Speech & Language Therapy in Practice, Summer 1998

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

guage
liherap
in Pice
SUMMERI998
(publication date 25th May)
ISSN 1368-2105
Published by:
Avril Nicoll
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High Street
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Avril Nicoll 1998
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 praduct or service offered.
Cover picture:
Accel'\t Method - breathing
(courtesy of Kirsten Thyme)

News/
Comment
Changing
communlcatJon
Lesley
Brown uses
a single
case study
to show
challenging
behaviour
can be
managed
through working with
carers on their
communication.
The counsellor
as a
companion 8
In a personal account, Christina
Shewell demonstrates how the
therapeutic journey rewards
client and practitioner.
The case for
language goals I I
Parent-child interaction therapy is
the trend for working through
parents. Dr Deb Gibbard argues a
more specific linguistic approach
is also required.
Reader Offer 14
Reviews -
education 15
2
4
COVER STORY
A dynamic
therapy 16
The co-founder of the Accent
Method explains its holistic
approach, particularly useful for
dysphonia and stuttering.
A glue ear
programmme 20
Sasha Bemrose and Charlotte Brown
work with other paediatric professionals
to provide an early intervention
programme for parents.
Further
Reading

This new regular
feature provides information
about articles in other journals
which may be of interest to readers.
Focus on
Marjon 26
The Course Leader in Human
Communication Studies at the
University College of st. Mark and
st. John Plymouth describes how
this new course is shaping up.
MyTop
Resources 30
Sarah Lloyd lists the ten items
she could not do without in her
work with pre-schoolers and
children who stammer.
Autumn '98 will be published on 31 st August 1998
IN FUTURE ISSUES
muscle speCificity . Communicate pal-enl-based intervention
dysphagia and t,-acheostomy AAC velopharyngeal incompetence
SPEECH & lANGUAGE THERAPY IN PRACTICE SUI\ IMER 1998 1
N EWS & COMMENT
Experience and learning
For many, experience is potentially the best source of learning. In her
personal account of counselling Christina Shewell takes us on a joumey,
sharing her wealth of experience. Facts are easy to teach and learn but
this article gives readers a rare opportunity to get in touch with the less
tangible aspects of a therapeutic relationship.
Every day, therapists are making efforts to pass on their knowledge and
experience to communication partners such as carers and parents. This
magazine has been active in making people think about how this can
be done. In this issue Lesley Brown asks why, even following
communication workshops, there is little observable change in the
communicative behaviour of staff working with adults with learning
disabilities? She discovers the need for practice and feedback on an
individual basis. Staff then find the changes they make bring their own
rewards in improved responses from the client, such as a reduction in
challenging behaviour.
Deb Gibbard reminds us that improving the communication impairment
of our clients is the main aim of working through carers. She argues
that, when working with pre-school children with language delay,
changing parent-child interaction cannot be the only outcome
measured as it is only of value if the child's language development
improves.
Sometimes therapy techniques just have to be experienced to be fully
appreciated and understood. The Accent Method is one of these but its
co-founder Kirsten Thyme gives us a flavour of this holistic approach.
Experience and research have shown the Accent Method to be effective
for a range of disorders, not just dysphonia or stammering, and it is
also useful as a preventative measure, for example with groups of
teacher training students.
The value of targeting resources towards preventing problems is
gaining credence in speech and language therapy. Sasha Bemrose and
Charlotte Brown's work with parents of children with persistent glue ear
suggests early, appropriate intervention can buffer the effects this can
have on communication and is therefore time well spent.
The variety of treatment approaches covered in this magazine should
enable experienced therapists to offer what Christina Shewell describes
as 'differential therapy'. At pre-qualification level the question is how do
we give students the optimum mix of theory and practical experience?
Martin Duckworth explains how, at Marjon in Plymouth, the course
design is split so each disorder is covered twice, once in theory and
then in more practical terms. It is hoped this will produce competent
practitioners who will go on to continue the lifelong process of learning.
In addition to a My Top Resources which shows how learning new
techniques - in this case the Udcombe approach - can enhance
experience, readers are introduced to a new feature in this issue,
Further reading. This is aimed at improving access to
relevant literature.
I will leave you with this thought:
'Having a lot of experience is no guarantee in itself
that you have learnt anything. For example, a person
may think he or she has twenty years' experience in
a particular area but on closer inspection really has
only one years experience multiplied twenty times:
(Royal College of Speech 8- Language Therapists'
Personal and Professional Development Planner User
Guide, 1997.)
Avril Nicoll
Editor
Lynwood Cottage, High Street, Drumlithie
Stonehaven AB39 3YZ
tel/ansa/fax 01569 740348
e-mail avrilnicoll@rsc.co.uk
~
SCOPE
fOR PI OPU WII H UIUIWAI PAl ~ y
Ta1king to parents
Healtll professionals are to be given
guidallce 011 tal/ling to pare/Its about
a flli/d's disability.
/\ series of one dll)' tmilling ellellls
drawillg togetller tile cxpe/ienfe of pare/Its,
disabled people and professionals Ilas
been plall/red by tile chm'it)' SCOPE as
part of ils Rigllt From tile Start illitiatitoe.
Tlris project aims to improve the ilia),
parellIs are told about tlreir chi/d's
disabilit), as the clrarilY's researcll IllIs
sllOlIIn tllis nellis is oJien presented
lIeg/llivel)' witll illSufficielll illforlllatioll
abollt tire collditioll or Irelp illlailable.
For information on the Northampton
day on 9 July, plice 70, tel. 01908
243619. A further date will be
confirmed for Yorkshire in the autunm.
Learning Disability
Tlust to dose
Staff, including five speech and
language therapists and an assistant,
face an anxious wait to learn the full
implications of a Trust closure decision.
The Mulberry Trust provides health and
social care seroices for people with
learning disabilities across Lincolnshire,
Leicestershire and Cambridgeshire. In
future, in line with the Learning
Disability Strategy from Lincolnshire
Health and Lincolnshire County Council
Social Services Department, seroices will
be divided into health care and social
care and commissioned from different
organisations. The Strategy aim.s to offer
increased opportunity and choice for
people in the services they receive.
Down's awareness
DOWN'S The Down's
SYNDROME Syndrome
ASSOCIATION Association is
:it,,,,,,,,,,,,dC,,,,"<, holding its Annual
Awareness Week from 6,12 June.
The campaign will focus on issues faced
by people with the syndrome and their
families. Regional and national events
are planned to raise funds and create
awareness. DSA, tel. 0181 682 4001.
MS standards
Around 50 people eve/}' week are diagnosed
with Multiple Sclerosis, yet appropriate
healthmre is not always available.
With this in mind, the MS Society has
produced standards of healthcare ill MS
in collaboration with the National
Hospital for Neurology. These are
designed to help professionals, families
and carers to identify need and ensure
equity of service. The Society's programme,
Measuring Success, encourages multi
disciplinary team.s to be assessed against
the standards.
MS Society, tel. 0171 610 7171.
SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 1998 2
A new regional communication aids service offers a range of sup
port for children with physical disabilities.
Team assessment of children from the South West referred to the
Paediatric Communication Aids Service is by a speech and lan
guage therapist, occupational therapist, physiotherapist, IT support
and a rehabilitation engineer as required. The child' s own paedia
trician and educational psychologist are also invited 10 participate.
A resource library allows equipment 10 be loaned 10 check suitabili
ty and the service also runs training days for professionals and carers.
Meanwhile, a local specialist high and low tech communication aids
service has been set up in Worthing.
The Worthing Assistive Communication Service is community
based and offers assessment and ongoing support to both children
and adults. Service Co-ordinalOr Steven Bloch says "We intend to
complement existing national centres of excellence whilst offering a
more local and responsive resource. WACS aims to take assistive
communication into the community stressing the importance of
reaching dients in their own environment. "
major
the
input
care
people
Improving diet in dementia
new Expert Working Group induding
report recognises Chief Speech & Language
need for Therapist Mary Heritage, the
speech and lan report takes a positive approach
therapy to the health of older people with
10 the dementia, focusing on improving
of elderly diet and physical activity. The
with need to take particular care when
dementia and offering pureed foods is empha
swallowing sised and round the dock avail
problems. ability of food is recommended.
A key recommenda The report also calls for all homes
tion of Eating Well fOT Older People 10 implement its nutritional
with Dementia is "In residential guidelines; a new software pro
and nursing homes, residents gram, the CORA Menu Planner is
and staff need 10 have access 10 available to assist.
the expertise of speech and lan RepOTt available from Eating Well
guage therapists, occupational for Older People with Dementia,
therapists and dietitians. This is PO Box 5, Manchester M60 3GE,
not always widely available." tel. 08706080213. Plice 12.99.
Compiled for VOICES (Voluntary CORA Menu Planner from
Organisations Involved in Caring DGAA Homelife, 1 Derry Street,
in, the Elderly Sector) by an London W8 SHY
Dyscovery roadshow
A series of awareness days has been held around the country for par
ents and professionals dealing with children with dyspraxia.
Orgamsed by the Healthcall Dyscovery Centre in Cardiff, established
In August 1997, the days included demonstrations of practical ideas.
The Centre, the only facility of its kind in the UK. has a multi-disci
plinary team including educational a.nd clinical psychologist, speech
and language, occupational and physiotherapists, behavioural
optometrists and specialist teachers.
Details: Dr Amanda Kirby, The Dyscovery Centre, tel. m222 222011.
NEWS
Complementny therapy success
The Parkinson's Disease Society
is calling for formal studies 10
investigate the value of comple
mentary therapies in the overall
management of the disease.
The plea follows a recent survey
of the Society's members who
report improved mental and
physical reJaxation and stress with events aiming to highlight
relief in particular across a the charaaeristic problems and
range of therapies such as mas how people can help. In addition,
sage, conductive education and a new pack, Parkinson's and the
aromatherapy. The most popu Speech & LanguageTherapist. was
lar is yoga, with sixty seven per launched at conferences in
cent of respondents benefiting Glasgow and Plymouth which
extremel} or considerably. considered new techniques and
lhere are more than 120 000 peo the benefits speech and language
ple in the UK who have Parkinson's. therapy can bring to people with
PD lel. 0171 383 5754. Parkinson's.
Parkinson's
Awareness
Wee k
(18-26
Apr i I )
was communication
"il/,'" "11 ,'1','1)"'11,' III rill" 11111111<1/
pi.'llt , ,),1"/11 (,' I,,' ,r/,'U (" (11,' II,','.!.' "/I'.-.,I'/!' 1I'llit ".111/111/,11" ,/i."r/l/itll,"
.11,//,',,'111 "'11/,1, '11,,' I ),/lIl,ii.III',II,' .\lill., Il("d 11r. "b,' ,'I ,11'1111111 ,./
,1111/('11'11" '1II/en',/it,'of,1 I'.'"/I"IS ill ,/.1'.'1.11,/.'11/1111" ".I/'/,lIlh'" I",,,,
(/'" "'1111'111(,.1 """", -'I.rll. ,/\)'.-11 111<'111/11.'1. "",
p,,/r,,' llIl.! lilt' (1/11('11 1Il1,'1I 11'111,,( 1'1t/,',1 '<illlL'I,1 11.1111,',/ "II
,Jlldturt'nl.' hrm /(t :,Jr't. ht ,I (IJHr'It/IOft
A I'ilir lIellrilig - J..slife (or Pe"ple Will, l.etlnlillg f)i.,a"ililh's II'd.'
II ".illl ("11/, ' 1,'11", I 'Illtl' I till' ."" 1,'1." ,111'/ ( "l1l1lll1l1il." (
NOlt': /l'l' WIII/,l II I)' Nom/ Sololl "lIt'TS Irllillill!( 10 lIIt'tlhd/l'm/" .,.,imlllh
ill('I1/"('" ill lIu'tlim-It'Slll II'"rli. / )"llIi/" (Will .\Illrll SII/OII, 0171 ')25
OllO.
B,rain day success
The Importance and exCllement of how the brain works was high
lighted on the first European Brain Day.
Co-ordinated by the European Dana Alliance for the Brain, a non
profit organisation that promotes brain research for a better life,
events involved scientists, charities, schools and museums.
In Leeds a Stroke Association workshop was held to share models
of good practice for community services for stroke patients. The six
teams presenting have developed integrated services to meet psy
chological. social. practical and health needs. Meanwhile, speech
and language therapist Lisa Teasdale organised a hospital reception
exhibition in Derbyshire with the assistance of Jane Haddock,
Practice Development Manager for PAMS. l.aorag Hunter, speech
and language therapist at the Centre for Brain Injury Rehabilitation
in Dundee, undertook 10 raise staff awareness of this new resource.
The AI liance suggests ten goals for the next five years of brain research:
1. Finding the genes that increase risk for
schizophrenia and manic depressive i.llness
2. Understanding. preventing and treating
Alzheimer's, Parkinson's and other major
neurodegenerative disorders
3. Improvement in the treatment of strokes
and spinal cord injuries
4. Finding genes involved in hearing and
visual impairments
5. New approaches to the management of
pain
6. The application of non-invasive meth
ods to the diagnosis of many neurolog
ical and psychiatric disorders
7. New advances in understanding and
treating drug addiction
8. Understanding how the brain learns and remembers
9. Finding more answers about the developing brain: how chi ldren
learn
10. Learning how the brain really works.
Details: E/aine Snell or Sharminee Kumaradevan, tel. 0171 935 374 .
SPEECH & LANGUAGE THERAPY IN PRACfICE SUMMER t998 3
ALD
Carer communication
- making ge
Using a single case study and a combination of general and direct teaching
strategies, Lesley Brown demonstrates how the communication of carers can
be changed to improve a client's challenging behaviour.
Figure 1 - Client profile - Miss A.
1. Personal details -23 year old female
-severe learning disability
-lives with carer
-attends Social Services Special Care Unit
2.Sensory skills -moderate, bilateral hearing loss
-reduced visual acuity, tunnel vision
3.Comprehension -good situational understanding
-1-2 word level comprehension out of context, more
consistent when signing used
-limited understanding of negatives and time concepts
4. Expression -vocalises and leads others
-small vocabulary of own adapted signs
-some challenging behaviours (eg screaming, throwing objects,
hitting others) identified as having communicative functions
Figure 2 - Miss ~ s communication needs
-Limited background noise and visual distractors
-Objects and signs presented near and within her visual field
-Speech to be loud and slow
- Language at no more than a 1-2 word level
-Positive language in the here and now
- Key words to be signed
-Use of objects to show what is to happen next
Figure 3 - Observation form
SPEECH AND LANGUAGE THERAPY SERVICE
OBSERVATION OF STAFF COMMUNICATION
STAFF NAME .. ........ ..... ... ........ . DATE OBSERVED .. .... .. ............... .................
ACTIVITY ............ .. ...... .. ........ .. OBSERVER ...... .. ... ... ... ... .............. .. ..............
CLIENT ...................... .. ............ START TIME ............. . FINISH TIME ..............
LAHGUAGE COMPlEXllY
SIMPLE lANGUAGE COMPLEX LAHGUAGE
MEANIHG WITH WITHOUT WITH WITHOUT
COHVEYED HOH-VERBALS HOH-VERBALS HOH-VERBALS HOH-VERBAlS
Attention Directing
Request for
Information (open)
Request for
Information (closed)
Request for Object
Request for Action
Agreement
Giving Information
Protest I Denial
Praise
peech and language thera
pists working in the field of
adult learning disabilities
invest a significant propor
tion of their time delivering
training to care staff.
Training is no longer an
oplional component of service delivery,
but an essential. ongoing commitment
(van der Gaag & Dormandy, 1993). We
cannot expect to change the communica
tion skills of clients without first changing
the behaviour of their primary communi
cation panners (Cullen, 1988).
Increasingly therapists are having to pro
vide evidence of effectiveness through out
come measures. These usually focus on
changes in the client's communicative
behaviours (Enderby 1997; Smith 1997).
If we accept the importance of changing
staffs use of communication, then we also
need methods of monitoring any input
which aims to achieve this.
Staff training is often provided in the form
of communication workshops. These aim
to change staffs attitude towards and
knowledge about communication and con
sequently enhance their practice. Workshop
packages are commercially available to
assist in this (eg. Intercom , An Introduction to
l 'i llwbollC, Talking Poin/.S) . A wide range of
training techniques may be utilised during
such workshops. These have been described
as having varying impacts on staffs practice
(Anderson, 1987). Landesman-Dwyer &
Knowles (1987) hypothesise the effective
ness of staff training wil.1 be a function of
four primary factors, the fourth of particu
lar importance:
1. How relevant staff perceive the content of
the workshop to be ('subjective relevance')
2. How applicable the new attitudes,
knowledge and skills are to the actual job
situation ('objectively validated relevance')
3. How effective the presentation format and
style is, the clarity of presentation and appro
priateness of delivery along with the extent to
which practical demonstrations are used.
4. How much time and opportunity is avail
able for exploration and practice of new
skills along with regular individual feedback.
Little ongoing change
My experience of communication work
shops is that they are frequently positive
SPEECH & lANGUAGE THERAPY IN PRAGnCE SUMMER 1998 4
ALD
forums for increasing general awareness of
communication issues and informing staff
about the role of the speech and language
therapist working with adults with learn
ing disabilities. Cullen (1987) suggests
training often results in positive evalua
tions by staff and improved staff morale.
However, in a similar way to Forshaw and
Richards (1997) and others, I have fre
quently observed little ongoing change in
staffs use of communication strategies fol
lowing a workshop. Perhaps, because of
caseload sizes and consequent time con
straints, we often ignore Landesman
Dwyer & Knowles' essential fourth factor.
In reviewing studies on staff training, van
der Gaag & Dormandy (1993) agree the
most effective technique is the ongoing use
of feedback - video, verbal and written.
Figure 4 - Examples of language observed at baseline
Simple utterances:
"Look at me."
"What do you want?"
"Do you want more?"
"Put the cup on the table."
"Lift up your feet."
"Yes, that's right."
"You've got dirty feet!"
"No."
"Well done!"
Complex utterances:
"You need to come over here and take a look at this one."
"How many men are there in the group?"
"Do you want your bells now or do you want a foot massage first?"
"Go into the toilet and bring me a towel and the talc."
"Hang on a minute! "
"You had the chance to have two cups of tea in the dining room at lunch,"
"We'll do the salt and pepper pots in five minutes. "
"Don't take your clothes off yet."
"Sally is here to give John a bath not to give you a drink."
When attempting to change staffs practice
we should bear in mind people remember
10 per cent of what they hear, 50 per cent
of what they see and 90 per cent of what
they do. In the words of the well-known
maxim, 'what I hear J forget; what [ see I
remember; what I do I know:
I had the opportuniry to put these ideas into
practice when J received a referral from the
Clinical Nurse Specialist (Behaviour
Therapy) on our multi-disciplinary tearn. He
was working to reduce the challenging
behaviour of a young woman with severe
learning disabilities (figure 1). A number of
behavioural guidelines had been put in
place. However, he was concerned that staff
at the special care unit she anended were not
adapting their communication suffidently
to meet her needs (figure 2). He hypothe
sised some of her chal.lenging behaviours
were a direa result of her misunderstanding
what was being communicated.
Overestimating level
The members of the staff team working
with Miss A. had attended one or several
communication workshops. They reported
they were using simple language assisted
by signing during their interactions with
her. Initial, informal observations did not
support this. Some staff were able to
demonstrate knowledge of what was
required. However, they seemed unable to
put this into practice. Many were overesti
mating Miss A:s comprehension level - not
unusual in my experience. A method of
formally measuring the communication
used with Miss A. was needed, in particu
lar staffs use of appropriate language and
Figure 5 - Baseline observation
LANGUAGE COMPLEXITY
SIMPLE LANGUAGE COMPLEX LANGUAGE
MEANING WITH WITHOUT WITH WITHOUT
CONVEYED NON-VERBALS NON-VERBALS NON-VERBALS NON-VERBALS
Attention Directing 6% 1%
Request for
Information (open)
1%
Frequest for
nformatlon (closed)
12% 2% 0.5%
Request for Object 3% 2%
Request for Action 12% 7% 0.5% 2%
Agreement 1%
Giving Information 6% 5% 3% 10%
ProtestlDenlal 5% 3% 5%
Praise 10% 3%
Figure 6 - Second observation
LANGUAGE COMPLEXITY
MEANING WITH WITHOUT WITH WITHOUT
CONVEYED NON-VERBALS NON-VERBALS NON-VERBALS NON-VERBALS
Attention Directing 4% 10%
Request for
Information (open)
Frequest for
nformation (closed)
2%
Request for Object
Request for Action 20% 4% 2% 6%
Agreement 3%
Giving Information 12% 2% 2%
Protest/Denial 10% 6% 4%
Praise 10% 3%
au'gmentative communication.
A form was devised (figure 3) to record
each utterance made by staff when inter
aaing with Miss A. Its use requires the
observer to consider three parameters:
a) The meaning conveyed by the lItterances - a
choice between nine identified categories.
b) The complexity oj the language used. Each
utterance is judged simple or complex. The
'cut-off between the two is set according to
the client. In this instance, complex utter
ances are beyond a two word level and/or
Figure 6a - Analysis
DATE OF OBSERVATION
% OF TOTAL
UTTERANCES
Baseline
observation
Repeat
observation
Final
observation
COMPLEX
UTTERANCES
21% 18% 11%
UTTERANCES
SUPPORTED
NON-VERBALLY
58% 60% 65%
SPEECH & LANGUAGE THERAPY IN PRACTICE SUi\ IMER 199 5
ALD
Figure 7 - Written feedback
SPEECH AND LANGUAGE THERAPY SERVICE
USE OF COMMUNICATION - INDIVIDUAL FEEDBACK
STAFF NAME .......................................... .....DATE OBSERVED ..............................
AREA OF COMMUNICATION COMMENTS
1. VOLUME AND TONE OF SPEECH
2. SPEED OF SPEECH AND SIGNS
3. USE AND ACCURACY OF SIGNS
4. SENTENCE LENGTH AND COMPLEXITY
5. USE OF OBJECTS
6. RESPONSE TIME GIVEN
7. OTHER AREAS
THERAPIST SiGNATURE............................................ DATE .................................
Figure 8 - Final observation
LANGUAGE COMPLEXITY
MEANING WITH
CONVEYED NON-VERBALS
Attention Directing 8%
Request for
Infonnation (open)
Request for
Infonnation (closed) 8%
Request for Object 4%
Request for Action 25%
Agreement 1%
Giving Infonnation 8%
ProtestfDenial 4%
Praise 6%
WITHOUT WITH WITHOUT
NON-VERBAL NON-VERBAlS NON-VERBALS
4%
1%
10%
1%
5%
2%
2%
1% 4%
6%
including linguistic concepts especially
negatives or time concepts (figure 4),
c) The use of augmentative communication
the presence or absence of explicit use of
signing and/or objects of reference,
On completion of this dedsion making
process the observer ticks the relevant box,
Some practice is needed in using this form ,
Ideally, staff would be videoed interacting
with the dient for subsequent analysis,
(This could allow the establishment of
inter-rater reliability if required.) However,
with repeated use, I now complete the
form as I observe. I find it useful to note
some examples of the communication
used to illustrate later discussion, It is also
necessary to note any qualitative observa
tions not recorded on the tick chan such as
background noise, volume and speed of
speech, accuracy of signing and response
time given, Completion of any observation
schedule needs sensitivity, Staff need to be
encouraged to ignore the observer and
continue with their usual routine, The ther
apist can assisi by being as inconspicuous
as possible, It is best not to begin recording
as soon as one begins obselVing,
Baseline
As a baseline assessment staff were
obselVed during eight 15 minute periods
spread randomly over several weeks, with
403 utterances analysed (figure 5),
1) Language complexity - 21 per cent of utter
ances were classed as complex, These sen
tences were very long and included concepts
of time, number and complex negatives,
2) Augmentative communication - 58 per
cent of utterances were sup poned non-ver
bally, However, signs and objects were fre
quently presented out of Miss .' visual
field, In addition, signs were inaccurate or
even wrong,
3) Qualitative observations - Other tactors
noted were:
a high level of backoround noise, espe
cially television and radio
attempting to communicate without first
gaining Miss A.'s attention
extremely limited response time given
with only two to three seconds between
utterances
lack of consistency in following through
requests or commands,
4) Challenging behaviour - incidents of chal
lenging behaviour did often follow staff's
use of a complex utterance without non
verbal support.
Targets for change
At the next unit staff meeting a communi
cation workshop concentrated on the gen
eral communication strengths and needs of
adults with learning disabilities,
Observation results were discussed and
reinforced with a written report, Findings
were discussed in the light of Miss A.'s per
sonal communication needs, Key commu
nicative behaviours were identified as tar
gets for change and agreed by all staff,
These focused on decreasing the complex
ity of language used and increasing the use
of key word signing as well as addressing
some of the qualitative factors noted above,
Four months later repeat obselVations
were made with 392 utterances analysed
(figures 6 and 6a) .
1) Language complexity - The proportion of
complex utterances had decreased by only
three per cent. From discussions with staff
they appeared still to be overestimating
Miss A.'s comprehension level.
2) Augmentative communication - Only a
two per cent increase in the use of sup
portive non-verbals was observed,
However, staff were attempting to present
signs and objects within Miss A:s visual
field, A marked improvement in sign accu
racy was also observed,
3) Qualitative observations - Other factors
noted were:
staff turning the television and radio off
before attempting to engage Miss A.
more use of Miss. A.'s name to gain and
maintain her attention
increased response time allowed,
4) hdlltmging Behaviour
A small reduction in the frequency of inci
dence of challenging behaviour was
recorded ,
Direct strategy
Again, results were summarised in a writ
ten repon and discu ed at a unit staff
meeting, laff admowledged they had
found it difficult to put the target behav
iours into practice. It was agreed direct
intervention was necessary to effect funher
change in staff's communicative behav
iour. A session was spent with each mem
ber of staff employing a sequence of train
ing strategies: modelling. prompting and
positive reinforcement. discussion, written
feedback and ad hoc reviews,
I. Modelling - I interacted with Miss A while
the staff member observed, I was explicit
that I was not aiming to produce a ' perfect'
role-model ; indeed, laughing at my own
mistakes was helpful. However, simple lan
guage and signed key words were demon
strated as much as possible, This stage is
essential to ensure the therapist has the
credibility to implement the subsequent
training strategies,
II. Prompting and pOSitive reinforcement - I
shadowed the staff member, suggesting
changes in the communication used and
giving positive reinforcement. verbal or
non-verbal. when this was achieved, To a
certain extent the latter was often redun
dant as Miss A:s responses selVed as rein
forcement. As with observation, this strate
gy requires sensitivity, Some staff would set
the pace by asking for guidance when they
SPEECH & l.AN GUAGE THERAPY IN PRACflCE SUMMER 1998 6
ALD
thought necessary; with others I needed t-o
initiate suggestions. I found it best not to
prompt every time a simpler sentence or
signed key word was needed. I tended to
say something like, You could try saying .. :
or 'How about signing.. :.
III. Discussion - I spent some time in discus
sion with the staff member refleaing and
identifying areas for further development.
IV. Written feedback - I provided a wrinen
summary of the discussion. A copy was
given to the staff member and their super
visor (figure 7)
V Ad hoc reviews -Whenever on-site I was avail
able for further observation and disrussion.
Analysis
Four months after the period of direct
intervention had begun the final set of
observations were made with 425 utter
ances analysed (figures 8 and 6a).
1) Language complexity - The proportion of
complex utterances had dropped by a fur
ther seven per cent (an overall decrease of
10 per cent from baseline). Staff now fre
quently re-phrased utterances when they
realised what they had said was too complex.
2) Augmentative communication - A five per
cent increase in the use of supportive non
verbals was observed (an overall increase
of seven per cent from baseline). The staff
team had identified a core signed vocabu
lary and were attempting to use this con
sistently. They had agreed to prompt one
another when signing was forgonen.
3) Qualitative observations - Other factors
noted were:
a significant change in staff attitude, more
self-monitoring and refleaion on practice
individual improvements on the devel
opment areas identified in written feed
back, for example one gentleman had
increased his speech volume and was using
a firmer tone of voice when necessary;
another had slowed the speed of his
speech and signing.
4) Challenging behaviour - Throughout this
period behavioural guidelines had
remained in place with revisions as neces
sary. An overall reduaion in the frequency
and severity of Miss A:s challenging behav
iour had been recorded. The rate of reduc-
Questions
tion was greatest during and after the peri
od of direct intervention.
Measured improvement
As this was not a piece of formal research,
the results of this single case study have
not been analysed for statistical signifi
cance. The percentage changes quoted here
are no t large. However, they represent a
cruciaJ an d measured improvement in
~ s A.' s communication environment.
Funber ..-od. j s n eded to establish how
long any POsilh'e eHeas of direct interven
tion are maintained. In addition, one of
the difficulties encountered was the
absence of comparative data on staffs use
of communication. I was able to compare
individual team members but was unable
to say whether, as a whole, the team was
doing well. It would be useful to measur a
number of teams who have been sub,ec
tively identified as 'good communicators'.
Improvements for Miss A. were greatest
when a communication workshop was
combined with 'on the job' feedback.
Results therefore have some similarities to
those of Money (1997) who suggests that
therapists need to, "combine teaching and
direct approaches to maximise the effec
tiveness of service delivery for both staff
and service users".
References
Anderson, S.R. (1987) The management of
staff behaviour in residential treatment
facilities: A review of training techniques.
Cullen, C. (1987) Nurse training and insti
tutional constraints.
Cullen, C. (1988) A review of staff train
ing: the emperor's old clothes. Irish Journal
of Psychology 9, 309-323.
Enderby, P., John, A., Sloane, M. and
Petherham, B. (1997) Therapy Outcome
Measures - Speech and Language Therapy.
Singular Publishing.
Forshaw, N. and Richards, K (1997) The
Brooklands Communication Initiative.
Speech and Language Therapy in f'ractice 6 (2).
Landesman-Dwyer, S. and Knowles, M.
(1987) Ecological analysis of staff training
in residential settings. '
Money, D. (1997) A comparison of three
approaches to delivering a speech and lan
guage therapy service to people with learn
ing disabilities. European Journal of
Disordm of Communication 32 (4).
Smith, S. (Feb. 1997) Outcome measures
with adults with a learning disability.
RCSLT Bulletin.
van der Gaag, A. and Dormandy, K. (1993)
Communication and adults with learning
disabilities. London: Whurr Publishers.
'In Hogg, J. and Mittler, P. (eds) Staff
Training in Mental Handicap. Beckenham.
Croom Helm.
Resources
Jones, S. (1990) INTERCOM: A Package
Designed to Integrate Carers into Assessing
and Developing the Communication Skills
of People with Learning Difficulties.
Windsor: NFER-Nelson.
Money, D.F. and Thurman, S.c. (1996) An
introduction to Talkabout. Nottingham
Community (NHS) Trust: Speech and
Language Therapy Department.
Thurman, S., Stewart, K. and Jones, 1.
(1991) Tal king Points; A Resource File for
Communication Workshops. Stass
Publications. 0
What is required for In addition to training being practical, relevant and
training t o be effective? , erceived as relevant, time for practice and individual
- -,
back is needed.
Do communication hile workshops raise general awareness and encour
workshops have '
limitations? they have learnt into practice.
lIIWHI:,t"e a p'ositive attitude, they do not help staff put
How does additional Using a sequence of modelling, prompting, discussion,
individual training help? written feeaback and review changes individual practice.
SPEECH & lANGUAGE THERAPY IN PRACTICE SUM II'.R 1998 7
COUNSELLING
The
In a personal
of counselling,
Christina Shewell uses
examples from
poetry and
psychotherapy to
show that art and
science both
hen we begin to work with a person who IS in
distress or disturbance or wishes to change In
some way, we embark upon a journey, We do
not know the route this will take and, indeed, it
may be very challenging. But so it should be:
"In every consulting room there ought to be
two frightened people; the patient and the psy
cho-analyst (or counsellor). If they are not one wonders why they are
bothering to find out what everyone knows." (Blon, 1974, quoted in
Cas ment 1985.)
The Greek poet c.p Cavafy's poem about the joum ey to the Isl and of
Ithaca is a slow un ilinding to the final verse, where t he reader real ises rt
may not be the goal but the Journey it self that ultimately rewards
and enriches,This poem speaks to the theme of travel
ling and, indeed, the language of exploration of the
Inner self has much in common with the lan
guage of poetry,
"arrived there, you will rnd Ithaka Often in our work as speech and language
therapists we never reach Ithaca - the
contribute to has nothing to offer any longer
perfect voice, the nuent speech, the full
but she is no cheat linguistic competence - and we may not
our work. complete the period of our therapy
she has not deceived you
contact wrth a cheerful, fully accepting
to her you owe your voyage
client or famil y member. But, as we
She
know, t here are many rewards along
all your wealth, all your wisdom
the therapeutic journey for both client
and therapist and it is usually impossible
to avoid 'emotional issues' coming up in
the meaning of Ithaka "
our work With people who want to change
how the
CP Cova/y
something.
demonstrates and you will know
therapeutic journey
can bring rewards for
the client and
practitioner.
Sum of both parts
The cl ient is referred wrth a primary problem as diagnosI s - language
impairment, a stammer, dysphasia, dysarthria and swall owing problems,
hearing loss - but there wi ll inevrtably also be a secondary Issue, t he emo
tional cause and I or emotional effect of t hat symptom on person and
family,The communication problem is the sum of both paris.
In voice therapy, rt can be useful to think 111 terms of percentages of these
contributions to a particular communication problem. How much is the
direct structural or misuse contribution, and how much the emotional I
psychologlcal7This can help to find an appropriate balance of practical and
counselling type work with a par'ticular cli ent in a particular session (case
examples I and 2).
On our journey of exploration through an unknown land, as In any tl"ip,
there are responsibilrties and there are views. VVhen we consider using
counselling, we usually focus on the needs of clients. Another way of look
ing at this is to address the question of what benefits the therapist may find
in the counselling transaction as slhe experiences both responsibilities
and new views.
SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 1998 8
RESPONSIBILITIES
I To set out prepared
We must be Willing to train for this journey - to go on courses, read, set
up supervision sessions and discuss cases with col leagues, Then we can
carry in our rucksack the tools, techniques and provisions we need,
We have t o learn how to truly li sten, how not to overwhelm the client.
how not to be taken over by them and when and how to refer on, We
are well trained and updated in t echniques and technology but attending
to the emotional life of clients needs the same attention to detail. If we
do not also have the option. at appropriate times, wrth approp';aie clients,
t o use both t op level and deeper level counsell ing skills. the dlent 1 emo
tional inner worl d may be neglected, This world 15 a . cal of:he I r
ney from disorder rough gro to some sort of c
Even if some therapists simply do not .r.mt to ra -:re
cific skills of counselling. ere Is also so""e- 'b ,',of; rr - '
awareness" that ust be taug 0 e- - \ ilK Jr- .:
any of their professional deaf gs, and maybe thei perc naI cc :2. :ts " 50
Thi s particular quality of listeni ng is the key t o:
a) attending to a speaker
b) allowing t he speaker to be themselves
c) containing a speaker.
Therapists who decide to undertake the deeper aspects of counselling In
speech and language therapy must experience counselling or psychother
apy themselves, and be willing to have regular supervision,
2To be physically fit
We should also be prepared to get bodily frt for the jour-
Three months into a six
ney because the mind / body link is so strong and one
frees or supports the other. Inner work on sel f-under
month run ofa play one very, expe
standi ng, attrtudes and beliefs leads to outer and
bodily change, but we can also work from the out
side-in;experiential work with voice and body can
lead to inner recognition and change,
cifIC breathing work. The kind of body work will
be chosen by the needs and character of the
therapist, but will benefit both client (case 3) and
practitioner. For myself. at times of particul ar stress
in a session when I recogni se I am holding my
breath and body braced against my own confusion or
the client's anger or distress, I have been greatly aided
by the simple technique of centring, Putting my hand on
my diaphragm / 'solar plexus' helps me open up in breath and
awareness, and I am then back in touch with my power and able
to truly listen,
Many speech and language therapists see cl ients who would
never agree to go to a counsell or; psychotherapist or psychi atrist
to open up about present fears and past pain (case 4),The label
'speech a language therapist' allows the option of both physi
cal or talking '1O!i<. and one can provide access to the other.
3 To walk in step or one step ahead only
The greatest gift we can offer a erson In distress IS to be there
full y for them in Spirit and listening.. hether the struggl e with
words is physical or psychological, there can then be space for
the speaker to find a way through I we do not rush too far
ahead in terms of goals or words,The silent listening witness role
is crucial in our counsell ing skills, Goethe be ins a famous
German poem: "Tell a wise person or else keep Silent", and the
poet Rilke wrote, "I want to be with those who know secret
things or else alone",
We need to cultivate wisdom and be comfortable with secret
things, but our job is not to leap in with interpretations, nor to
push the person into revelation, We must sense or even ask
expl icitly - do you wont to look at that view? Some people want
only to work practically and concretely and that must be
respected, whatever we think we are picking up. On our journey
we will have our own thoughts and conclusions but we serve
our client best if we walk in step - or just ahead - rather than
pushing them along a side path, or at worst over a precipi ce of
ation, but often needed to
talk about his troubled past
and demanding p,resent,
both mqjor contributors
to his voice problems. He
reallY, needed to see a
psychotherapist and I
encouraged him to see a
very eminent analyst for
at 'least an exploratory
consuttation. However
COU NSELLI NG
ase I
.. A twenty-two year old is referred with vocal

nodules. She Has a contented personal life and
herself as 4 on an imaginary I - 10 Stress
Scale (where 10 = highly pnysically and

emotionally stressed). )he is in a musical with
eight shows aweek and has poor
posture, asthma an.d a lack 0 voice training
f resulting in habitual vocal strain.
This client's voice problem could be rated 90 per
cent use, 10 per cent emotional contributions.
Case 2
AtwentY,-two year old is referred with vocal
nodules. She rate.s hersel f as 8 on the
Stress )cale and is
significant p,ast and present distress:-!:>he has
noticeably increased muscle tension and hates
her current I'ob understudying the lead in a
st End pay.
IS c ient's voiae problem could be rated 30
per cent use, 7 per cent emotional
ontributlons.
Case 3
Christina Sh
works attire
nenced actress, never preViously In any
vocal trouble, developed dY,sphonia, During
the r,rst session it emerged ner much lovea
father had died shortly be'{ore the opening and
she had had no real ?pportunity to moum [or him.
She was literally and metaphorically bracing her
selfagainst the pain, shallowly, with ,audible
Thi s does not mean energetic exencise but can
include massage, Alexander technique,
Feldenkrais, yoga, relaxati on techniques and spe
asps ofInspiration In orGinary conversation.
Altnough She said she did not want to talk about
this, practical work on bodY, release and deeper
breathing enabled her to let go physically and
emotionallv. This allowed her to cry and talk
when she needed tO
I
and led her .
to re-occess a healthier
vOice use,
Case 4
A senior MP was
referred with frequent
episodes of dysphonia.
The ENT dlagr;losis was I slightly
vocal folds marked
antenor-p,osterior constriction:'
He liked the practical work on
breath and physi cal relax
Case 5
Aclient aged 36 was
referred With a diagnosis
of severe muscle tension
dysOhonia.At times his vOice
would almost disappear so
constricted was the laryngeal
area. He was a Bosnian
restaurant owner who had
experienced the loss of his
village and way oflife.He !.ave
some hints as to the depth of
his grief at the point we met
He only wanted to work
practlcol/y, He was not
ready to talk about his war
could not bring.himselfto do
experiences, and or
this.With practical voice ther
1
was reSDeC!ffi
and some basic counselling
he made a imp,rove-
I
ment but Ifeel there is considerable
'unfinished business' and the voice e
roblems well reoccur.
SPEECH & lANGUACE THERAPY IN PRACTIC W.1/1.1ER 1998 9
COUNSELLING
self-disclosure that can lead to despair. In a recent newspaper interview
the writer Saul Bellow said, "Socrates said that the unexamined life is not
worth living, but sometimes the examined life makes you wish you were
dead." It is crucially important to respect the client's sense of direction
and timing (case 5). Such responsibil ities may feel onerous at first but
bring their own rewards.
In addition, though, we wi ll find signi ficant other riches, and these I have
termed views.
VIEWS
I Space for direct action work to be effective
Unlike 'straight' counsellors, speech and language therapists have a dual role:
to let happen - the feminine or yin role
to make happen - the masculine or yang aspect.
As in life, the feminine infiuence (using Jungian terms) can be to enable,
to allow the active masculine to do. Feelingsof grief. anger, confusion,
numbness, resentment and so on will block concentration and the effec
tive use of assessment, advice or therapy for client or carer.
It's so obvious, and yet often in medical or speech and language therapy
sessionswe see this primary blocking as the therapist neglects the client's
reaction and then the secondary blocking, as the patient 'cuts off' from the
therapeutic relationship. .
The sensitive use of counselling skills allows the client to com
municate about what is in his/her heart so that the head may
work more efficiently, We are then more successful with that overall
aim of improving communication.
2 Intellectual satisfaction
Travelling into aspects of someone else's psyche is enormously interesting
and challenging. We will be drawn to a particular school of counselling or
psychotherapy according to our own psyche, intellect and experiences,
and can then use the knowledge and insights offered there. There are
many school s of thought, and a huge range of literature
As we gain in experience though, we may also be challenged to do dif
ferential therapy. This is as important as the ability to make a differential
diagnosis, on which great emphasis is pl aced. That means that although
drawn to working within a particular t heoretical framey.,IQrk, we need to
be open to a range of techniques from which to choose for a partJOJIar
client. And that consideration brings further intellectual S3tbiac"uon
3 Deep knowledge of aspects of another person
As we work with our cl ients it seems to me that in that transaction Ie
both touch and are touched in a very deep way by another person; as
the poet Rumi says "Soul receives from soul". I use 'soul' In no narrowly
doctrinaire sense but as Whyte (1994) uses it. "Soul is the indefinable
essence of a person's spirit and being ".
As Carl Rogers wrote, "".I rejoice at the privilege of being a midwife to
t he emergence of a self, a person, as I see a birth process in which I have
had an important and a fascinating part. It is about both the client and me,
as we regard with wonder the potent and orderly forces which are evi
dent in this whole experience, forces which seem deeply rooted in the
universe as a whole."
Thi s links into the final gift of t he journey - the
4 Opportunity to grow as a self
A colleague once told me she felt at her most relaxed when working one
to one with a cl ient. Although initiall
'
sUI-prised, I have observed myself
over time and find this is often the case. It is as if all the work and train
ing ever taken can find its natural place In what can be seen as the tip of
the upturned pyramid - that contact with another person. Here the ther
apist's ego is safely unobtrusive and undemanding and it is as if the work
through rather than from the practitioner.
Sometimes we will not know what to say or to do, and we feel helpless.
Thi s not krowing, this opportunity to be rather than to always do can be
enormously creati ve, and respects the client's own process of growth, as
my own therapist once showed me most powerfully.
I had already had a long peri od of psychotherapy and was going through
a particularl y troubled time. I felt apologetic to Kenneth Lambert, that I
had let him down by not Improving in response to all our work together.
He said "but to feel sorry for you or that you should not be going through
this would be an arrogant assumption that I krew better than you what
you needed to go through, in order to grow."
Going into the dark can lead to new insights.
"Instead of trying to bring a brilliant, intelligent, knowledgeable light to
bear on obscure problems, I suggest we bring a diminution of the 'light'
a penetrating beam of darkress; a reciprocal of the searchlight.. .Then the
darkress would be so absolute that it would achieve a luminous, absolute
vacuum. So that if any object existed, however faint. it would show up
very clearly.Thus, avery faint li ght would become VIsibl e in maximum con
ditions of darkness" (Bion, 1974),
In the therapeutic encounter we experience the drama of another human
life with all its JOY, confuSIon. exhaustion. illumination, exhilaration,
frustration, inspiration. inrita . - to Mme but a few. Although we may
feel comradeship .- dent. th e demands and nature of that rela
tionship are q ,e d ,erem to 'riendship; our egos are only relevant in so
far as ha-,e brough us to his point. But the paradox is that during
part - r sort of attending, being there, being a receptacle, there is
a'l enomous potenttal for inner growth - for both the client and the
speech and language therapist.
A 'erslon of this paper was given at The SIG Counselli ng in Speech and
language Therapy Conference, July II, 1997. It is dedicated to the memory
of the late Kenneth Lambert Jungian analytical psychotherapist.
References
Casement, P(1985) On learning from t he Patient. Routledge: London and
New York.
Rogers, c.R. (196 1) On Becoming a Person. Boston: Houghton Mifflin.
W hyte, D. (1994) The Heart Aroused: Poetry and the Preservation of the
Soul at Work. The Industrial Society: London. 0
This article is the third in a short series looking at how speech and language therapists have used training in other fields to assist their work.
Neuro Linguistic Programming and Personal Construct Psychology have featured previously and family therapy will be covered in a future issue.
Questions
How much use should we can be guided by what percentage they feel is a
make of diagnosis and how much emotionar factors of
skills"? cause and / or effect contribute to the problem.
What resp'onsibilities do Counselling req,uires sensitive attending and timing and a
therapi sts have when . to Incorporate emotional, intellectual and
using counselling skills? phYSical work into their preparation.
Does a counselling
relationship benefit the
satisfaction and self development are benefits
_Mil r practitioners.
therapist as well as the client?
10 SPEECH & LANGUAGE THERAPY IN PRAGn CE SUMMER 1998
CHILD LANGUAGE
-
e
The trend in the fi eld of
child language is to focus on
parent-child interaction.
In the first of two articles,
Dr Deb Gibbard argues a more
specific linguistic approach is
also required when working
through parents.
here is a need in the
Health Service today,
more than ever before, to
demonstrate an evidence
based child health ser
vice. It is no longer
acceptable to intervene
with a child in a particular way just
because "it seems right" or "I've always
done it that way".
Alongside this, policy-makers (Hall, 1996)
recommend a philosophy of parent-pro
fessional partnership as essential in pro
moting child development. In paediatrics
during recent years there has been an ever
increasing popularity towards working
with parents as there are potentially
greater treatment effects resulting from
intervention in a child's usual communica
tive context as part of his daily routine.
Additionally, indirea approaches are attrac
tive to managers and service providers in
that they have the potential of demonstrat
ing economy in service delivery.
The aim of working through a parent
where their language-delayed child has the
potentia'l for improvement - must be pri
marily to develop the child's language
skills. Therefore, evaluation of methods of
intervention must include measures of
child language levels before and after a
period of intervention. Although ques
tionnaires on client satisfaction and per
ceptions of the service offered are impor
tant, it is not sufficient to use these as the
sole objective measure of effectiveness.
Secondly, we must aim to find the most
effective methods of intervention. These
may well differ for different children
according to features of the parent-child
dyad such as the initial language abilities
of the child. Further, given that the devel
opmental course of expressive language
delay is variable and that there is debate
over the potential usefulness of expensive
treatment intervention strategies for this
condition (Whitehurst & Fischel, 1994), a
cost-effective service delivery model is
clearly also required.
Sparse evaluation
Much work with parents, such as the
Hanen Parent Programme (Manolson,
1992), has been based on parent-child con
versational approaches to u'eatment, incor
porating features of child-directed speech
(CDS) . However, not only has evaluation
of such approaches been sparse but, given
the body of research into CDS, it is far from
clear what the benefits of a conversational
model alone to intervention may be, partic
ularly on children's syntactic development.
The study of CDS claims certain special
properties of caretaker speech playa causal
role in child language acquisition. In its
weaker form, it asserts the more the parent
or caretaker uses this special type of lan
guage, the faster language learning ",ill
occur. The research evidence sho" t.ha
although caretaker speech is related 0
SPEECH & LANGUAGE THERAPY IN PRACTICE SU MMER 199 11
Mo
M :::
w",at-'s s",e
6",e1 w",at- ",oe
s
CHILD LANGUAGE
and that these two sample 1)<.U
that the language impairment will
figures had to go Language for lunc",1
r
affect the two-way flow of commu
everywhere with them. pre-therapy oU 0ivin0 ",e
nication, irrespective of the direc
Michael's mother MO: 'j tion of influence. In particular it is
",av"'''''
important to stress to parents that,
t
h
ere
f
ore wor
k d
,on . Beans?
although they are not to blame for
the language Beans. avi 0
1
n
their child's language delay, they
set, encouragmg two M: else is s",e '" .
can now learn what to do to
M . w",a
v
\:7 ans, IS
word utterances such as: o. Beans. . t- ",avin0 e
encourage language to develop.
"hello Jess" (for two 0"', \:7eans1
word greetings) t-"'I '" !1'1
1
look Frequent, familiar,
r
"Pat's nose' (for two M: NIce. s",e likeS t- e . '" !1'1a
ke
",e repetitive and salient
. Nice1 , ",aIr an
word utterances with pos- M!1'1!1'1' II we "'0 ",oll'jS k Research has begun to identify
session) M'o: \..ook. ;",a '" t- ",oe
S
s",e 100 the features of early language
"letter Pat" (for two word rJret-t-;l' W a learning imponant for child
M '(ean I ok J r language acquisition. The
utterances wi
th
an 0
b
ject :0' Make 0 significance of the relation-
and a person). M . like now. ship between the child's
During the parent-based ses- M: Nice. t-nil'lk sne wal'lt-s focus of attention and the
sion, the parents were also t-nat- 00 'lou linguistic input has been
asked to encourage the two Mo: 00 ;IOU t-o eat-1 emphasised (eg.
word utterances during daily t-nat- t-o eat-.. 'Z Tomasello & Todd, 1983;
. M' h I' th M' IV , c",alr. 1'1 tnere. ne Akhtar, Dunham &
routmes, IC ae s mo er M' .O\<.. tne t-eaa'js OU sit- 0 Wnat- ao
eS
6 Dunham, 1991) . Bruner
reported using the following Yea"', 'oit t-o
O
'ole (1983) suessed the value
naturally occurring situations: Cal'l are. On, s e 'Z of turn-taking. The use
gr.eetings with friends and Mo: . like "otato. wnat- was t-nat- of language in familiar
relatives M: somet-nl.l'le like Fotatoes. t-o. . k of and repetitive contexts
sorting out the washing pile to Mo'. Sometnll'le 't j'ust- sne t-n\1'I has been found to be
f'ot-at
o
. s",e cal'l 'Z ,."a
v
of importance (Harris,
encourage two word utterances M: Wnat- else1 I'Il'1a e
lve
nero 1992). Parent inter-
with possession (eg. "daddy's Mo: Wnat- are we eo vention models are
shirt") and t-n.a
t1
It-'S all eOl'le 1'I0W. therefore based on
setting the table to encourage M the premise of pro
'th b' t Mo: Is 1 . W c& viding a frequent,
two word utterances WI an 0 Jec M' Yean. . ner aril'lk 1'10 '. 1'1 a co"ee. . . . .
and a person (eg. "fork mummy"). . . Gooa e
lrl
. tS to nave sne's na
vl
13 .. familIar. repellllve
Mo. NoW sne wal'l '1'113 a... NoW and salJent Illput for the language
...._______________ M: NoW she's na
vl
impaired child.
Case Illustration
Michael was referred to the speech and language therapy department at
his local health centre by his health visitor. He attended a speech and
language therapy assessment aged two years and eight months, where
the therapist assessed his receptive language as mildly delayed and
expressive language as moderately delayed. He used single word utter
ances only and his mother estimated a vocabulary of around ten words.
Michael's mother attended a parent-based intervention course and six
months later Michael's language was re-assessed. The therapist observed
Michael was using sentences of up to six and seven words in length and
his language abilities were age-appropriate. Michael was discharged.
Course Progress Extract
During session 6 of the parent-based intervention course, the language
objectives set included developing specific types of two word utter
ances. Some of these were to:
develop greetings within two word utterances (eg. "bye daddy");
develop two word utterances involving possession (eg. "mummy's
nose");
develop two word utterances involving an object and a person (eg.
"pen daddy").
The clinician demonstrated a method of working on each type of two
word language structure during the parent-based session and the par
ents were asked to adapt the activity demonstrated when working on
the language objective at home. They were asked to follow their child's
lead and use activities of interest to their particular child, ensuring all
words were within their child's current expressive vocabulary.
Michael's mother reported he was very keen on Postman Pat,
had recently received a cat - duly named Jess - to
go with his Postman Pat doll, tS
ac
early language development in some way,
cause and effect relationships between
parental input and child language develop
ment have not been demonstrated.
Reciprocity of interaction
Researchers have studied not only the nor
mal process of language development but
also variations in caretaker speech between
normal and language-impaired chiJdren. It
has been argued both that matemal speech
to language-impaired children is different as
well as similar to that of normal language
leaming children. Some studies suggest
caretakers of children with language diffi
culties may not synchronise well with the
child or may not provide sufficient stimula
tion, whilst others claim they compensate
and adjust their interadive behaviour.
Although methodological differences may
account for some of the discrepant findings,
it is clear the language influences are bi
directional. Given this reciprocity of interac
tion, it is difficult to determine the effeds
one partner has on the other. Galloway &
Richards (1994) give a detailed description
of the relationship between parent-child
interaction and language development
and Conti-Ramsden (1994) provides a
succind account of interaction with
atypical language learners.
For clinicians, the imponant fact is
12 SPEECH & LANCUACE THERA PY IN PRACTICE SUMMER 1998
C HILD lANGUAGE
However, many parent language interven
tion models using naturalistic intervention
procedures have provided general lan
guage stimulation rather than aiming to
achieve specific language objectives or tar
gets. Indeed, evaluation of one interactive
approach found no improvements in chil
dren's linguistic abilities at the end of a
course (Tannock, Giralometto & Siegel,
1992).
General interactive approaches such as the
Hanen Parent Programme may be most
suitable for children where the aim is to
increase conversational competence, or to
develop early language learning such as a
single word vocabulary, but may be less
useful where the objective is to increase
and develop linguistic structures.
Language targets
The parent-based language intervention
model evaluated in Gibbard (1992; 1994)
uses a combination of the setting of clear
linguistic objectives and an interactional
approach. Several other studies have also
advocated the setting of language targets as
part of parental training programmes
(McConkey, 1979; Warren & Kaiser, 1986).
The programme's emphasis is on develop
ing a child's expressive language through
the use of daily routines and situations of
importance to them. Over a period of
eleven group sessions, fortnightly language
objectives are set for the parents to work
on at home with their child. A structured
teaching demonstration takes place during
the group sessions for each language objec
tive set to explain and clarify each objective
to the parent, ensuring their full under
standing. Practice activities are also
devised during the sessions to encourage
the parents to think about each language
objective flexibly. However, each parent
then implements the language objectives
at home in a different way, according to
the particular routines and interests of the
child. The parents are encouraged to fol
low their child's lead at home and strong
emphasis is placed on achieving the lan-
PORT \ \() lJT H
Healtl-Care
guage objectives through the use of dail
routines and situations (see case illustration) .
One of the objectives of the Parent-based
Intervention Programme (Gibbard, 1998)
is to develop syntactically from a single
word vocabulary of approximately less
than 30 single words to a level using utter
ances of around four words in length.
During the evaluation of this model of par
ent-based intervention, many children
even exceeded this level of syntactic ability.
The success of the programme in meeting
the evaluation criteria described has led to
its implementaLion and further evaluation
across Portsmouth Healthcare NHS Trust,
to be discussed in a future article.
Resources
'The Parent-based Intervention Programme
- a group approach for language-delayed
children' (1998) is available from
Winslow, f47.50 (tel. 0800 243755 for
orders).
References
Akhtar, N., Dunham, F. & Dunham, P.
(1991) Directive interactions and early
vocabulary development: the role of joint
attentional focus . Journal of Child Language
18 (41-49).
Bruner, ) (1983) Child's Talk Learning to
use language. Oxford University Press,
Oxford.
Conti-Ramsden, G. (1994) Language inter
action with atypical language learners. In
Galloway, C. & Richards, B. (eds) Input
and interaction in language acquisition.
CUP, Cambridge.
Galloway, C. & Richards, B. (eds) (1994)
Input and interaction in language acquisi
tion. CUP, Cambridge.
Gibbard, D.) . (1992) An evaluation of
parental-based intervention wi th pre-school
language-delayed children. Unpublished
PhD Thesis, University of Portsmouth.
Gibbard, D.I . (1994) Parental -based inter
vention with pre-school language-delayed
children. European Journal of Disorders of
Communication 29 (131-150).
Hall, D. (ed) (1996) Health for all children
(3rd edition) . Oxford University Press.
Harris, M. (1992) Language experience
and earl y language development - from
input to uptake. Lawrence Erlbaum, Hove.
Manolson, A. (1992) It Takes Two To Talk.
The Hanen Centre: Tornonlo.
McConkey, R. (1979) Reinstating parental
involvement in the development of com
munication skills. Child: Care, Health and
Development 5 (17-27).
Tannock, R., Girolametto, L. & SiegeL L.S.
(1992) Language intervenLion with chil
dren who have developmental delays:
effects of an interactive approach. American
Journal of Mental Retardation 97 (145-160).
Tomasello, M. & Todd, J. (1983) loint
attention and lexical acquisiLion style. First
Language 4 (197-212) .
Warren, S.F. & Kaiser, A.P. (1986)
Incidental language teaching: a critical
review. Journal of Speech and Hearing
Disorders 51 (291-299).
Whi tehurs!, G.). & FischeL I.E. (1994)
Practitioner review: early developmental
language delay: what, if anything, should
the clinician do about it? Journal of Child
Psychology and Psychiatry 35 (613-648). 0
Questions
What makes a good Intervention should develop children's language
therapy model for.. involve parents and be cost efficient .
expressive language
in pre-school children.
Does an interaction
approach to remediation benefits ,. . in terms of conversational competence and single
of language delay have ."s rather tha n syntax.
limitations?
IliMI.nteraction approaches tend to be general, often bringing
How can specific Following structured explanation of language objectives in
language objectives be a group i"!1p'!ement the objective.s at
taught through parents? home fleXibly, follOWing their child s lead and uSing dally
routines and situations.
SPEEC H & LANGUAGE THERAPY IN PRACfICE SUMMER 199 13
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2nd Edition
Lee Ann C. Golper
5 ecial fea tures ',sted as:
aSIC concep '}Int A' - Me' (net1'a"a
s
lticularly USCI"
are mentioned but the main value
' ts, Th' book would be texl
mrerveJ:lto' IS s it IS (j I' nd
the book to a speech and langua
s : develoPmen ' n, for students 0 a cula Ion a
therapist may be to blilid up a
t anaf;sis for all courseSttonen by o leading re
knowledge of the more general
,- I' I ffiI wrr """Ies a
aIYsls and' phono Obi , logy. b a"," effects of alcohol abuse in cHen
and em;nteryention, teacher in of lo'W'0ges
Engfish gi en (Om a af'ld
o( SChool damplmg ana the s' ers advice Of] and chapter \ duded to
exerCises bntrodUction to
ate), mcludin- thecp, eXplain, enhance un 5 eve/oPment Language
Stage Cott MCLaughl
Used II) th,e p ,{; In
th
' rei ace th
IS Introd, e author "
Uctory te '<.u es 7'1 ,,_..
IntenlJon t It has miring
Sourcebook for Medical Speech Pathology
Of the a Prr:Mde an IIJ-<J, noc been my
has bQ;esearch literature o"epth Ci77pilatiOil
/, c n my exp' ' er the u.... .
onguagede enence In te It
Students cOurses
PrOVIdes a comprehensive reference list of rer
th l(en find UOUC'
mlnology and medical procedures needed by
e trees tn' themselv.
Wading thro:r;g to flnd the /Ores 10st in
speech pathologists worf<jng in medlcol settings.
Instead tf,' 'gn SUch trearm t When
Includs new terminology. abbrevialJons and dragnosllC tests. , oIS text lents
On eS'ab" h Glrempts l &_.
Organises all terminolog'! and tests IX':Ordlng to their ( liS ed Int: 0 I"(:US
classic conCeDts Ormation and
corresponding spedalt</ areas,
care Ofth ;, ,thar /&Im lh /998
Indudes the latest information on documentallon procedures , IS VIS,,"I e / 56
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Includes updated neonatal data and revised and expanded
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fc
Or Students to ' sound fOund. .
information on paediatric problems related to reeding and
(OSCinatlng ph conllflue SllJdyi
tracheostomies.
,enomenor)," ng thIS
Promotes the development of cll11lcol competence In novIce
cfinrcians
Readet Offer
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As a 'coursebook' this is Inr.ended n t only (or
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readm but for writing on os well. The left hand
an communffy-based trearm
This IS a Praaicol ent pages show speCJnc examples of genero/,
IncJudi manual
sCientjfic or professional writing. often both the
trea Ing assessment protocols.
mcorrecr and correct verSIons. The corresponding
lInent ta>ks (OfT'pe
right hcFld ,age IS for proczice exercises. strategIes and 0m !y' h nsotory
I ' , andouts,
In addltJOn to co,ering t/'Ie basic rules such as
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Susan A. Storti
REVIEWS
Compatible with
current practice
Language Lessons in the
Classroom
Susan Diamond
Available from Wi nslow
ref 004-3202-98 25.00
l anguage Lessons In the Classroom is a
large, spiral bound publication containing
lesson plans and some photocopi bl e
activity sheets designed to develop lan
guage skills in an educational setting. At
the front activities are listed i terms of
lesson length. Howevel; cliniCi ans may find
it more benefi cial to use the Skills Index at
the bad of the book when selecting
lessons. This enables qui ck ccess to activ
iti es listed according to the language skill s
they ai m to develop.
The lessons themselves contai n a combi
nation of well known and anginal ideas
with some new valiations on old themes
which would be helpful when looking to
consolidate skills. The lesson plans are
clearly set out with objectives, mate :als
and procedures concisely shown. Some
suggestions for modifYing or extending
the actNitlesare also gIVen on each page.
The book (ontal s many practJcal ideas
relevant to the school setting and compat
with current classroom practice.
ActMties to develop descriptive language
are particularly strong and proved popular
WIth the group of Key Stage 2 pupils I
\'1On.: with. As the activiti es are clearly
described they could be carried out effec
by a speech and language therapy or
curric lum support assistant worki ng
under the guidance of a teacher or speech
and language therapist This would make
the book a useful source of informati on
when pia ning targets for Individual
Education Plans. Tile activities vary a great
deal In complexity WIth a number being
suitable for pupils up to the end of Key
Stage 2 and beyond which fLrther extends
the appeal 0 the book.
The disadvantages of the book lie 111 its
US origins a d somewhat dated presen
tation. As it is a US publication a number
of hemes, such as baseball and
Thanksgiving, have limited meaning to a
UK audience. Also, cli ni cians need LO
check vocabulary and spelling carefully
before using some of the activities In UK
classrooms as pupils may find the
American vocabulary confUs.ng.1 also fek
the presentation of some of the actMty
sheets for pupils was unappealing and
would personally wish to rewnte them
before giving them to children.
The need for modrfication of some themes
and vocabulary and the possibility of having
to rewnte some activity sheets may make
the book less attractive to classroom
teachers. Howevec Language Lessons in the
Oassroom contains many useful ideas for
developing a wide range of language skills
which could be used effectively in the clin
ic or the school setting and, as such, would
be avaluable addition to any departmental
library.
Catherine l1ottocks is Q Speoalrst Teacher I
Speech & Language Theropisr. Service 10
Co mUl1Icatian Drsordered Pupils, Abbeyfields
Co my First Sdlool. Morpeth,
Narthumberlan<1.
Particularly useful
f<?r pragmatic
difficulties
150 "What's Wrong
With This Picture?"
Scenes
M Thomas Webber Jnr and
Sharon G. Webber. lIIus. Mark
Bristol
Avorlable fram Wms/o\'!
re(II4-3127-98 [23 50
The book CCl,:sts of 150 photo
coplable pirtves which are dNl o
ed Imo three graced sections,
each contarnlng appromately SO
pictures. Each pictu'-e depcts a
different scene from a de range
of si tuati ons aM topi cs. Some of
the pictures ma be as
complementary material for
school based topics as tJ les
incl ude 'Indian Village', 'Restaurant'
and 'Helicopter'. The OlalJl-es are
black and white line dlC,wlr.es and
photocopy well. The authof sug
gests the atenal would be useful
as teaching aids to de !clop skills
in 'visual perception' and 'anguage
expansion'.
The pictures are in cartoon form
and are therefore arrraCil\e t o
most age groups. I was preased
the children's will ngness to
diSCUSS each scene.
The material was partlculari: use
ful when working with child-ell
who have pragmatic djtnc ltJes.
These activities expos gaps in
their reasoning skJlIs and gave an
insight Into the child's ercepuon
of the world around them.
C ildren who ha e pragmatlC dif
fi culties are often confused by
their lack of uooer'5tan Ing and
have difficulty making sense of sit
uations. This resource allowed
them to reflect 0 each scene
and gave opportunities to devel
op the child's a '!are ess of what
is appropriate.
The piaures were an excell ent
resource fN children with poor
ocabulary or word finding diffi
culties as they prov1de an oppor
tullity to encourage vocabulary
expansion. The tasks were also
beneficial for children who have
expressive language difficulti es:
most of these chi ldr-en were able
o 'spot' the error in each scene
but iound It difficult to explain
'wh ' things were wrong.
As all the pictures are in cartoon
mode, it was occasi onally diffic It
to decide what was actually
'wrong' With each scene. It may
have been helpful if the pictures
had been more real istic and true
to life. Overall , I found the children
enjoyed the tasks and theactiVities
provided a good st1mulus for a
range of teaching objectives.
Mrs R. Davison is 0 Specialist Teadler
at Morpeth Collingwood School Unit
(or Camm nicatiorl Disordered
Children
Knowledge needed
to pick and choose
Teaching Kids of all Ages
to Ask Questions
/v1onlynToomey
A'lOilable (rom Winslow
re(073-3283-98 25.00
This book is comparatively user
fri endly in that it is well organised,
clearly printed and may be photo
copied for your own use.
There are three main sections.
The fi rst contains activities for
young learners and is quite well
structured and planned. All ques
tion words are dealt with except
for 'how much)' and 'how many?'
T ere is also some material to
practise subject I verb inversion
questions but unfortunately some
of th ese pages use capital letters.
The characters used are appeal
ing to children and the ill ustra
tions are attractive.
The second secti on contai ns ref
erence material for the 'teacher'
and covers all kinds 0 verb forms.
It is Informative and easy to
understand because It is well laid
out. There is pOSSibly too ucn
information about verb forms not
commonly used and there are
some American variations.
The ird section contai ns ater
lal for ol der studentsand adults. It
is also well structured and starts
with practJce of parti cular gram
mati cal features. Some of these
are Inevitably rat her contrived.
The more general 'revi sion' exer
ciseslater on prOVide some excel
lent examples of scrambled sen
tences, matching questions and
answers and reading fOI- co pre
hension.
T e book is printed and pub
li shed in Ameri ca and there are
American expressions, spellings,
vocabulary and reference to
American nolldays and culture.
This is not evident on every page
and can be adapted, but some
people may find this 00 imtatmg.
Although the fi rst section is good
It could not be used systemati cal
ly by a teacher without knowl
edge of normal language develop
ment. Question words are not
introduced developmentally and
far more practice is usually need
ed with the si mple questions such
as where is / are) Whoever uses
thi s book needs to have the
knowledge to pICk and choose
appropriate material and 0 revise
each concept as necessary.
This book is a useful additional
resource for busy teachers In lan
guage units and speech and lan
guage therapists who need a vari
ety of matenal for the teaching of
question fonms.
Felicity Wngh is Speoalrs Teacher I
Speech & unguage Theroprsr,
Service rar Communicouon
Disordered Chrldren, Northumberlana
EducolJon Amharity.
Excellent in most
respects
Practical Language Activities
Materials for Clinicians and
Teachers
JoAnn H. Jeffnes & Roger D. Jeffnes
f
AVOIlable from WInSlow
re( 004-3263-98 26.50
The book has been written primarily
for an American a d.ence and. as such,
is directed towards teaching within the
'Least Restriaive Envi ronment'
requirement now common to most
US schools, and that natJon's trend
towards inclusive education and away
from withdrawing children onto spe
cial education programm es. Th is has
guided the authors to produce a book
designed to give chil dren the oppor
tunity to develop oral expressive lan
guage skills within that Wi der teaching
environment.
The book is divided into thl-ee main
sectIOns - Semanti cs, Syntax and
Morphology and Pragmatics These
sections are sub-divided into series
of activiti es deSigned to develop the
oral expressive language skills of the
children whi ch are followed-up by
worksheets aimed at reinfOrcing, or
e pl oiting where appropriate, the
child's abi lity to make auditory / VISual
connections.
In spite of the cultural and education
al context in wnl ch the book has been
written, I found it to be excell ent in
most respects.TI-, e most obVIOUS and
frequent weakness IS the use of
American vocabulary and Idioms such
as 'Kool-Ai d', 'si dewalk' and 'cooki es'
Howevec it would not be difficult for
professionals using the ActJvlty and
Work Sheets to modify these minor
irregulantles in a way that will render
the material perfectly acceptable or a
British audience. The book can be
used by children covering a ide
range of abilrti es, he programmes
being written In a way tha the work
rogresses rom least to most difficult.
believe this approach Will give teach
ers the fiexibiHty to vary the starting
point for children, thiS being depen
dent on their skill s levels.
The contents have obviously bee
thought through very carefully and
there IS a clear logic udin linking activi
ties and their concomitant worksheets
The Instructions are cogent and precise
The book can be used by a wide
range of professionals including
speech and language therapists and
language specialists and also by main
stream class teachers when reinforcing
various aspects of language learng. It
could be used as ateaching tool in the
development of the Naiollal
Curriculum's Speaki ng and Teaching
Activities.
june E. Palmer is SpeCialist Teach! In
Charge o( the Untt (or Communicaon
Disordered Children based 01 Hexham Ecm
County First School. Northumberland She
hasa Postgraduate Diploma in MICJlCed
EdJ(alJOn Slllclies (Child Language avJ
Language DlsoMues) from NWCfJSLe
UnNt' tW(
SPEECH & LANGUAGE THERAPY IN PRAcnCE SUM.MER 199 15
1
COVER STORY
Accent
A holistic approach
useful for dysphonia,
stuttering, articulation
problems, dysarthria and
prophylactic voice work,
the main goal of the
Accent Method is to
improve the individual's
total communication by
achieving the best
possible coordination
between breathing,
phonation, articulation,
body movements and
prosody. Co-founder
Kirsten Thyme
describes how.
he Accent Method is a complete
speech and voice training system
based on the rhythms and ges
tures that occur in normal
speech. The aim is not to treat
the patient' s disorders directly,
but rather to develop and train
normal speech function as far as possible.
When the therapist seemingly does not con
cern herself with the patient's voice problems.
the patient loses interest in the malfuncttons
and what is inefficient. and concentrates on
normal speech. Patients are never criticised.
The therapi st chooses exercises to suit each
patient's individual needs and an-anges t reat
ment In such a way that the patient does not
experience the voice and speech defects. Self
confidence is strengthened through positive
personal experiences. When the normal
speech functions are trained consciously with
voice exercises having a normalising effect, an
unconscious treatment of the symptoms
occurs (Thyme, 1992).
The accent method, and the theoretical expla
nation of its elements, is based on studies of
physiology acoustics (Thyme & Frokjaer-Jensen,
1987), psychology and linguistics (Smith &
Thyme, 1980), and finall y on an understandi ng
of the principles of kinaesthetic feedback
(Alexander. 1985). It provides a logical series of
voice exercises which are developed into text
and finall y into exercises using spontaneous
speech, facilitating the transition from the guid
ed sessions to the final goal - free and untrou
bled speech outside the clinic situation. The
practical training is based on
I. good abdominal expiration
2. phonatory elements such as vocal fold elas
ticity, mobility of vocal range, clear voice quality
and efficient voice production
3. articulatory elements like distinct articulation
and good resonance
4. linguistic elements, for example, well struc
tured sentences with good prosody, use of
pauses and eye contact with the listener duri ng
the speech act
a
-
c
5. communicative elements incl uding a natural
and lively logical gesture.
Relaxed and natural
The preparation for voice therapy begins with
breathing at rest. The patient lies on his/her
back on a bed or mattress with small pillows
under the neck and knees (picture I ).To ensure
abdominal breathing is established, it is impor
tant for the patient to be physically, emotional
ly and mentally relaxed. Playing soft gentle
music will often facilitate this.
The movements desired are simi lar to the pat
tem for natural breathing observed during sleep,
especially in children and animals, where the con
traction of the diaphragm resuh:s in an out and in
going movement ofthe abdominal wall.This form
of breathing is also the most efficient way to
breathe during speech as it is based on the
relaxed and natural pattern of respirati on at rest.
The purpose of the abdominal breathing exer
cises is to learn to breathe in as much air as
possible with the least possible muscular effort
(Sataloff, 1991). During training the number of
breaths per minute falls as a result of the
increased control of the diaphragmatic respira
tion pattem. Lowered respiratory frequency is
sai d to innuence the whole circulatory system
and thereby the metabolism, resulting in a psy
chic reassuring effect.
When patients are able to breathe correctly at
rest they are asked to place one hand on their
stomach to feel the abdominal movement (pic
ture 2). The stomach rises during inspiration
and fall sduring expiration. Inspiration and expi
ration should be of approximately equal dura
tion, and the expiration wil l fade out into a
pause or rest phase of the same length during
whi ch the whole body is at rest.
These exercises are also carried out when the
patient is lying on one side, then in a sitting
position and finally standing (picture 3).
Dynamic Posture
In the standing position the abdominal breath
ing pattem creates a rhythmic swinging move
16 SPEECH & LANGUAGE THERAPY IN PRACfICE SUM MER 1998
COVER STORY
ment of the body forwards on inspiration and
backwards on expiration, Thi s is a physiological
ly natural movement because the point of grav
ity is shifted a little forward when the abdomen
moves forward duri ng the inspi ration, As a
result the posture can no longer be considered
static but becomes dynamic. Moreover. static
posture should be discouraged in any form of
trai ning involving respiration or speech as It
may create unnecessary muscular tension.
Thus, the basic movement dun g respiratJ()1 ;
a slight sWinging movement of e boGl a ,{" .
of'pumping' (feated equa by
cle groups: the Insplratorv -:: an _ e
expiratory a mil r:-: ,:Jes.. Agonist and
antagonist a i: : _ _xcessively. The
first f usde grew 51':'-<.5 cootract. then con
tracts WUngly bet. _ reeasing e tension
slowly as t ,f' muscle group starts its
, r';: to complete the respira
tc C', - E. en performing breathing or
voICe exerci ses this body movement is sup
ported by swinging arm movements - moving
forwards synchronously with the inhalation and
swinging down with the exhalation, thus con
stituting a rhythmical, natural and gentle gesture
based on alternating slight and increased mus
cle tension which supports the phonation,
Driving voice production
The accent method aims to develop the chest
register or modal voice, It IS based on the myoe
lastic-aerodynamic theory of voice production
(Smith, 1957; van den Berg. 1958; Tftze, 1980)
hich suggests voice production IS driven by a
combination of aerodynamiC forces - the sub
glottal aU- pressure and the airllow through the
glotus - and the elastic properties of the vocal
fold tlS-.e, The greater the subglottal air pres
sure. me greater the airllow at the glottis and the
ce :cn:efiJ the vocal folds are blown open,
Th:' ::re.ner the Iocity 0 e airfow, the more
nu::ous membranes of the vocal
:u!::, - ;-e 5. ed together by the negative pres
sJfe created as a.1" passes the narrow glottis
- the Bemou_ effect. Snee the velocity of the
airflow depend, 00 the subglottic air pre sure, a
sutbent'y high a pre'isue below the ocal
folds supports good ooenrng and 5'Mft: closing of
the vocal folds. aSSIsted by the e of the
tissue, thus creating a well dosed pIlase
to the vibratory cycle,
The closed phase is important, as sudden do
sure generates an acoustic spectrum with
strong harmonics necessary to carry dear
articulation, whi le a suffiCiently long closed
phase is important as it reduces damping of
t he supraglottal resonance system, resulting in
a more clearly defined formant structure to
VOiced sounds, The task of the laryngeal mus
cles dunng phonation is to adduct and tense
the vocal fol ds appropriately for the sound
generation. The thickness and tension of the
vocal folds is then adjusted to produce the
desired frequency. intensity and quality, The
whole system of sound generation is primarily
governed by the subglottic air pressure - the
abdominal expiratory activity
Initiall y, the phonatory exerCises are produced
in a low pitched, breathy soft voice using
closed vowels [i, uJ. The exercises are per
formed using a low pitch because the vocal
folds are thickened and lax for modal voice.
The breathy quality IS trained initially as it
encourages a high alrfow between the vocal
folds, thus establishing good closure and devel
oping good movement of the vocal fo ld
mucosa - the Bernoul li effect, Soft phonation is
used in order not to strain the voice initially,
very important especial ly when dealing with
dysphonic patient s. Finally. the closed vowels [i,
uJ or oiced obstruents [v, Z, b] are used to
increase the supraglottal ai r pressure (a con
stnctJoo in the vocal tract seems to activate
the glottal and respiratory funct ions -
Laukkanan, 1992) and thereby reduce the pres
sure drop across the oeal folds, thus allowing
pa ents to train abdominal expiration inten
sively wrthout liskmg damage to the vocal folds,
Taking turns
The therapist and patient take turnswhen per
form1ilg the oice exercises. The basic exercis
11te for all Speech & Language Therapists
Winslow's 1998 catalogue features man)'
innovative and ground-breaking resources
from all over the world designed to sup
port every speech & language therapist.
As the leading supplier of resources to the
profession in the United Kingdom,
Winslow continues to offer accessible
qualit)' resources for all those concerned
with the special care of people. More than
200 new items are featured in the 1998
catalogue, including:
Makaton Parent/Carer Training Pack
Created especially for the Winslow Catalogue by
the Makaton Vocabulary Development Project,
this pack has been produced in response to the
need for distance learning materials for those
people who are unable to attend Mabton work
shops. Check out these materials on page 21 of
the Winslow catalogue.
Therapy Guides for Language & Speech
Disorders
Kathryn Kilpatrick's photocopiable materials
offer many functional ideas covering wide ability
levels. Enthusiastically reviewed by a British
speech & language therapist. [he five manuaJs
include WO'I'king wiU, Wards, RetulilIg
Comprehension and A Sehxtion oj Stimulu.s Materials.
See page 90 of Winslow's 1998 catalogu".
Autism Resources from Future Horizons
Feacuring seven neW' titles [roin the autism spe
Cl aJjSl. Future Hor izons, Winslow has sourced a
r:tng<: of qualit y material> will help to
improve social communication. Titles such as A
TrcfbU rI' ChB.lI oj Behavio'lIral Siralegif<, Vis/wi
Sl mlrlf'.Jor improving Comm.lInication and The
S et)) Social Slory Book can all be found on page
34.
Groupwork with Learning Disabilities:
Creative Drama
by Anna Chesner, this title is the latest
in a of practical, hands on pholOcopiab1e
mate ria ls published by Winslow. It offers basic
principles of working, a variety of approaches
LO drama and a number of lIseful drama struc
Lures - ideal for voice..: \var k, sensor)" work and
developing socia l skill s. Featured on page 58 of
the vVinslow catalogue.
Rating Scale of Communication in Cognitive
Decline
For those speech & language therapists working
within the older population, this assessment not
only determines verbal and non-verbal communi
cation skills but a lso helps establish strategies to
enhance comrnunication for this group of
patients. This resource. one of many for use wjth
dementia, is featured on page 103.
\Vinslow's 1998 catalogue features more than
900 resourceS 011 140 pages across the follow
ing categories: Education, Health, Elderly &
Social Care. The catalogue itself is a vital tool
that no speech & language therapist should be
without. To receive your free copy telephone
Lyn Smith at Winslow on 01869 244644.
WINSLOW
Telford Road
Bicester
Oxon OX6 OTS
Tel: 01869 244644
Fax: 01869 320040
EMail : winslow@dial.pipex.com
SPEECH & LANGUAGE THERAPY IN PRACfICIo SUMiI4ER 199 17
COVER STORY
Tempo I - Largo (shown with one stressed vowel):
Logoped: 3/4 J I d
> inspiration
.I J
>
Patient: 3/4
Figure I
~ I ~ ~
in s p i ration
J I d
> in sp iration
Tempo Il- Andante (shown with three stressed vowels):
Logoped:
4/4 '7 J' IJ .I
J ~ I ~ ~
'7 I'
-
I .I
insp. > > > p a u s e insp . > >
Patient: 4/4
~ I ~ ~ ~
'7 JIJ .I .I ~ I ~
p a u s e insp. > > > p a u s
Figure 2
Tempo III - AUegro (shown with live stressed vowels):
Logoped : 4/4 '7 .1'1 n n .I ~ I ~ ~
insp. > > > > > p a u s e
Patient: 4/4
~ I ~ ~ ~
'7
.1'1 nn J
p a u s e insp. > > > > >
Figure 3
improved respiratory function, both lung capacity (elasticity of the tissue) and
the ability to produce a strong expiratory muscle contraction
improved phonatory function due to faster and more complete closure of the
vocal folds and a normalising effect on the vibratory pattern of the vocal folds
air flow is reduced, suggesting it is utilised better by the vocal folds after training.
Figure 4 - Physiological results
1. The fundamental frequency of pitch is normalised, for some individuals changing
up to six semitones.
2. Modulation of pitch (intontation range) is distinctly improved (Thyme & Frokjaer
Jensen, 1993). Pitch period perturbations Gitter) are reduced (Thyme, 1977).
3. Intensity level increases (Smith & Thyme, 1976). Vocal energy is usually maintained
even through long sentences so the whole utterance is clearly articulated (Thyme,
1987). The variation in intensity that occurs in speech is also significantly
increased. Amplitude perturbations (shimmer) are reduced considerably.
4. Pitch and dynamic ranges increase (Thyme & Frokjaer-Jensen, 1980).
5. Voices, including those of people with unilateral vocal fold paralysis, sound
brighter and clearer after training.
Figure 5 - Acoustic Results
es, Tempo I (figure I), consist of an unstressed
vowel foll owed by one or two stressed vowels
resolving back to an unstressed and breathy
-sound in such a way that the distinct articula
tion of the vowel(s) coincides wrth the stressed
element(s) of the sound(s). The vowels used
are closed vowels, and voice is produced con
tinuously wrthout any unvoiced [h] sounds
dividing the initial unstressed sound and the fol
lowing stressed sound(s).
These voice exercises may be accompanied by
simultaneous large and gentle movements of
the jaw, tongue, velum, lips and pharyngeal
muscles alternating between various vowels
and consonants. In this way we also get an
articulatory training. The rhythmic patterns may
be mixed and adapted to the patient's individ
ual needs or for use with groups of people.
When the patient masters a good coordina
tion between respiration and phonation and
the voice quality has improved towards a more
sonorous timbre, s/he is ready to proceed
with Tempo II (figure 2), which is performed
wrth a quick inspi ration, just as in real speech,
foll owed by an unaccentuated upbeat and
three accentuated beats, ending with a full bar
pause of four beats. Tempo II may be per
formed with rhythmic variations t o strengthen
the elasticity and mobility in voice and body
musculature. These variations are experienced
by the patient as lively and stimulating.
Then foll ows Tempo III (figure 3) wrth fi ve
beats and a somewhat faster tempo, where
beats one and two are subdivided into four
accentuated eighth beats. The purpose is to
keep the optimal balance between the sub
glottal pressure and the adjustment of the
vocal fold adduction even when making fast
and small accentuations (expi rations).
Body movement
The accent method emphasises movement
because movement in general supports
speech, and because adding the movements to
the speech training produces extra stimulation
of the neurological systems, The voice exercis
es therefore go together with characteristic
movements of the body, arms and hands.
During exercises both the therapist and the
patient are active so that, little by little, the
exercise turns into conversation, at first with
out words while prosody is trained, but later
with words and short sentences, moving finall y
into free and natural conversation building up
both the prosody and articulatory skills.
Movements of the body, arms and hands are
constantly used to support the prosody by
accentuating stressed words.
Tempo 1 - Largo
In the Largo rhythm, the body moves slowly
forward during inspiration and backwards dur
ing expiration. These body movernents are
large and gentle and performed in great har
monious cycles, each takjng five to six seconds
to complete and corresponding to the norrnal
rhythm of breathing. A large swingi ng move
ment of one or both arrns may be added to
general body movement. the arms li fting during
inspiration and SWingi ng down again during
expiration and phonat ion. This tempo can be
used to express deep feelings or exclamations
such as "help", "Get going" or "Get out ".
To begin wrth, the stressed vowel (eg. [au] in
"Get out") is trained separately, the unstressed
vowel always having the same vowel quality as
the fi rst stressed one, that is. [au - AU]. not [e
- AU]. The exercise may then be supported by
a swinging movement of the whole arm with
the accent or stress on the word "out ".
Tempo II - Andante
In the Andante rhythm. the body sways slightly
from side to side around an imaginary axis
through the spinal column. The arms may be
used to accentuate the stressed beats by means
of an up and down movement of the forearms
both in the exercises and spontaneous speech.
This tempo is used when different rtems are
selected, for example "I want this. thi s. and this"
is said wrth three selective movements of the
forearm possibly combi ned WITh slight turns of
the upper part of the body; neutral. logical
movements supporting the stressing of select
ed meanings. "He has lost house. wIfe, and
mQney" is trained wrth an unstressed and three
stressed vowels: [au - AU - AI - A].
18 SPEECH & lANGUAGE THERAPY IN PRACTICE SUMMER 1998
COVER STORY
Tempo III - Allegro
In the Allegro rhythm, slight fiexible Jumps
accompany the accentuated beats. Up and
down movements of the hands may be used to
accentuate the stressed beats in exercises and
during speech. Tempo III is used for stresses
that follow each other quickly and can be
grouped together. Observation of speakers on
television for example often shows gestures
contain small quick hand movements or sImul
taneous small nodding movements of the head
when stresses are grouped together In mean
ing and follow e3ch other quiddy, This tempo
contains two or more stresses and the speak
ing rate as well as the rhythm of the exercises
is often somewhat faster than Tempo II. It is
often used in normal daily speech, ego "Hurry
Upl" or "Get goingl" In the examples, the
stressed vowels are underlined and those
belonging to the same group are joined:
"He isn't here."
" w ~ i l besin is hillf dQne."
These exercises are adapted to each patient
individually, using various texts, and the training
is continued until patients are found to use the
technique In their spontaneous speech.
Results
Proven physiological and acoustic results of the
accent method are summarsed in figures 4 and 5
respectively It is importart to note changes are
observed in voiceless as well as voiced sounds and
consonants as well as vowels, even if the training is
canried out using o n ~ gentle, low-prtched, breathy
and close vowelsThis way of training is scientifical
ly based and unique to the accent method.
Perceptually, the general impression of a voice
trained using the method is one of greater
intelligibility, greater volume and a more lively
prosody, especially more varied stress patterns.
Furthermore, the training in text reading and
free oral speech results in better communication
generally, wrth appropriate pausing and good
eye contact between speaker and listener.
Psychologically, when patients feel that they are
able to speak better; they gain greater self-con
fi dem:e dlld ,eel freer and more extrovert. The
body and arm movements coordinated with
the exercises help a good deal to achi eve this.
Questions
How does the accent
method work'?
What level of
participation does the
therapist have'?
Is there evidence that the
accent method is effective?
The exercises have also proved to have an
astonishingly good effect on stutterersThe rea
son is, probably, that the exercises destroy the
bad refiex-Ioops and establish new, correct
refiex-Ioops. After the rhythmic phonation
exercises have been trained on vowels and
consonants which are easi ly pronounced by
the stlltterer; the more difficult phonemes are
mastered automatically, and a transition to
exefCIscs relatmg to real speech with good
prosody can be smoothly made. Even after
only a few seSSions, the stutterer feels an
Improvement whICh gives self-confidence and
bui lds up the psychological stability not obtained
by other techniques (Smith & Thyme, 1978).
Training
As the accent method is essentially experi en
tial, practical training is highly recommended.
Therapists should contact the authors for fur
ther Information. The full version of this paper
containing descriptions of research into the
efficacy of the method is available to Speech &
Language Therapy in Practice subscribers on
application to the editor.
Kirsten Thyme-Fr0kja:r is Speech Pathologist and
lecturer and Borge Fr0kja:rjensen Associate
Professor In Phonetics at the Danish Voice
Inistltute, Ellebuen 2/, DK-2950 Vedbaek,
Denmark Kirsten worked with Professor Svend
Smith (rom 1967 developing and extending the
Accent Method. When he died in 1985 he
bequeathed the copyright to Kirsten.
Acknowledgement
We want to express our appreciation to speech
and language therapist Sara Harris and consul
tant atolaryngologist Tom Harris (or their valuable
comments and proof reading o( the English text.
References
Alexander, G. (1985) Eutony - The holistic
Discovery of the Total Person. Felix Morrow,
Great Neck. New York
Berg, J. van den (1958) Myoelastic-aerodynam
ic theory of voice production. Journal o( Speech
& Hearing Research I.
Laukkanan, AM. (1992) Voiced bilabial fricative
as a vocal exercise. An electro glottographic
and acoustric investigation. Scandinavian Journal
o( Logopedics and Phoniatrics 17 (3-4).
Satalof( R. T (1991) Professional Voice, The
Science and Art of Clinical Care. Raven Press.
New York.
Smrth, S. (1957) Theorie aerodynamique de la
vibration des cordes vocales. In A Aubin (ed),
Larynx et phonation ... Presses Universitaires de
France, Paris.
Smrth, S. & KThyme (1978) Accentmetoden.
Specialpa:dagogisk Forlag, Herning, Denmark
(Remaining copies from: Danish Voice Instrtute,
Ellebuen 21, DK-2950 Vedbak. Denmark)
Smith, S. & Thyme, K. (1980) Die Akzent
Methode. Danish Voice Instrtute, Ellebue 21,
DK-2950 Vedbak. Denmark
Smith, S. & Thyme, K. (1976) Statistic research
on changes in Speech due to pedagogic treat
ment (The Accent Method). Folia Phoniatrica 28.
Thyme, K. ( 1977) The application of elec
troglottography for Fo measurement. Proc. (rom
the XXVllth IALP congress, Copenhagen.
Thyme, K. (1987) Die Akzentmethode.ln Horst
Gundermann (ed.), Aktuelle Probleme der
Stimmtherapie. Gustav FischerVerlag, Stuttgart,
Germany.
Thyme, K. (1992) A rational way to treat stut
tering (The Accent Method). Proc. XXllnd IALP
World Congress. Hannover, Germany.
Thyme, K. & Fr0kja:r-Jensen, B. (1980) Results
of one week's Intensive Voice training. Proc. (rom
XVllith IAL.P Congress. Washington Dc.. USA
Thyme, K. & FmkJa:r-Jensen,B. (1987) Analyses
of voice changes during a 10 months' period of
voice training at the education of logopeds in
Copenhagen. Proc. (rom the Ist International
Voice Symposium. Edinburgh, Scotland.
Thyme, K. & Fmkja:r-Jensen, B. (1993)
Stottererbehandlung nach der Akzentmethode
und eine Untersuchung der Ergebnisse nach
drei Monaten und nach einem Jahr Behandlung.
Proc. (rom Jahres(ortbildungstagung des
deutschen Bundesverbands fur Logopddie.
Munster, Germany.
Trtze, I. (1980) Comments on the myoelastic
aerodynamic theory of phonation.
Journal o( Speech & Hearing Research 23.
Answers
The accent method uses the rhythm and gestures of
normal communication to improve function, so has an
unconscious normalising effect on speech and voice.
Clinician and client carry out lively and stimulating
exercises in turns, moving from prosody to words to
sentences to conversation, with the content and rate
appropriate to the individual client.
Research has shown physiological, acoustic,
perceptual and psychological gains particularly for
clients with dysphonia or a stutter.
SPEECH & LANGUAGE THERAPY IN PRACTICE SUM1'.IER 199 19
0
EARLY INTERVENTION
ue e-...
me
Many children with a histor-y of glue ear- go on to
exper-ience speech and language difficuh:ies.
Sasha Bemrose and Charlotte Brown wor-k with
other- paediatr-ic pmfessionals to pr-ovide a preventative
programme for- parents of those children at risk.
esearch suggests approxi
mately four out of five chil
dren will have at least one
episode of glue ear before
their fourth birthday.
Although the specific rela
tionship of this condition to
speech and language devel
opment is argued, many studies confirm a
link between persistent glue ear in the first
year of life and speech / language impair
ments (Figure 1).
It has been well documented that not all
children who suffer from glue ear will
experience developmental difficulties.
However, the following areas appear sig
nificant in determining the effeds:
1) Age of onset-before 18 months (Friel
Patti et at, 1990)
2) Number of episodes (Teele et al, 1990)
3) Fluctuating nature of hearing loss
(Bamford & Saunders, 1992)
4) Other factors such as language environ
ment (Freeark & Frank et ai, 1992), pre
and peri natal history (Bishop &
Edmundson, 1986) and the physical envi
ronment such as smoking and use of day
care (Haggard & Hughes, 1991).
Need fOI intervention
A review of practice within our working
environments indicated the needs of chil
, dren with glue ear were met in a variety of
ways:
assessment and advice only
awaiting ENT management before speech
and language therapy intervention
regular review
ongoing therapy.
[n most cases, the focus for therapy was on
the. speech and language deficit and not
the important coexisting factor, glue ear.
We and colleagues in paediatrics and ENT
felt there was an opportunity to develop a
programme specific to these children's
needs to work alongside the speech and
language therapy services already available.
We wanted to offer carers a workshop where
learning about glue ear and its effeds could
take place in a variety of ways. We also wan t
ed to work collaboratively with carers to
enhance the child's language environment.
Critical period
From our observations, children with glue
ear felJ into two groups. The first group
were mainly over two and a half years old
and had been referred to speech and lan
guage therapy clinics for assessment. The
Top: John
Cleese who stars
in Videos for
Patients
Right: Sasha
Bemrose
second group had been seen in a joint
speech and hearing clinic before they were
eighteen months old and did not seem to
require speech and language therapy input.
However, many of these children later pre
sented for assessment due to delayed com
munication skills.
The critical language acquisition period is
known to be the first eighteen months of
life. We hypothesised that, by targeting
children at the pre-verbal stage, we might
reduce the likelihood of them developing
speech and language delay. The original
programme was therefore devised with this
age group in mind.
Pmgramme
The programme aims to increase the carer's
knowledge and understanding of glue ear
and its possible effects on communication,
maximi e the child's speech and language
development through enhancement of
carer' interaction skills and develop carer's
a,"areness of optimal environmental con
ditions for language learning. Referral cri
teria are in figure 2.
The following format has been used for six
glue ear programmes run over the last two
years. The exact structure of each pro
gramme has varied according to the need
and circumstances of participants. The
most frequently used model consisted of
one carer workshop session with no chil
dren - between two to three hours - and
four carer-child individual interaction ses
sions of approximately one hour each. The
programmes were implemented by one
specialist speech and language therapist
plus one other professional su,h as ~
teacher of the deaf or health visitor.
On arriving for the workshop carers com
plete a questionnaire to gain a baseline
measurement of their knowl edge about
glue ear and communication and to orien
tate them to the topics presented (Figure 3.
This questionnaire is one which the
authors have devised and is in no way a
definitive list).
20 SPEECH & lAI'1GUAGE THERAPY IN PRACTICE SPRING 1998
EARLY INTERVENTION
Participation
An imponant aspect of the workshop is
carer panicipation facilitated by group
gelling activities where carers share infor
mation about themselves and their child.
To provide information about glue ear in
an interesting and accessible way panici
pants watch the video 'What You Really
Need To Know About Ear Infeoions and
Glue Ear' (Videos for Patients). The con
tent of the video is then discussed and the
carers have the opponunity to comment
and ask questions. A fre uent question is
'how to prevent glue ear?'. There appears to
be little agreement or research in this area
but ideas we talk about may include
Alternative practices such as cranial
osteopathy and homoeopathy. It has been
stressed this needs to be carried out by a
trained praoitioner.
Changes in diet, for example milk free.
Allergy related factors such as dust mites,
bed bugs.
For an older child, frequently blowing
their nose.
To understand the imponance of listening
/ hearing, carers panicipate in a variety of
activities. Specific emphasis is given to
adapting the home environment to accom
modate the child with glue ear so, for
example, carers brainstorm visual and
auditory distractions in the home, thus
facilitating selective listening. In addition,
we address the ways children learn early
communication skills and discuss tech
niques for language development. Before
their next session, carers are asked to
record the visual and auditory distractions
they note in their homes.
There is a body of research available
describing the influence of carer interac
lion style upon child language acquisition.
In addition to this, positive parental inter
action can buffer the negative effeos of
glue ear on language (Freeark & Frank,
1992). In the light of these findings, we
followed a therapy model adapted from
Kelman & Schneider (1994) for the indi
\idual sessions and developed an assess
ment profile. The carer-child interaction
therapy involves video recording play ses
sions between the carer and child using a
selection of toys with the carer encouraged
to play in a natural way as they would at
home (Figure 4).
Increased understanding
Results have been evaluated in a number of
ways. Change in carer knowledge was mea
sured through analysis of questionnaires
pre and post programme. The general
trend indicated increased understanding of
glue ear by the end (Figure 5).
It was apparent at the workshop carers
were uncenain about the nature of glue ear
and its effeos on their children. This was
despite, in some cases, several attendances
at audiological clinics. We felt this was not
due to a lack of information but rather the
way information was presented. The group
Figure I Summary of research findings suggesting areas of
speech & language development affected by glue ear.Taken
from McConnick 1993.
Attention and listening deficits
Receptive language delay
Expressive language delay
Phonological delay
Behaviour management difficulties
Figure 2 Programme referral criteria
a) the child must have a full audiological assessment.
b) the d iagnosis of glue ear must be observed for at
least six months.
c) the child mayor may not have grommets
inserted.
d) the child mayor m ay not p resent with speech /
language d ifficulties at t ime of referral.
e) the child should not p resent w ith significant
motor or cognitive impairment.
f) the child should be three years old or under.
g) one carer must attend the full programme.
Figure 3 Glue ear questionnaire.The carers are asked to answer
true I not sure I false to each statement at the beginning and at
the end of the programme_
PLEASE ANSWER - TRUE / NOT SURE / FALSE
Glue ear affects your chi ld's ability to hear.
Glue ear is most likely to occur after colds and ear infections.
Grommets help the middle part of the ear stay air filled.
Grommets stay in the ear drum until the doctor removes them.
Children need to hear well so they can learn to talk
Children w ith hearing problems sometimes need extra help to
to talk
learn
Young children find it easy to listen to different sounds at the same
time.
It helps children to concentrate if you look at them when you are talkjng.
If your child does not hear you speaking, you should shout.
If your child has hearing difficulties when they are young, thi s
their talkjng when they grow older:
affects
Lots of children get glue ear at some time in their childhood.
As children grow older; they are much less likel y to get glue ear.
Glue ear wi ll usually get better by itself
Glue ear can come and go.
Your child can swim when they have grommets.
Playing with children helps them learn to talk.
Your child's speech should always be clear. Correct them
something wrong.
if they say
Glue ear damages your child's ears permanently
SPEECH & LANCUACE THERAPY IN PRACTICE SUMMER 1998 21
EARLY INTERVENTION
setting provided a relaxing environment
where discussion, activities and reinforce
ment could take place. Carers specifically
commented on this aspect of the workshops.
Enhanced interaction
Change in carer interaction style was mea
sured through a video assessment profile,
before and after the programme. Carer
communication behaviours are profiled
and rated on a scale of 1 to 5 where 1 =
never appropriate and 5 = always appropri
ate. A combination of non-verbal and ver
bal skills are observed including eye con
tact, turn taking, initiating communica
tion, repeating child's vocalisations. All car
ers were able to enhance their interaction
skills in the target areas by differing degrees
and some generalised these skills into other
aspects of communication with their child.
Children's communication skills were
assessed at the three month review. From
our sample, children who were referred
with no existing communication delay /
disorder did not require further therapy
(two years post programme). The majority
of children who presented with speech or
language delay / disorder at referral, many
with a moderate to severe impairment,
required child centred therapy at a later
stage (figure 6).
Children who appeared to present with no
speech or language problems were general
ly those whose carers demonstrated a pos
itive interaction style. This concurs with
Freeark & Frank et al (1992) who suggest
that active and engaging parental verbaJisa
tions appear to buffer developing language
abilities from the effects of glue ear.
From our observations and parental
reports, children who received grommets
during the programme made rapid
progress in their attention and listening
skills. This was more marked in children
below two years of age.
Posrtive
Carers' attitudes towards the course were
measured through an evaluation form at
the end. Most of the comments were posi
tive and specifically related to the work
shop style of teaching (figure 7). Some car
ers found it difficult to make arrangements
for child care during the workshops, par
ticularly for courses which involved more
than one workshop. Attendance for the
longer programmes was poor, particularly
when children had no apparent speech or
language difficulties. Parents commented
that a time commitment of more than six
weeks was difficult to make.
It may be possible to reduce the pro
gramme to one workshop with no individ
ual sessions. It is important that interac
tion style is addressed, but this may be
viable within other areas of the service, for
example the Health Centre teams. This will
depend on the services currently being
offered in the district. [f carers attend only
one workshop, it would be beneficial if a
refresher could be offered, perhaps after
four months. This would encourage them
to carry out some of the ideas at home and
provide an opportunity to discuss develop
ments. [t would allow a forum for discus
sion on how useful the programme was
and any other suggestions for the future.
Access
The outcomes from the programmes to
date have been positive, both for the carers
and the children. The majority of referrals
to the programme from agencies such as
ENT, health visitors and other speech and
language therapists were of children with
existing speech / language difficulties. [t
proved difficult to access the younger chil
dren unless the therapist had active
involvement in joint speech and hearing
clinics. This difficulty could be alleviated
through close liaison with health visitors.
The programme outlined is flexible and
can be adapted to meet the needs of the
clients and the therapist. These ideas can
be used for a variety of children with glue
ear, those
with no speech or language difficulties
with speech or language difficulties
with or without grommets
with a history of glue ear, but who cur
rently have normal hearing.
We would welcome any comments or sug
gestions regarding this programme and
would be pleased to hear from colleagues
about their services to this group of children.
RESOURCE UPDATE. ..RESOURCE UPDATE. ..RESOURCE UPDA"TE..
Options in stammering therapy
speecJ:1 and language therapy services for
adults mthe UK
A new leaflet from the British
Stammering Association explains
speech and language therapy services
for adults in the UK.
Written by speech and language thera
pist Anne-Marie Cray with the assis
tance of the BSA Speech and Language
Therapy Advisory Panel, it summarises
approaches to therapy and suggests
useful contacts and books. SOp per
copy, 4 for 10 inc. pap
BSA, 15 Old Ford Rood, London, 29PJ.
Incentives
The Incentive Plus catalogue focuses
on

products to moti
vate children, nurture
self confidence and
self esteem and
encourage appropriate
behaviour. Books,
stickers and stamps
are included.
For afree copy, tel.
01296715738 I fax
01296715125.
I
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web page J
http'//WWWd"Sb'I'
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Government Disab'rt
Rights To kf. ' . Itl Y
public ac s IS gIVing the
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Internet.
Taskforce is Worki
deliver civil rights fo d .
ng
to
people. InclUded
p.age are discussion
mmutes Of pli . ,
and f ks eVIOUs meetings
m .to other information
on disability matters.
Parents with
learning disabilities
First Steps to Parenthood is a new
photocopiable manual assessing
and training parentcraft skills
where one or both parents have
learning disabilities. The system
is designed to be adapted to
individual need. Price 71.50 inc
p&pfrom Pavilion Publishing, tel.
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Infrared keyboard
advance
A new keyboard is helping users with motor
control and mobility problems access computing.
The concept Universal Plus Infrared Keyboard
(177 + VAT) communicates with the computer
via an infrared receiver and can be used from a
distance of up to three metres. It is designed
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free of cumbersome leads.
Details: The Concept Keyboard Company, 01705
372233.
22 SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 1998
EARLY INTERVENTION
Sasha Bemrose and Charlolle Brown are both
Specialist Speech & Language Therapists work
ing in the field of deafness. When the glue ear
programme was first developed they were work
ing for Camden &Islington Health Authority.
Resource
What You Really Need to Know About Ear
Infections and Glue Ear' is available at a
cost of f 17.50 inc. VAT and p&p from
Videos for Patients Ltd, 18 Denbigh Close,
London Wll 2QH, tel. 0171 938 3160, fax
01719381490.
References
Bamford, J. & Saunders, E. (1991) Hearing
Impairment, Auditory Perception and
Language Disability 2nd Ed . Whurr.
Bishop, D. & Edmundson, A. (1986) Is
Otitis Media a Major Cause of Specific
Developmental Language Disorders ?
British Journal of Disorders of Communication
21 (321-338).
Freeark, K. & Frank, S. et al (1992) Otitis
Media, Language Development, and
Parental Verbal Stimulation. Journal of
Pediatric PsychoLogy 17 (2) (173-185).
Friel-Patti, S. et al (1990) Language
Learning in a Prospective study of Otitis
media with Effusion in the First Two Years
of Life. Journal of Speech & Hearing Research
33 (188-194).
Haggard, M. & Hughes, E.(1991) Screening
Children's Hearing: A Review of the
Literature and the Implications of Otitis
Media: London, HMSO.
Kelman, E. & Schneider, C. (1994) Parent
Child Interaction: An Alternative Approach
to the Management of Children's Language
Difficulties. Child Language Teaching &
Therapy 10 (1).
McCormick, B. (1993) Paediatric
Audiology 0 - 5 years. 2nd Edition. Whurr.
Teele, D. W. et a!. (1990) Otitis Media in
Infaney and In tellectual Ability, School
Achievement, Speech and Language at 7
Years. Journal of Infectious Diseases 162
(6 85-694).
Questions
i
What evidence is there
[
that early intervention for
children with perSistent
glue ear IS needed?
Why do carers find a
workshop format
useful?
How can outcomes of an
early intervention
programme be measured?
Figure 4 Carer-child interaction progranune.
SESSION I Carer-child interaction assessment video (before measure)
Informal screen of child's interaction skills
SESSION 2 Observe assessment v ideo w ith carer
Praise, reinforce & discuss language enhancement strategies
Practise specific strategies and discuss home implementation
SESSIO N 3 Review use of strategies
D iscuss new strategies if appropriate
SESSION 4 Revi ew strategies
D iscuss new strategies if appropriate
Carer-d l il d interaction assessment video (after measure)
Repeat glue ear questionnaire (from carer workshop)
Set r eView d ate - three months post programme
Figure 5 Change in
response to questions pre
and post course
Figure 6 COlTllTlunication
outcolTles two years post
prograJTIlTle.
required no
further further
25
"cherapy therapy
20

required
No sp/l ang 0% 100 %
impairment
<5 15
10
at referral
5
Sp/lang 86 % 14 %
impairment
at referral
o ___...I..""'''''i.-.,-cmcr-+
IClI01KT ccmCi r.te:ma ccma
I}W\I(UJ RE5I'ONS( TOCUSOONS 1lI!',t,'<'C POll WJfiSl:
Figure 7 ExalTlples of carer feedback.
"I found being w ith other people w ho have a child with glue
ear very helpful:'
'The most useful parts were when we had discussions and
games about listening and how children learn to talk."
"It helped me understand why he finds it hard to listen."
Answers
Effects of glue ear during the critical language
acquisition period on later speech or language
impairment can be reduced given appropriate stimulation.
Workshops allow learning in a relaxed atmosphere, with
encouraging participation, sharing and
brainstorming.
In to considering speech and language skills, a
pre and post programme questionnaire can assess
carers' knowledge, video recording can tap interaction
style and an evaluation form can gauge attitudes.
SPEECH & LANGUAGE THERAPY IN PRACTI CE SUM,\ IER 199 23
1
Memory and testing
Turkstra, L.s., Hol land, AL (1998) Assessment of syntax after adoles
cent brain Injury: effects of memory on test performance. Journ al o{
Speech, Language and Hearing Research 4 1 (I) I 37-49.
This study investigated the o{ working memory load on
performance o{ a task designed to measure recep Uve syntax ability.
Subjects were six brain-Injured adolescents and six hospitalised control
subjects matched {or age, sex, and general ability. Each subject was
administered the Listening/Grammar subtest o{ the Test o{Adolescent
Language (TOAL-3) and a modi{led version o{ this subtest with identical
syntax and {ewer response choices (i.e. a reduced working memory
processing and storage load) .The syntactic structures tested on these
tasks also were measured In spontaneous narratives. The brain-injured
subjects' performance was signi{lcantJy worse than that o{ controls on
both versions o{ the syntax comprehenSion subtest. There was a
significant group-by-task interacUon, as brain-
was significantly worse on the Listening/Grammar subtest than the
modified subtest. whereas con trol subjects' performance did not differ
across the two tasks. In their spontaneous narratives, subjects In both
groups produced the syntacUc structures tested on the receptive syntax
tasks, with no between-groups difference in syntax producaon. The results
are discussed in terms o{ test validity and the impact o{ measurement
methods on test performance in disordered group s.
Employment opportunities
Odom, AC, Upthegrove, M. (19 97) Moving toward employment
using Me case study. AugmentaUve and Alternative CommunlCa on
13(4) 258-62.
This case study outJlnes the development o{ employment (or a person
who used a high-technolog'1 assistive commun;cao
communicate and {or employment. Is sues discussed include rhe persoo's
history o{ experience with augmentative and altema Y
(MC) , technology support at the worksite and the benefits o{ supported
employment. The Importance o{ a belief system that considers
employment {or all people as a baSIC expectaUon is emphaSised.
Communication IS not the (lnal goal o{Me intervention. Incre ased
quality o{ li{e, which includes is the more important purpose.
Differential diagnosis
Davis, B.L, jakielski, K.j., Marquardt. TP (1998) Developmental apraxia
of speech: determiners of differentia l diagnosis. Clinical Linguistics and
Phonetics 12( I) 25-45.
Developmental apraxia o{ speech (DAS) IS a neurologically based disorder
in the programming o{ sequential anticulatory movements This definition,
based purely on motonc IimitatJons, is {raught with controversy concerning
aetJology clinical mani(estations, and even identi{lcation o{ the
disorder as a separate clinical entity. An understanding o{ developmental
apraxia depends on consistent utilisation of a group o{ symptoms {or diag
nosis so data-based results can be used to generate in{erences about the
disorder. Results {rom studies o( children diagnosed with developmental
apraxia, but who may not be apraxic, complicates application to theories
attemp 'ng to account {or observed symptoms. A longitudinal study o{
children with DAS has been under way at the University o{Texas at
AustJn since 1985. O{ 22 children re{erred as apraxic, a diagnosis has
been confirmed in only {our. Phonological and language evaluation data
{or five clients evaluated during this project are presented. One was
diagnosed Vi th developmental apraxia o{ speech. Each o{ the other {our
subjects was diagnosed with speech and/or language disorders without
the presence o{ develop mental apraxia o{ speech. Diagnostic results {or
all (lve are presented. to illustrate criacol {eatures (or differential diagnosis.
24 SPEECl-1 & LANG UAGE THERAPY IN PRACTICE
FURTHER READING
This new regular feature aims to provide information about articles in other journals which may
be of interest to readers. The Editor has selected these summaries from the 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 Y07 4PP, tel. 01765 640283, fax 01765
640556.Annual rates are: Disks (for Windows 3.1, can run on Windows 95): Institution 90;
Individual 48. Printed version: Institution 60; Individual 36. Cheques are payable to
Biomedical Research Indexing.
injured subjects' performance
'on deYICe to
e com unICaOOfl
AAC
Beresford, SA (1998) Communication aids for people ;nh degenerawe
neurologicaJ cmditJons. BntishJournal o(TherafYi and RehabfflrotJon 4( I ) 8- 11
The range o{ eqUIpment available to Old communication has Increased
conSiderably ove,- the past {ew years. The advent of the microchip has
opened up many ev, areas in electronic equipment and this looks set
to increase as interoctrve computing becomes more widely available. This
anucle discusses means o{ obtaining {Inance, simple reading aids and
page turners, voice amplifiers, mechanical communication eqUi pment,
portable e/ectroOic commuOicators, computers and environmental control
systems. people are soil not {amiliar With computers and they may
pre{er mechamcal communication which allows more personal in teraction.
While communicalJon aids enable relationships to continue even in
severe physical disability. it is pOinted out that speech is still the quickest
{orm o{ (ace-to-{ace communicatJon.
Phonological awareness
Fazio, B.B. (1997) Memory for rote linguistic routines and sens' ivity
to myme: A comparison of low-income chil dren with and Without
specifiC language impairment Applied Psycholinguistics 18(3) 345-72.
This report deSCribes MO studies on memory (or rate linguistic
sequences and senSitivity to rhyme in young chJ/dren with and Without
language impairment. In the 10 low-income kindergarteners with
speci(lc language impairment (SLI) were compared with age- and
income-matched classmates on reciting common nursery rhymes, reciting the
and (ate counang. Children with S di splayed lower performance
on most o{ the rate linguistic sequence tasks. espeoolly on their kJJowledge
o( nurseq my es. 1e second swdy examined the learning and retentJon
of nursery rhymes in eight young children WIth SU after six weeks o(
dassroom InSlftJC!JOi'l Low-ilocome. DOr and yeJr'01d cJvldren with SU
nd the (age- coo classmates '!fIe wugfl five novel
rsery rhymes cocnng a f<L-ge-group actMty. Children were
res ed before and o{!ff the [6 emioo 00 their ability to recite nursery
rhymes and wdetect rhyme. en compared With their peers, children
with SU had di{flQJlty repeating the nursery rhymes, despite daily classroom
exposure, Although the performance o{ children with SLI on rhyme recita
tion and detection tasks was poor. their relative performance was better
on a c/oze task based on the set of nursery rhymes. The results suggest
children '.'11th SLI have difficulty storing and/or retrieving lines of memorised
text. Traditional in{ormal techniques (or teaching rote linguistic sequences
may need to be modi{led to give children With SU more opportunities to
practise rote sequences.
Group therapy
de Angelis, E. C, Mourao, L.F, Ferraz, HB., Behlau, 1'1S., Pontes, PA,
Andrade, LA (1 997) Effect of voice rehabilitation on oral communi
cation of Parkinson's disease patients. Acta Neurologica Scondinavica
96(4) 199-205.
VOice and speech disorders are common in ParkJnson's disease patients
and may lead to social isolation. Rouune cHnKal voice therapy measures
were employed to evaluate the effect o{ voice (ehabilitation. Twenty
patients with a stable drug regimen participated. The patients were
assessed be{ore and after a program o( voice rehabilltaaon consisting o{
13 group therapy sessions during one month, With emphasis on the
increase in laryngeal sphincteric activity. Voice rehabilitation produced an
increase in maximal phonation times, decrease in the values o( s/z ratio
and air ir,crease in vocal intensity. decrease in the complaints o{
weak and stJalned-strang/ed voice and monotonous and Unintelligible
speech and elimination o{ complaints o{ swallowing alterations. These
data indicate a greater glottJc efficiency after voice rehabilitation
a more {unctional oral communication.
SUMMER 1998
e aspifatJon stows
_
_ ..
Parent personality
I
Plven, j, Palmer; P, Landa R, Santangelo, S., jacobi, D, Ch ildress, D. (1997)
Personality and language charaderiS"bcs in parents from multiple-incidence
autism families. Americanjoumal o(tvl ed:cal GeneDcs 74(4) 398-411.
Several studies have suggested the genetic liabili ty (or autJsm may be
expressed In non-autistic relaDves o( autistic probands, in behavioral
characteristics milder but qualitatively similar to the defining (eatures o(
a tism. Avariety o( direct assessment approaches are employed to
examine both personalIly and language In parents with two autistic
children (multiple-incidence autism parents) and parents of Do n
syndrome probands. Multiple-Incidence autism parents had higher fOles
o( particular personality characteristics (rigidity. aloofnes, nypersellSJlMty
to critJcism and anxiousness), speech and progmQtK I deficits,
and more limited (riendships than parents in the (ompons<Y group. The
implicatIons o( these findings (or (I wJe geneoc sruae:.s (o_ic91'l ere
discussed
I
Prade,...WiIIi
N<efeldt. A.. Akefei , B .. Gillberg, C. (1997) VOice, speech ard .::
guage charactenstics of children Wit h Prader-Willi syndrome.)o! _
o( Intellectual Disability Research 41 (Pt 4) 302-1 I.
Eleven individuals with Prader-Willi syndrome (PWSj, aged bet'tleeI)
and 25 years, were compared Wi th II non-PWS children o( the some sex.
age, body moss Index and IQ level. Voice, speech and language skills
were generally impaired in subjects With PWS. Oral motor (unction, pitch
level and resonance were speCl{tca/l y disordered and clearly differentiat
ed the two groups (rom each other Certain biological pennatal (actors
separated subjects With PWS from other obese children and adolescents,
but di d not differentiate within the group With PWS and could nO(
account for the speechl/anglJage problems. Underlying cerebral dysfunction,
combined With a characcenstic anatomy o( the mouth and larynx In
PWS, contflbu es to altered voice, speech and language (unction.
Worster-Drought
Neville, B. ( 1997) The Worster-Drought syndrome: a severe test of pae
diatnc neurodisability services? Developmental flledicine and Chtfd
Neurology 39( I I) 782-4.
PaedloU'ic neurodlsabllity services are delivered by a multi-dlsdplinary
team whi ch has close working relationships with other paediatric med
lcol speCialist services. ThiSblond statement may conceal a lack o(
Integrated practices able w cope with the common problems encountered
In children with muluple impairments. Family diffirul!l es in dealing With
the statutory services were highlighted at a recent meeting to inaugurate
a parent support group. ThiS paper combines personal clinical eVidence
and the experiences o( these families. Essenlial and subSidiary (ea ures
of the Condllion, including speech and language and feeding problems,
Ofe descnbed.
V
Irearmen
vOice tfe
Efficacy
R<lmig. LO, Verdol:ni, K. ( 1998) Treatment effi cacy: voice dtsorders,
joomt:!/ of Speech, Langl.1age and Heanng Research 41 ( I) Suppl. S101-1 6.
, ora: e '-e'. ews !he lice ature on the efficoC'; 0 U'eatmellt for VOice
disorders pomarl ' uSUJg swdIes published in peer-reviewed journals.
oice disorders are de ned. Li',e reqtJet1C1 ofOCt 'rrence ocross le li(e
i
span reported. and !her 71pon ihe es 0 mdivlduals', th VOi ce
disorders documented. The goal of VOICe lfealment 15 to maximISe vocol
effecti eness given e existing dtsOfckr ond 0 1E<1.1C rhe handicapping
effect of the voice problem. Voice treatment may be (a) the preferred
treatment to resolve the vOice disorder "hen me<kal (s tglcal or
pharmacologTcal) treO[fnents are /lot indlCac.ed; (b) rhe IfllUal treatment
In ((!ses where medlcol treatment oppears indlco Ed; i may 0 'lIme the
need (or medical treatment; (c) completed before and otter surgical
maximise long-term post-surgiCal vOICe; and (d) a preventative
treatment to preserve oeal healrh. Experimental and cl:nieal data are
reviewed that support these roles applied to various di sorder types: (a)
vocal misuse, hyper{unClJon and muscular imbalance (I equen y rEsulting
In oedema, vocal nodules, polyps or contact ulcers); (b) medical or
physical conditions (eg.laryngeal nerve trauma, Parkinson's disease); ond
(c) psychogenic disorders (eg. converSion reacUons, personal:ty disorders) .
DireCbons for (uture research ore suggested which maximIse cllnlcol out
comes and SClentipc ngour to enhance owledge on the efficacy of
unenl.
FURTHER READING
Word finding
rhe
I
d>e WF
'fC-
(OS.,
2ti ,-
McGregor. K.K. ( 1997) The nature of word-finding errors of
preschoolers with and wrthout word-finding deficits. journal of
Speech, Language and Hearing Research 40(6) 1232-44.
Twelve preschoolers wi th word-(inding de{tCits (WF) and their age
matched normally developing (NO) peers partiCipated in three tasks
requinng word (inding. the noun-naming and verb-naming subtesl.S o( the
Test ofWord Finding (TWF-N. TWF-V) and story retelling. The general
error profiles o( the two subject groups were similar Semantic errors
were always more common than phonological errors and were typically
more common than unrelated errors (eg. "I don't know" responses). The
predominance of errors that bore semantJc relations to their targel.S
produced by both ND and WF groups suggests an early and robust
organisauon o( lexicol storage into a network o( related In(ormation.
Des ite si ml /onues between the two subject groups, the word-finding
deficits of the WF group were manl(ested in two ways. First, compared to
Dgroup, the WF group demonstrated slgni(icantly higher rotes o(
naming errors on 01/ three tasks; second, they demonstrated Significantly
d fferent proporuons o( error types on two of the three tasks. Specifically.
cup produced a lower proportion of related errors on the
000 a /o'.'/e proportion o( semantic errors on the story-retell
Oroe dUJ;coJ ImplICation of these (indings concerns measurement o(
ouu:omes.A reducuon In the number o( errors as well as a
_ emY pro ile wwards higher proportions o( related errors,
seo:allJ( errors may indicate progress In word finding
Primary progressive aphasia
Westbur>, c.. B D. (1997 Pnmary progressive aphasia: a review of
/12 cases. Brum c' __ g _ - 1) 381-406.
Pnmary progre ,e aphasKJ r . was rSl rer..ogmsed by Mesu/om in
1982. Althovgh dozens _r ca;e; .i: SII'lCe been described, It has been
difficult 0 place thESE cases 00; C (ooetE:1l frcmework dJJe to the WIde
variation In measures tEf};,,-=d 0 XVc re'IIe; ,'S 170 co tacts wrrh
112 patJenrs to prrMde 0 (Il': _ : _'OO'momJCQi, and neuropsycholog.cal
profile of patJenl.S WIth -' e dlscrdr: "1 P'Og-ESS-tin or the disease is
analysed over a IO-year repornng oeood illI",ng from symptom onset
to show how progressIon a(fe.: r i: ge em! sktlls: oral and
wflt ten naming, reading, repe on and gcr:'eflll comprehension. The
pattern o( functional and neurolOf}col deims III PPA IS heterogeneous.
Differences In the distribution of euro1ogJCOJ anomat, es between
patients With b:1ateral and Unilateral changes suggest: fhoJe may be two
separate disease processes involved.
Conversation analysis
Bryan, K, Mcintosh. j., Brown, D. (1998) Extending con ersa on analy
sis to non-verbal communication, Aphasiology 12(2) 179-88.
This paper reports the application o( the prrnaples of conversation
analySiS to the non-verbal interaction o( an aphoslc speaker who has
minimal verbal output bu modera ely well preserved com rehens/on.
The results show detailed analYSIS or interaction con hrghl:ght the elie ts
abilities as well as claflrllng the strategies employed by the non
dysphaSIC communicative portner whi (oCili ate Interaction. The results
were used to advise staff who cored (or the cl:ent in a residential home
on how to achieve posi 've and success(ul commullica on.
Identifying silent aspiration
Leder. S.6., Sasaki, CT, Burrell , M.I. ( 1998) Fiberoptic endoscopic evalu
ation of dysphagia to identify silent aspiration. Dysphagia 13( I) 19-2 1.
The tradrtJo/lal bedSide dysphagia evaluotJon has not been able to Idenufy
silent asplrotl on because the pharyngeal phase of swallOWing could oot
be objecwely assessed. To date, only has beer; used to
detect silent aspiration. This Investigation assessed
o( 400 consecuCJve, at risk subjecl.S by (iberop uc endoscopic evalu cion of
swallOWing (FEES), The study demonstra ed that 175 of 400 (1" per cen)
subjects were without aspiraIJon, I 15 of 400 (29 per cent) exhibired
aspiration With a cough and I 10 o( 400 (28 per cen) oSPMed
silently. No significant differences were obserred (or age or gen<kr cn1
aspira 'on mus. The FEES, done at bedSide, OVOids irrooaoon ex.postn
is repeatable as as necessary. tises regular food, con be
(or review and IS a paUent (rlfndly method 0 idetJufylrog Si4>J1t asp
SPEECH & lANCUACETHERAPY IN PRACTICE SU,\lMER 199 25
FOCUS ON
Maron
To gain validation and
accreditation, speech and
language therapy degree
courses must satisfy tough
theoretical and
practical
demands,
ensuring
graduates are
thoroughly
prepared for
the variety of
work therapists
Martin Duckworth (back row, fourth do. Wider credibility is
left) is Course Leader in Human also needed to attract
Communication Studies at the students, maintain links
University College of St. Mark and with local therapists and
st. John Plymouth (Marjon). increase the employability
and career satisfaction of
graduates. The leader of a
new course explains how
he and his team are
achieving this.
26 SPEECH & lANGUAGE THERAPY IN PRAcn CE SUMMER 1998
FOCUS O N
n February of this year the first 12 graduates of the Honours
degree in Human Communication Studies from the
University College of St. Mark and St. John shared the plat
form with Archbishop Desmond Tutu in Plymouth's
Guildhall. He, like them, was collecting a degree award. His
is for a lifetime's achi evements while the students are just at
the beginning of their professional lives. It seemed a fitting
end to the long journey for 'our' students to be at such a special
degree ceremony
The journey began a decade or so ago with k en speech and lan
guage therapy managers in the South Wes t. lla Bailey. Pat Is n
and Fiona Halstead being perhaps the foremost amon them. They
felt recruitment and retenli n was such a major issue in the omb
West that proaai ye measures were needed to ensure the speech and
language therapy service here was adequately covered. They argued
students might be Likely to stay in the South West once th , fini.sh
their training. There was an even stronger argument that th re
would be a number of mature students in this area who might wi h
to make a career change and who would, once trained, be likely to
stay here. In the event, six of the seven mature students who came
from this area have sought - and found - jobs or further study in the
South West. I am sure the demographic study of where people
train and their first appointments is worthy of study in itself but
the predictions are, so far, holding up.
Agreement achieved
Once the idea was born, an educational home had to be found.
have no idea just how many colleges were canvassed. Apparently,
some of the first ideas suggested to this University College were
remarkably radical and involved multiple sites and a floating teach
ing staff. Perhaps that will be a model for the future but delivering
a course which would be validated by Exeter University, to which
this College is affiliated, and would be accredited by the Royal
College of Speech & Language Therapists required a somewhat
more traditional framework. The story of how all the parties
brought their ideas together and achieved agreement is a tale of
persuasive speech and language therapy managers, a supportive
Trust chairman, and a University College which was actively devel
oping professional degree programmes outside of the traditional
teacher education role it had occupied for many years. The
University College already had teaching in linguistics, biology, psy
chology and sociology which could be harnessed towards an
undergraduate speech and language therapy course and a feasibili
ty study convinced the management the basis of an acceptable
course was already here.
Turning ideas and co-operation into a three year course with a cur
riculum, staff. a set of rooms and equipment and, above all , with
the blessing and support of speech and language therapists
throughout the South West, took a long time. Even by the starting
date not evel)'thing was in place. The first cohort in 1994 had to
wait until their final year, 1997, before they leamed they would be
given profeSSional accreditat.ion. Exeter University had validated
the degree but the Royal College of Speech & Language Therapists
(RCSLT) asked to see some development and changes befor<:>
accreditation was granted. To have achieved this is no mean feat.
The University College of St Mark & St John is the first UK institu
tion new to RCSLT to have developed a successfully accredited
speech and language therapy course in over a decade (Appendix 1).
.
Enthusiasm and vision
The course was designed by Jackie Stengelhofen with her unmis
takable enthusiasm and vision. Jackie, acting as a consultant,
turned the expressions of intent and goodwill from speech and lan
guage therapy managers and the results of the feasibility study into
agreements about the structure of the course, the use of local exper
tise in its delivery, and a set of objectives for clinical training accept
ed by all the clinical managers in the South West. All of this is still
in place.
Obtaining support for a four year course is not feasible in the cur
rent climate and the course had to exist within an established mod
ular framework. As a result it is a modular course with longer
terms to accommodate extra teaching and block clinical place
ments. It has similarities with other courses, not least because
RCSLT maintains an overview of the broad content areas for all
courses.
Range of expertise
Like many other courses we use a number of visiting lecturers.
Constraints have also meant the core speech and language therapy
team is small and consequently the number of visiting lecturers is
fairly large. Having a major hospital on our doorstep helps us
greatly in finding specialist medical input. We also regularly use a
wide variety of specialist speech and language therapists. Many of
these e.xtend the lecture programme with practical presentations of
ca e material. Although many visiting lecturers are involved, stu
den have n er reported feeling the course is fragmented. On the
concrary. they in variably point to the range of expertise and the
quality of the practical examples brought to the course.
We are al 0 keen to share our teaching with local speech and ther
api ts. To thh end during the two extra teaching weeks around
Easter we hold ' Unk eminars'. These are day events often with vis
iting leaurers on themes which aim to draw together teaching on
various parts of the course. We realised these events would be of
interest to local lherapislS and 0 we offer them free of charge to
those taking our rudenlS and at low cost to others. We have also
joined with the psychology depanment of Plymouth University in
developing Continuing Professional Development courses for
speech and language therapistS. There our role is advisory and in
providing input to some o f the course but we see it as a positive
move to link with Plymouth University as well as with Exeter
University. There is no doubt thaI the South West has many acad
emics with considerable interest in the work of speech and lan
guage therapists and we aim to develop our network of contacts
over the years.
Opportunity to reflect
If there are similarities in broad content between the Plymouth
course and undergraduate courses elsewhere in Britain there are
obvious differences too. Jackie Stengelhofen's regard for the
process of learning moved her away from a paediatric I adult split
in speech and language therapy academic and clinical training.
The structure she created was to use Year 2 to introduce most of the
disorders of communication and then use Year 3 to discuss man
agement strategies. Our 'what is it?' / 'what do we do about it?'
structure means most communication disorders are deal\! with
twice. The advantage is that students have the opportunity to
reflect upon the theory behind a communication disorder and to
become familiar with the appraisal of communication disorders
before moving on to management. Spending a year focusing on
understanding about a person and a communication problem cer
tainly does not mean lots of assessments have to be administered
or that a Plymouth student cannot be involved in carrying out ther
apy. Our Year 2 students will need to be well guided in therapy but
we hope their observations about the way the person responded to
that therapy will show an understanding of what 'progress' might
mean and how it can be monitored.
Close links
All clinical placements need careful preparation, regardless of the
course. It is fortunate that the course began with the support from
local speech and language therapists. On one memorable occasion
the managers joined forces with us to respond to concerns by an
accreditation team about some aspects of placement organisation
and assessment. Their input has led to clearer definitions of what
constitutes clinical success and failure, and we have a better under
standing of the route a student can take who is unable to complete
the clinical work successfully. This refleas the ongoing close links
between Marjon and practising speech and language therapists.
Managers from the South West are invariably present at out Course
Committee meetings and we have excellent attendance at meetings
SPEECH & LANGUAGE THERAPY IN PRACfICE SUMMER 1998 27
Appendix 1 - Accreditation
1. RCSLT is responsible, through its
Academic Board, for accreditation of
for therapists who take our students.
All this has helped us to explore with
our colleagues how students in train
ing learn and how all sorts of clinical
placements can be used to help stu
dents develop their theoretical
awareness of problems while, at the
same time, they learn how to
become a therapist.
Finding clinical placements is a
major task for both therapists and
coUeges. The second half of the
Academic Year is when all our place
ments are concentrated. From
January to May we have to find
around 60 concurrent placements in
different clinics, about one third for
Year 2 and the remainder for Year 3.
Then, during the Summer Period,
there will be over 40 block place
ments to find: two week 'active
observation' placements for Year 1
students, and six week placements
for Year 2 students. All colleges have
their difficulties in finding place
ments. We have been well supported
in finding placements by speech and
language therapists in the South
West. Nevertheless we have students
travelling to Dorset, Somerset and
even into Wiltshire for a day's place
ment. As a result some have to trav
el the day before to arrive on time.
Radical assessment
We have also moved to a radical
review of clinical assessment. We
visit all Year 2 students and a selec
tion of Year 3 students. However,
unless there is a specific problem,
the visit is a meeting between
University College Tutor, Clinical
Teacher and Student to discuss the
opportunities offered by the place
ment, the objectives of the student
and to discover whether further sup
port needs to be offered by the
University College. We do not
observe a therapy session unless this
has been requested. We may make a
second visit to do this or we may ask
our External Moderator to observe
the student in this way. This does
not mean we do not see the majority
of the students working. On the
contrary, every student has to submit
a video of themselves working with a
client. The video is accompanied by
a case file, a rationale for the work
pre-qualification courses for speech and
language therapists in the UK.
2. A course is assessed approximately every
five years through written submissions and
by a visiting panel comprising members of
the Board or its representatives, all of
whom work in the profession in an
educational or managerial capacity or in a
related discipline such as psychology or
linguistics.
3. The panel looks for evidence that the
course's structure and content gives
students adequate opportunity to develop
and apply core knowledge and skills.
4. The Board normally makes recommendations
for changes to courses and reviews progress.
5. Where possible, courses are supported
in their efforts but RCSLT does have the
final authority to grant, deny or withdraw
accreditation.
6. Graduates can only receive a certificate
to practise as a speech and language
therapist if they have satisfied the clinical
and theoretical requirements of an RCSLT
'accredited' course. Students passing only
the theoretical component 'validated' by
their educational establishment may be
awarded a non-clinical degree.
7. Should the pending ballot of the speech
and language therapy profession lead
ultimately to members being part of a new
Council for Health Professionals, the
accreditation process will be subject to
change.
Practical points - Focus on Marjon
1. A local course can aid recruitment and
retention in the area.
2. Building links with local therapists
facilitates joint research, specialist teaching
and clinical placements.
3. Separating theory from management in course
design may enable more effective learning than
a traditional paediatric / adult split.
4. The clinical placement assessment
process should allow college tutors to
target support where it is most needed.
5. Video is a useful tool for students to
develop clinical skills.
assessmen t exercise. We were
delighted to be awarded a rating of
two. While this is not high, it does
g.ive recognition to the work we are
trying to develop. It is not easy with
a small staff to run the course, teach,
deal with students, liaise with clini
cal teachers, work in our own clinics,
organise mini conferences at Easter
and develop research initiatives but
between us we have interests in such
areas as:
voice quality following tracheoto
my, and articulation following
orthodontic surgery (both in liaison
with the local hospital Trust)
conversation analysis with people
with aphasia
therapy and healing
friendship development in children
the assessment of students in clini
cal placements.
It would not be true to say we are
able to pursue all of these interests
fully, despite the team's enthusiasm.
In addition to the above list of
'things to do' there are new demands
as we move from Department for
Education and Employment to
Department of Health funding.
Attractive
So far we have had no difficulty in
recruiting good quality students and
we have not had to engage in any spe
cial marketing exercises. Although
the course was set up with applicants
from the South West in mind we have
students from all over Britain and
have even attracted overseas students
here. About half our intake is of
mature students and about half come
from the South West, though there is
certainly no positive discrimination
policy. Of course, the South West is
very attractive - I would understand
anyone wishing to study here where
our library has stunning views of
both the sea and Dartmoor and,
when books can be put aside for
once, there are some wonderful
beaches just a short journey away
from Plymouth. If that isn't enough
to tempt an applicant I must say I feel
pleased to be able to show intervie
wees our new library, the set of
rooms built for our course, and the
computer laboratory established for
our students. The University College
planned and a self appraisal of their performance. The speech and has made its new course very welcome and the students we attract
language therapists on the University College team review the are frequently commented upon very positively by our colleagues
videos and conduct a tutorial which is a sort of viva / practical It is also very pleasing to report that all students who obtained a
examination on the work with that person. One of the advantages certificate to practise are now employed or in further study. The
of this method is that both written and video material can be sam South West has some new therapists from us, so has Scotland, and
pled by our External Moderator. the Midlands. We will be interested to hear how well our students
We are constantly reviewing this key area of the course and are feel they have been prepared for practice. We have tried to avoid
putting together a research proposal to examine the process of the focusing exclusively on the face to face aspects of care. There is so
assessment of practical work. This is one strand of the research much more that speech and language therapists do, and we hope
interests we have here. Two members of the speech and language our students will not have started their first jobs by saying HI never
therapy staff were entered as research active in the last research realised I would have to do that"l D
28 SPEECH & lANCUACE THERAPY IN PRACTICE SUMMER 1998
1998
EVENTS
Wednesday 17 June
UK SIC in Cerebral
Palsy
Topic: OlOlIenging
Bel1aviour and AGM
Venue: London
Details: Kathryn
McCormick
01483 770046
home/ ansa
A POSITIVE
APPROACH
F=C > ~
COMMITTED
PROFESSIONALS
Contributions to
Speech &Language
Therapy in Practice:
Full information
appeared in the
Summer '97 issue.
Contact the Editor for a
copy of that article and /
or to discuss your plans.
Please note:
articles must be of
practical use to
clinicians
use case examples
and list useful resources
length is generally
around 2500 words
supply copy on disk if
possible
keep statistical
information to a
minimum
photographs and
illustrations will be
returned.
POSTCOOE:
POSTCOOE:
. . . ....
1. Stammer counter
I was lucky enough to be trained to
use the Udcombe Programme of Ea rly
Stuttering Intervention in January
1998.ihe programme places a great
deal of emphasis on clinical measures
and the stammer counter saves time
With a calculator and stopwatch as it
automatically calculates the percent
age of syllables stuttered and the syl
lables per minute rate without being
tOO obtrusive. Gentle tapping on the
syllable counter button or the error
button is easy to do and does
break up the floW of conversation.
,0. Dartboard (Early Learning Centre.
4.99)
The dartboard is velcro covered and divided
up intO different sections of primary
colours. numbered up to six. An children
can manage the darts by throwing or simply
putting them on to the dartboard.
I use it for colour matching for the younger
ones. for example. the child has to give a
brick the same colour as the colour on the
board hit by the dart. For older children it
is useful for many different activities including:
*If they hit a red section on the dartboard.
they choose a picture from the red pile to
tell me about ."
.. if they hit the number 3 on the dartboard.
they have to find three things beginning
with a certain target sound in a picture,
t . Play",
These,. obil
ere Ittle fi
pia ellent fo gUres and
th lY skills fo r develop ' accessor'
ree wh r ail Child Ing langu les are
Pieces "" 0 can ren OVe age and
"' ' rJOsc ma' r th
..... UStrate reCencly the age of
" 'OUgh prepo ' 'Ie e t'
child' they S/tions used th my
s fI are and em t
for I greac for pronoun 0
bra" . Com angua asse ' s,
legs'(en! (m menc on ge; Will th SSmg a
) ask w! figures sOmethi ey ask
;:ar. did Y at the ti often lack ng that:S
tegral Ou know ny bit is hair 0
With pare of p Chat 'f for!S" r
th
IUI/ d lay I -yo ' the
ey eCJlls mobll u los
b may W Co the You c e an
rOken pa ell send manufa an Write
(e-mail; free! you che cc.
urer
and
de I MA mtern . mlssin
vV"f'f6.2476 at/ona/@ g Or
@comp Playmob'l
userv I.
e.CO
m
) .
8. Usborne bOO\<s ot all is called The
The one I use most d Words by \-l eather
U
sbO
rne
First ry aood for
95) ihlS IS ve b
(t..rnery VA: . Lidcombe-type theraPY
dernonstratlllg a composite pictUres
seSSion uSing the ch ihe
se
piC
establiSh stutter-free and it is not
tUres are well from a single word
difficult to vary the f ur wordS and
onse to three or o . .
resP enera
l
conversatiOn In a ,
on to g h'ldren the Where
s
For older c I
way. Iso very useful .
\:10
0
\<5 are a
True-Talk Professional Speech Rater
available from SynergistiC ElectroniCS
Pty Ltd, PO Box 1066, launces
ton
, Tas
7250, Australia
phonelfax +6 I 3 6327 2048
e_maiUnfo@synelec.com.au
UBHT
T EAC HI NG CA RE
Sarah works f
Bristol Trusts She <;>ne of the
.. working t'ime . .Ivldes her
general between a
health I caseload at a
with ch'ld centre and working
I ren who sta
are referred th h mmer and
roug the Trust.
7. Phonology bag
This is a bag of d'"
d
. Illerent toys d .
use In Bristol to an ob,ects
assess pho I
past couple of years f h no ogy over the
Therapy Effective In t e STEP (Speech
project. Younger child e-school Children)
Interesting than . ren find them more
about delving and are excited
as the butterfly 0 ag to find such items
get some idea of e You also
they relate the ob' CIS level of play as
,ects to each h
as other language k'lI ot er as well
each item. SIS as they comment on
A simple score sheet m
a glance which pr eans you can see at
d
. ocesses the h'ld '
an which you mi ht n C I IS using
(Information abou! to assess further.
Language Therapy R rom the Speech and
H esearch U ' F
ospltal. tel. 0 I I 7 970121 2 nit at renchay
ext. 2219.)
4.
I
uSed g mach'
hOle to USe me
I cuc 0 a cardb
n-/aw h UC of th oard b
(aim as im e front b ox w' h
k OSt) 'W proVed Ut m IC a
nobs ch orkin on th' Y fa ther_
a barte at click h
g
model IS wich a
A.II Chi/dry driven 'd andles th which h n
a ren rum at cwo as
nd ic's enjoy I ' 1st and
_b' gr eac r. oadi
Ig sock Or Co ng and
I dry, pl ' 1 lict/e ncepc d unloadin
c . am / sOck, I eve/o r
I omprehe Stripy as c ean / d' Pmenc
eVels .,.. . nSlon , Well a Irey, W
I ' I hIS W aCt,vit' s SOrt' et
Ot of ashin les at I mg and
clothln general I; machine a I different
"Wh g and nguage generates
o m ' washi to d a
wearin Ight W ng. for 0 With
c I g ear h' exa
o OUr)" .. sOmeth' C's?" "'A,;,ple
' H In . .
OW do g the o's
You PUt th ' same
IS On?"
5. Useful textbooks
At the moment I'm very reliant on the
Udcombe Programme Handbook for
reminders and problem-solving to do with
Mark Onslow's Early Intervention approach
to eliminate stuttering. This is explained in
his 1995 Singular publication BehaviOural
Management of Stuttering (ISBN 1_56593
633-7. 1.25). I'm also reading Jenny Lewis's
The Stammering Handbook A
Guide to coping with a Stammer which is a
very sensible book about stammering.
containing useful information and case histo
ries (,Vermilion. ISBN 0 09 181660 2. 8.99).
In the clinic I have found Peter Hatcher's
book sound Linkage: an Integrated
programme for Overcoming Reading
Dif!icu/ties invaluable for older children with
poor phonological awareness (Whurr.ISBN
1-897635-3 I _I. 37.50). For giving clear.
well set out information about phonology
to parents as well as good ideas I use Lesley
flynn and Gwen Lancaster's Children's
Phonology Sourcebook (Winslow, ISBN 0
86388 1564. 39.50) .

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