. an explanation of the communication and
memory assessment results
3. a standard presentation on approaches to com
munication and confusion in dementia
(Barnes, 1998)
4. demonstration of a range of approaches to
communication
5. the opportunity to have carer: patient interac
tion observed and discussed
6. a written record of no more than three key
recommendations
7. an agreed number of follow-up appointments
or telephone contacts.
My approach to working with carers is based on a
number of beliefs, though particularly I attempt
to:
I. Discuss the possible range of approaches to
managing confusion and memory difficulties
rather than prescribing carers one approach to
cover all situations.
II. Use visual material in the form of a colour pre
sentation called Chatter Matters to help explain
the difficult abstract concept of 'communication'
and provide some structure to giving advice.
III. Limit the number of recommendations made
and subsequent pressure on the carer by setting a
limit of no more than three key recommenda
tions. Examples of these specific recommenda
tions are in figure 1.
10 SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 1999
dementia
When a carer asks "What
should I do when he says
something that isn't
correct?", I answer by
discussing the range of
options open to them
Figure 2 - Options example
Question from relative:
What should I say when my husband tells
me he's off to work? His job was his life,
but he's been retired for 10 years now!
CoI;n Barnes M.A., B,Se., reg
M.R,(S.L. T;s a full time specialist
speech and language therapist
HealthCare NHS Trust.
Figure 1 Specific recommendations
* Introduce using his hearing aid for two
hours each day over lunch
* Fill a small box with photographs and
mementoes to act as subjects of conversa
tion. Keep the box by his chair, placing it on
the coffee table when friends visit.
* When the family come for dinner, ask her
to clean and peel the vegetables. Talk about
her hard work during the meal.
* Keep labels from food cartons. Put these
together into a picture book to help her
select which food she would like.
Range of options
The discussion with the carer is primarily about
the ethics of approaches to communication and
aims to equip them with an understanding of the
pros and cons of a range of approaches that they
can use across most situations. When a carer asks
What should I do when he says something that
isn't correc!?" , I answer by discussing the range of
options open to them (figure 2), from correcting
he person (Reality Orientation) to ignoring their
error and encouraging them to tell you more
(Validation), In some situations, it may even be
possible to talk with the relative about positively
encouraging some confused ideas, an approach
hich is used selectively by the Specal group in
xford.
Answer:
You have a choice:
1. You can correct him ('Reality Orientation'
- see Zanetti et ai, 1995) but you should ask
whether he is likely to remember what you
have said - this will depend on his memory
skills and how often the error occurs - and
how it will make him and you feel.
2. You can listen to what he says neutrally
without comment, ignore him or even dis
tract him. But you should consider if he is
likely to notice that you haveignored his
first comment. You may want to introduce a
well established subject of conversation or
ask an alternative question ('Reminiscence'
see Bourgeois, 1991), for example "Do you
remember the good old days when we used
to... ..
3. You can let him tell you more about what
he has said, for example about work. Ask
him more using 'where', 'when', 'what',
'how' questions Ifke a reporter (,Validation
Therapy' - see Feil, 1995).He is more likely
to enjoy being listened to, but you should
ask yourself whether he is likely to realise
that he has madean error and that you
have gone along with it.
4. You can positively reinforce the reality of
what he has said using props. For example,
if he says he is off to work, you can give
him a briefcase and diary and wish him a
good day at the office. This may seem
deceptive, but you should ask yourself how
it will make him feel or whether you are
reinforcing something that is likely to lead
to further complications. This may depend
on the value he attributed to work and the
previous nature of his job. ('Specal'
approach - see Garner and Godel, 1996)
The idea of introducing a range of approaches is
based on my experience that many carers natural
Iy feel obliged to correct their relative irrespective
of whether it is in their relative's best interests. A
tendency to orientate may be associated with
common perceptions of caring as a job of ' making
better' or 'rehabilitating' , Another tendency
amongst carers may be the idea of respecting an
individual's rights, Unfortunately, though, this can
mean carers asking patients to answer questions
which are beyond their understanding, leading to
decisions which are not in their best interests,
The presentation Chatter Matters is also used to
illustrate the equal importance of content and
quality in conversation, I explain that too great a
focus on the content of conversation may lead to
a reduct ion in quality and ultimately cause the
person with dementia to lose interest and w i t ~
draw, Other popular topics of discussion include:
How to involve their relative in conversation
Which things to correct and ignore
What to say when they return from the day centre
Asking questions
How to make major decisions between them
What kind of activities they could be doing
Coping with repetition,
Real attitudes
Research suggests tha y en asked, GfEB
invariably comment po . Iy a posi .
a service they ha e r ei ed, esp.::oa
being asked by the seMce provider
1993). To identify e ca er;' real a-,itudes to my ~
SPEECH & LANGUAGE THERAPY IN PRAalCE AUTUMN 1999 11
dementia
...when asked, carers will
invariably comment
politely and positively
about a service they have
received, especially if they
are being asked by the
service provider
~ visil, I employed an independent interviewer
(another mental health professional) to visit each
carer four weeks later. Other researchers argue
that interview responses alone are not sufficient
t o measure carer benefit and, therefore, follow
ing Knight et ai's (1993) recommendation, the car
ers in this study were also asked to complete a
Subjective Measure of Carer Burden Scale
(Montgomery et ai, 1985). This scale was complet
ed twice, at the beginning of both the speech and
language therapy and interviewer visits. It consists
of thirteen statements designed to reflect the
extent of burden the carer may be feeling, for
example 'I feel that my relative doesn't appreciate
what I do for him/her'. The carer is as ked to rate
their agreement with the statement from rarely
or never to most of the time.
Along with a second independent researcher, I
analysed the anonymous results from the inter
views, typed verbatim onto transcripts, and the
Carer Burden Scale. The results from the study can
be broken down into three areas:
1. The Subjective Measure of Carer Burden
Scale
The results from this measure were disappointing.
On average, all carers reported an increase in bur
den between visits and following contact with the
speech and langu age therapi st. However,
decreased burden was indicated in two questions
which suggested that the majority felt less nero
vous and depressed and interpreted their relative
as being less demanding .
Th e scale was introduced to give an additional
quantitative element to the study though the
results did not illustrate the trend expected. The
answers to the quantitative questions clea rly
showed that the carers found the visit very help
ful. It therefore seems unlikely that the carers
should have experienced an increase in burden.
Closer examination of the results also suggests
that some difficulties may have been experienced
in interpreting the questions in the measure and
t hat additional differences were created by hav
ing two testers. Whilst I would tend to concl ude
that no real significant increase in burden was
experienced, we should never dismiss the real pos
si bil ity that our intervention can add to a carer's
burden.
2. Quantitative (Yes/No) responses from the
interview
Unfortunately, one carer was unable to complete
the interview fully as the patient had insisted on
remaining in the room and objected to being
talked about, therefore only the results for the
other fi ve carers are given.
Interview Questions
Average Scorel
Response
1. Was the visit helpful? 2.8 *
2. Was an explanation of
the assessment results helpful? 3
3. Was it helpful to Simply
talk about your
communication difficulties? 3
4. Was it helpful to be given
information on communication? 2.8 *
S. Did the visit influence
your thinking? All said Yes
6. Have there been any
changes in your attitude
and approach? All said Yes
7. Were you able to carry
out the recommendations
made? All said Yes
3. Qualitative (reasons why to what
extent) responses from the interview
The comments made by each of the carers (five
people) were sorted into ten categories agreed
by the two researchers, then key themes were
identif ied using a method of content analysis.
Although the quantitative responses in the
study clearly indicate that this sample of carers
found their contact with a speech and language
therapist useful, the qualitative data from the
study is able to provide some possible reasons.
The five most significant themes are described
with resulting suggested learning points giving
directi on for best practice:
i. Comments and insights into the caring
role
Surprisingly, over thirty comments about being a
carer were volunteered though none of the inter
view questions had asked for these. Of these com
ments, twentyone were negative including being
tired, not sleeping, being alone with noone to
talk to, only conversing when the patient wants to
and having to compromise.
Learning Point: Be careful not to
over-empathise. Although we may
spend much of our working life with
people with dementia our experience
is emotionally very different from the
family carer.
ii. Practical i ties of the visit and speech and
language therapist approach
The majority of carers preferred having the meet
ings in their own homes. They reported appreciat
ing having time to talk, having realistic recom
mendations and simply being encouraged .
Difficulties arose when carers failed t o understand
the purpose of the visit that is, that it was for
them as much as their relative.
Learning Point: Be clear about the
purpose of our visits and offer the
carer a range of options to ensure
their interest and attention.
Carers were asked to give responses using a three
point scale where
l=not helpful, 2= helpful and 3= very helpful.
*One person gave a score of 2 instead of 3. This
appears linked to their comments that some of
what was said was common sense.
Carers also varied in their ability to understand
the idea of 'communication'. Two appeared to
misunderstand what is meant by this term.
It was also clear that carers were more able to
apply and remember recommendations that
involved specific activities than more general
changes in approach such as "Try talking in less
complex sentences".
Learning Point: Allow for varied
understanding of 'communication'
and consider using very specific,
preferably activity based,
recom mendations.
ill . Changes in Belief. Attitude and
Understandi ng
In keeping with the aims of the visit, three out of six
carers reported a change in belief that it was now
more acceptable to go along with confused ideas or
errors. All six reported an increase in knowledge and
two reported more tolerance in attitude.
Learning Point: The speech and
language therapist has a val id role in
helping some carers to broaden their
beliefs and knowledge about ethically
acceptable approaches to
communication in dementia.
2 SPEECH & LAN GUAGE THERAPY IN PRACTICE AUTUMN 1999
dementia
Photographs courtesy of
Alzheimer Scotland
iv. Changes in approach
From five carers, twenty mainly activity based
changes were reported. These included relaxation
and talking to their relative and others about
household tasks they can be given to do, such as
washing, peeling, polishing and folding. The car
ers also reported difficulties in introducing anoth
er eight changes. For example, one carer found
talking books didn't help and another was unable
to follow the suggestion of returning from trips
with a memento such as a menu because they
don't go out much.
However, the carer who reported the greatest
success in introducing changes also reported look
ing for alternative approaches after four weeks.
They appeared to be looking for more variety,
although their relative was unlikely to appreciate
this.
Learning Point: We may need to
prepare carers to cope with
repetition. It is likely that some of
the most successful changes made
will be those that happen at least
once aday.
v. Changes in carer and patient well-being
All comments in this section were related to com
munication activities and none to changes in com
lunication style. The main benefit reported by
carers was the value of being listened to and
being encouraged. However, two carers found it
difficult to see how the carer contact could help
the patient.
Learning Point: Carers by definition
provide the majority of care for their
relatives. If they find gratification in
what they do, it would seem likely
that they will be able to carefor
longer. The carers appeared to
appreciate encouragement about
the job of caring they are doing and
may benefit from contact with a
.'knowledgeable professional'.
Worthwhile
Consideration of the results of the study suggests
that communication advice and training for carers
of people with dementia is worthwhile because it
provides for more understanding of the patient's
difficulties and needs, more success in communi
cation and interaction, less difficulty being realis
tic about the future, encouragement about the
job of caring they are doing, confidence to
employ a broader range of approaches and an
opportunity to talk about the difficulties they are
experiencing.
This study considered the value of working with
dementia carers on communication in more detail
than any other known published study. Even so a
number of limitations, including the relatively
small sample size, call for future research. This
could address at least three further questions;
Which and what proportion of carers benefit?
How long do the benefits last'
What is the potential for and interest in further
contact with a speech and language therapist'
References
Barnes, C. (1998). Chatter Matters. A presentation
for carers of people with communication and
memory difficulties. To be submitted for publica
tion in 1999.
Bayles, K. & Tomoeda, C. (1993). The Arizona
Battery for Communication Disorders of
Dementia. Canyonlands Publishing - distributed
by Winslow Press in the UK.
Bourgeois, M.S. (1991). Communication treatment
for adults with dementia. Journal of Speech &
Hearing Research 34, 831-844.
Feil, N. (1995) The Validation Breakthrough.
Simple techniques for communicating with peo
ple with Alzheimer's-type dementia. HPP.
Garner, P. & Godel. M. (1996). Specialized Early
Care for Alzheimer's: Making a present of the
past. A report available from the authors at
Burford Community Hospital, Oxfordshire, OX18
4lS.
Knight, B.G., lutzky, S,M. & Macofsky-Urban, F.
(1993) A meta-analytic review of interventions for
caregiver distress: Recommendations for future
research, The
Gerontologist 33 (2) 240
248.
Re ections:
Montgomery, R,J .V.,
Gonyea, J.G. & Hooyman,
1. Do' try to
N.R. (1985). Caregiving
and the experience of sub
encourage
jective and objective bur
change without
den. Family Relations 34,
increasing
19-26.
Zanetti, 0, Frisoni, G.B., feelings of
Deleo, D., Buono, M.D.,
burden?
Bianchetti, A. & Traucchi,
M, (1995). Reality
2. Do'
Orientation Therapy in
genuinely
Alzheimer's Disease:
attempt to alter
Useful or Not? A con
trolled Study. Alz. Disease
my practice
and Associated Disorders 9
based on what
(3) 132- 138.
the users of my
service think?
Resources
3. Do' enable
The 24 hour Dementia
people to see
Helpline (Scotland) on
freephone 0808 808 3000
they always
and the
have more than
Alzheimer's
Helpline (England, Wales,
one option?
Northern Ireland) on 0845
300 0336 (local rate) pro
vide information or emo
tional support about issues to do with dementia.
To contact Alzheimer Scotland - Action on
Dementia tel. 0131 2431453. For the Alzheimer's
Disease Society (England, Wales, Northern
Ireland) tel. 0171 3060606.
0
reviews
Evidence
PARKINSON'S
based
Parkinson's and the Speech &
language Therapist
Information Pack (Revised)
Parlcinson's Disease Society 8.50
Perhaps this is the best evidence
based information pack so far pro
duced by the Parkinson's Disease
Society. It is mainly an overview and
not meant t o be an in-depth resource.
The seven sections are printed on dif
ferent coloured A4 paper for ease of
reference. They include commun ica
tion problems; eating, drinking and
swallowing; handouts for carers and
people with Parkinson's; a checklist
for the therapist to use as a summa
ry of detailed assessment; and useful
addresses. Each section has an up-to
date list of references. Best of all is
the section on background papers,
highlighting recent clinical findings.
Last but not least is the section on
efficacy. It provides a useful list of
references on the ever increasing
need to promote "the level and stan
dards of services which the providers
of health care should deliver".
Being so reasonably priced, no
newly qualified therapist should be
without it.

':J;MIWII Il;i- and user -fnendly
Right Hemisphere Damage - Disorders of Communication and Cognition
Penelope S. Myers
Singular
ISBN 1 56593 224 2 36.00
Right hemisphere (RH) communication disorders have always been difficult to define and therefore difficult to treat.
Although further research into the RH is needed, this book takes you easily through every identified aspect of RHO,
offering clear examples of deficits to aid the experienced and inexperienced clinician recogn ise and treat the often
subtle intricacies of RH language impairments and the wider cognitive implications.
There are comprehensive sections on assessment and treatment techniques including a good overview of standardised
.._________-. tests and many user-friendly treatment ideas that can be easily adapted and built upon
by clinicians working within this field .
To aid the student or clinician new to the area of RHO, there are useful chapter out-
Expensive lines and summaries to enable information to be located rapidly.
but exc,'t,' ng A resourceful book for anyone working within the area of neurological impairment.
___________
Neuroscience of Communication (2nd ed)
Douglas B. Webster
Singular
ISBN 1-56593-985-9 30.00
It is tempting to assume that this book is the essential neurology
resource book for the student speech and language therapist
but it isn't. What would be the impli<[ations for therapy and who
would need such a detailed study of neural organisation? It is a
must for the specialist speech and language therapist who has an
eye for detail and who has a caseload of neurological and neuro
surgical patients in the acute setting. It is an excellent tool for
improving diagnostic skills as it describes in detail the interaction
of neural impulses, their timing and coordination which are
responsible for that perfect activity known as communication.
It may be expensive, but it is worth having a personal copy
because it will probably be years before anyone comes out
with anything as exciting.
Nassar is a speech and language therapist (acute adult neurosciences) in East London.
broader role
Joanna Rassell is a speech and language therapist
for Brain Injury Services in Colchester.
Answers
common questions
Developmental Phonological Disorders
A Practical Guide for Families and Teachers
Caroline Bowen
Australian Council for Educational Research
ISBN 086431 12563 $24.95 (Aust.)
This book is written by an Australian teacher /
therapist for the parents and teachers of phono
logically delayed / disordered children. It describes
phonetic and phonological development in an
easy-to-read format. The importance of the fami
ly in therapy and the use of metalinguistic tasks
in conjunction with direct speech work is
emphasised. There is a useful chapter
answering questions that are com
monly asked of therapists, such
as "Is my child lazy?" or "Why
The Voice Book - for everyone who wants to make the can't therapy be continu
Wanting to Talk (Counselling case studies in
most of their voice ous'" However, the rec
communication disorders)
Michael McCallion ommended service deliv-
Ed. Diana 5yder
F;,ber & Faber ery (ten weekly 40-45
Whurr
ISBN 0-571-19525-3 7.99 minute sessions) may
ISBN 1 86156 067 2 19.50
This updated edition of Michael McCallion's 1988book follows the same easy be unrealistic in
This is a va luable book to dip into for speech and lan
to-read format but includes an additional section of ideas and techniques stretched community
guage therapists who wish to accord the criteria of
based on his experience of working with voice professionals from all walks of cl i nics. A glossary
"thinking, feeling and subjective experience ... some
life and his years as voice teacher at the Royal Academy of Dramatic Art. would have been
respectabil ity." It includes nine counselling case histo-
It would be an excellent recommendation to the voice patient who wants to useful to describe
ries written by speech and language therapists, psy
go a "step further" after therapy or for the student or therapist, new to voice some commonly used
chologists, counsellors and psychotherapists. Each
work, who wants to explore their own voice and develop practical skills. terms in more detail.
describes their own approach - including use of Personal
It makes little reference to speech and language therapy and I would This book may be use-
Construct Therapy, hypnotherapy and psycho-analytic
question some of his advice on vocal care especially regarding hydra ful to dip in and out of
psychotherapy - with a particular client. Clients include a
tion and smoking. to select appropri ate sec
young autistic child, mother of an infant with learning dif
However, it would be a useful addition to any library and - at tions for parents, teachers
ficulties and an adult with articulation problems.
. the price - excellent value for money! and students. Modifications
Celia Levy, in her chapter on the Therapeutic Relationship,
shows how traditional speech and language therapy focuses pri
Jean McGowan is a voice therapist at may be needed to explain par
marily on the disorder and only secondarily on the person. For those
GJoucestershire Royal Hospital and current ticular clinician's approaches and
prepared to challenge such an approach, this book demonstrates a
chair of the Oxford Voice and individual client's needs.
range of possibilities for a broader role for speech and language therapy.
Laryngectomy SJG. Liz Wilson is a speech and language
Helen Rose is a speech and language therapist with deaf adults in London. therapist in North Durham.
reviews
eVlews
Inspirational .
n1U*tc"i'_ aaaptations
F u n d . ~
Soft Options for adults who have difficulty chewing
Rita Greer
Souvenir Press Ltd.
ISBN 02856344X7X 9.99
This recipe book is suitable for people with a wide range of cooking experience. Some of the detail
(nutrition & healthy eating; cooking equipment & utensils; rationale and techniques) is at a very basic
level, but ideal for a spouse who is new to it all.
I was impressed with the thought that has gone into the adaptation of meals, so that a near-normal
variety can be offered, including foods which are traditionally left out of a dysphagic diet, such as
bread, cakes and pizzas. However, like all recipe books, it would have benefited from some colour
photos to whet the appetite!
This is a valuable resource for inspiring and guiding families and one I have already
recommended several times. Catering departments should also find it
The Dysfluency Resource Book
helpful.
Heather de la Croix is a speech & language therapist who
divides her time between the NHS in Wiltshire and her
STAMMERING
Excellent value
Independent Practice in the Bristol area.
Jackie Turnbull and Trudy Stewart
Winslow
ISBN 0 86388 206 4 33.95
Positive
IUeas
Groupwork with Learning
Disabilities- Creative Drama
Anna Chesner
Winslow
ISBN 0-86388-190-4 27.50
This is a very practical book, written by a
dramatherapist with experience of group
work with people with learning
difficulties. It begins with a discussion
of the value and benefits of
using creative drama and
how to structure the
group and the
sessions, and
presents a five
A resource book offering practical therapy ideas for working with adult
phase session
stammerers, covering individual and group therapy, and with over thirty
clear, concise and very useful (photocopiable) handouts thrown in - sounds design which
n1UU4ijti' approach
Management of Adult Neurogenic
too good to be true? Well, for once, it isn't.
links up with the
Dysphagia
There are thirteen chapters ranging from the general (for example,
succeeding
Maggie Lee Huckabee and Cathy A. Pelletier
Communication Skills) to the specific (Desensitisation; Avoidance Reduction;
Singular
chapters. These
Rate Control to name three), and the layout is user-friendly and flexible. The
ISBN - 1-56593-871-2 40.00
authors include well-trodden techniques by the usual suspects (Dalton, Kelly, chapters then
This American book, written in an easy-to-read
Sheehan, Van Riper et al) while adding plenty of slants and suggestions
describe activities
format, looks primarily at the long-term
management of patients with neurogenic
dysphagia. It provides a detailed
chapter on the compensatory
techniques that can be used with this
client group but its main strength is the
positive approach it gives to the role of
the speech and language therapist in
dysphagia rehabilitation.
It achieves an excellent balance
between giving an overview of the
whole area of dysphagia management
for therapists new to this area, and
enough information to provide the
experienced,therapist with new
therapy tools, ideas on how to
set/measure goals and guidelines on
how effectively to document
information in our increasingly 'legally
aware' society.
Lucy Swain is a specialist speech &
ianguage therapist with East Yorkshire
Community Healthcare NHS Trust.
gleaned from their own clinical experience.
which can be used
At 34, it represents excellent value for all the use you should get out
of it.
for each of the
John Swan is a speech and language therapist working with stages including
VOICE
adults for Worcestershire Community Healthcare. When
arrivals and greeting,
I other caseload commitments allow, he runs an
body and voice work,
Wealth evening dysf/uency group in Worcester.
information
Vocal Health and Pedagogy
Robert Thayer Sataloff
Singular
ISBN 1-56593-963-8 33.95
This book is designed to be a clinical companion to the much
longer and more expensive Professional Voice, 2nd Edition,
and as such is focused on the professional performers' voice.
However, it is able to stand alone with information relevant to
other professional voice users and amateur performers' voices
more commonly seen in clinic.
The 31 chapters range from the standard Anatomy &
Physiology and Vocal Tract Resonance to the not-so-standard
Choral Pedagogy and the Singing Voice Specialist. Particularly
interesting for clinical use are chapters about the vocal effects
of allergy, endocrine dysfunction, nutrition and medications.
Overall, at under 35, it is very good value for money for
the wealth of information conveyed.
Hilary Armstrong is a speech & language therapist within
the adult team for Mid-Essex Community & Mental Health
NHS Trust, based in Chelmsford.
sensory activities, drama
activities and closures. The activities
are clearly explained together with their
purpose and how they can be further
developed.
I found this a very easy book to read,
with a fund of ideas for anyone working
with a group, or providing advice on
how to run such a group. I would
recommend it as a useful resource for
any special school, day centre, or
community learning disability team.
Jenni Kay is a senior specialist speech
and language therapist wit h Cheshire
Community HeaIthcare Trust working in
a community team for adults with
learning disabilities.
groups
How do we deliver an effective
speech and language therapy
service to mainstream school
children on the autistic spectrum?
Following their highly successful
one week intensive group,
Liz Spooner and Sally Hewison
provide us with a wealth of
suggestions for therapy activities
and organisation,
I
-
peech and language therapists in com
munity clinics are receiving increasing
referrals of children on the autistic
spectrum , These children have difficul
ties in understanding and using lan
guage, and also with understanding
social rules, interacting appropriately with other
children and adults and developing insight into your behaviour can affect other people, using
their own and other people's feelings, Therapists knowledge about other people to make an
often feel unable to address such complex needs informed prediction ,
effectively within the clinic setting so, last year,
some children were removed from community Addressing all areas
clinic caseloads and seen on a one week group All children were referred by community thera
intensive course during school holidays, Therapists pists, Seven children attended ranging in age
who normally work in language units ran the from six years five months to eight years, working
course as they have a depth of experience work with two therapists and a therapy student.
ing with school-aged children who Parents were asked to attend an
have pragmatic difficulties, One appointment before the course to rate
therapist who is term time only was Therapists their child using the Surrey
funded for one extra week to pilot Communication Profile (SCP) (Cave and
often feel
the course which was structured to McG regor, 1996) and to identify
unable to
address: strengths, weaknesses and aims for the
developing understanding of lan address such week, The SCP was chosen because it
guage - semantics, implied meaning, rates children's expressive and receptive
complex
understanding and remembering language along with behaviour, interac
needs
instructions, listening skills, tion and social skills, and the course
using language - organisation of
effectively
aimed to address difficulties in all these
ideas, giving instructions, giving areas, Therapists evaluated each child
within the
appropriate amounts of informa independently on the first day, Children
tion,
clinic setting
were re-assessed by therapists using the
understanding the rules of play SCP at the end of the week and again
and conversation - turn-taking, win- with parents six weeks after the course
ning and losing, sharing, teamwork, understand to determine whether any progress had been
ing other people's points of view, achieved and whether it had been maintained,
self-control/insight into behaviour - developing Parents were also asked to complete a question
awareness of other people's feelings and how naire at the end of the course on course content,
Figure 1 Task progression
Target - Insight Into ownIother people's feeUngs
Day 1 The Present Game
Using real objects - asking children to Identify
a present they woutd lHce, and an appropriate
present for another group member
Day 2 How Do You Feel?
Using Imaginary but extreme situations. ego
you have an InJection, It's Christmas
tomorrow.
Day 3 How Do You Feel?
Using Imaginary but a mbiguous situations.
egoyour teacher asks to hear you read. It Is
salad for tea tonight.
Day 4 How do they feel?
Using Information about two imaginary
people to predict how they would feel In
different situations. ego someone Is
frightened of water - how would they feel
about an Invitation to go swimming
Day 5 Guess Who?
The homework task was to write about whot
makes you happy and cross. Children have
to use their knowledge Of other group
members to match the homework to the
child.
any progress noted and preferences for types of
future therapy.
A day was allocated the week before the course
for meeting the parents and identifying a range
of priorities for each chi ld, and the first day was
planned with these objectives in mind. The course
ran every morning from 9.30 - 12.00 for one week,
whole group acti vities combining with rotated
small groups. Each day contained about eight
activiti es and eva luati on and planning f or the
next day w a ~ done every afternoon. In the future
less time should be required for planning as a
bank of thera py resources and ideas has now
been created. A homework task was set at the
end of each morning, which was incorporated
into the following day's therapy. These tasks
enabled us to build a guessing/predicti on task and
progression into each day's activit ies (figure 1) .
Examples of therapy tasks for different targets
are in figure 2 and information for parents about
the session plan for day thr ee in figure 3.
Figure 2 Examples of therapy tasks
1. Insight/Prediction
Sets of these happy/sad/cross/surprlsed cards were used dur- .
Ing the week to help the ch.ildren Identify their own and other
people's feelings during octlvltles working on predictIon and
inSight. They were particularly effective Ln activities designed to
show that people could have different responses to the same
situation and In providing a structure when asking children to
predict how another group member might feeL
2. Organising language/giving Instructions to other group members
,'\\({(///1'""
\ {I r //
" -:
~
,\(( (1//
w
W
\ ( r/ /",.
" -
-
w
u'
'"
We used the barrier game as an activity during the week but
gave It greater structure by giving the speaker in the group a
picture prompt to help him tell the other group members what to do. This gave on added to
challenge, as he had to sequence his own Instructions accurately to achieve the correct goal
for other group members. The speaker was able to look at what the listener was doing and,
during the week, the children became more effective at using this Information to mOdify the
speed, complexity and number of their instructions.
3. Team Gomes/Listening to instructions
A running race team game using semantic categories was Incorporated into each day's activi
ty where each team member hod to carry out a sequence of 4 actions. a(:h day we altered
the Instructlons so that the sequence and/or one of the instructions changed. Initially the chil
dren relied on their memory of the previous day's game (and did not listen to the change of
instruction) and consequently did not carry out the game correctly. By the end. of the week
they had learned how important it was to listen to aU the instructions and not rely on their
knowledge of the previous day's routine.
Figure 3 Programme for day three
1. The Family Photographs Guessing Game 30 minutes
The children have to Identify.
Who is In the photo?
How they feel?
How can you tell?
Why they might feel that way?
2. Making happy, sad, cross or surprised masks 30 minutes
3. Take One Step 15 minutes
A game where you have to listen to instructions and decide whether they apply
to you - we didn't have time to play this yesterday!
4, . Chinese races 10 minutes
Developing eye-contact. recognising other people's feelings and using
non-verbal skills to convey Information.
5. Rotating Groups 15 minutes/group
0) Lotto by Description b) How might you feel?
today the children take prediction of your own
turns to describe the feelings and those
pictures (developing of other group members
self-organisation, listening. in a variety of settings
and expressive language)
6. The Toybox Team game 10 minutes
We are changing the structure Of our team game to check the children are
listening to instructions, rather than following routine.
7. Who does thi s toy belong to? 15 minutes
Guessing Game - the children need to identify other chi ldren's likes and di slikes
rather than their own, to guess successfully.
8. The Present Game 15 minutes
Developing o n ability to "read" other people's feelings and predicting possible
causes for how people feeL
Homework
Can your child bri ng ina photo Of themselves as a baby (With thefr nome on t e
back please!)
groups
Figure 4 Post-course questionnaire
SPEECH AND LANGUAGE THERAPY OUESTIONNAIRE
We would be very grateful If you would take ttme to fill In the following Ouestlonnalre about this week's Course. Your answers
help us In planning effective therapy in the future.
Child's Name ............. .. .. .... .. .. ...... .. ...... ..
1. Do you think the Course helped your child in the following areas? (please tick)
No Change Slight Improvement Some Improvement Big Improvement
Understanding Language
Confidence
Concentration and Listening
Talking
2. The Course also aimed to develop your child's understanding of other people and insight into his/her behaviour. Do you
think the course helped your child in the following areas?
No Change Slight Improvement Some Improvement Big Improvement
Self Control
Understanding of other people's
point of view
Understanding the rules of play
and conversation
3. What did you think about the Information given about the Course? (please circle)
It is likely that
Too much Not Enough Useful Very UsefuL
the parents'
4. What did your child enjoy about the Course?
view more
closely
5. What kind of Speech and Language Therapy would you choose for your child in the future? (please circle)
reflects any
Individual Appointments Another Group Course
generalisation
6. Do you have any other comments about the Course?
of progress
that resulted
from the
Thank you for taking the time to comp.lete this Ouestlonnalre.
course.
.... The results of a post-course questionnaire to par the course. another group and only two wanted some level of
ents gave an immediate positive response (figures It is interesting that the questionnaire completed individual therapy alongside another group. We
4 and 5). We found the changes made in self con by parents immediately aher the course showed see two major benefits of group therapy:
trol, understanding of other people's points of only three of the children's parents felt they had 1. Structured therapy for language and social
view and understanding rules of play and conver made any improvement in understanding of lan skills is delivered in the context of familiar social
sation particularly encouraging, as these kinds of guage. However six weeks later, when completing activities - team games, play, construction activi
difficulties had not been targeted in the previous the SCP, all parents ident if ied some progress. All ties. This increases each child's ability and oppor
model of individual therapy. the children made some progress in interaction to tunity to generalise the skills learnt.
Therapists identified more progress on re-assess varying extents as measured by both parents and 2. Course design can enable children to recognise
ment with the SCP than the parents did (figure 6) . therapists. This is particularly pleasing because it their progress and to gain confidence and moti va
However, it is important to consider exactly what had not been targeted in the individual therapy tion from succeeding at activities with other chil
they rated. The therapists judged the progress of the children had received prior to the course. dren. This ohen contrasts with their experience at
the children relating specifically to the routines school.
and activities of the group while the parents rated
Group benefits If we were repeating the same type of group, we
their own child according t o their experience of
Parents were asked on the questionnaire which would complete the SCP with each child's Special
him/her in a range of settings over a period of six
kind of therapy they would prefer for their child Educational Needs Coordinator (SEN-Co) and
weeks. The parents' ratings may also be affected
in the future - another group, or individual identify with them their priorities for that child
by the interpretation of their child's difficulties
appointments. Given our previous experience prior to the course. The SCP provides a useful
(which varied considerably within the group). It is
when asking this kind of question, we felt the framework for discussing a child's needs with
likely that the parents' view more closely reflects
answer was likely to be 'both'. It was, therefore, teachers and we feel more information about
any generalisation of progress that resulted from
pleasing to see that five parents would prefer how each child is managing in school would pro
i
groups
Figure 5 Post-course questionnaire results
No Change Slight Some
Improvement Improvement
Understanding 4
Language
Confidence
Concentration
and Listening
Talking
Self Control 2
Understanding
of other
people's point
of view
Understanding
rules of
play and
conversation
Figure 6 Surrey Communication Profile results (6 weeks post-course)
Number of Children making progress In at teast half of the Items In each
category (total number of children = 1)
Expressive Interaction
Language
Therdplsts' rating 5
Parents' rating 3
vide an extra perspective to make therapy more often made us realise
effective. We would also re-assess with the SEN-Co the extent of a chill'J's
post-course to establish whether any progress had difficulties.
generalised to school. 3. Homework:
We learned a lot generally from the course which Pred iction / guess
we will take into account when planning further work - bringing baby
groups. In particular, we would recommend:
1. Take nothing for granted: All children on the
course are functioning in a mainstream school
environment but we still had to teach very basic
skills -., for example, recognising basic facial
expressions - at the beginning of the course.
2. Incorporate a craft' practical activity: We
planned a practical activity for each day to sup
port our themes for the week, for example mak
ing masks of different emotions and a bedroom
door sign to show how you feel. This also gave us
the opportunity to see how the children applied
their listening and organisational skills in a struc
tured activity outside speech and language thera
py. The results were always enlightening and
pictures, family pho
tos and favourite toys from home enabled us to
incorporate a guessing game into an activity
where children had to use their knowledge about
other group members to inform their predictions.
4. Planning and evaluation with parents:
Working with parents to plan priorities for the
course enabled us to establish very specif ic targets
for each child and to use the parents' knowledge
of their child's strengths and interests to ensure
activities were motivating for each child.
Involving parents in evaluation enabled us to
identify progress made on the course, and to see
how progress had been generalised in the chil
dren's everyday lives.
5. Location: The course was held in a -;:,
porary classroom of a local , -ea
school. This had positive benefits
children's behaviour and attitudec .
py (compared to a clinical se .
has a 'pre-school ' feel) In addi ' Il
a playground and playing field" _
which were invaluable for the more a .
Liz Spooner and Sally Hewison are speed' G --::
guage therapists with Worcestershire c:
Healthcare NHS Trust.
References
SPEECH & LANGUAGE THERAPY IN PRACTlCE 9
In my e.xperlence
As speech and language
therapists we enjoy
immensely privileged
access to the stories of
our clients. In exploring
the power of narrative
in the therapeutic
setting, Carole Pound
urges us to rise to the
challenge of modern
day practice to both
value and hear the
stories we are told.
tories have to repair the damage that
illness has done to the person's sense of
where she is in life, and where she may
be going. Stories are a way of redraw
ing maps and finding new destina
tions.. .whether ill people want to tell
stories or not, illness calls for stories' ( Frank, 1995,
pp53-4). Therapists have long been aware of the
power of 'being listened to' and the centrality of
'listening skills' in our bag of therapeutic tools.
Many therapists, myself included, would have rated
listening skills as high on our list of clinical attrib
utes. Only recently, however, have I revisited
through a growing literature on narrative and
identity - my own shortcomings in the listening
department and my developing skills in listening
to and helping clients to construct their unique
narratives of health, illness and disability.
Two-way traffic
Greenhalgh, 1999, outlines the important bridging
function which narrative plays between the teller
and the listener and notes 'the more one studies nar
rative, the more one realises how very complex this
bridge between teller and listener actually is' ( p xiii ).
Much two way traffic passes across the bridge mak
ing each story told and each story listened to a
unique event with gaps of meaning and significance
constantly open to a new construction. Greenhalgh
and her co-authors argue that the dominance of
modern biomedicine has led to an undervaluing of
the lived experience of the patient's side of this
bridge. In turn, this has led to some neglect of the
many powerful reasons why narrative might prove a
valuable resource for modern healthcare practition
ers. Narratives have the power to allow therapists
access to the lived experience of people's lives in a
way which the more structured, clinician-led case his
tory may not. As such, they can provide a framework
for supporting diagnosis and therapeutic options as
well as a rich means of educating professionals and
expanding the research agenda (Greenhalgh and
Hurwitz, 1999). Within the diagnostic encounter, for
example, listening to the patient's meaning allows an
intimacy with their lived experience, an empathetic
bridging between clinician and patient and a con
struction of meaning in addition to the sign posting
of diagnostic clues regarding the presenting illness.
Therapeutically, narratives may be healing in them
selves, through the power of being listened to or by
opening up suggestions for therapeutic paths based
truly on a holistic and person-centred approach to
therapy. At an educational level, Greenhalgh and
Hurwitz underline the power, when teaching, of
memorable stories which both engage the student
and encourage important self-reflection. And finally,
at a research level, narratives have the power, by
moving away from clinician-determined interests, to
generate new hypotheses and re-d irect the research
agenda to one which is not just paying lip service to
a 'patient-centred' approach.
The developing trend within healthcare research to
listen to the voice of the 'patient' is not however an
easy option to tread, nor often is it necessarily a
comfortable story to hear (Parr et ai, 1997). As clin
icians, it is far easier to listen to the accolades of our
grateful customers than the stories of neglect,
abandonment and lack of meaningful change
which our best efforts bring to some people's lives.
It is far easier - and superficially quicker - to make
assumptions about what a client needs and steam in
to deliver that intervention. Not only have we, until
recently, lacked the tools and education to listen to
the narratives of our clients, but perhaps we have
also lacked the open, non-prescriptive context to lis
ten to and value these narratives within our prac
tice. Furthermore, perhaps we have lacked a will
ingness to review and reflect upon what supports
and blocks the development and constant fine-tun
ing of listening skills - not just in the early days of
training but throughout our professional career.
In this context, I am not referriT'lg to the blocks to
listening which are well documented within the
field of counselling and interpersonal skills and
which we also need to revisit regularly. Instead, I
wish to focus on the barriers which seem to arise
from the powerful trend of professionalism and
professional expertise - a barrier which, left
unchecked, is likely to grow rather than diminish
with length of experience.
Breadth of alife lived
Medical and paramedical training is still largely
based around disease-based models and teaching
delivered by clinical specialists who, whilst (hope
fully) verbally promoting the notion of transferable
skills, do little to model their own transferable skills
since they understandably teach and demonstrate
their own specialism and 'expert' knowledge. As a
user of health services, my desire is to have consul
tations with the expert who is most able to fix my
problem and return my ailing body to normality. As
a practitioner working with an aphasic person's lan
guage impairment my desire is to use my 'expert'
understanding of language processing breakdown
and therapies to best support progress and change
i n the person's language skills. Why then my con
cern about the development and dominance of pro
fessional expertise? Well, perhaps because many of
t hese expert skills - whilst appropriate within a
model of short term illness and cure - do not, by
themselves, fit the complexities of long-term chron
ic disability. My personal and professional experi
ence is that strongly held views of specialists who
spend their lives pursuing rather narrow fields of
impairment-focused study and practice place seri
ous constraints on listening to stories about the
breadth of a life lived with that same impairment.
Some examples from my own career path may help
ill ustrate this. As a specialist aphasia clinician, I have
spent much of my career mixing with practitioners
from a similar acquired neurological background.
Ime pressure and the drive to develop relevant skills
and practices have meant that, until recently, I neglect
ed not only the literature and developments from dis
ability theorists and researchers but also some very rel
evant work from, amongst others, the fields of learn
. g disability, mental health and child language. One
has only to look at the very specialism-orientated
-hemes at last year's Royal College of Speech &
l anguage Therapists (RCSLD conference or at the lack
o broad focus Special Interest Groups (SIGs) to realise
at impairments and special isms retain a powerful
old on our professional development. This can rein
force our difficulty in listening to more diverse dis
courses whether from the social sciences, ethnogra
y, philosophy or - more importantly still - from our
and their families. A number of recent articles
the RCSLT Bulletin by therapists who find them
selves on the 'wrong side' of the therapist / patient
divide have highlighted the gulf that exists between
-he experience of the service provider and the 'strug
1]ling to be heard' service receiver. The seminal work
Parr et ai, 1997, in the field of aphasia and some of
-:he creative app/oaches to helping people with learn
g difficulties (Sampson, 1998), dementia (Killick,
998) or those in hospices (Bolton, 1998) to tell their
wry and be heard in their own voice seem to me per
ive arguments for developing more 'holistic' and
_ ant interventions which do not compete with but
omplement our skills as the clinical expert.
Hering perspectives are a source of common con
within healthcare settings 'in which different
social groups frequently hold different distinctions
and explanatory frameworks, or narratives for
identifying and navigating illness' (Donald, 1999).
Learning to listen and helping our clients to navi
gate their illness must then entail both a monitoring
of the specialist language or interpretive jargon of
the profeSSional and a sound understanding that
different ethnic groups, social classes and genera
tions of people who use our services do not share
the same causative frameworks or socially construct
ed narratives of the specialist clinician who listens to
them. 'Doing therapy' is not just about listening to
the voice of the 'patient'. It entails a clear aware
ness of ways in which the identity of the therapist
and the identity of the service in which we work
may produce a clash of narratives - how we might
be influenced by the predominant medical narrative
of impairment, abnormality, coping, rehabilitation,
adjustment and/or by the struggle of the client to
construct a new ontological* narrative. Listening
and, importantly for us, facilitating the telling of
these narratives which help disabled people make
sense of and act upon who they are in the context
of their disability, can avoid the danger that 'we, as
isolated individuals, are trapped within the story
lines of the prevailing narratives' ( Thomas, 1999, p
55). This, in turn, has the potential to impact signif
icantly upon positive and hopefully meaningful out
comes from our therapeutic services.
A powerful modern influence on effective or filtered
listening in the healthcare setting is Evidence Based
Medicine (EBM). Donald (1999) expresses her hope
that the drive of EBM may provide the 'discursive
space' in which previously opposing narratives can be
reconciled and both patients and practitioners can
state their views on whether or not treatments work
compared to other or no treatments. Hopefully, as
an understanding and valuing of different method
ologies takes place this will be the case, though cur
rently there is the additional barrier to listening for
many clinicians that the gold standard of much
research remains firmly located within a dominant
reductionist discourse of impairment-based interven
tions and quantitatively measured change. This is a
tangible pressure for clinicians and researchers, many
of whom (myself included) have yet to develop the
tools, expertise and confidence which might enable
us to mine the narratives of patients and clients for
an alternative form of golden evidence.
Learning to listen - the third way?
Power, perspectives, professionalism, preoccupa
tions and priorities might all then conspire to influ
ence the true 'listening' capacity of the therapist.
Does this mean that therapists should seek safety in
either the super-expert role or the generalist reha
bilitation assistant? Though I would not underval
ue the role that either of these players adopts in a
multi-faceted approach to long-term support, I
hope that most of us have a range of alternative
narratives which we may also be able to develop.
Enhanced listening skills offer a number of exciting
new foundations on which to build. At an educa
tionallevel this involves the development of cours
es which are liberated from the uni-dimensional,
professionally constructed view of disability and
embrace diversity - models which place impair
ments and their study firmly alongside education
about the socially constructed disadvantage which
many disabled people face daily throughout their
experience of disability. At a research level, quali
tative methodologies such as in-depth interviewing
place at their very core a need to listen to the
respondent and subject this narrative to rigorous
and systematic analysis such that it yields a reality
and richness which statistics and quantitative
methodologies have supported in other areas of
advancement. At a practitioner level, the new
drive to include service users in the dialogue and
decisions about their care similarly provides the
impetus and challenge to listen intensively and
reflectively to the narrative of the storyteller.
Carole Pound works at City University as the Director
of the City Dysphasic Group, a centre offering long
term therapy and support for people with aphasia.
*ontological: reflecting nature and essence; pure
being
References
Bolton, G. (1998) Writing or pills7 Therapeutic
writing in primary health care. In C. Hunt and F.
Sampson (eds.) The Self on the Page. London:
Jessica Kingsley.
Donald, A. (1999) The
words we live in. In T.
Re ections:
Greenhalgh and B. Hurwitz
(Eds.) Narrative based med
1. Do I recognise
icine. London: BMJ Books.
Frank, AW (1995) The the need for
wounded storyteller.
continuing to
Chicago Chicago
develop my
University Press.
listening skills?
Greenhalgh, T. and
Hurwitz, B. (Eds.) (1999) 2. Do I allow clients'
Narrative based medicine.
unique stories to
London: BMJ Books.
set the direction of
Killick, J. (1998) A matter
therapy?
of life and death of the
mind: Creative writing and 3. Do I look
dementia sufferers. In C.
beyond my own
Hunt and F. Sampson ( eds.)
narrow speCialist
The Self on the Page.
area?
London: Jessica Kingsley.
Parr, S., Byng, S., Gilpin, S. and
Ireland, C. (1997) Talking about aphasia: Living with
loss of language after stroke. Open University Press.
Sampson, F. (1998). Men wearing pyjamas Using
creative writing with people with learni ng disabil i
ties. In C. Hunt and F. Sampson (eds.) The SeH 0
the Page. London: Jessica Kingsley.
Thomas, C. (1999) Narrative identity a d th dis
abled self. In M. Corker and S. Fre ch (eds.) D" - bi!"
Discourse. Buckingham: Open Uni ersity
For information on the Royal Coll ege of Speech &
Language Therapists tel. 0171 613 3855 or see
http://www.rcslt.org 0
SPEECH & LANGUAGE THERAPY IN PRAalCE AUTUMN 1999 21
further reading
rther read ing This regular feature aims to provide information about articles in other journ
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 YO
4PP, tel. 01765 640283. fax 01765 640556.
Pri nted version:
Institution 90
Institution 60
Individual 60
Individual 45. Cheques are payable to Biomedical Indexing.
SYNDROMES
Rosen, A.c.. Newby, R,E, Sauer, C.M" Lacey, 1, Hammeke,
lA. and Lubinsky, M.S, (1998) A further report on a case of
Floating-Harbor Syndrome in a mother and daughter. J
C1in Exp Neuropsychol 20 (4) 483-95.
We present the most extensive neuropsychological and lan
guage assessment yet reported of patients diagnosed with
Floating-Harbor Syndrome (FHS), a rare genetic condition
characterized by dysmorphid figures, short stature, and
speech-onset delay. This is also the second reported occur
rence of both a mother and daughter with FHS. Whereas
the child demonstrated gross deficits in verbal expression,
speech and language problems were largely ameliorated '
in the mother. Neuropsychological assessment also revealed
a strikingly similar pattern of cognitive problems additional
to language dysfunction, including difficulties with atten
tion, mathematical, and visuospatial abilities. A mood dis
order continued to be quite disabling for the mother.
VOICE
Ylitalo, R. and Lindestad, P.A. (1999) A retrospective study
of contact granuloma. Laryngoscope 109 (3) 433-6.
OBJECTIVES: This study evaluates the clinical features of
contact granuloma and compares the results of voice thera
py in operated versus unoperated cases. STUDY DESIGN:
Retrospective review of 123 patients with contact granulo
mao Thirty-six patients had undergone one or more surg
eries before phoniatric consultation. After their final oper
ation, 33 patients had recurrence. The three patients who
were cured by operation were not studied further. The
course of disease in the 33 patients with recurrence was
compared with that of 87 patients who did not have
surgery. METHODS: The hospital records were reviewed
concerning age, sex, symptoms, side of granuloma, and out
come of treatment. RESULTS: The predominant symptoms
were vocal fatigue, vocal discomfort, the need for excessive
throat clearing, and hoarseness. The recurrence rate after
operation was 92 %. Twelve months after voice therapy,
35% of the operated group and 51 % of the unoperated
group were cured. The patients who had surgery had
almost twice as many sessions of voice therapy as the unop
erated group, and their mean recovery time was 17 months,
compared with 8 months for the unoperated group. CON
CLUSIONS: The recurrence rate after surgery was high.
Surgery may prolong the recovery time. Subjective symp
toms diminished during voice therapy, but we cannot con
firm that it was beneficial for the healing process.
CONVERSATION
Wilkinson, R. (1999) Sequentiality as a problem and resource for intersubjectivity in aphasic con
versation: analysis and implications for therapy. Aphasiology 13 (4-5) 327-43.
Investigations of non-aphasic conversation have displayed the importance of sequentiality in the
meaning and understanding of utterances in conversation. Sequentiality refers to the way in whi ch
an utterance is constructed so as to display its relation to the immediately preceding utterances
and to make expectable a certain type of utterance in the following turn. As such, it has been
shown to be a central resource for participants in achieving intersubjectivity, or a state of mutual
understanding, in conversation. In this paper, sequentiality in aphasic conversation is investigated.
It is found that aphasia can disrupt the speaker's ability to display the sequential properties of
utterances in conversation and can, therefore, be an important reason why certain aphasic turns
can be difficult for hearers to understand. However, aphasic speakers
are also shown to be able to use the sequential context of ear
lier turns as a resource to aid communication by referring
deictically to prior utterances. It is suggested that
these findings have clinical importance in assessing
functional language use and planning therapy.
de Kinkelder, M. and Boelens, H. (1998)
In particular, it is noted that these conversa
Habit-reversal treatment for children's stutter tional problems may require a different
ing: assessment in three settings. J Behav Ther
approach to the types of therapy employed
for disorders at the word and sentence
Exp Psychiatry 29 (3) 261-5.
level. Some ways in which a more interac
Two boys (9 and 14 years old) participated in an eval
tionally focused therapy may target
uation of treatment for stuttering. Habit reversal pro-
these problems are discussed.
cedures (awareness training, regulated breathing,
and social support) were combined with teaching
VIRTUAL TRAINING
positive attitudes to parents. During treatment, stut-
Brooks, B.M., McNeil, J.E., Rose, ED. ,
tering frequencies decreased, speech rates
Greenwood, R.J., Attree, E.A. and
increased, and speech naturalness ratings
Leadbetter, A.G. (1999) Route learning in a
increased. These changes occurred in the clinic,
case of amnesia: a preliminary investigation
the child's home, and the child's school. After into the efficacy of training in a virtual envi
ronment. Neuropsychol Rehabil9 (1) 6376.
treatment, stuttering remained low in the
A patient with amnesia was trained in route findi ng
clinic and at home, but increased stut
around a hospital rehabilitation unit using a detailed
tering was found at school.
computer-generated non-immersive 3D virtual environ
ment based on the real unit. Prior to the training, she was
unable to perform 10 simple routes around the real unit, all involving
locations which she visited regularly. She was tested at weekly intervals on these same 10 routes
around the real unit during the course of the study. Her first course of training involved practising
two of the 10 routes in the virtual environment for 15 minutes each weekday. After three weeks'
training, she successfully performed these two routes in the real unit and she retained her knowledge
of these routes for the remainder of the study, despite not receiving any further training on these
routes . For her second course of training, two more of the original 10 routes were chosen, one of
which she practised in the virtual environment and one in the real unit. Within two weeks, she had
learned the route practised in the virtual environment, but not the route practised in the real unit,
and she also retained her knowledge of this route. The results of this preliminary study indicate that
training in virtual environments may prove an effective method of teaching new information to
patients with severe memory impairments.
LEARNING DISABILITY
McLean, L.K., Brady, N.C., McLean, J.E. and Behrens, G.A. (1998) Communication forms and functions of children and adults with severe mental retardation
in community and institutional settings. J Speech Lang Hear Res 41(6) 231-40.
The forms and functions of expressive communication produced by 84 individuals with severe mental retardation were assessed using a structured communica
tion sampling procedure. Symbolic communication acts were produced by 39 participants, and 27 of these communicators produced one or more multi
word/multisymbol utterances. Of the remaining participants, 38 produced intentional but nonsymbolic communication acts; 7 were not observed to produce any
intentional communication. For all participants who produced intentional communication, there were significantly more imperative than declarative communi
cation acts. Significant differences in the frequencies and functions of communication acts produced by these participants were associated with differences i
their communication levels (contact gesture, distal gesture, or symbolic), age (child vs. adult), and residential status (community home vs. large facility).
how I
Fiona Robinson is a
speech and language
therapist / lecturer and
adviser in head and neck
cancer for the Royal
College of Speech &
Language Therapists. She
has organised the National
Head and Neck Oncology
Rehabilitation Conferences
in Nottingham since 1987,
with the fifth one to be
held in September 2000.
Jane Machin is a speech
and language therapist
and lecturer based at the
Royal Marsden Hospital.
She is co-author of
'Working with Oral Cancer'
published by Winslow.
Susan Salt MB BS, MRCGP
is a specialist registrar in
palliative medicine at
Manorlands in Keighley,
,
West Yorkshire. She is also
a trainee on the Yorkshire
Palliative Medicine rotation.
.. manage
head and neck
cancer
Management of clients with
head and neck cancer is
generally driven by
specialist centres which concentrate
expertise and experience and
involve large multidisciplinary
teams. As the bulk of therapy
following surgery is likely to be
offered more locally, it is crucial
for specialists and non-specialists
alike to have an appreciation of
what is required at the
pre-operative, post-operative and
in some cases - terminal stages,
and to work together to provide the
best possible service. Three
contributors offer their perspectives
on professional standards,
working within a team and
palliative care.
how I
Setting
the
stanaara
In the head and
neck cancer
fjeld. specialist
therapists are at
the forefront of
the speech and
language
therapy
profession's
general drive to
set standards
and improve
clinical
effectiveness.
Fiona Robinson
charts their
progress.
S
tandard setting is about ensuring that the therapy we
provide is effective. Standards of quality are equally
applicable to the service we provide and to the work
force which provides it. As a profession we need to
have evidence that speech and language therapists are fit for
purpose. That is, the education, training and resources pro
vided to speech and language therapists should ensure that
they can carry out clinical practice that is safe, effective, and
evidence based.
Following publication of the Caiman Hine Report (1995), can
cer services are undergoing a huge shift in organisation and
delivery. For the first time there is much visible collaborative
work, particularly generated by the surgeons. This is taking
the form of writing down what we all actually do, identifying
best practice, and committing to paper - and therefore scruti
ny by our peers, purchasers and users - the processes by which
patients travel through this stage in their lives.
The Caiman Hine Report has provided the impetus for
change, and colleagues around the UK are being asked to
contribute to a range of working parties, committees and
planning groups. These have included
identification of Education and Training needs across the
professions
Primary Care Frameworks documents
frameworks of practice documents across the local cancer
centres and units.
As stated in Communicating Quality 2 (1996), Standards and
Guidelines represent the benchmarks of speech and language
therapy practice and, as such, they should provide measur
able criteria against which compliance can be judged.
Another Royal College of Speech & Language Therapists
(RCSLT) publication "Clinical Guidelines by Consensus for
Speech and Language Therapists" (1998) states that guide
lines should be agreed with other relevant professionals and
reflect user and carer views.
For me, writing standards and guidelines in the area of head
and neck cancer has been a task which starts with a blank
page and a look at how others are tackling this thorny issue.
Once a first stab has been made, I tend to rope in colleagues
from speech and language therapy and other related disci
plines to comment and refine.
Logical progression
As a profession, we have well established and effective mul
tidisciplinary working with our surgical colleagues, particu
larly in ENT, and latterly with the maxillofacial surgeons who
are beginning to manage some of these tumours in some ser
vices. Incorporating the multidisciplinary ethos has therefore
been a logical progression, readily embraced in documents
since 1995.
Regional incidence of head and neck cancers varies through
out the UK from 7.7 (SE Thames) to 15.3 (Wales) per 100,000
population. The commonest sites of UK head and neck can
cers are (BAO-HNS, 1998)
Larynx 2376
Oral Cavity 2156
Pharynx 1241
With such small numbers comes the issue that the speech and
language therapy component of rehabilitation is indeed a
tiny fish in a very sma ll pond, and local isolated contributions
would not further our national evidence base nor provide
frameworks for services across the UK. Indeed, the Caiman
Hine report points out the importance of planning cancer
care at a macro level with centralist direction.
In the summer of 1998, for the Midlands and SE Head and
Neck Cancer Special Interest Groups, I reviewed the Caiman
Hine Report and a further document about the workforce
planning and training implications (1997). Interestingly, the
latter did not consider speech and language therapy services,
but important inferences can be drawn from the other pro
fessions. Feedback echoed my own concerns that, as a pro
fession, we were in danger of contributing to frameworks of
practice for local policies only.
Lack of information
At this time, there was no national consensus statement
about what the speech and language therapy profession felt
was best practice in this clinical area and what would be
achievable. Neither was there information about workforce
planning to support the changing organisation of services to
head and neck cancer patients, nor any statement about the
education needs of therapists to ensure effective and evi
dence based practice in this field beyond undergraduate edu
cation. Just as important, there is little information about
what the users of the service identify as essential practice.
Both these documents assert that the Royal Colleges and
Professional Bodies will playa central role in providing and
seeking information to inform essential planning work. The
group felt a national audit of the service now being provid
ed nationally by our profession was crucial. The information,
(collected and analysed by the Audit Department at the
University Hospital , Nottingham in September) will be dis
seminated through the RCSLT.
Furthermore, myself and colleagues have been trying to
define standards and guidelines for three main areas in head
and neck cancer
1. our work in the multidisciplinary team
In 1998, Paul Carding and I were delighted to be involved in
the multidisciplinary BAO-HNS Consensus document. Our
contribution "Rehabilitation of Speech and Swallowing"
begins to identify good practice during the pre, post, and late
post-operative periods, with statements about the skill level
the patient should expect from the rehabilitation team .
2. our own clinical skill and effectiveness
The Professional Standards Board of the RCSLT convened a
multidisciplinary working group to provide guidelines (1999)
on invasive procedures, which include Tracheo-Oesophageal
Puncture Prosthesis (TOPPs). These consider areas such as
knowledge and skill required to carry out procedures, and
the health and safety requirements.
3. standards to ensure our training and education
underpins our work
In April I was asked to provide statements of quality objec
tives and outcome measures in head and neck cancer
(Robinson, 1999) (see figure 1 for examples) for another
national document "Practice guidelines for clinicians partici
pating in the management of head and neck oncology
patients in the UK" (Draft document. 1999) being edited by a
local ENT surgeon. It was crucial to involve learned colleagues
in this despite a three week time scale and, remarkably, we
have produced a consensus document drawn from specialist
clinicians from the UK.
The outcome measures are crude, mainly "it is happening, or
it isn't", and will need further refinement by a wider panel.
But the important thing is that we have a voice in the docu
ment which can be modified at a later date.
Wider picture
In reviewing the completed work, there were concerns that
some of the objectives were unachievable within their own
local service, but - and this is the crucial part - no-one want
ed to water it down. Despite being unable to achieve an
objective, perhaps because of local geography, contributors
felt it was important to consider the wider picture and
include objectives considered good practice to aspire to and
which may be used to highlight deficiencies in service provi
24 SPEECH & LANGUAGE THERAPY IN PRAalCE AUTUMN 1999
how I
Figure 1 - Examples from draft guidelines
QUALITY OBJECTIVE
PRE, PERI AND POST OPERATIVE CARE
a) to minimise the delay in seeing patients with
communication and swallowing difficulties
following surgery/radiotherapy
b) to facilitate early communication strategies
in the early post operative stage
c) to minimise the number of outpatient visits
MULTIDISCIPLINARY TEAM WORK
a) to ensure that information about the patient is
available to inform team management decisions
b) to ensure a co-ordinated approach to
rehabilitation of swallowing and communication
sion locally. The consensus document produced is not com
prehensive, not formally evidence based and should be
viewed only as a starting point. However, it will be available
from RCSLT to provide a reference for services across the UK,
and will need to be revisited regularly to ensure relevance.
The work carried out so far has drawn on evidence which
relies heavily on the contributing clinicians' own experience
and knowledge. The AHCPR (1995) states that national direc
tives on the establishment of clinical guidelines should be
based on evidence from "expert committees, reports or opin
ions and / or clinical experience of respected authorities" .
Our professional challenges over the coming months and
years include
to identify and report good clinical practice
to m o n i t o ~ and modify standards of quality
to continue to develop and contribute to national and local
multidisciplinary guidelines and policies
to provide accredited education and training opportunities
to provide research evidence to support this work.
We have informal networks of advisers and experienced clin
icians. By collaborating widely and contributing and sharing
our practice and opinions to produce consensus standards
and guidelines, we are ensuring that these are representative
of the profession as a whole and, as such, are useful and rel
evant to the professional practice of each individual clinician.
OUTCOME MEASURE
the speech and language therapist (SLT) will see
inpatient referrals within 2 working days .
the SLT will see outpatient referrals within 15 working days
the SLT will introduce strategiesladjunctive communication
aids where appropriate
the SlT wiJl initiate surgical voice restoration (SVR) as soon
as the patient is fit
the SLT will schedule appointments to tie in with
attendance at the Combined Clinic
the Surgical Voi<e Restoration Clinic will run alongside the
main Combined Clinic
the SLT will liaise appropriately with colleagues
and patients/carers
the SLT will be available to attend case conferences, ward
rounds and clinics
the SLT will liaise with the patient's local services ego SLT
the SlT will contribute to the multidisciplinary patient record
the SLT will provide in-service training, advice and
supervisiolifor designated members of the multidisciplinary
team ego in SVR
References.
Caiman Hine Report (1995) A policy framework for commis
sioning cancer services. A report by the Expert Advisory Group
on Cancer to the Chief Medical Officers of England and Wales.
RCSLT (1996) Communicating Quality 2. Professional
Standards for Speech and Language Therapists.
RCSLT (1998) Clinical Guidelines by Consensus for Speech and
Language Therapists.
British Association of Otorhinolaryngologists (BAO-HNS)
(1998) Effective Head and Neck Cancer Management.
Consensus Document.
Cancer Collaboration: Improving cancer patient care (1997)
The Workforce Planning and Training Implications of the
CalmanlHine Cancer Report.
RCSLT (1999) Invasive Procedures Guidelines for Speech and
Language Therapists.
Robinson, H.F. (1999) Quality Objectives and Measures of
Outcome in Head and Neck Cancer for Speech and Language
Therapists. A consensus document.
Draft Document (1999) Practice Guidelines for Clinicians par
ticipating in the Management of Head and Neck Oncology
Patients in the UK.
Agency for Health Service Policy and Research (1992) AHCPR
Publication 92/0038. US Department of Health and Human
Services. Rockville, M.D. .00
SPEECH & LANGUAGE THERAPY IN PRACTICE UTUM 1999 25
how I
A

shareu
Working within a
team is not just
best for the
patient and
their family - it
also provides
the team
members with
professional
and emotional
support. Jane
Machin extols
the particular
benefits in the
field of oral
cancer.

............

,..-
THE ROYAL
MARSDEN
O
ral cancer is particularly distressing, as often it
impairs eating, drinking and communication, so the
patient can easily feel socially isolated in addition to
all the other concerns about living with a life
threatening disease. We find that working as a multidiscipli
nary team with this patient group is beneficial all round. The
different team members are knowledgeable about one anoth
er's work and it is sometimes appropriate to manage patients
jointly (Kelly, 1994). By the same token, multi-disciplinary team
members have their individual, highly specialist skills, so the
work of all the professionals involved combines to offer the
best possible rehabilitation for the patient and their family.
The list of core team members would usually include the clin
ical nurse specialist and nursing staff, speech and language
therapist, dietitian, physiotherapist, specialist dentist and oral
hygienist, medical staff, prosthetic specialist and socia l work
er, but others could be added.
We usually aim to meet the patients and their family or carer
at the Joint Head & Neck Clinic (so-called because all the dif
ferent medical specialists - surgeons, radiotherapists and
medical oncologists - are available). At this point the patient
has just recently received their diagnosis. Frequently the
patient and their family can then arrange to meet the multi
disciplinary professionals most relevant to their needs again,
prior to undergoing surgery or radiotherapy.
Overwhelming
We have all been aware that the initial vis it to the Joint Clinic
could seem very overwhel ming to some patients, with a lot of
information to absorb at a time when they may feel shocked
and anxious. With this in mind, our Clinical Nurse Specialist
and Out-Patients' Sister are together establishing a pre
admission clin ic at a separate t ime. Then patients can be
seen, by appointment, by mUlti-disciplinary team members in
a more relaxed setting. We issue written information as
appropriate, often booklets from our carefully produced
Patient Information Series (see resources) supplemented by
literature from various charitable organisations such as
Cancerlink, BACUP, or Changing Faces. We explain again
what to expect from surgery, radiotherapy or chemotherapy
in terms of function and rehabilitation, answer questions,
give extra information and offer reassurance.
Many patients have significant dysphagia as a presenting
symptom so the speech and language therapist and diet it ian
work jointly in identifying and managing patients at risk
nutritionally and because of problems with the mechanics of
swallowing (Machin and Shaw, 1998).
Close contact
Once a patient is admitted to hospital for their treatment or
begins daily attendance for radiotherapy, the team members
involved maintain close contact with one another and, of course,
the patient and their family or carer. On a weekly basis we have
a meeting prior to the main ward round where all patients'
progress and needs are discussed. The main focus is on those
with multiple problems or whose treatment or recovery is not
progressing as well as had been hoped. The meeting affords an
opportunity, for example, for all in the team to review a video
fluoroscopy result or discuss a treatment plan in more detail.
There is also a meeting on the ward once a week led by a
member of the specialist nursing staff, with the other para
medical staff present as appropriate. The aim is to think
towards and plan discharge so that, when the time comes,
any support services or extra help needed by a patient or
their family have been set in motion. It also serves as a forum
to alert members of the team to particular difficulties experi
enced by a patient I family. For example, someone may be
ident ified as needing referral for psychological support, extra
care from the oral hygienist or maybe access to the com ple
mentary services, such as therapeutic massage or art therapy.
When a patient has completed treatment, they are invited reg
ularly via the Joint Head & Neck Clinic (which takes place week
ly), although they may of course also be having ongoing out
patient appointments with one or two disciplines. For those
who live at some distance, we may arrange for these appoint
ments to be on the same day or, if appropriate, share care with
more local services. In the latter case, individual therapies liaise
with the relevant disciplines locally, keeping them informed of
therapy plans and overall management of the cancer or its
treatment. At this stage, all the benefits of teamwork described
with reference to the initial appointment again come into play.
Open access
As time passes, many of our patients experience recurrence of
their disease with all the attendant problems - they may need
further medical treatment or management of unpleasant
symptoms, and here we find the open access to the palliative
care team invaluable (Scholes et ai, 1997). Their out-patient
clinic is held at the sa me time as the Joint Head and Neck cl in
ic, so members of their team are freely able to come and
advise on pain control in particular.
Patients often remark that they find it reassuring to attend this
joint clinic - whether it be for a routine check-up or to deal
with the news of recurrence - as they are familiar with all the
various staff and know they will be available to help with a
given individual's needs at that ti me. If they are feeling unwell
or tired it is useful to have everyone in the same location.
Having worked within this team setting for many years, I would
be the first to recommend the benefits strongly. Functioning as
a part of a team affords individual team members professional
support and also emotional support when dealing with what
can be the harrowing effects of this disease and its treatment.
More importantly, patients, their families and carers all benefit
from the shared expertise of a range of experienced profession
als; solutions can be found for many of the difficulties they are
experiencing at a given time. It would be wrong to suggest that
there are never any difficulties in teamwork, but ways of over
coming these are well documented elsewhere (Herbert, 1996).
In our setting the approach proves beneficial to all con
cerned, especially as we are often dealing with patients with
advanced disease drawn from a wide catchment area.
Resources I organisations
Royal Marsden booklets
Available from Hochland Communications Ltd, 174A Ashley
Road, Hale, Cheshire, WA15 9SF, tel. 01619290190.
Cancerlink
11 -21 Northdown Street, London Nl 9BN, tel. 01718332818.
Freephone cancer information helpline, 0200 132905
http://www.cancerbacup.org.uk
BACUP
Booklets include the Understanding Cancer series - Mouth and
throat and the Living with cancer series - Facing the challenge of
advanced cancer.
From 3 Bath Place, Rivington Street, London EC2A 3DR, tel.
0171 613 2121, Cancer informati.on service, freephone 0800 18
11 99. Counselling Service: 0171 6969000.
Changing Faces
1-2 Junction Mews, Paddington, London W2.
References
Kelly, R. (1994) Nursing Patients with Oral Cancer. Nursing
Standard 8 (32) 25-9.
Machin, J. and Shaw, C. (1998) A multidisciplinary approach
to head and neck cancer. European Journal of Cancer Care 7,
93-6 and Corrigendum, EKC (1998) 7, 263.
Scholes, c.. Frankum, L. and Maher, J. (1997) Management of
Advanced Head & Neck Cancer. Progress in Palliative Care 5
(2) 54-59.
Herbert, S. (1996) A team approach to the treatment of dys
phagia. Nursing Times 92 (50). D
how I
P
atients with head and neck cancer form a heteroge
neous group about whom it is hard to generalise.
Their primary tumours range from the larynx or phar
ynx to the oral cavity, paranasal sinuses and beyond.
It is a devastating illness which is increasing in incidence and
still has a poor survival rate despite improving treatment tech
niques (Hindle and Nally, 1991). Problems faced include:
Grief and bereavement at facing a life-threatening illness.
Loss of identity, confidence and self-esteem because of the
disfigurement of surgery, radiotherapy or the tumour itself .
Loss of sexua I ity.
Difficulties of the family in accepting the illness and its
impact.
Social isolation.
Two case examples illustrate some of the complicated issues
involved:
Case 1
AK was a 50 year old alcoholic. He hadspent many years
living in bedsits, dependent on benefits. He had lost
contact with his family. In April 1997 he presented to his GP
with a hoarse voice. Four months later a diagnosis of
laryngeal carcinoma was made, delayed because of his
failure to attend appointments. He went into hospital for a
larynge.ctomy only when his cat was taken in by his social
worker for the duration of his surgery and convalescence.
Post-operatively he took his own discharge from hospital at
four days and defaulted from follow up. In January 1998 he
developed pain in his right hip and an l(-ray confirnied the
presence of a metastatic spread to his right femur.
Throughout, he continued to drink heavily. His pain
responded well to .oral morphine, but his chaotic lifestyle
was such that there was concern about how safe it was to
prescribe it on a regular basis. He struggled to
communicate his needs, reluctant to use a speaking device
and to write because of his alcohol induced tremor. He
found it hard to relate to health care professio[1als whom
he felt had robbed him of any quality to his life by
removing his ability to speak. He was referred to the local
community palliative care team for symptom control.
advice and support. He deteriorated over the nel(t four
months and died in a local hospice in June.
Case 2
KG was a 60 year old married man. He was diagnosed
with a malignant paranasal tumour in 1995 and
underwent el(tensive surgery and post-operative
chemotherapy. He was able to return to work as a
draughtsman sil( months later. In November 1997 he
experienced vague discomfort in his right cheek. Initial
investigations were unhelpful. He continued to feel
generally unwell and fatigued. His wife was concerned
about his weight loss and reluctance to eat. In February
1998 a Magnetic Resonance Imaging (MRI) scan showed
recurrence in his mal(illary sinus with spread to his
cervical lymph nodes. After extensive discussion. he
decided to undergo further surgery. Post-operatively he
developed a wound infection and ultimately
reconstructive surgery failed. He was referred to the local
hospice for pain control and psychological support. He
had a percutaneous gastroscopy feeding tube (PEG) as he
was unable to maintain an adequate oral intake. He was
devastated by the failure of the surgery and talked
openly about the possibility of sui.cide or euthanasia. His
wife was exhausted and felt no one was hearing how
much the family as a whole was suffering . . She felt the
surgeons ha'tl abandoned her husband to a slow and
painful death. After five weeks in the hospice he went
home. Two months later he was readmitted and died five
days later.
Restoring quality
For patients like these it is usually not possible to alter the dis
ease trajectory but, by using a multi-professional approach, it
can be possible to restore some dignity and quality to the
ti me they have left. How is that achieved? It necessarily needs
time, patience and a willingness for all professionals to use a
palliative care approach, meaning "the active total care of
patients whose disease no longer responds to curative treat
ment, and for whom the goal must be best quality of life for
them and their families" (WHO, 1990).
Thus the aim of treatment shifts from cure to comfort, from
restoring function to maintaining residual function. Most
patients with head and neck cancer will need some input
from specialist palliative care services via the hospital, com
munity and / or the local hospice (NCHSPCS, 1995). Whatever
the specialist input, it is essential to maintain the primary
health care team (Gp, district nurse) as the key workers in the
community. The role specialist palliative care can play for
physical, psychological and social issues is illustrated by look
ing at the two case histories in a little more detail.
1. Physical symptoms
Symptom control is a priority. Chronic, uncontrolled pain affects
every aspect of a patient's life and frequently leads to depression.
Pain in head and neck cancer can often be vague which can cause
problems in making an accurate diagnosis of its aetiology. The
pain may be due to the cancer itself or due to other factors such
as previous surgery, poor dental hygiene or infection.
Appropriate measures need to be instituted and adequate anal
gesia, often strong opiates, given. In the case of AK, slow,
releasable, soluble oral morphine was given once a day, in the
morning when he was usually sober and could safely take the
correct dose. A transdermal patch of a strong opiate was used by
KG so he did not have to rely on administration via his PEG tube.
80th needed careful and regular mouth care. The hospice trained
KG's wife to do this allowing them to share some of the burden
of his illness. Other physical symptoms which need addressing
include anorexia, taste changes, drooling of saliva, skin break
down and the problems caused by distant metastatic spread.
2. Psychological problems
80th cases illustrate the profound psychological consequences
of this devastating illness. Considerable time and skill is need
ed to help these patients communicate their frustrations,
whether through voice, writing or, in the case of AK, drawing
and painting. To avoid the feeling of abandonment by the
head and neck cancer team, it is helpful to get some members
of the palliative care team involved early in the course of the
illness, even at diagnosis, which can allow a gradual transition
of care from one approach to the other (figure 1).
Figure 1 - Theoretical relationship acute / palliative services for
a cancer patient
DIAGNOSIS DEATH
' _ ' _ ' _ " '_' ,._. . -.-;:;;,z.---+.TIME '"
acute services include surgeons, oncol09ists, clinical nurse
D
specialists, speech and language therapISts, dietitians etc.
palliative care services include clinical nurse
LJ doctors, speech and language therapists, dietitians etc.
Many patients have fears about the process of dying including:
choking to death
bleeding to death
dying with uncontrolled pain because they can no longer
swallow tablets
dying alone in a pool of vomit.
Talking openly about such fears and explaining what can be done
to avoid them often reassures both the patients and their families,
3. Social issues
A key to caring for the patient is also to care for the carers.
Mundane matters such as finances can seem overwhelming
and basic benefit advice is essential, particularly when the
patient is the main wage earner. In the case of AK the palliative
Head and neck
cancer is
devastating for
patients and
families. Susan
Salt illustrates
how palliative
care can have
an impact at all
stages of a
patient's illness.
SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMIII 1999 27

care team gave support to his social worker who was carrying
the main burden of his care. KG's wife and daughters needed
time to talk about how hard the preceding four years had
been, confirming the normality of grieving for him before his
death and allowing them to express their anger with KG and
each other. This helped them all to continue to care until his
death. The hospice continued to provide bereavement sup
port after the death of both these individuals.
Impact
Palliative care can have an impact at all stages of a patient's
illness. What is certain is that it only works when it is based
on a team of individua ls using their professional expertise
together for the benefit of each patient.
References
Hindle, I. and Nally, F. (1991) Oral cancer: a comparative st udy
between 1962-67 and 1980-84 in England and Wales. British
Dental }ourna/170: 15-20.
World Health Organisation (1990) Cancer pain relief and pal
liative care. Technical report series 804. Geneva.
National Council for Hospice and Special ist Palliative Care
Services (1995) Specialist Palliative Care: A Statement of defi
nitions. Occasional paper 8. London .
Further reading
Doyle, D., Han ks, G.w. and MacDonald, N. (1997) Oxford
Textbook of Palliat ive Medicine (2nd ed) Oxford Medical
Publications, Oxford.
Doyle, D. (1997) Symptom Management in Advanced Cancer.
Radcliffe Medical Press, Oxford .
Fallon, M. and O'Neill, B. (1998) ABC of Palliative Care. BMA
Books, London.
Practical points:
1. Team working is essential for clients, carers and professionals.
2. Service planning must take account of the wider implications of a major illness_
3. When a client is dying, aims shift from cure to comfort and maintenance of residual function.
4. Speech and language therapists, particularly those working in small specialist areas, should
share experience and good practice nationally.
5. Specialist centres and local services need to maintain strong links.
6. Written information booklets back up what has been explained to clients and carers.
7. Professional standards and guidelines should facilitate best practice and not just reflect what
is immediately achievable.
spe
g

Autumn 99
speechmag:
Reprinted articles
Intensive group treatment
- a positive approach to
therapy (Gina Wilson and
Marsha Evans, May 1989)"
Nottingham paediatric
team charts progress in
cochlear implant programme
(Tracey Twomey and Dee
Oyar, August/September
1995)**
Dementia - The power of
carer perceptions (linda
Armstrong and Sheena
Borthwick, Feb/Mar 1997)*
All from Speech Therapy in
Practice" I Human
Communication*", courtesy
of Hexagon Publishing.
http://www.speechmag.com
Top Tips
Do you work with adults with learning disabilities? What's
on your mind j ust now? In a sentence or two, share your tips
on therapy approaches, outcome measures, caseload man
agement and resources.
Students
What's the best thing about your course? Let us know!
Top Tips for the Spring 99 speechmag was on formal assess
ments. Readers were asked to say in a sentence or t wo why
a particular assessment, new or old, is invaluable and for
whom.
Helen chooses two assessments. Does any reader know
where you can get hold of either of them)
The Phonological Awareness Assessment by Clare North
and Michelle Parker
HThis is clearly set out and a manageable length. The pic
tures are useful especially with younger children to intro
duce the concept of rhyme; that is, it can be a teaching aid
as well as an assessment tool. It is a good starting point as it
goes through all the main areas of phonological awareness."
Verbal Reasoning Skills, Canterbury and Thanet
HWhen working with children with semantic-pragmatic dif
ficulties this gives more detail about semantic system break
down and ideas for therapy."
Liz likes the
South Tyneside Assessment of Phonology (STAP) from STASS
Publications.
"The pictures are nice for children and it elicits a good
range of speech sounds."
Linda hasn't found an 'ideal ' assessment but recommends a
couple:
CELF-R UK from the Psychological Corporation
"This is not the be all and end all of assessment but shoul d
be used in conjunction with other things, especially prag
matic profiles. It is useful for highlighting a language prob
lem or particular areas that need to be looked at more
closely. I am not so keen on the pre-school version because
it doesn't give you any idea of spontaneous language."
REEL (Bzoch & League, 1971) from NFER-NELSON
"The Receptive-Expressive Emergent Language Scale is not
a forma l assessment as such but starts from birth and is par
ticularly useful for the 0 - 9 months level. There are quite a
few jumps and gaps in the 12 to 24 months part."
Abi is keen on the
CAPPA (Con versation Analysis Profile for People with
Aphasia) by Ann Whitworth, Lisa Perkins, Ruth Lesser from
Whurr, 55.00.
"This is lengthy, but gets to the heart of things. The structured
interview section is really helpful, as it gives clients and carers
the opportunity to think about what they do in conversations."
IMPORTANT NOTICE
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EVENTS
Estill Voice Training Systems (EVTS) (UK) Limited
Seminars scheduled for Autumn 1999 to Spring
2000 take place in Dublin, London, Glasgow,
Newcastle, Bri stol, Leeds, Birmingham and
Oxford and range from an introductory day to
core courses, belting and specialist courses for
actors and singers.
Prices are f rom 60.
Details from Felicity Blair, Administrator, EVTS
(UK) Ltd, 707 Quentin Road, London SEI3 5DG,
tel. 01814630543.
International Special Education Congress 2000
'Including the Excluded'
University of Manchester
24-28 JUly, 2000
Call for papers - deadline for submissions 30
September, 1999
Themes: From rights to policy, Listening to dif
ferent voices, Changing roles, Developing prac
tice, Positive outcomes.
Details: ISEC 2000 Programme Committee, CEN
School of Education, University of Manchester,
Oxford Rd, Manchester M13 9PL.
Contributions to
Speech & Language Therapy in
Practice:
Contact the Editor for more information and /
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Speech & Language Therapy
in Practice has moved.
PLEASE SEE CONTENTS PAGE FOR DETAILS
1) Communication Support Workers (CSW)
When I am working with the post-16 group
vho are in further/hi gher education, CSWs
act as sign language Interpreters between
myself and the adult. This makes my life eas
i er as there is no need to pa nic if I forget a
si gn or am unable to read back some fast fin
ger spelling. It also means my own signing
51: ills suffer from lack of practice. However
ere are occasions when there is no CSW to
bale me out, and I find the Dictionary of
British Sign Language/British (compiled for
t he British Deaf Association 1992 pub. Faber
and Faber, 20.00) a valuable resource.
2)PThL..
For the analysis of speech production pat
erns I use PETAL (Phonological Evaluation &
Transcription of Audio-Visual Language)
developed by Ann Parker and available from
Winslow, price 89.50. The assessment takes
t ime but gives detailed information about a
chi ld's phonetic and phonological features of
speech. A good quality tape recorder is need
ed to record the assessment, preferably with
headphone attachment so that the therapist
( an control unwanted background noise lev
els that may detract from the quality of the
ecording such as shoes banging on chair
legs . To use PETAL successfully you are
advised to attend a training course and this
leads to......
3) ...Tralnlng courses
organised by CSD (Communication Skills
Development) tel. 0181 8580822, which are
devised and delivered by a group of special
ist speech & language therapists for thera
pi sts working with the hearing impaired. The
group is responsible for running the prereq
ui site courses needed for further post gradu
ate training such as the MSdACS at City
University, and they will also run tailor-made
(ourses/workshops according to therapists'
training needs. These have been very suc
cessful and are a valuable resource for those
wanting to extend or update their knowl
edge, Also attendance at Special Interest
Groups has been a value-for-money and
practical way of networking and extending
my knowledge.
4) Computers
I was given an aged laptop PC when I started
thi s job. Being a technophobe at the time I
as apprehensive as to its practicality but as
't is now drawing its last breath I realise how
much I have come to rely on it and am eag,!!r
Iy awaiting its all singing and darrEing
replacement. Because my work is peripatetic,
I need equipment that is portable and easily
accessible. It means I am not secretary
dependent, can keep up to date with the lat
est technological advances that the hearing
aid manufacturers produce and shall soon be
pl ugged into e-mail.
~ ~ - - - - ~ - - - - - - ~
5) Auditory training programmes
Published programmes such as DASL II
(Developmental Approach to Successful
Listening, Stout and Windle, Resource Point
$49.95) are a valuable resource on which to
base an individualised auditory training / lis
tening programme. DASL is paediatric biased
and I use the Geoff Plant material such as
Commtram (a communication training pro
gramme for profoundly deafened adults),
Commtrac and Syntrex for the adult based
work. These are available from Holland
Audiological Services tel. 01661 823281 and
could be adapted for ot-her client groups.
6) Vlbrotoctlle devices
I find these invaluable in developing a
greater awareness of sounds such as length
features, syllable number, the presence or
absence of sound and awareness of environ
mental sounds. These devices can be costly
but the use of a simple hand held vibration
unit, attached to a speech trainer, can be just
as effective in a training session where tactile
awareness is raised alongside auditory and
visual information. PC Werth, tel. 0181 675
5151, is able to supply these devices, 98,
which are compatible with the Kamplex DU7
Speech Trainer.
7) BooI<s I videos
There are lots of books that I 'dip' into rather
than accessing .one or two texts exclusively.
McCracken & Sutherland's ' Deaf Ability not
Disability'(ISBN 185359-0800, 9.95) is a
sensible straightforward text to hand out to
parents and mainstream teachers / Learning
Support Assistants to read. A useful refer
ence book is 'Cochlear Implant
Rehabilitat ion in Children and Adults' ed.
Dianne Allum (Whurr, 1996, ISBN 1897635
54-0) as many of the strategies can also be
applied to hearing aid users.
The video 'Look, I am Hearing' (500 Belgian
francs, tel. ++32 9/223 8171) is an animated
subtitled film about how hearing works, how
hearing aids can help and when a cochlear
implant is necessary. All the parents I have
shown it to find it easy to understand and it is
included in our information packs for parents.
an Educational
Audiologist by
Staffordshire
Local
Education
Authority (LEA).
As well as
prescribing and
verifying
hearing aid
fitting following
hearing
assessments
s'he Is
responsible for
the co
ordination Of
care for
cochlear
implanted
children in
Staffordshire
LEA and
language
assessment
within her
education
support service.
Prior to taking
on this role two
years ago,
Susan was
employed as a
specialist
speech and
language
therapist with
deaf people.
She still
practises on a
part-time basis
with a mixed
adult/paediatric
caseload and
is a Regional
Clinical Advisor
to the Royal
College Of
Speech [,
Language
Therapists.
8) Toys
Various peg boards, stacking toys, men in the
boat/bus and so on are all useful when work
ing on listening skills. Mr Potato Head and
Peg a Picture can also be adapted according
to the task. I have just received a new free
field audiometer, Meg FF II, which produces
lots of interesting sounds for children to
respond to at a measured intensity and fre
quency level. This is particularly useful when
I am working with the multisensory
impaired child and trying to ascertain their
level of functional hearing skills and when I
am determining the residual aided hearing
levels of young children.
9) ;&.$se.ssments
There are many assessments around to test
the understanding and use of spoken lan
guage and I use and adapt whatever is
appropriate such as the Reynell
Developmental Language Scales, Test for
Receotion of Grammar, Clinical Evaluation of
Lang'uage Fundamentals, Derbyshire
Language Scheme, South Tyneside
Assessment of Syntactic Structures. The
Pragmatics Profile is a checklist that can be
adapted to the needs of the hearing
impaired child and there are a lot of
resources being developed by the cochlear
implant programmes that can be adapted to
the hearing impaired population as a whole.
The Bigmouth Sound pack (42.00 Winslow)
is a useful visual prompt for hearing
impaired children, and I use the Nuffield pro
gramme or Letterland to support sound
work if appropriate.
10) And finally...
At the risk of sounding trite, my colleagues
are a great source of knowledge and infor
mation . both the therapists and education
alists. They often have a new approach to an
old problem or can give you information
about a new resource they have tried out.
What can be sorted out over a cup of coffee
never ceases to amaze me!
Staffordshire
eo.t,c-I

Speech & Language Therapy in Practice, Autumn 1999

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Speech & Language Therapy in Practice, Autumn 1999

Speech & Language Therapy in Practice, Autumn 1999