Speech & Language Therapy in Practice, Spring 1999

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WinTh e winner

of the Winter

98 reader

offer of React

Th

Speech & Language T herapy

in Practice has a coPY ofTheTest of Pretend Play (ToPP).courtesy ofThe PsychologicalCorporation. This new assessment no rmally retails for£31 2.23.To enter, all you have to do isfind seven three-letter realwords using the letters of theword 'P LAY'.The winner willbe picked randomly from allcorrect entries. Send your listwith your nam e (and,if youknow it, your subscriber number) to Avril Nicoll. Speech &Language Therapy in Practice.FREEPOST SC0 2255.

STONEHAVEN AB39 3ZL*or e-mail [email protected] note t he winner willalso be required to rev iew the

ToPP or provide a case study

based around it for th eAutumn 99 issue.

• For readers outside the UK.the address is Lynwood Cottage,High Street, Drumlfth/e,Stonehaven A839 3YZ.

eader Offer

Test of Pretend Play by Vicky Lewis and JillBoucher is designed to be used by professionals working with young children, Including speech and language therapists.

It can assist with assessment and diagnosis and provides a framework for observing and gaining qualitative Information from structured and free play.

Administration time is 45 minutes and the age range I to6 yean.

In addition to finding ou t whether a child can incorporate several symbolic actions into a meaningful sequence, the three types of symbolic play are assessed: • substituting on e object for another object or per

son• attributing an Imagined property to an object orperson• reference to an absent object, person or substance.

Th e kit contains tw o versions of th e assessment, on enon-verbal, the other for children who have sufficient~ m p r e h e n s l o n .The ToPP has been co-normed with th e Pre-schoolLansua. Seal.3 (UK) assessment to enable direc tco mparison.

Competition ru les:I. Entrants must sub-scribe to Speech &Language Therapy inPractice and only Qneenlty is allowed per sub-sc,r/ber number.2. Entries must be received

by the editor on or before

31st March 1999.3. A person nominated bythe ecfltor will randomlyselect the winner from all

correct entries , but w ll

not know who the

entrants are .4. The winner WIll benotified by 6th AprH 1999.5. The winner will provide

eIther a review of theToPP or a case studybased around It 10

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TIle Tesc ofPretend PlGy Is ovallable (rom The Psychological CorporotJon.Foots Cray High Street. S/clcup. Kent DAI4 5HP. tel. 0181 308 5710.

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Reader O ffi

Sienificantly improvedThe-Reynell Developmental Language Scales III (RDLS III) The University o(Reading Edition Available from NFER-Ne lson, £375 + VAT

Th is third vers ion of the Reyn ell is intended 0 follow current thinking on

language developmen t and . o quo te from the ma nua l, "to reflect a devel

opme ntal logic In terms of lingu istic structure".

We were mildly perturbed wh en the very fam iliar black exec utive brref

case arrived in the office - wel"e the conten ts going to be simi l r to the

o her vers ions l Would we still go through bu ilding the fence. men ding

th e bed (wi th o ~ a p or blu-tack) and tying the limb back on the dol r.We we re however de lIghted with the co ntents, wh ICh are modern.

attractive and of sturdy quality It would also seem that rep laCing indi

vidua l items ISnot going to be a problem.

This vers ion ISso different to he first ones. t hat careful reading of the

manual is essential before emb arking on any test ing. The chapterson the

des cnp Ion of the sca les and the admin istration of them are well laid out

and easy to read. There ISno precise ceil ing for aband on ing the tes t and

th erapists have to use their own discret ion to some exte nt. A strong

magnifying glass and ruler are recomme nded for read ing th e percentile

and stand ard score tables.

The first t ime we admin is ered the test was a nightmare. We couldn 't

remem ber whic h boxes he toys went back in and a certain amount of

manua l dexterity was reqU ired getting teddy to wave a nag,whilst hold

ing a bi ro and keep ing the chi ld's atten tion. After only a coup le of

attempts, admi nistratIon be came organ ised and s ick and th e clear record

bo oklet was easy to use. Once a th erap ist IS fami lIar with the test it

shou ld take between 20 and 30 minutes. The ch ildren clear ly fo und the

toys interesting and in ost cases enjoyed the test. The switching from

objects to pictures a d b ck again was useful in holdi ng children's atten

tion.W hen testIng with the expressve section we we re left with the fee l

ing that he taskswere very difficu lt for the ch ildren and hat thewscores

would be poor However this was not the case and age equivalent levels

were accw·ate.Sconng the test is straightforward and compares we ll to other assess

me nt s.The test provid es a range of scores . including age equivalent. stan

dard and percen tIle scores wh ich are invaluable when comp lirng repor ts

fO I- th e Loca l EducatIon Authority. The quan.ative informa ion prOVided

has also been useful and the record bookJet has section head ings which

are elpful wh en inte rpret ing a ch ild's pe rformance.

Overal we feel thiS is a significan tly improved assessment and shoul

become part of any paedlatrrc speech and language therapist 's diagnos

tic krt. If someone cou ld tell us how we cou ld w in another 20 for our

Depa rtment we wou ld be most gratefu ll

Barbaro McLennan is Head or speech and language therapy and ErmlyMcA rdle a PinCipal speech ond language therapist wich Wi I and WestCheshire Community (NHS) Tust at S( Carhenne's Hospital, Brkenhead(-hiS rev'ewel-s wen ths }sseS,f"Ylent In a ccrnpet,tlor n A ItJmn 98

S,llE: of 5Deecn & Lansjage I heldDY 111 Practl e)

mailto:[email protected]




Further Reading 24

& ~ e e c hguage

TheraJ)in Pm ice

www .sol.co.uk/s/speechmag

SPRING1999(publication date 22nd

February)

ISSN 1368-2105

Published by:

Avril Nicoll

Lynwood Cottage

High Street

Drumlithie

Stonehaven

AB393YZ

Tel/fax 01569 740348

e-mail : [email protected]

Production:

Fiona Reid

Fiona Reid Design

Straitbraes Farm

St. Cyrus

Montrose

Printing:

Manor Group Ltd

Unit 7, Edison Road

Highfield Industrial Estate

Hampden Park

Eastbourne

East Sussex BN23 6P T

Editor :

Avril Nicoll RegMRCSLT

Subscriptions and advertising :

Tell fax 01569 740348

©Avril Nicoll 1999

Contents of Speech & language

Therapy in Practice renect the views

of the individuol outhors and not nec-

essorily the views of the publisher.

Publicotion of odvertisements is not

on endorsement of the advertiser or

product or service offered.

Any contributions may also

appear on the magazine's

Internet site.

Cover picture:Epilepsy - a speech andlanguage therapist's gu ide .

Picture from St Piers

School

~ ~ C O N T E N T ~ S ~ ~ Parent / professionalews/

Comment 2 partnership . 20

Epilepsy is the commonestserious chronic neurological conditionin childhood. Linda Edwards illustrates why special careduring assessment and flexibility in therapy is neededin specialist, mainstream and community settings.

There are problems in the way

COVER STORYEpilepsy 4

Nasality 9Sarah Moore and Anne Hardingsuggest how generalists andspecialists can collaborate toprovide effective therapy for

children with nasality problems.

Dysphagia 12Continuity of patient care and theprovision of food of appropriateconsistencies are perennialchallenges in dysphagiamanagement. Penny Gravil! reportson the experience of one hospitalover an eighteen month period.

Reviews 16VOice, genetics, audiology,aphasia.

Leaming throUghdrama 17Having covered Beginnings andEndings in Part I of her article onusing drama in therapy, here inPart II Myra Kersner demonstratesthe versatility, flexibility andcreativity of the main body of thework, the Middle.

SUMMER '99 will be published on 31st May 1999

IN FUTURE ISSUES• working with older children • Communicate • stammering

• rhyme • new assessments • Top resources - brain injury

Language development, hearingimpairment, brain injury, voice,dysphagia, severe aphasia.

How 1work withassistants 25Three therapists offer their viewson training and assessment, thecomponents of a good working

partnership and the kinds of

tasks and responsibilitiesassistants can take on.

My TopResources 30Gwenan Roberts chooses tenthings she could not do without

in her work with clients withchallenging behaviour.

parents aretold abouttheir child'sdisability.AnneLeonardfrom Scopeexplainshow RightFrom TheStart is

working tomake a difference byensuring aconsistentapproachbased on

best practice.

SP EECH & LA NGUAGE TII £RAPY IN PRACfl CE SP ill G 1999 1

http://www.sol.co.uk/s/speechmag











NEWS & COMMENT

Crossing specialisms In How I work with ass i'stants, Kate Richards describesthe training for assistants developed in her Trust: "thecompartmentalising of human communication disordersinto that which is relevant only to certain age groupsis challenged; for example, students learning about

language development are asked to consider why thisis relevant to adults with a learning disability:Clinicians adopting th is attitude benefit from cross-fertilisation of ideas and a wider range of experiencethan they would get from being tightly focused on aspecialism or diagnosis.Just think, then, what opportunities Myra Kersner's childdrama activities would also provide for groups of peoplewith dysphasia, dysarthia, dysphonia, dysfluency andlearning disabilities, indeed for any group needing torehearse and practise communication skills in a realSituation. Sharing a diagnosis with parents is one suchsituation where all professionals can improve theirskills according to the Right From the Start project.Excerpts from the template of good practice give us

food for thought. What measures do we take to checkpeople are alright once they get home? When do weever give people time alone to think over what wehave said? How often do we make it easy for peopleto ask more questions? User involvement is a trendyterm. The challenge for us is to respond to it.Penny Gravill's work in developing a system for dysphagiamanagement in a neurosciences unit meant gettingfeedback from nursing staff about how well the systemwas working and then making amendments as aresult. Frustrating and time-consuming? - certainly. Butnecessary for the system to function effectively and animportant part of any process of change.Dysphagia teams are a relatively new development

compared with those for cleft palate. However, amajor shake-up in cleft services means specialists andgeneralists are going to have to spend more time oncollaboration. Sarah Moore and Anne Harding providevery clear suggestions as to how this can be achievedalong with the latest thinking and resources.In her comprehensive and enlightening article onepilepsy, Linda Edwards also passes on experiencegained as a specialist. Her enthusiasm is catching, andit is clear she finds it "a fascinating challenge to try tofollow the path through the maze, and an endlesslyrewarding opportunity to offer some, often hugely

appreciated, help."Whatever new things are goingon in any area of the profession,

we want to bring you news of

them - where else would youhave heard about Gwenan

Roberts' red tool box? So, keepyour ideas, feedback and articlescoming to the magazine that ismaking a difference.

Avril Nicoll

Editor

Lynwood Cottage, High Street,Drumlitllie, Stonehaven AB39 3VZ

tel/ansa/fax 01569 740348

e-mail [email protected]

Centre's achievementsThe success of The Speech, Language an d Hearing

Centre's early intervention philosophy is detailed in

its annual report.

In addition to an outstanding OFSTED report an d

the launch of an Outreach Training Programme, a

Department of Health funded research project

showed good progress was made at the Centre by

children with speech and language delay and autistic

spectrum disorders. The Centre has also established

a number of partnerships. Working with the National

Deaf Children's Society, it will develop familly

workshops for recently diagnosed deaf babies.

The Speech, Language and Hearing Centre, rei. 0171 383 3834.

Education eventOver six hundred exhibitors at The Education Show

1999 will include those specialising in special needs.

Seminars will include raising literacy standards and

the underachievement of boys.

The Education Show nms from 11 - 13 March 1999,

NEC Birmingham. Ticket Hotline 01203 426549.

; : ~ ! ~ e e C a S ~ ~ \ ~ ~ ~ K , an organisation of

professionals working to help people keep their

voices healthy and to communicate effectively, has

been awarded charitable status.

As the next step, the Network hopes to start a

refereed journal. Details of this from Lesley Hendy,

tel. 01223 836175.

Practical interactive study days for potential network

tutors are planned for 29 March in London and 24

April in Edinburgh. VCN, tel. 01926864000.

Screening reviewThe report Screeni ng for speech and language delay: a

systematic relliew is now available from National

Coordinating Centre for Health Technology

Assessment, Mailpoint 728, Bolderwood, University

of Southampton, Highfield, Southampton S016

7PX, tel. 01703 595586,

http://www.soton.acuk/Nhta/htapubs.htm

SIGNALONG move

The SIGNALONG group has moved to The

Communication and Language Centre, Chatham

Historic Dockyard, Chatham Maritime, Kent ME4

417, .

Nel'" publications include National Curriculum

Science, KSI (Life Processes & Living Things ) an d

Signs for Literacy Strategy. Collections ofYelY

Important People and This is Mel are planned and

individual core vocabularies can be produced on

request.

Details. 01634 819915.

Web updateThe National Autistic Society has a n ev>,ly designed website

which includes specific information ro r professionals.

hup: //www.oneworld.org.autis m_ lI/,;

Winslow Press aims to crea t a Uniqlle ce n tre of

information, news, discLission groups an d resource

materials for everyone invo lved in rehab ilitation an d

educational special needs \\' Lh its site. n on-line

catalogue and Therap\' \\ 'eekJ ;' are included.

hItp://www.II'inslow-pres '. [(1 .II I;

SPEECH & LANCUACE THERAPY IN PRACfICE SPRINC 1999





http://www.oneworld.org.autis/



http://www.oneworld.org.autis/



." ,

oo

. :"0u.r:on

W".r:U )

o5J:c..

Alan Hewitt, Chair of the

Action for Dysphasic

Adults working group on

the Disability

Discrimination Act

(1995) presents the

group's report to the Minister

for Education an d Employment, MargaretHodge. Sue Gilpin of the working party and Ruth Coles, ADA

Director, look on.

The Minister has agreed to include language impairment in depart

mental documents where appropriate. She suggested evidence col

lected from individual cases would help establish the specific needs

of people with dysphasia when being considered for benefits.

Details of the repoTt 'Open Hole the Stony Wall' from ADA, tel. OJ 71

261 9572. ADA also has a range of merchandise for sale including pens,

badges and t-shirts.

Primarycare for

Parkinson'sA guide to recognising

and managing

Parkinson 's Disease in

primary care has been

distributed to every CI '

in the UK.

Produced mai nly by GPs

for CPs, in association

with the Parkinson's

Disease Society, the

guide promotes onward

referral to specialists an d

members of the multi

disciplinary team. Each

GI' has on average less

than three people with

Parkinson's an d is the

first person seen by

people experiencing the

symptoms.

Details: PDS, tel. 0171 931

8080.

Rare disordersAn awareness week has

focused attention on rare dis

orders.

Initiated by the Rare Disorders

Alliance - UK an d co-ordinated

by Contact a Family, the chari

ty which supports families

who care for children with dis

abilities an d special needs, the

campaign highlighted the need

for research into rare condi

tions and information-sharing

across the world .

Of the 15000 children born or

diagnosed \vith a disability

each year, at least 1200 will

ha\'C on e of more than 5000

differing rare disorders. The

main problems these children

face include late diagnosis, lit

tle patient-friendl y informa

tion. contact with other fami

lies an d awareness of the con

ditions and expertise among

professiona'is. Research into

rare disorders suffers from

severe limitations including

poor statistical collection and

scarcity of subjects.

Rare Disorders Alliance - UK

c/o Contact a Family

tel. 0171 383 3555

e-mail [email protected]

Efforts to improve communication

between doctors an d patients with

leaming disabilities have been recog

nised with a national award.

Professor Sheila Hollins of St

George's Hospital Medical School

used actors to role play people with learning

disabilities during drama workshops for medical students. She

has also produced practical resources for patients and their car

ers. A series of 17 picture books includes 'Going to the Doctor',

'Going to Out-Patients' an d 'Michelle Finds a Voice', the latter

co-authored by speech and language therapist Sarah Barnett.

Accepting the BUrA Foundation Communications Award from

Professor James Watson, Professor Hollins said she believes that

if future doctors can acquire the skills an d positive atti.tudes nec

essary to communicate with people with learning disabilities

then they will find it easier to communicate with the majority

of their patients.Books Beyond Words cost fl O each from the Royal College of

Psychiatrists, tel. 0171 235 2351 ext 146.

People's PanelFindings of a national panel to

research the effectiveness ofgovernment services haveimplications for speech andlanguage therapy departments.The People's Panel of over 5000randomly selected people has be(71

set up to help generate ideas on

how services in the public sectorcall be improved. The first waveof research found that

• the services which members feelare most important to them are GPs

and NHS Hospitals respectively

• in general, the better a serviceis at keeping people informed, thehigher its satisfaction rating

• heart disease and strolle are themost important health-relatedissues for possible futuregovernment campaigns, afterdrug misuse and cancer• nine OlH of ten people wouldlil1e a one-stop, 24 hour telephone

illj(mnation line on governmentservices that is answered personallyra ther thun electronically

• Iline per cent of the panel areconnected to the Internet at home

• the use of new technologyappeals to 65 per cent in the 16-

34 year age group 17w only 25per cent of the DUeT 65s .The Panel is open to all publiclyfunded bodies and will be el.'aluated

over the next three years .

Details: http :/ /www.service

first. gov.uk/panel.htm

- - - ~ - - - -

New discussiongroupEasyspeak is a new e-maildiscussion group which aims to

bring together people interested in

children 's communication difficulties and to provide another forumfor links between practitioners in

education and health services.Anyone with Internet access can,

at no cost, join the list of memberswhich is managed by CarolMiller of the University of

Birmingham's School of Education.The mailing list software is on a

computer at the BritishEducational Communicationsand Technology Agency (BECTa) ,and you can send on e ('-mailmessage to reach everyone, orrespond individual/y.To join , send an e-mail as follows,without adding any further textor a subject line:

To: [email protected]

Subject:

Subscribe easyspeak

Your request to join will beacknowledged and you will besent an introducto ry file giving

more details about the list andhow it operaCEs.Details: http ://www.becta.org. . sencoor e-mail [email protected]· uk

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRlNG 1999 3

http://www.service/

http://www.service/

http://www.service/

http://www.service/

http://www.service/

http://www.service/

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http://www.service/





EPILEPSY

Epilepsy' -a speech and

langua -e

Epilepsy is the commonest

serious chronic neurological

condition in childhood( I),

affecting 5- lOin everyI ,(xx) children(2). tt

signposts the possibility of

some disturbance of brain

function which has the

potential to affect

communication, and

indicates the need for special

care during assessment and

flexibility in therapy

Linda Edwards takes acomprehensive look at

epilepsy in four parts - the

condrtion rtself, effects of

medication, assessment and

therapy - to demonstrate

the implications fo r

specialist, mainstream and

community settings.

therapi sguide I.The eoileptic

contJrtJon

T

e most dramatic impact of

epilepsy on our practice is also

the rarest - that it may be the

speech and language therapist

wh o is the first to identify

symptoms of epileptic disorders. The best

known example is the rare Landau-Kleffner

syndrome (acquired epilepsy and aphasia),

which presents most commonly between

three and eight years. Almost half of these

children show language problems first.

with regression of language after a period

of normal development. It may start with

an acute or gradual loss of verbal compre

hension, followed by phonological errors,

prosodic disturbances or paraphasias, pro

gressing in the severest cases to an auditory

agnosia(3)(4). Language symptoms may

fluctuate markedly, while behavioural

problems and autistic features may appear.The electroencephalogram (EEG) shows

abnormal discharges in one or both tem

poral lobes, especially during sleep,

SPEECH & lANGUAGE THERAPY IN PRACTICE

although up to a third of these children do

not have recognised seizures.

Voice suspicions earlyThe prognosis for language recovery, as

with acquired auditory disorders rather

than acquired aphasia(S), seems better in

older children. It may also be bener where

deterioration of comprehension happens

more suddenly(6). Con trolling the epilep

sy does not directly improve language but

recovery may be related to how long the

abnormal EEG discharges continue(7), so

there is good reason to voice any suspi

cions early. Where recovery is incomplete,

special educatio n may be required. Speech

and language therapy will combine audito-

ry / phonological training with visual sup

plements such as signing. symbols, written

language, colour coding or articulatory

cueing.

Other epilepsy-related disorders may first

present to the speech and language thera

. pis!. The EEG in one of the commonest

epilepsy syndromes in children - benign

partial epilepsy with centrotemporal

spikes, characterised by hemifacial motor

SPRING 1999

seizures often related to sleep - looks like

that in Landau-Kleffner syndrome.

Intermittent drooling. phonological dis

turbance, dysarthria or oromotor dysprax

ia lasting days to weeks may occasionally

occur(S). These temporary disturbances

reflect the site of the epileptic focus and

can occur without visible seizures(9).

Most seizures controlledFar more commonly, the therapist sees a

child wh o is already being treated for

epilepsy. Many children will have few if

any seizures, and minimal disruption to

their lives or education. With progress in

anti-epileptic medication in recent years,

up to sa per cent of people will have their

seizures well controlled. However, this is

not always the case. The therapist will want

to ask parents or teachers: Does he have

seizures in the daytime? Ifso, what do they

look like? How long do they usually last] Is

any help ever needed? This way, a seizure in

a session can be recognised (not always aseasy as it sounds) and reported . If a child

does have a majo r seizure, these are almost

always self-limiting and very little interven

4



EPILEPSY

tion is actually required. You should:

• cushion the head from hard objects

• not move the child (unless in danger), or

restrict movements

• not put anything between the teeth,

including your fingers• turn the child into the recovery position

when any jerking is over

• stay with the child and be reassuring

until s/he is fully recovered

• look ou t for any incontinence which can

be distressing afterwards.

Other types of seizure are less immediately

recognisable, panicularly complex panial

seizures which can look at first like pur

posive behaviour, for example repeated

picking at the clothes. These also should

be identified and reponed.

Developmental

and acquiredThe impad of epilepsy on ou r practice is of

course wider than the small chance of a

seizure during a session. Epilepsy may occur

at any age, resulting from trauma, infection

or other cause, or it may arise spontaneous

ly, perhaps with a genetic predisposition.

Depending on age at onset, a child with

epilepsy may present with a developmental

or an acquired communication difficulty, or

sometimes both. There may be pragmatic

impairments, language disturbances, and

effects on prosody or fluency. More global

effects also occur. There is a high rate of

epilepsy in children with autism. It is said

thatup

tohalf of

all children with epilepsyhave some learning difficulties. A figure of

up to 50 per cent of boys and 15 per cent of

girls has been suggested( 10). Sometimes the

original cause of the epilepsy causes learn

ing disability too, but it is also possible for

uncontrolled epilepsy itself to cause brain

damage and hence learning difficulties.

UnderachievementAlthough most children with epilepsy are

of normal intelligence, underachievement

at school is common. Children make less

academic progress than expected for their

IQ and age(1l)(12). There is an increased

risk of problems with reading comprehen

sion, perhaps more so with spelling and

arithmetic. These difficulties can persist to

secondary school and beyond. The outlook

is best where the epilepsy starts later, there

is only on e seizure type an d a quick

response to a single anti-epileptic drug( 13).

Educational problems are more likely to

arise where seizures persist for severa .1years.

Speed of information processing, memory,

alenness, sustained and focused attention

and motor fluency appear to be particular

ly vul nera ble skills( 14). As the difficul ty

can vary with the type of epilepsy, age of

onset or seizure frequency, the therapist

will find it helpful to know what type of

epilepsy the child has. Several criteria areused to classify epilepsy:

• seizure type - partial, generalised (arising

in both hemispheres) or unclassified

• aetiology - idiopathic (spontaneously

arising) versus symptomatic (associated

with known or unknown brain damage of

varying degrees)

• anatomical localisation (eg. frontal, tem

poral). Seizure types are further subdivided. In

idiopathic generalised epilepsy, there

seems to be an association with visual

memory and visuomotor deficits. Four

main subtypes of learning difficulties have

been suggesled(2):

• memory deficits, associated with tempo

ral lobe dvsfunction

• a [ \ e n t i o ~ deficits, associated with gener

alised tonic-clonic seizures (formerly

known as 'grand mal')

• slow information-processing, associated

with multiple medication, and

• difficult.ies in verbal reasoning an d con

cept formation. Many of these difficulties can create com

munication problems for the child. They

can also affect assessment results and

response to therapy.

Behaviour debateThis low performance at school can lead to

poor self-esteem and impaired social inter

actions, compounded sometimes by low

expectations from parents or teach

ers( 15)( 1). Parents frequently report that

the epilepsy has affected their child's

schooling, feelings about themselves and

plans for the future( 16). There may also be

an effect from missing periods of schooling. About half of all children with epilep

sy and normal intellectual ability have

some degree of behaviour disturbance,

more than their own siblings, age and abil

ity peers, or children with other chronic

diseases( 17). Anti-epileptic drugs can have

(reversible) adverse effects on behaviour.

This association between poor school per

formance an d behaviour problems has

caused some debate, with each being felt

by some authors to cause the other.

Then there are more specific effects on

communication. Some epilepsy-related

communication difficulties are transitory

and related to the seizure itself. In both

generalised tonic-clonic an d complex par

tial seizures, consciousness is impaired

and temporary associated language distur

bances may occur. These may involve a

'prodrome', a variable period leading up to

a seizure when there may be changes in

behaviour, especially irritability(18).

There may be bizarre language or perhaps

swearing. Sometimes this is parents' only

clue that a seizure is 'brewing'. The child

may become dysphasic as a type of 'aura'

just before a seizure. During a seizure there

may be vocalisations, gestural automa

tisms or other behaviours that may look

purposive. Afterwards, a child may be

mildly dysanhric or dysphasic. This can be

distressing. David, aged 14, told me: "I

want to tell people not to crowd round me,

but I can't say it. "

Advocacy mlePerformance can be affected for hours or

even days after such seizures. There may be

after-effects on attention from general ised

tonic-clonic seizures for up to 30 days( 14).

Nocturnal seizures are believed to have a

detrimental effect on language functions,

memory and alertness the next day, per

haps through disturbed sleep patterns. The

therapist has a role as advocate for the

child, supporting the parents in alerting

staff to what to expect.

Tonic (stiff) or atonic seizures (drop

attacks) carry an obvious risk of injury as

the child can crash to the floor. Some of

ou r children wear helmets to protect heads

an d faces. Sometimes front teeth are bro

ken, or occasionally there may be worse

damage such as a broken jaw or lacerated

tongue. .Acute effects on speech or eating

an d drinking skills from such injuries, an dsubsequently from any surgery or onho

dontic work needed, can require short

term speech an d language therapy.

Cumulative effectGeneralised seizures of a far less obvious

kind are absences (formerly known as

'petit mal'). Lasting typically 5 - 10 sec

onds, with little to see other than perhaps

eyelid flutter, they can easily be missed

altogether or mistaken for daydreaming or

noncompliance. Each on e interrupts con

sciousness only briefly but the cumulative

effect of frequent absences can be very dis

ruptive. Absence seizures are commoner inteenagers, and in girls rather than boys. In

the uncommon childhood absence epilep

sy (which affects less than 1 in 1,000 chil

dren under 16) there can be up to thou

sands in a day, undetected without special

monitoring.

The resuLt can be loss of concentration,

reduced comprehension of long or com

plex language, difficulty holding the thread

of a conversation, or other memory prob

lems. The child misses social as well as ver

bal cues and may appear "out of it". At the

extreme, a child may have a period of non

convulsive status, that is with no recovery

between absence seizures. Here the childmay appear depressed, withdrawn or unre

sponsive. Even a child with few clinical

absences may have reduced attention con

trol between seizures. Some are aware that

they miss things, while others are simply

bewildered. Their ow n speech can lose

coherence, with frequent jumps of topic or

filler-phrases in an attempt to stay in con

trol. This type of epilepsy usually responds

well to medication and tends to resolve in

the teenage years. However, treatment which

successfully reduces seizures may not always

eliminate the difficulty in atten tion co ntrol.

Focus effectWith partial seizures, where discharges are

concentrated in on e area, the location of

................. .continued over ...

SPEECH & LANCUAGE THERAPY IN PRACTICE SPRING 1999 5



EPILEPSY

the focus of discharges will have an effect.

Dominant temporal lobe epilepsy is often

associated in adults with impairment of

verbal memory, especially affecting long

term consolidation and retrieval( 19). In

children with temporal lobe epilepsy,

impairments are less consistently evident.

They also may show memory impair

ments, which can be related to hemispher

ic specialisation(20) although are not con

sistently so(21). Children with left-sidedfocus may show poorer performance on

reading comprehension( 11) or phonologi

cal and syntactic lexical tasks(22).

Children with a focal seizure disorder can

develop effective language, perhaps due to

the mediation of the normal hemisphere,

although development may be

delayed(23). In benign partial epilepsy with

centrotemporal discharges, verbal functions

generally seem less affe aed, although there

may be subtle impairments in auditory per

ception and short-term memory(24).

Children with right-sided focus may per

form less well on tasks requiring attention

control and visuospatial processing(2S).There can be effects on prosody, for example

slowed speech rate. Adults with right-sided

focus have been found to use a smaller fre-

quency range(26) and this may occur in

children as well. Intonation in our children

is certainly often reported as monotonous.

j i l l EEG pattern known as CSWS (continu

ous spikes and waves during slow sleep) is

associated with severe and complex neuro

logical impairment, mainly in language and

behaviour. It can occur in more than one

epilepsy syndrome(27) .

Frontal lobe epilepsy may lead to an

inability to concentrate or a 'dreamy' qual

ity(28 ). Frontal lobe seizures can include

complex gestural automatisms, vocalisa

tions or facial movements. Phonemic and

semantic verbal fluency can be reduced. In

my experience, word-finding problems

and a tendency to perseverate can hamper

communication in these children.

T a n ~ r t o r y cognitiveImpaIrTnentA child does not need to have visible seizures

at all for effects on communication to occur.

Some people with frequent 'subclinical' dis

charges, showing up on EEG but not

observable as seizures, appear to experience

transitory cognitive impairment (TCI). Thiscan affect attention, immediate memory

and speed of reaction. Children can show

reduced verbal learning when they have

subclinical discharges during test

ing(29)(14), with clear implications for

the reliability of formal assessment. The

effects may show up between discharges as

well(30). Landau-Kleffner syndrome may

be an example of subclinical discharges

disrupting language function, but it also

occurs more widely. Although these are

no t observable seizures, anti-epileptic

medication such as lamotrigine can be very

effective in reducing the discharges, with

associated improvement in function(31).Mood, alertness, concentration, and school

performance can improve(32) and with

them , communication.

If a child has a past history of seizures,

there is some chance of lasting effects on

communication. Status epilepticus (pro

longed or serial seizures without recovery

in between) in young children may be fol

lowed by specific deficits - for example

memory problems, following damage to

the hippocampus, or losing early words, at

least for a time(33). However, long-term

adverse effects may be decreasing(34) .

Children without epilepsy, but with a his

tory of neonatal seizures, may show specif

ic learning difficulties such as in spelling

and arithmetic possibly arising from the

same subtle neuro-developmental vulnera

bility which led to the early seizures(3S).

II. r;1edicationet1ects .

Anti-epileptic drugs can, as we have seen,

improve cognitive function through their

action in reducing seizures or abnormal

discharges. However, they can themselves

sometimes have side effects which impaa

on communication, or on general cogni

tive skills. Of the older drugs, high levels of

phenytoin can cause cerebellar ataxia and

dysarthria It can also lead to gum hypertro

phy, while over long periods there can be

motor slowing and impairment in higher

intellectual functions. There may be specif

ic effects of some newer drugs also. Word

finding problems have been noticed after

topiramate(36) although this is temporary

and has not yet been studied in children.

HypersalivationIncreased salivation can be a side effect of

certain drugs such as clonazepam and

related benzodiazepines, which can also

lead to hypotonia, affecting oral co-ordina

tion and thus the ability to deal effectively

with the saliva(37). Hypersalivation can

also occur with some other drugs, particu

larly when first prescribed , or can occur as

a result of uncontrolled seizure activity.

Drooling is a problem which tends to be

resistant to therapy but can improve

noticeably with medication changes.

All established anti-epileptic drugs can

have unwanted neurological effects, suchas on memory, concentration, mental or

motor speed. Evidence about effects on

cognitive function in children is conflict

ing(21). Side effects may no t necessarily

occur in children, or may be mild and part

ly offset by the benefits of a reduction in

seizures(38), bu t worry about them may

tempt parents to discontinue use. If they

do occur they can be particularly disruptive

for the child 's development as, even

though they appear reversible when the

drug is stopped , they can limit learning

during the important years.

Most anti-epileptic drugs can cause drowsi

ness, including carbamazepine(39), sodium valproate and phenytoin(40), as well

as many of the newer drugs such as

gabapentin, lamotrigine, topiramate, viga

batrin( 41) . The child with epilepsy may

already tend to sleep more in the day, fol

lowing night disturbances or tonic-clonic

seizures. Carbamazepine can have effects

on rnemory(42), perhaps secondary to

more general cognitive effects.

Concentration problems can occur for

example with phenytoin or topiramate,

mood changes occasionally with vigaba

trin, slowed thinking with barbiturates

such as phenobarbitone, used in treatment

of acute episodes, or the similar primi

done. Paradoxically, barbiturates can also

produce hyperexcitability in young chil

dren and tend to be avoided for long-term

therapy. Tremor may be associated with

SPEECH & LANGUA(;E IH ERAPY tN PRACfICE SPRING 1999



EPILEPSY

sodium valproate, diplopia with carba

mazepine, motor speed may be affected by

phenytoin while response delays can be

associated with higher levels of medica

tion. Adolescence may lead to erratic com

pliance with a medication regime, withresultant risk of seizures and associated

problems reappearing(l) .

III. AssessmentWhat are the implications of epilepsy r. r

assessm ent?

I. BaselinesFrequently repeatable baselines may be

needed along with formal tests. As well as

in therapy planning, our observations of achild's performance can be helpful in eval

uating the results of medication changes, if

we can locate and inform the prescribing

doctor. Co urses of steroids can sometimes

produce dramatic improvements in speech

and language, at least during treat

ment(43). There can be substantial

improvements in language and communi

cation when frequent seizures or dis

charges are brought under better controL

indicating that skills are not necessa rily

lost but suppressed . When I first met

Justin, at 12, he spent much of his day

asleep in a corner of the classroom. He

could notrem

ember

whoI was, select pictures on request or tell me what he was

doing. Three years later, after starting on

lamotrig ine, his cheery voice greeted me all

over campus, "Hi, Linda' Are you seeing

me today?"

For a few children with highly resistant

seizures, neurosurgery may be an option,

and the local therapist can help the hospi

tal team with pre- and post-surgical assess

ments to chart progress. Depending on the

site of surgery, there can be some chance of

specific deficits afterwards, but the

improvements in imaging techniques in

recen t years give much better localisation

of function, so that the operation can be

tailored to minimise this risk. The risk is

further reduced in young children by some

degree of plasticity and / or behavioural

compensation. Language is usually

thought to have lateraIised by the age of six

years, an d earlier damage may affect cere

bral dominance(21). After temporal lobe

resection, likely to affect verbal learning

and memory in adults, children tend to

show unchanged or improved learning

(19), although deficits can also occur(44).

There can be temporary naming problems.

Children can show substantial improve

ments in cognitive function , behaviour

and communication after neurosurgery,

whether thi s is caused by a reduction inseizures or by reduced need for anti-epilep

tic medication. Improvements tend to be

greater in those who become seizure-free.

2. InterpretationFormal assessments may not show up what

the therapist is expecting. Close observa

tion may indicate lapses of awareness dur

ing testing. Any deficits apparent may be

transient, directly related to a seizure.Temporary 'peri-ictal' disturbances may

need management strategies, but should

not be confused in assessment with any

long-term residual language problems .

Test results may reflect problems other

than speech an d language disorders.

Children \ ith epi lepsy may score poorly

on as menlS need ing a tt en tion controL

uch as the TR OG , o r those we ighted

towa rds memory skills. such the CELF-R,

or tho e mak ing I isuo- perceptual

demands, such as BI' Develop men tal

assessments will also not be design ed to

pick up aphasic type disorders. Decidi ng

whether naming errors are semantic p raphasias or immature vocabulary is an exam

ple of the questions that may arise. Hearing

should be checked, as many of the effects of

subtle seizures mimic hearing impairment ,

but a (eal loss may also be present.

3VariabilityThe response to assessment is like ly to be

variable. Variability is one of th e key fea

tur es of epilepsy, although with newer

drugs there may be more stability(12). It

causes much confusion for parents, teach

ers and therapists. One day a child can

hold a reasonable conversation, the next

he misunderstands questions, barely

replies, shows word-finding problems,

slurred speech or perhaps dysfluency.

Repeated assessment results fluctuate, or

suggest loss of skills. It is easy to blamebehavioural problems, or to feel that other

people's accounts of him are unrealistic.

With th e perspective of a fluctuating

epilepsy these inconsistencies become

more comprehensible. The picture can

vary from minute to minute, or with the

time of day, or over longer periods.

Choosing the best time of day to assess,

taking into account last drug dose, seizure

pattern and alertness can make all the dif

ference. A close relationship with the carer

or perhaps classroom assistant is a real

help here. The speech and language thera

p ist has an important role in assessing

function at both 'good' and 'bad' times,

an d providing strategies for managing

communication in the bad times.

Slowness of thought is another dlaracteristic

to watch for, whether caused by the epilepsy

or its medication. It can look like a lack of

social skills, if the child answers a question

too late, when the conversation has already

moved on. Stephen, 16, can answer eventu

ally, if allowed to do so in his own time.

Interrupt his train of thought, however, with

a well-meant prompt, and he will have to

start processing all over again. Timed assess

ments put the dlild at a disadvantage....... ..... .... . .........continued over ...

SPEECH & LANCUAGE TH ERAPY IN PRACTICE SPRI NG 1999 7



EPILEPSY

IVTherapyEpilepsy has implications for therapy as

well as assessment. Flexibility and team

working are the keys, to target intervention

to fit the child's needs and ability to benefit.

Ideally, this means constantly reviewing

alternative models of therapy and keeping

in touch with other agencies. The speech

and language therapist can provide impor

tant emotional support for the child and the

family by acknowledging that the commu

nication difficulties are real. Compensatory

strategies to try are those providing some

kind of anchor. For example, with absence

seizures, as auditory processing appears

most vulnerable, static visual cues in the

form of photographs, pictorial guides or

written instructions can help a child re-ori

ent to the task in hand. Rebus symbols help

by supplementing the meaning of text. An

awareness of alternative and augmentative

communication methods is helpful.

Simply waftingChildren can respond better to paired or

small group work than in a large class.

Reducing distracting background noise

where possible helps. Spoken instructions

can be reduced in length an d information

content, overlearning can be built in

through frequent repetition across a range

of contexts, an d understanding can be

checked frequently. It is important to work

through the child's individual areas of

strength. Therapy is often best if practical

and functionally based, that is, delivered in

context rather than through withdrawal, as

children may have difficulties in generalis

ing. Extra information-processing time

should be allowed. It can be a real chal

lenge to encourage others to simply wait

for delayed responses, or provide nonver

bal cues, when both adults an d peers are

anxious to help by explaining even more.

Strategies and teamworkSocial skills intervention can be appropri

ate, as the child 's often over-protected envi

ronment , missed schooling an d perceived

Unda Edwards Is

senior speech

and language

therapist at St

Piers in Llngfleld,

Surrey, aresidential centre

(or children with

epilepsy and

other special

needs.

difference from his peers limits his oppor

tunities and so his confidence. Add to this

lapses of awareness, limited attention an d

perhaps visual perceptual problems, an d

children can prove poor at picking up sub

tle nonverbal social cues. Slowed response

times are a further hindrance. Even with

out memory problems or limited language

skills, the child can be considerably disad

vantaged in the fast-moving whirl of play

ground chat. Coping strategies can be

taught with some success, at least to staff

but also to a receptive child. Paediatric

occupational therapists also work with

social skills, so it is worth investigatingwhether there is any input. Joint working is

a luxury well worth taking up if ever avail

able, as ou r complementary approaches

can provide a really rounded therapy.

Where a child has epilepsy, there is an extra

incentive to set therapy tasks at the right

level, as either boredom or stress can

increase the frequency of seizures.

Clinicians ask whether using computers

brings on seizures. This is unlikely, both

because the rate of screen flicker is too fast,

and because only two to five per cent of

people with epilepsy are photosensi

tive( 40). It is twice as common in girls and

often presents around puberty. For a pho

tosensitive child, television flicker may be

more 'risky' than the computer, especiaJly if

the child is too close to the screen. It is

worth noting that patterns such as stripes or

checks can trigger seizures as well as flicker,

so a computer task or even the screensaver

may be relevant. Remember dothes too

my navy an d white narrow-striped shirt has

had to be relegated to weekend wear.

Epilepsy can affect commun ,cation an d

the delivery of speech an d language thera

py for children in many ways. fo r me, it is

a fascinating challenge to try to follow the

path through the epilepsy maze, and an

endJessly rewarding opportunity to offer

some, often hugely appreciated, help.

Suggested reading

Cull, C. an d Goldstein, L.H. (1997) (eds.)

Th e Clinical Psychologist's Handbook of

Epilepsy: Assessment and Management.

London: Routledge.

Lees, J. and Neville, B. (November 1996) Fit

for Neurosurgery? Bulletin Royal College of

Speech & Language Therapi sts (RCSLT).

Lees, J. an d Neville, B. (June 1998)

Landau-Kleffner Syndrome. Bulletin RCSLT.

Lees, J. (1993) Children with Acquired

Aphasias. London: Whurr Publishers.

Lees, J. and Urwin, S. (1997) Children with

Language Disorders. London: Whun

Publishers.

Parkinson, G. (July 1995) Complex epilep

sy and language disability. Bulletin RCSLT.

Other references

A full list of references (indicated by num

bers in brackets) is available to subscribers from the editor, tel. 01569 740348 or as a

file attachment to an e-mail (avrilni

[email protected]).

Contacts

British Epilepsy Association (BEA) Tel:

0113 243 9393

National Society for Epilepsy (NSE) Tel:

01494601300

St Piers, Lingfield, Surrey Tel: 01342

832243

Resources

'Epilepsy at School' (1995) NSE Leaflet

'Drug Treatmentof Epilepsy' (1998) NSE leaflet

'Epilepsy and Children' (1995) BEA leaflet

for parents

'Epilepsy an d Education' (1998) BEA

leaflet for teachers

Test for Reception of Grammar (TROG)

(Bishop 1992) is available from TROG

Research Fund, Dept of Psychology,

University of Manchester tel. 0161 2752557

British Picture Vocabulary Scales (BPVS)

(Dunn, Dunn ,Whetton and Pintillie 1982 ,

2nd ed, Dunn, Dunn, Whelton an d Burley

1997) is available from NFER-NeJson, tel.

01753 827249

CELF-R (Wiig, 1988) is available from The

Psychological Corporation, tel. 0181 3085750. •

Questions AnswersWhy do all speech and Given its prevalence, an understanding of the effects

language th erapists need of epilepsy and its drug treatment on functionalto know about epilepsy?1 1 M ~ . " ' M ! I ! ! I 1 I ! . 1 communication skills and assessment performance is

needed.

How will the presence of Depending on the bias of the assessment, results mayMIIliliR4 ~ 1 M 1 ! I i 1 i l l l l ~ . i ~ ~ ~ i l l ~ N , - I , , ' f 4 f i i ' t t l reflect attention control, memory or visuo-perceptualpilepsy influence the choice

of standardised assessment? problems rather than speech and language disorders.

What makes speech and language therapy effective? 'with other disciplines gets the best response. .

M• • i U ! ~ . . .n Flexibility according to individual need and team working

SPEE CH & U\NGUACE THERAPY IN PRACTICE SPRING 1999





NASALITY

Nasality:

what,WhX and when to refer on Therapy for children with nasality problems is usually provided in a

co mmunity clinic. The generalist therapist needs clear criteria to identify

when special ist input is required while the specialist therapist benefits

from her colleague's know ledge of the 'whole' child. Here, Sarah Mooreand Anne Harding suggest how generalists and specialists can

collaborate effectively.

Management of speech disor

ders involving nasality can be

a daunting prospect for gen

eralist speech an d language

therapists. However, their

role as part of a wider team of professionals

is crucial (figure 1). Stengelhofen (1989)

observed that the majority of babies born

with a cleft develop normal communication

whilst 40 per cent require intervention from

a speech and language therapist. The com

munity clinician is in a position to view the

'whole' child and is able to relay pertinent

information to a cleft team regarding issues

such as educational ability, social factorsaffecting therapy and the child's ability to

cope with invasive assessments.

In addition, since not all speech disorders

involving nasality are a consequence of a

cleft palate, a number of children in com

munity clinics present with resonance and

airflow disturbances without any previous

specialist assessment. This includes children

with nasal fricatives replacing fricatives and

affricates, or children with unclear and

"muffled" speech and enlarged tonsils.

Sharpening skillsSpeech assessment requires transcription of

unusual speech patterns. Current defini

tions of speech characteristics associa ted

with velopharyngeal function can be found

in Harding and Grunwell (1996) , Sell et al

(1999), and Wyatt et al (1996). Therapists

often feel unable to make judgements of

resonance an d nasa l emission an d ill

equipped to transcribe compensatory artic

ulations in cleft palate speech, but there are

many ways to sharpen your skills:

1) liaise closely with the relevant specialist

speech and language therapist

2) experiment with your own velopharyn

geal sphincter

3) arrange a workshop with colleagues to

watch the GOS.SP.ASS. video (see resources)4) invite a specialist speech and language

therapist to carry ou t a transcription work

shop

5) use the International Phonetic Alphabet

(lPA) chart (1993) and extensions to the

IPA (Duckworth et aL 1990). See Harding

and Grunwell (1998) and Grunwell and

. Harding (1996) for an accurate transcrip

tion of nasal fricatives .

Speech assessment by a community clini

cian may be requested by a cleft team fol

lowing surgery or may be in response to a

referral from the community. A full speech

assessment and a cleft palate protocol

should be interpreted in relation to oral

struoure and function . For example, lack of

pressure consonants would suggest that the

velopharyngeal sphinoer is unable to closefully. This might be due to a short soft palate,

a large nasopharynx or an immobile palate.

"Muffled" speech might be caused by

enlarged tonsils and adenoids. Glottals and

nasal fricatives may be developed as a result

of effort to establish intra oral pressure.

If the specialist speech an d language thera

pist forwards copies of a recent assessment,

the community therapist could base thera

py on this data . Cleft speech, orofacial an d

general developmental speech and lan

guage assessments should all be carried

out by the generalist and / or the specialist

clinician. An equipment checklist for cleft

specific assessments is in figure 2.

Cleft speech assessment1. Commercially available assessments:

• PACS toys (especially for younger chil

dren, 1;6-6;0)

• South Tyneside Assessment of

Phonology (STAP)

• revised GOS.SP.ASS. '98

2. Resonance

There is a distinction between resonance and

nasal emission. Resonance relates to voice

and can be rated listening to vowels and

approximants /w I j /. Nasal emission relates

to nasal airflow and can be rated listening to

voiceless pressure consonants / p t k s f sh /.To judge resonance, listen to numbers or sen

tences with no nasal consonants (2,3,4, 5,6),

and eliminate voiced pressure consonants as

well ego"Hurry Harry, you 're late."

3. Hyponasality

Judge hyponasality on counting, particu

larly the "nasal-loaded" numbers, (seven

teen, eighteen, nineteen, twenty).

4. Nasal emission

Inaudible nasal emission can be detected

by holding a small mirror under the nose

during production of sustained fricatives

/sss fff/ an d voiceless plosives. The special

ist speech and language therapist may have

access to nasal airflow instrumentation for

confirmation of the perceptual impression.

_---------------------, 5. InstrumentationFigure I Team of professionals ............... (p lastic) surgeon

or thodontist

Videofluoroscopy and

nasendoscopy can be per

formed in the specialist cen

tre.

G. Voice quali ty

Voice quality needs to be

noted . Patients with

velopharyngeal dysfunction

have a higher incidence of

voice disorders and an y

_

dysphonia may result in a misleading reso

nance judgement.

7. Health

In addition to speech characteristics information about hearing, eating. sleeping.

mood an d general health may rE':'v<.'31signs

................ .....continued wer .. .

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 1999 9

Figure 2 Equipment checklist

• assessment protocol

• tape recorder

• spatula• pe n torch

• small mirror

• IPA chart.



__

NASALITY

Figure 3 Diagram of oronasal structure for oral examination

Figure 4 "Cleft Palate" speech summary

Sam 0 ,- 9ame / Ref. Age

i 2 i ,.. __ .,GlottaJa1.Jcuf(J{ion[Q] No rmal ad ult targets

D Cleft-type real isations

!:::::i Non -Eng lISh compensatory sounds

Comments:

-+ continued from previous page.... .............. .

of fluctuating hearing loss, nasal obstruc

tion or allergic rhinitis . This informati o n,

when considered by the specialist team,

may influence managemen t decisions.

8. Other factors

Idea lly, the community clinici an and th e

cl eft specialist discuss whether and when

th e child is ready for direct intervention or

whether a different approach is required,

for example, input thera py for very young

children. Attention levels, language ski lls

and family dynamics need to be taken

into account.

Orofacial examinationUseful checklists for an orofacial examina

tion are in Working with Cleft Palate and

GOS.SPASS. (see figure 3 for a summary).

Be sensitive to the child's feelings relating

to an oral examination. Look in a puppe t

< or the parent 's mouth before asking the

child to open their mouth.

Speech a nd language therapists are fre

quently the first profeSSionals to suspect a

submucous cleft palate. The features are a

bifid uvula, palpable notch between the

hard and soft pala te, and / or an opaque

line medially in the hard palate. In addi

tion to oral structure and function, anysyndromic features should be noted. A

small mo uth , flat affec t, slanting eyes, long

tapered fingers, and shon stature may indi

cate velocardiofacial syndrome (Sell and

Nyak, 1998). The therapist's

concerns should be shared with

the consultant or GP.

Categorisation oferrorsPre-speech assessments can be

plotted on a phonetic diagram

(figure 4). This provides evi

dence of the range of conso

nants available, with an indica

tion of the use of the speech

m e c h a n i s m .

Conso nant reali

sations are cateD a t e ! ' 9 , 97 gorised as cleft

type or developHypemasalttymen t a I

HyponasalitySpecialist spee ch

Nasalemission

assessment willNasal turbu len ce have ca tegorisedFistula consonant pro-

Mouth breathing duction erro rs

Hearing loss within four

Dysphonia Yes/@ descriptive cate

gories: anteriorOral structure

cleft type characAnterior fistulaterist ics (CTCs) ,

-] posteri o r CTCs,

non oral and pas------------------i:r sive. These are

defined an dSpecialin speechllanguage therapist described by

Harding an d

Grunwell (1998). Having categorisedCTCs in relation to oral structure they

should be distinguished from develop

mental speech patterns. As an example,

backing alveolars to velars is a CTC rather

than a normal developmental process. The

term 'developmental ' includes both

delayed ma turation and phonological dis

orders. In addition, speech a nalysis might

reveal other speech and language distur

bances such as a vowel disorder, word

order or word finding difficulties which

may be masked by cleft-related un intelli

gibility.

Therapy v surgeryRecent research (Harding and Grunwell,

1998) reveals active and passive processes

in cleft palate speech. This means when

children cannot achieve intra-oral pressure

at th e time of speech acquisition , they

either find alternatives (active processes)

or make do with what comes naturally

(passive processes ). It is currently thought

that active processes may respo nd to thera

py and are unli ke ly to be affected by

surgery. In contrast, passive processes may

no t respond to therapy until surgery has

facilitated structural change. Indeed, surgery

alone may eliminate some passive processes.

If a child has nasal fricatives replacing f, s,sh and ch but normal plosive production,

the therapist can establish whether air is

actively forced into the nose during con

sonant production by gently holding the

child's nose during production of sus

tained /fff/ and /sss/. If the consonant pro

du ction is impeded, an active nasal frica

tive is diagnosed. This is a learnt phenom

enon which requires therapy. If the noseholding facilitates an oral realisation, this

is a passive process and will possibly

require surgical intervention .

PhonologyPhonologica I analyses are necessary as the

aniculation disorders associated with cleft

palate usually involve phonological conse

quences (Harding and Grunwell, 1996), for

example, if /p / is realised as Ihl, other

voiceless plosive targets are likely to share

the same realisa tion . When /p , t, k/ -+lhl

there is a loss of contrast and" pea, tea and

key " would a ll be perceived as Ihi].

Analysis is vital for diagnosis of the problem and for subsequent planning of ther

a py. It is vita l that community clinicians

receive information about the reasons

behind recommendations for "therapy

rather than surgery". Therapists sho uld feel

abl e to contact centre clinicians for infor

ma tion and advice at any point in the ther

apy process.

The case examples 1 - 3 on page 11

describe children managed in a specialist

centre but whose therapy has been deliv

ered in a community clinic.

As a result of the Clinical Standards

Advisory Group (CSAG) repon (1998) ,

cleft palate care is expected to be cen

tralised in major centres, reducing the

number of tea ms from 57 to between 8

and 15 nationwid e. Whilst it is hoped that

specialist speech and language therapists

in these teams will consolidate communi

cation links with local therapists, it seems

likely that the maj o rity of therapy will con

tinue to be provid ed locally by com muni

ty clinicians.

We hope that, in the future, stronger links

will be forged between the specialist and

the community clinician . Harding and

Tate (1998) recently reponed on a pilot

scheme whereby liaison clinics allow close

collaboration between the th era pists on

neutral ground. This enables realis tic man

agem ent plans to be devised and fosters

mutual profess ional respect. A mod el of

service such as this helps to meet the rec

om mendations of the CSAG repon as well

as a llowing professional develo pment for

the therapists involved. Ultimately, it is the

patients who should benefit from such

approaches.

Sara h Moore and Dr Anne Harding are speech

and language therapists with North Herts NHS

Trust at Lister Hospital, Coreys Mill Lane,

Stevenage, Herts SG1 4AB , tel. 01438314333.

Resou rces

Cleft Lip and Palate Association (CLArA) leaflets from Gareth Davies, 134

Buckingham Palace Road, London SWI W

9SA, tel. OJ71 824 8110 , fax 0171 824 8109.

GOS.SPASS. vid eo details from Speech &

10 SPEECH & LANGUAGE TH ERAPY IN PRACfICE SPRING 1999



NASALrrY

Case example I (see also figure 4)

Details:Sa m (9 months), repaired bilateral cleft lip and palate.

Action:

Language Therapy Dept, Great Ormond

Street Hospi:al, tel. 0171 4059200 ext 5043.

Micronose details from Medical Physics,

Pinderfields Hospital , Wakefield, tel.

01924 201688.

PACS toys from NFER-Nelson, tel. 01753

85896l.

Working with Cleft Palate (ed . J.

Stengelhofen, 1990) an d Cleft Palate

Sourcebook (L. Albery and J. Russell , 1994)

available from Winslow, tel. 0800243755.

STAP avaiJable from STASS Publications,

tel. 01661822316 .

References

Clinical Standards Advisory Group Report,

1998. HMSO

Duckworth,M., Allen, G. , Hardcastle, W.

and Ball, j\\ . (1990) Extensions to the

International Phonetic Alphabet for the

transcription of atypical speech. Clinical Linguistics and Phonetics 4, 373-283.

Grunwell, P. and Harding, A. (1996) A

note on describing typ es of nasality. Clinical

Linguistics and Phonetics 10 (2) 157-16l.

Harding, A. , and Grunwell , P (1996)

Characteristics of Cleft Pal a te Speech .

European journal of DisoTdeTs of

Communication 31, 331-357.

Harding, A. and Grunwell, P. (1998) Active

versus passive cleft-type speech characteris

tics. International journal of Language &

Communication DisoTders 33 (3), 329-352.

Harding, A. and Tate, H. (1998) Cleft

palate across the specialist divide. RCSLT

Bulletin,September.

Sell, D., Harding, A. and Grunwell, P.

(1999) GOS.SP.ASS. '98: An assessment for

speech disorders associated with cleft

palate an d / or velopharyngeal dysfunction

(revised) . International Journal of

Language & Communication Disorders 34

(1) , 17-33.

Stengelhofen, J. (ed.) (1989) Cleft Palate

the Nature and Remediation of

Communication Problems. Churchill

Livingstone.

Wyatt, R., Sell, D., Russell, J., Harding, A. ,

Harland, K and Alber)" E. (1996) Cleft

palate speech dissected: a review of current

knowledge an d analysis. British journal of

Plastic SUTgery 49,143-149. •

QuestionsWhat can generalist therapists

a) Observe and, through play, elicit babble - plot phonemes on phonetic diagram or GOS.SP.ASS.

b) Introduce sound play - a bubble popping 'p', a leaky balloon 'ff' Key concern: Looking for evidence of any pressure consonants in vocalisations and babble, indicating velopharyngeal closure post operatively. Key aim: Input modelling new patterns for Sam to compare and store to eventually produce a new motor programme. Advice to parents: a) Ensure that they understand normal speech development and possible effects of cleft. Back this information up in writing. b) Give an idea of the sounds Sam might begin to produce post-operatively, ego should get bilabials but not sounds on the end of words as yet, and f, s, sh, ch will not be present. c) Reassure parents that it will take time (months) before full function is developed. d) Encourage parents to "pattern-back" Sam's utterances, particularly new sounds, so that output is reinforced. e) Babble play with "turn-taking" f) Model front consonants - encourage Sam to look and listen; no need to teach, just model.

Case example 2

Details:

Michael (5 years), non-cleft child with an active nasal fricative replacing [s,z,sh,ch,;] and dysphoniaDiagnosis:Phoneme specific nasality, therefore only therapy reqUired, not surgery. (For this diagnOSiS, try holding the nose during production of [s, z, sh, ch, i).lf this stops production of the sound the child is producing an active nasal fricative resulting from mislearning. If the sound changes to a more normal production ego m / ~ [ b l this needs investigation and possibly surgery.) Action:

• Elicited's' through repetitive'r'• Micronose used for visual feedback (or the therapist could draw two faces with an enlarged noseon one and a small nose on the other. The therapist makes sounds "through the nose" or "throughthe mouth" and the child points .)Outcome:The phonological disorder resolved qUickly once the child was made aware of it. The dysphonia wasinvestigated by ENT and showed vocal nodules.These may be linked to misuse of the vocal tract butMichael is also a"shouter". As he was not motivated to change by therapy, he was discharged.

Case example 3

Details: Christopher (3;2 years), repaired soft palate, single words, small vocabulary, no pressure consonants ('passive pattern'), would not cooperate with articulatory exploration in therapy. Key issues: Possible velopharyngeal insufficiency or mislearning. This complex situation requires a differential diagnosis by a specialist speech and language therapiSt. Therapy:• Input modelling of whispered sounds for non speech targets (see Harding and Grunwell 1998). Aim was to facilitate new articulatory motor programmes which could establish potential for velopharyngeal closure. • Experimentation with effect of nose-holding to give oral airflow. Outcome: No evidence of oral pressure, therefore videofluoroscopy carried out and palatal surgery, but changes in phonetiC repertoire and language development were slow due to co-existing dyspraxia and language disorder.This shows the importance of liaison with a specialist to establish which features of speech

are directly cleft related and which might be co-occurring with a speech and language disorder.

~ A n s w e r sTherapists can attend workshops, liaise with and learn

do to sharpen their phonetic• ' I , j . M ' f ~ from specialist colleagues and use the newtranscription skills?

Why is differential diagnosisnecessary?

How is a decision regardinctsurgery reached?

GOS.SP.ASS. training video.

When nasality is involved, i t is easy to make assumptionsand to overlook co-occurring speech and language disorders.

Specialist speech assessment followed byvelopharyngeal investigations are essential beforesurgery is undertaken.

SPEECH & LANGUAGE THERAPY IN PRACfICE SPRI NG 19 99 11

I



DYSPHAGIA

In Figure I Care plans, stages I - 4

Swallowing inslrudions Name: Date: Stage 1 • Nothing 10 eat or drink

Ongoing assessment by speech and language therapist

• Administration of medicines through feedingline or IV infusion

Signature:

Swallowing instrudions Name: Date: Stage 2 thick smooth consistency only Fluids: normal

thickenednone

Posture: patient sitting upright in bed or chairlevel of supervision: requires supervision dur-ing meal times Y 1 Nl 1Requires nurse ta complete menuAdministration of medicines: through feedingtube, IV infusion or crushed in food (ie. Sometablets may be crushed)Verbal instrudions:Signature:

Swallowing instrudions Name: Date: Stage 3 soft food onlyFluids: normal

thickenednone

Posture: patient sitting upright in bed or chairlevel of supervision:

• requi'es ~ cloring M tires Y 1N 1• by nurse only Y [ 1Nl 1• FlO! tl assist a t i e r t ~ menu seIedion Y 1N 1Administration of medicines:

soluble Y 1N [ 1syrup Y{ 1 N[ 1tablets Y[ 1 N[ 1crushed Y[ 1 N[ 1capsules Y [ 1 N [ )

Verbal instrudions:Signature:

Swallowing instructionsNome:Date:Stage 4 varied consistenciesAny consistency still to be avoided:Fluids: yesPosture: patient sitting upright in bed or chairlevel of supervision:• requires ~ <lmg meal tires Y ) N )• FlO! tl assist paieriwifJ menu seIedioo Y ) N ) Verbal instrudions: Signature:

ysp agIa. ..:.. \t<' \ 1/ 1.;.-

r - - - - - . Continuity of patient care and thet'\ ~ } > - provision of food of appropriate

I, 111\"

consistencies are perennial challenges in

dysphagia management. Clinical effectiveness

depends on the extent to which a tean1 approachis embraced and implemented. Penny Gravill reports on one

hospital's experience over an eighteen month period.

Aworking group was instigated

by the Nurse Consultant on

th e Neurosciences Unit

(NU) , Aberdeen Royal

Infirmary to:

1. produce a local protocol

for management of dysphagia in the neu

rologically impaired patient in accordance

with the Scottish Intercollegiate Guidelines

Network recommendations (SIGN, 1997)2. promote safe management of the dys

phagic patient

3. educate nurses in dysphagia.

The group comprised a speech and lan

guage therapist , senior staff nurse, dietit ian

and diet cook. A physiotherapist and occu

pational therapist became "occasional "

members, attending meetings when issues

directly involved them.

Classification agreedOne area of conflict identified was the dif

ferent terminology used to describe the

same food consistency. This not only

occurred between th e difierent professional groups but also between members of the

same profession. We therefore agreed on a

classification:

• Stage 1 - nil orally

• Stage 2 - thick smooth consistency

• Stage 3 - soft consistenoies

• Stage 4 - varied consistencies.

Following assessment and subsequent

reassessment by the speech an d language

therapist, a patient's needs were to be met

by on e of these stages. An 'alert sign' spec

ifying the stage was put by the patient 's bed

and the care plan into the patient's Kardex

(figure 1) . To request a stage 2 menu , the

patient 'smenu

card had 'Stage 2'wrinen or

stuck on . To order a stage 3 diet, the soft

option was selected (indicated by [s] on

the menu card).

Four months after introducing this system,

a questionnaire was sent ou t to all nurses

on the NU to gain their feedback on the

system and any effect on the management

of dysphagic patients. A total of 49 ques

tionnaires was sent out. Included in this

were 11 to permanent night staff, only on e

of whom completed the questionnaire.

Of the questionnaires sent out, 23 were

returned.

ResultsPercentage of retumed questionnaires - 47%

Familiarity with trial - 52%

Management of dysphagia

- easier - 57%

no change - 22%

- more complicated - 4%

- no comment - 17%.

Comments are in figure 2. As a result of

this feedback four changes were made:

1) Introduction ofa Stage 2 menu card

The original system of writing or sticking

'Stage 2' on the standard menu card was

no t working consistently.It had been a long term problem for nurs

ing staff and speech and language thera

pists alike that a "soft smooth I pureed Iliquidised" diet - or 'Stage 2' as it was now

known - was frequently no t of an appro

priate consistency. This may have been

partly because there was only on e diet

cook with experience and, if she were off,

the seconded person did no t have the

knowledge to do the job to her standard.

The dietitian suggested offering training to

three other members of the catering staff

to ensure cover is available in both hospi

tal kitchens. This is still to be pursued.

In the meantime, a 'Stage 2'menu

card wasintroduced (figure 3) . This is a different

colour to the standard menu cards and

allows easy identification of the special

requirements .

12 SPEECH & lA NGUAGE THERAPY IN PRACTICE SPRI NG 199 9



2) Introduction of liquids to Stage 2

The original Stage 2 care plan did not allow

for liquids to be taken unless they were

thickened to the appropriate consistency as

this would be the usual recommendation.

The change allows for 'normal' liquids, assome patient groups with an unimpaired

pharyngeal phase of swallowing - for exam

ple, a facial palsy following excision of an

acoustic neuroma - could manage normal

liquids but require a Stage 2 diet due to

impaired oral preparation.

3) A 48 Hour 'Total Intake Chart" at Stage 2

All patients recommended for a Stage 2

diet following the speech and language

therapist's assessment should be put onto a

Total Intake Chart' to allow the dietitian

and nursing staff to be more aware of nutri

tional status. This group of patients could

easily be malnourished du e to their dietary

restrictions.

4) Colour coding of 'alert signs'

To make the system clearer, the 'alert signs'

by the patient 's bed were colour coded:

Stage 1 pink/red

Stage 2 orange

Stage 3 green

Stage 4 white

An A4 laminated sheet with a definition of

each stage was placed in each bay within

the ward to allow for easy reference . The

Stage 2 menu card was made the same

colour as the Stage 2 alert sign for easy

identification for menu completion.

ModificationsTo gain more feedback regarding this system, it was introduced onto the hospital's

Acute Stroke Unit (ASU) although two

modifications were made to accommodate

their different working arrangements:

1) Colour coding

On the ASU the different therapy services

are colour coded, therefore all alert signs

and Kardex care plans were made on e

colour to fit in with this system rather than

different colours as on the NU.

2) Menu card stickers

Prior to the introduction of the Stage 2

menu card, the ASU used 'Stage 2' and

'Stage 3' stickers to alert the kitchen to con

sistency requirements. These have becomeredundant, though 'Stage 3' is still written

on the menu cards as a back up to the

selection of the 'soft' option from the stan

dard menu.

The ASU staff were asked to complete the

same questionnaire as the NU staff to pro

vidS' feedback as to the usefulness of the

system. The sample size for this unit is

markedly smaller than for the NU and, as

the total number of permanent nursing

staff is smaller, the results appear rather

more favourable . The ASU also had the

benefit of a 'tried and tested' scheme being

introduced, as opposed to on e which was

modified whilstin

use. The totalnumber

of questionnaires sent ou t was 28, with 15

returned . The comments provided by the

nursing staff are in figure 4 ..

DYSPHAGIA

Figure 2 Feedback from Neurosciences Unit nursing staff

"Good ideo. Encoul'C!9es standard throughout hospital with clear guidelines. Could have beenimplemented more effectively with leaching sessions for 011 stoff prior ta use. Would be usefulta haveguidelines printed on sheet."

"Maybe having the different stage diet sheets that go above the bed in different colours". " Stage 2 diet comes up 100 liquidised." " Stage 2 can sometimes manage soft option." " liquidised food is nat appetising in any way. Far 100 big portions, often frothy." " I was unaware of the trial, however, the swallowing ossessment sheets in Kardex help nurses ta know how ta deal with 0 patient's dietary needs."

" Documentation clear and helpfuf." " Stage 3 and 4 often mistaken; common belief that Stage 3 is nannal diet." " Very helpful as Iwork part time therefore at a glance Ican tell whet stage the patient is on." " I hink we have a good rapport with the speech and language theropists on Ward 40 regarding

continuity of patient care. They always make it clear ta the nursing stoff what they have found on assessment and what the patient is able ta take."

" As a member of permanent night stoffc{p /T 2 nights /week), we sometimes miss news of what's happening on the ward unless it's posted ta us personally, like the questionnaire."

Figure 3 Stage 2 Menu Card

Aberdeen Royallnfinn<l)' Aberdeen Royallnfinnary Aberdeen Royal Infirmary

Ward No. Room No. Ward No. Room No. Ward No. Room No.Name: Name: Nome:

Stage 2~ StaMa2Brea st

Are you vegetarian? Y[ I

Lvnch High Teo

Are you vegetarian? YI I Are you vegetarian? YI IN[ I N[ I NI I

[ I Pureed HP Soup I I Pureed HP Soupwith pololo I I Pureed Porridge

I I Weetobix

with poIoIo

I I Pureed Main Course [ I Pureed Main Course[ I Ready Brek

[ I Pureed Potata I I Pureed Potata

I I Yoghurt [ I Pureed Vegetable [ J Pureed Vegetable thick and creamy

[ J Fruit Juice

[ I Milk Pudding [ I HP Milk Pudding[ I Pureed Fruit [ I Pureed Fruit

I I Yoghurt [ I Yoghurt [ I Enterothick and creamy thick and creamy

I I Entera I I Entera

Figure 4 Feedback from Acute Stroke Unit staff

" The pink sheets make it clear for anyone ta read." " Good ideo ta have different stages. Makes it easier for all stoff and new stoff." " Clearer instructions as ta what each stage is for new stoff." " On Stage 3 diet, sometimes the patient does not get a meal, nor a yoghurt." " ... na clloice ta the patient ... items added on are not put up from the kitchen." " Puddings should automatically corne up for Stage 21lut they never do. The trial certainly saves time." " Why is it that you prefer trained stoff ta feed some patients when the auxiliary nurses have the

practical experience."" Could the nursing stoff be shown 1) the 3 stages of swallowing; 2) the complications of dysphagia and

3) types of equipment used, ego ~ i a CUt"" Definitelv improved with the type of fOod se patients con eat ... problems with kitchen putting up

correct fOod."U Excellent idea."" Originally menus nat ticked as recommended for Stage 3 and then nothing arrives. Overall a great

help for nursing stoff knowing correct consistency - huge improvement."" ... the diets are left for the diet cook to fill in that means that sometimes patients have puddings missed

out if the diet cook is off."

Results Stluctured assessment1) Percentage of returned questionnaires With the feedback from the two Units and

53% modifications made, the working group

2) Familiarity with trial 100% drew up a protocol (Appendix L page \ 5).

3) Management of dysphagia To conform to the recommendations ma

- easier - 100% in the SIGN Cuidelines (1997) we th en- no change - 0% worked on the intIoduction of an as

more complicated - 0% ment for screening dysphagic patien ts.

- no comment - 0% .... .wntinued over -+

SPEECH & LANGUAGE THERAPY IN PRACfICE SPRJNG t999 13



Figure 5DONSS SCREENING ASSESSMENT

Patient must be AWAXI and reasonably AI.IIn'. They must be in an UPRIGIn' position for assessment.The following procedure should be administered 3 TlMES:-

1 Give patient a teaspoon of cold water.2. Walth for swallow.3. Observe the following risk signs: NO SWAllOW

IMMEDIATE OR DELAYED COUGHWE T VOICE ON SAYING "AH"

BREATHLESSNESS AFTER SWAllOWINGIf YES to any of these If NO to all of these1) Nil orally 1) Continue with hoK a glass of cold wafer,2) Refer to SLT one sip at a time

2) Observe for risk signs

Adapted from Guys & Sf Thomas Swallow Tesf

If YES

Refer to SLT

If NOProceed caAioWt with scIt choicefrom menu with normal liquidsObserve for risk signs

If YES refer to SLT

Figure 6 Feedback on DONSS introduction

a) Neurosciences staff

" Appearsto be

apositive

andworthwhile

move."" Have not had the chance to screen a patient yet but feel it is a good idea for experienced nurses to beaHowed to screen patients."

" Positive definitely. It seems very worthwhile, especially at a weekend."" Very helpful."b) ASU staff"The more screenings you perform the more confident you become at doing the procedure."" Sometimes the nursing staff are really busy and Ifeel at times it is quite time consuming."" Although it appears appropriate for nursing staff to carry out this procedure, Ido consider the

screening to be yet another task for nurses to add to their busy schedule."

Figure 7 Strengths and weaknesses of dysphagia protocol

Strengths1) Clear unambiguous terminology.2) Clear instructions and procedures for all to follow.3 lime saving for speech and I o ~ therapist and rursing staff in documentation.4) An increase in the awareness of dysphagia.

5) Steady progress indicator.6) Greater awareness of the patient's nutritional status.7) Nursing staff able to feel mare c o n ~ d e n t re patients put onto oral intake as screening procedure helps

identifY potential problems.8) Amore structured approach to the assessment and management of the dysphagic patient.Weaknesses1) Apatient can remain on the Stage 1 level for a long period of time if early referral is made and poor

progress is mocle.2) The speech and Ionguage therapist works regular"office hours" therefore progress can be hailed by

unavailability for assessment.3) Stage 2 consistencies continue to cause problems.

Although an audit had previously estab-

lished that 100 per cent of neurology and

93 per cent of neurosurgical patients

referred to speech and language therapy

from the NU for management of dysphagia

were appropriate, a more structuredapproach giving useful baseline informa-

tion could only be of benefit.

Following a review of the literature and

documented assessments, The Guys and St

Thomas ' Swallow Screening Assessment

was felt to be the most suitable and per-

mission was sought to use and modify this

work. It was adapted to include our

labelling system and tenninology and pro-

duced in the form of a flow chart for easy

use (figure 5).

Nurse trainingWe decided to introduce the Department

of Neurosciences Swallowing Screening(DONSS) simultaneously to both the NU

and the ASU. Nursing staff were asked to

attend on e of four 45 minute training ses-

sions scheduled to introduce the assess-

ment. Th e session was run by either of the

speech and language therapists responsible

for the Units or the 'Dysphagia Nurse' on

the working group. The nurses to be

trained were Grade E or above from the

NU, but included some Grade D nurses

with a minimum of one year's experience

from the ASU, as their staffing arrange-

ments required this.

The training session involved background to

the project and the reasoning behind theDONSS. Practical 'hands on' experience was

included to ensure confidence. A time for dis-

cussion encouraged the exchange of observa-

tions and raising of queries or concerns.

These training sessions remain ongoing and

are arranged as the need arises. The speech

and language therapist on the ASU carries out

ones for the nursing staff there and the

Dysphagia Nurse on the NU provides its staff

with ongoing training and support.

Spring 99 sPeechmag:

reprinted articles:• Assistants· who are they and what do they do? (Anna van der Gdag and Phmp Davies, February 1993)

• Intentional communication of adults and children with ep;Jepsy (Gm Parkinson and Denise Volpato, May 1993)

.. • Challenging to communicate (Jois Stam.t;eld and Sally Cheseldine, May/June 1994)

All from Human Communication, the previous title of Speech & Language Therapy in Practice, courtesy o( Hexagon Publishing

student section

Top Tips on formal assessments:

New or old; say in a sentence or two why a particular assessment is invaluable and for whom. It would be helpful if you could also say where it is available from_

The Winter 98 speechmag asked for Top Tips for Circle Time. The book Turn Your School Around by Jenny Mosley was recommended. It ispublished by Chris Lloyd Sales and Marketing Services (1993), ISBN 1855031744, price £19.95. The same author has a more recent (1996)publication, Quality Circle Time in the Primary Classroom, ISBN 1855032295, price £19.95.

14 SPEECH & LANGUAGE THERAPY IN PRACfICE SPRlNG 1999



On e month after the introduction of the

DONSS, the nursing staff who received the

training were given a further questionnaire.

ResultsNeurosciences unit / Acute stroke unit

(figures in brackets)

1. Returned questionnaires 58% (83%)

2. Nurses who had used assessment

43% (100%)

3. Nurses who had carried ou t assessment

alone 43% (60%)

4. Nurses who had carried out joint

assessments 66% (60%)

4a.lf joint assessments carried ou t

agreement in findings is achieved·

always 100% (100%)

sometimes 0% (0%)

never 0% (0%)

The most obvious contrast is the apparent

ly more favourable result from the ASU. It

should be noted that the difference in sam

ple sizes is significant, being 12 and 6

respectively. In the NU, medical and nurs

ing staff can screen any patient they feel

may have a dysphagia bu t this is by no

means a routine procedure administered to

all patients. On the ASU, part of the

admissions procedure is to screen a patient

for dysphagia.

A greater return rate with a higher percent

age of nurses having carried out the

DONSS assessment may have been

achieved if more time between the intro

duo ion of the assessment and the ques

tionnaire being sent ou t had been given.Some staff had no t had the opportunity to

carry ou t the procedure due to the patients

not requiring it, annual leave, shift patterns

and so on.

Each nurse who returned the questionnaire

felt the training was at least adequate and

the way the theoretical questions were

answered showed a consistently good level

of understanding of the rationale behind

the assessment.

The contrast in 'comments' made by the

two Units is interesting (figure 6). The

general feeling from the Nt! i posil i · .

with an improvement in pa ti ent care.

However on the ASU there i more of afe el ing of this being an additional duty fo r

Questions

management system be31IIII..,introduced quickly?

What will make a newsystem more effective?

Why does a nameddysphagia nurse improvedysphagia services?

_M• • • I

Stage 3 - Soft o p ~ from menu

Pureed vegeloblesMashed potatoes

Stage 4 - Soft o p ~ from menu

Pureed vegetables

Mashed potatoes

nurses which was originally with medical

staff Perhaps this panly reflects the faci

that this system has come from another

unit and is not an ASU development as

such.

The recent development of a named

'Dysphagia Nurse' on the SU may

improve perceptions. The 'U's DysphagiaNurse encourages and reminds staff that

the project is mutidisciplinary. The nurse

has a very active role to play alongside the

speech an d language therapist and is no t

dictated to bv he r_The success of systems

such as our may be highly dependent

upon th ,k il l of th is individual who can

liaise wit h lh o ther professionals and pro

ide ad\'ice an d suppon to less experienced

memb rs of e nursing staff

The 0 era ll response to the dysphagia man

agement projeo is encouraging (figure 7)

and it will be rolled ou t next to the ENT

a nd Oral-Maxillofacial wards. They have

slightly different needs as the patients' dysphagia is not of a neurological nature.

DYSPHAGIA

Appendix I - Excerpt from dysphagia management protocol

Four main types of patients referred

1. Stroke patient with poor or no swallowing reAex or chewing.

2. Neurological d isorders which affect swallowing.

3. Poor swallowing as a consequence of ageing4. Oesophageol.strictures which affect swallowing.

Dietetic Referral

D i e ~ ~ a n should be notified at onset of treatment if ony of the following criteria are mel.

1. P a ~ e n t is already on a therapeutic diet ego Diabetic or Coeliac.

2. Patient is obviouSly underweight - ie. BMlless than 19.

3. P a ~ e n t is declored unsafe 10 swallow any food or drink ond enteral feeding is indicated as support.

Stages of Consistency

Stage 2 - Smooth pureed high protein soups and puddings, yoghurt.

Pureed savouries blended with Thick and Easy.

Discussions are also underway regarding

the medical wards. Having been tried ou t

in the various surgical and medical con

texts within the acute hospital setting, the

suitability of this system can be more accu

rately judged for other settings, such as

home or schooL

A review of the procedures and protocolwill be carried ou t at regular intervals to

ensure the remit of the projeo continues.

Implicit in this is more effective manage

ment of the dysphagic patient

Mrs Penny Gravill is a specialist speech and

language therapist with Aberdeen Royal

Hospitals NHS Trust.

References

SIGN Guidelines (1997) are on the

Internet at http:((pc47 .cee.hw.acuk(s ign(

home.htm

Smith and Lockard (1995) The Guys an d St

Thomas' Swallow Screening Assessment. StThomas' Hospital, London. •

Can a new dysphaftia111111 Time is needed to plan, pilot, review and modify a new

Answers

system before i t can be implemented fully.

All team members - including kitchen staff - should be

involved in the process from the star t and anyadministration required should f i t in with existing systems.

A skilled d y s p h a ~ i a nurse facilitates multidisciplinaryworking, profeSSional development and continUity of care.

SPEEC H & LANGUAGE THERAPY IN PRACTICE SPR ING 1999 15

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REVIEWS

Hearing impairment atthe forefrontPractical Audiology for

Speech.language TherapistsJanet Doyle

Whurr

ISBN I 86156 059 I [19.50

Whilst my own experience is limit

ed, I think it wo uld be fair to say that

most therapists use little of their

aud iology training In day to day cl in

ical case loads This book has brought

ho me to me just how important It is

for hearing im pairment to be at the

forefront of every speech and lan

guage therapist's mind. Not only

does the therapist need to be able

to identify cl ients, both adults and

children, for whom an audiology

assessment may be beneficial, but

also to have an understanding of

hear ing aid funct ion and relevant

troubleshooting skill s. The sections

on screening tests and hear ing aid

provision, usage and problems may

thenefone be the most useful.

Practical Audiology will be a useful

revision aid foI- any practising thera-

pist who feels their knowledge of

audiology issomewha t rusty and for

newly qualified therapists and stu

dents, the book being "practically

oriented".Eugenie Booth is a student in the

Department of Speech, University of

Newcastle.

A fundamental resourcelearning about voice. Vocal hygiene

activities for children.A Resource

Manual (includes audio tape)

Michael I Moran and Elizabeth Eyna Jones

Singular

ISBN 1-56593-942-5 [3350

This manua l is a fundamental resource for any

speech and language therapy department. The

programme itself is easy to follow and may be

adapted to both individual or group therapy

contexts Its use encompasses more than ch il-

dren and it may be appropriate ly used wrth

adolescents. The illustrations are delightful andappeal to many age leve ls. In particular Its depic-

tion of what are frequently elusive vocal para

meters is excellent, for example prtch: tuba ver

sus nute, bear's roar versus bird's chirping.

This book provides both a rationale for a vocal

hygiene programme and a var iety of sugges

tions for actiVities to ach ieve its clearly defined

aims and objectives. The programme spans six

stages and wrth in each stage goa ls are speCi fied

and procedures suggested.

Tru ly a resource!

Fiona Mongan s a commun ity based speech and

language therapist in Co. Laois, Ireland

Easy to digestGenetics, Syndromes and

Communication Disorders

Robert Shprin tzenSingular

ISBN 1-56593-620-5 [36.00

This book may not immediately

sound like light bedtime reading,

but the author makes the topic

easy to understand and digest.

Rather than an everyday clinical

guide, this is an informative and

useful neference book.

The text serves a varied audi

ence. The first three chapters

wo uld be helpful and accessible

to students, and speech and lan

guage therapists wanting to

revisrt the field of genetics.

The later chapters are more

climcalr/ usefu l and include a

series of suggested questions

which may help speech and lan

guage therap ists refine the diag

nostic process and get the most

out of taking a case history.

Therapists working with chil

dren wrth a syndrome or in

child development centres will

want to turn to the appendices

which list around 350 known

syndromes which have related

communication disorders.Elaine Christie is a speech and

language therapist with the British

Stammering Association.

Useful chapter on cochlear implants A starting pointAudiology in Education Approaches to the Treatment of Aphasia

Ed NancyHelm-Estabrooks & Audrey L. Ho llandd Wendy McCracken and Siobhan Laoide

Whurr Singular

ISBN I 86156 017 6 [3500 ISBN 1-56593-841-0 [34.00

Atthough wr itten primarily for teachers of he deaf. selective This is the result of a mini-confenence where well-known aphasia

clinicians discussed approaches to the treatment of aphasia throughhapters provide some useful information.

The first section provides information about the diffenent the presentation of single case studies.

This book provides a weatth of ideas for aphasia treatment and isudiological assessments in use. It includes discussion of the

implications of a conductive or sensori-neural hearing loss informed by theoretical models. It will be a starting point for stu

on language acquisition, different syndromes associated wrth dents and newly qualified clinicians in providing a model for a spe

deafness and the needs of a muttiply-handicapped deaf child. cific approach to a specific area of language breakdown. More expe

The second section contains a very detailed description of rienced aphasia therapists may have liked amore in-depth study with

hearing aid technology, more nelevant to an audiological sci mone emphasis on current literature and neferences, although for

those clinicians who are interested in writing up their own cases, thentist. A very useful chapter by Sue Lewis on Cochlear

Implants is far easier to digest. It includes a description of models provided here could prove a welcome starting point.

Each case presentation is followed up with a discussion and clinicianshe ethical issues, rehabilitation and recent resea rch on out-

comes which proves to be both informative and thought are not afraid to state whene they may have chosen an alternative

treatment option or where a tneatment may not have been as sucrovoking.

The final section discusses the day to day management of cessful as was hoped.

hearing aids, selection of classroom amplification and the need The final chapter puts the treatments wrthin the context of managed

for optimum listening environments and includes a detailed care and makes salient suggestions as to how clinicians may need to

desc ription of the Audrtory Rhythmic Training programme. change their approaches to fit in with a changing heatth care system.Aileen McKay is Speech and Language Therapy Adviser in Elsje Prins is a speCialist speech and language therapist with Harrogate

Hearing Impairment for Grampian Healthcare NHS Tru st. Health Care NHS Trust.

16 SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 1999



GROUPS

~hiPMiilil le

Through drama we

learn how to act inlife, how to be in

different situations

(Starratt, 1990).

Myra Kersnercontinues her

exploration of the

use of drama inspeech and

language therapy

groups to improve

clients' language

development,

social interactionand pragmatic

skills.

Part 1 in the

Winter 98 issueaddressed

Beginnings and

Endings. Part IIdemonstrates the

versati ty,flexibility and

creativity of the

main body of the

work, the Middle.

Myra Kersner

creativetherapy-Leamlngthrouglldrama

ne of the major advan

tages of using creative

drama when working

with children with com

munication problems is

its versatility. [n speech

and language work it

may be not only in relation to gener

allanguage development and enhancement,

but it also may be useful when concentrating

on work with a more specific focus, forexample: sequencing; sound work; auditory

awareness and discrimination, or when

developing social skills. In addition to

improving language skills, McClintock

(1984) suggests that, through drama work

children often benefit "in the areas of imagi

nation, communication and in their social

and emotional development". Another

advantage of using drama with communica

tion-impaired children is its flexibility; for

most dramatic techniques, individual activi

ties, games and exercises may be adapted

specifically to meet individual children's

needs according to their age and their lin

guistic abilities (see Kersner, 1997).

Beyond wordsCreative drama enables children to enjoy a

wide range of different experiences (Peter,

1995) . As the importance of such work

lies 'in the experience itself (see Part I), the

drama process provides ways of learning

how to use that experience effectively

(Courtney, 1981). Drama allows children

to express themselves as they experiment

and 'play', though not necessarily through

lan guage, for the language of drama

extends beyond words. Essentially, howev

er, drama is a shared process which devel

ops through a flow of interaction an d rec

iprocal response (McGregor et aL 1977).

Thus, whether they are communicating

verbally or non verbally the children learn

how to be with, an d relate to others, and

through simple dramatic techniques they

have the opportunity to reinforce and gen

eralise their speech and language work in a

variety of naturalistic settings.

Developing creative dramaAims and objectives

The main body of drama work is devel

oped in the Middle section of the session

and it is within this section that exercises

may be geared towards the specific aimsan d objectives devised for each child, as

well as towards the group aims. However,

each exercise and activity in creative drama

may fulfil a variety of aims (as shown in

example 1) and, conversely, each aim and

objective may be approached in a variety

of different ways (as shown in e.xample 2) .

Example 1: Mirroring

Working in pairs, the children are asked

to face their partner. Child A is asked to

initiate' a hand dance ', to create a series

of movements using only the hands.

Child B is requi red to mirror those move

ments, to follow them and copy them

exactly. The roles may be reversed. Time

is then given for the two to discuss the

experience from each of the perspectives.

Some of the objectives which may be

achieved by this exercise include: the devel

opment of confidence in the leading child;

providing opportunities for spontaneous

creativity in the Ieading child; the develop

ment of visual observation ski.ls in the fol

lowing child; the development of trust and

co-operative working between the pair; the

development of self-discipline, concentra

tion and attention skills for both children.

and conversational skills. In addition, irre

spective of any of the specific aims, there

will be incidental learning about social

behaviour, as this inevitably results from

working in pairs, or small and larg group

...cominued at't'T ~

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 199 9 17



GROUPS

However, if for instance the improvement

of social behaviour and the acquisition of

social skills are the specific focus of the

work, there are many different ways in

which this may be approached throughdrama. Example 2 shows this in relation to

working towards the objective of develop

ing group co-operation.

Example 2: Group co-operalion

• The group may be asked to form them

selves into a line according to their

respective height.

• Children with limited verbal skills may

be asked to build something together

from materials provided .

• Children with verbal skills may be

asked to agree on a topic for discussion,

or devise an outline for a brief improvi

sation relating to a specific social situa

tion.

• Children of any age and abilities may

be asked to work together to create an

inhabited space planet, either by drawing,

using materials provided, or using their

initiative to find appropriate materials.

Extending dramatic techniques

As the Midd Ie section is usually the longest

part of any drama session, on e of the pri

mary aims of the therapist will be to l<eep

th e children engaged and interested to

maintain - and possibly improve - their

attention an d concentration. In most

instances this may require a frequent

change of activity. However the nature of

these changes and the type of activities

chosen will differ according to the needs

of the children.

Targeting specific skills

It may be necessary for example, for the

dramatic techniques to be directed towards

the acquisition of specific skills required

for speech and language development. In

such instances there may be no obvious

theme or link between the individual activ

ities and exercises as each may be targeting

a different aspect of speech and / or language.

This is illustrated in examples 3 and 4.

Example 3: Auditory awareness, audito

ry discrimination an d sound making

A sound, or a word, is aSSigned to each

child. The group are then asked to listen

carefully to a story as it is narrated by the

therapist and to insert the relevant sound

or word into the story appropriately. This

activity may begin by using the sounds

made by noise makers or musical instru

ments; it may progress to the children

making their own vocalisation or ver

balisation according to their individual

abilities. The level of difficulty ma y be

increased if the sounds given to each of

the children in the group have minimal

phonemic contrasts or if pairs of chil

dren are assigned minimal pairs of

words. Written words could also be used .

Example 4: Sequencing

• Activities for work on sequencing may

include a simple well known listing and

memory game such as 'I went to the zoo

and 1 saw .. : played verbally or using

objects or pictures where each child

repeats the previous animals or objecls

seen, adding an additional on e of their

own.• A more complex activity targeting a

similar objective could involve a familiar

story which is broken down into individ

ual scenes. These may be practised and

developed separately establishing the

sequence of the action within each scene.

The scenes may then be chosen at ran

do m to be briefly enacted or presented in

tableau to the remainder of the group .

Finally, the group, or on e child acting as

'director' - must re-assemble the scenes

in order.

• At a more difficult level, two sub

groups could develop scenes from two

different stories. Eachgroup could then

'show' the individual scenes ou t of

sequence, asking the members of the

other group to re-order them.

Practice and rehearsalThe Middle section may also be used to

build on dramatic techniques which may

be required for a larger piece of work.

These may extend from the warm-up exer

cises used in the beginning of the session

(see Pa n I in Winter 98). If, for example,

the ultimate-goal is a social skills exercise

in which the group will enact a role play,

the exercise will be of greater value to the

participants if they are able to develop theirskills and techniques for example, in rela

tion to improvisation, character develop

ment and taking on a role. These tech

niques may be developed using activities

such as those described in examples 5, 6

and 7. Practice and rehearsal may also help

the children to desensitise to performing in

front of each other, so that they are not

inhibited by the nature of the task itself,

and thus will be able to use the exercise

more effectively.

Example 5: Expressing feelings

• There are several ways in which these

skills-may be developed. A simple ·initialexercise may be 'passing the facial

expression'. On e child is asked to express

a feeling using only facial expression.

The next child is asked to imitate this

expression, then the next, until each

child has imitated the initial expression.

Alternatively, ensuing children may be

asked to change on e feature of the

expression each time it is passed on.

• The children could be asked to show

their feelings through movement, walk

ing and moving as if they were angry,

excited, or afraid.

• They could be given an emotive topic

and asked to express their feelings aboutit, in pairs, communicating only by

sounds, or animal noises, or using a sin

gle word such as 'rhubarb'.

Developing the work

Using creative drama, children are able not

only to rehearse specific skills and techniques,

but also to create situations within which

these skills may be practised meaningfully.

For as Starratt (1990) says, through drama

we learn how to act in life, how to be in dif

ferent situations. We learn how to react and

respond, how to expect others to respond

and how to control different situations. We

learn the conventions and mores of our

own society and begin to understand about

the different roles which people need to

play. Thus, creative drama encourages the

children to be themselves while at the same

time providing opportunities for lhem to

take on the role of 'another'. This enables

them to see the world from different perspec

tives and helps them gain insight not only

into their ovm actions but also into the effecLS

of those actions on others (Kersner, 1989).

On e of the most popular examples which

demonstrates how drama may be used

most effectively in this way is in the devel

opment of social and interactional skills.

Many of these skills begin to develop inci

dentally as a result of the activities under

taken within the drama sessions. For exam

ple, from the moment the group forms lhe

children begin to acquire the basic skills of

negotiation an d compromise, learning

how to function co-operatively within a

group, how to share and take turns, how to

work with a partner or in a small sub

group. However, for those with adequate

verbal skills it may also be possible to

develop more advanced social skills

through creative drama, an d to focus

specifically on such skills development, for

example using a social skills improvisation

as illustrated in example 8. In such an exer

cise it is possible to involve the wholegroup in different aspects of the improvi

sation according to their abilities, the aims

for the group and the individual children,

and the time available.

Example 6: Developing character

• Following on from the warm-up exercise

for characterisation described in Pan /, each

group member is asked to think of a

famous person, or a person they know well,

and to think about how that person walks,

talks, and uses gestures. By imitating these

and by incorporating any specific manner

isms, they then try to be' that person,• Older children may be able to invent an

individual character, crealing a life histo

ry and developing their movements an d

actions accordingly.

Example 7: Improvisation

• Group members could begin to impro

vise individually by finding a movement

sequence involving their whole body to

represent the sea, a jelly on a plate, a pair

of scissors, or an electric light bulb.

• They could then be given a speCified

place such as a doctor's waiting room , or

a park and, in pairs, using their previous

ly developed characters they couldimprovise together a short interactive

scene, either verbally or using move

ments and gestures only.

18 SPEECH & LANGUAGE THERAPY IN PRACfICE SPRING 1999



GROUPS

Example 8: Social skills improvisation

o Once the decision has been made

about the type of scene to be enacted,

such as eating in a restaurant, making a

complaint about poor quality goods pre

viously purchased or asking for an exten

sion for a piece of work at school, the

group may be involved in setting the

scene. This may be done physically using

props, or merely imaginatively.o Unless the whole group is taking part

in the action, they must then decide who

are to be the initial players and who the

audience.

o The roles to be played must be clearly

defined and some time may be spent on

characterisa'tion and role development as

discussed above, although the audience

may also become involved.

o It may be important to rehearse some

basic improvisation - see example 7.

o While the 'scene' is being enacted, it

may be helpful for the therapist to

'direct', possibly stopping the action at

critical points for discussion. Once again,the audience may become actively

involved, suggesting different approaches

to the problems so that the actors may

experiment with alternative solutions.

o The actors and audience may replace

each other as appropriate so that all the

group have an opportunity to be audi

ence and players.

When the group reflects and discusses the

enactment at the en d of the session it is

important that the exercise is not 'judged'

according to the acting abilities of the play

ers . Such an improvisation can only be

evaluated in terms of the manner and styleof the social interactions, and on the

potential effectiveness of th e solutions and

approaches to each of the problems.

The condusion of the

middlelust as it is important for the whole sessionand series of sessions to have a specified end

ing, so it is critical that at the end of the main

body of work the children have an opportu-

nity to derole, (see exercise 9). They need to

be 'centred', refocused back into their own

role so that they are able to put behind them

any of the characters they may have played

and any strong feelings which they have

expressed as that character. They must be

able to act once again as themselves within

the context of their normal lives. In addition,

wherever possible, the group should derole

the room, dismantling the acting space cre

ated for the session and reruming the furni

ture to its original position.

Exercise 9: Deroling

o All those who have taken on a role

must have the opportunity to shake off

the costume and the character they have

embraced. They may do this by saying: 'I

am no longer (name of the character) I

am (name of child)'.

o They may wish to add a sentence either

referring to something they are wearing,

something they are going to do next out

side of the session, or something they

like to do at home.

o They could be asked to name three

ways in which they are different from the

character they have portrayed .

If this section is then concluded by an

Ending as discussed in Part I, the drama

session may be considered to be complete.

References

Courtney, R. (1981) Drama Assessment. In

Schattner, G. and Courtney, R. Drama in

Therapy Vol I. New York: Drama Book

Specialists.

Kersner, M. (1989) Drama in therapy is

more than acting. Speech Therapy in

Practice 5 (5).

Kersner, M. (1997) The use of drama in

working with children with learning dis

abilities. In Fawcus, Ivl. (Ed) Children with

Learning Difficulties London: Whurr

Publishers.

McClintock A.B. (1984) Drama for

Mentally Handicapped Children. London:

Souvenir Press.

McGregor, L., Tate, M. and Robinson, K.

(1977) Learning Through Drama. Oxford:

Heinemann Educational.

Peter, M. (1995) Making Drama Special.

London: David Fulton Publishers.

Starratt, R.J. (1990) The Drama of

Schooling The Schooling of Drama.

London: The Falmer Press.

A'lyra Kersner is a Senior LeCLUrer in the

Department of Human Communication

Science, University College London.

Address fOT deUliis of drama courses and corre

spondence: Myra Kersner DHCS, UCL,

Chandler House, 2, Wak efield St, London

WCl N 1PC Tel: 01 71 504 4217e-mail [email protected] .uk •

Questions AnswersI . I f l ~ M i ~ i t 4 ! i M i l ~ i M ~ By its nature, drama is a shared process which gives us

undertaken in a group?Why should drama be• insight into our own and others' communication.

How should drama The value of drama lies in the way it facilitates socialexercises be evaluated?. M I ' t ~ interaction and problem-solving, not in 'acting' ability.

What does d e r o l i n ~l l M M ~ J Structured activities for individuals and theirmean'? surroundings enable group members to throw off roles

and associated feelings.

NEWS ..NEWS ...NEWS ...NEWS...NEWS...NEWS ...NEWS

Stammering developmentsThe British Stammering Association IS to 'lake the vital message of

eafly intervention to the parents of the 188000 UK under fives who

stammer.

Following the flllal report of the successful primary healthcare work

ers project, due out in June 1999, the new three year campaign aims

to have stammering seen largely as a preventable childhood illness.

The BSA has already introduced a National Telephone He lpline and

is hoping to secure funding to provide employm ent su pport services to

people who stammer. In 1999 its schools liaison officer will pro

mote in-service training courses on stammering throughout the UKfollowing a successful pilot period.

BSA Telephone Helpline (sUlffed by a qualified counsellor), JOam-4pm Mon

day to Fliday, tel. 0845 6032001.

Changes for Paget GormanWith Mr R. Newey, Development Officer of the Paget Gorman

Society retiring at the end of March 1999, the charity has new

arrangements for publications and information .

Paget Gorman Signed Speech publications are now only available

from STASS , 44 North Road , Ponteland , Northumberland i\E20

9UR, tel. 01661 822316, fax 01661 860440. Prices on applicati o n.

General information enquiries should be addressed to PC S, 2

Oowlands Bungalows, Dowlands Lane, Smallfield, Surre, RH6

9S0, tel. 01342 842308, e-mail [email protected]. with theInternet site remaining at http://www.pgss.org

Bob Newey will be available on a personal basis to run cour . C mad

him at 3 Gipsy Lane, Headington, Oxford 0X3 7PT, tel. 01 865 76190

SPE EC H & LAN CUt\CETHERAPY IN PRACTICE SPRI NG 1999 19





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PARTNERSHfP

From

StartThe end of the (bad)

beginning? In spite of previous efforts to :"Ilpmve how

parents are told about their childs disability. there

has been IrttJe actual change.Anne Leonard

explains how the charity Scope and its partners

are working to make a difference by ensuring a

consistent appmach based on best practice,

ight From The Start (RFTS) is

now a national project to

improve the way parents find

out about their child's dis

ability, following four years

of hard work on the pa rt of

Scope and its many partners.

It arose from several sources. Innumerable

research findings (1) showed widespread

parental dissatisfaction with the process as

it is generally experienced. Aw areness of

the research was coupled with Scope's

direct day to day knowledge, through the

Cerebral Palsy Helpline and field workers'

reports, of the disastrous way parents are

affected by their experience at the time of

diagnosis and disclosure.

Further, a Scope study of parents' views of

the assessment and statementing proces s

for special educational needs (A Hard Actto Follow, 1993) dramatically highlighted

the pre-existing evidence. Many of the par

ents contacted spoke or wrote sponta-

neously about the pain and distress of the

process of learning about their child's dis

ability. The research did not ask qu estions

about this issue, but the qualitative study

allowed parents to flag up their own con

cerns. Their unhappy experience at the

time of diagnosis and disclosure was what

emerged. This direct and unedited quota

tio n summarises responses:

"I (ound my biggest upsetment was the way in

wh ich I was told that my daugh te r was handi-

capp ed, wh ich I think mos t pa rents would agree.I be lieve doctors should explain cor rec tly and then

answe r all questions hones tly. I am very lucky to

have lived nea r a schoo l (or speCia l needs and

they explained everything to me at a time I (elt

very alone. My only Wsh was that I had bee n to ld

earlier in her li(e, as the docto r always made an

excuse whenever I asked ques tions and never

expla ined what was wrong with her apa rt (rom

te lling me she had bram damage which was left

to my imagina tion."

Scope consequently published a compila

tion and analysis of the unsolicited evi

dence about parents' experience of diagno

sis and disclosure in the report 'Right From

The Start'. Its launch in June 1994 also saw

the start of the campaign to attempt to

remedy the situation.

We were well aware of the enormous ener

gy and skill that had already been directed

at this problem (2). It was also clear that

progress had been disappointing.

Accumulated experience

The first task was therefore to draw together as many as possible of the individuals

and organis a tions who had previously

done work on this issue, or for whom it

was relevant. This included parents and

disabled adults. In this way, we intended

to learn from earlier initiatives and bring

together all the interested parties to make a

concerted effo rt to find new ways to deal

with the problems. The RFTS project is

thus a genuine consortium basing its

efforts on learning from accumulated

experience.

Our original professional partners, the

Roy al Colleges of Paediatrics and Child

Health; of Nursing and of Midwives, andthe National Portage Association have

been augmented by the Royal College of

General Practitioners, the Health Visitors

Association and the English National

Board . The voluntary secto r partners

Contact a Family, Hemi-help, Mencap,

Royal National Institute for the Blind,

Downs Syndrome Associa tion and the

National Portage Association continue towork with us on all our activities. Above

all, parents and disabled people are active

ly involved at all levels - on the Working

Gro up, in training activity, in conferences

making the project a true partnership of

professionals, voluntary groups and users

of services, just as the Warnock Report, the

1989 Children Act and the 1993 Education

Act envisaged .

The RFTS Working Group is comprised of

expert and experienced representatives

from all the sources listed. Its first task was

to attempt to understand why earlier suc

cess had been so limited and sporadic. The

reasons which emerged form the basis ofour approach to th e key task of the RFTS

strategy and include:

• isolation of people or groups working on

the issue

• discontinuity

• dependen ce on single 'champions ' or

single groups

• th e complex nature of the problems of

diagnosis and disclosure, such as: the dif

fering stages of a child 's life when disabili

ty might become evident; the large number

of professionals who might be involved;

the variation in circumstances an d

responses of families themselves.

Finally, and probably mo st significantly, itwas agreed that there had been insufficient

concern with the underl ying problem of

values - the widespread negative attitudes

to disability which undermine relations

20 SPEECH & lANGUAG ETHERAPY IN PRACTIGE SPRIN G 1999



tor members are mobilised to

combat the isolation of previous activities.

Discontinuity is being replaced by persis-

tent and consistent activity made possible

by our wide and powerful membership in

both the professional and the voluntary

sedor. The collective efforts of the group

have replaced those of single energetic

individuals who inevitably burn out' or

move on. Above all, there is a consensus in

the working group around the values iden-

tified as crucial to progress on this issue.

between parents and profes-

sionals as th.ey go through the

process of acknowledging a

child's disability.

Persistent andconsistentThe RFTS consortium has

responded to these

intractable difficulties using

the collective strengths of the

Working Group. The well

established national an d local

networks of the voluntary sec-

Social modelThe key message of the RFfS project is the

need to value disabled children as children

first an d foremost. to move away from the

'medical' approach to a child's disability,

and to take on the positive messages of the

'social' model of disability. Allied to this is

the recognition that the foundation for

real partnership is good communication

based on mutual respect. The majority of

parents of disabled children do not think

that this has been achieved.

Progress on improving the way

parents of disabled children

are told about their child's

impairment will bring benefits

not only to those parents and

their disabled children, bu t to

all users of services wh o

depend on the flexibility an d

communication skills of

providers of services. The

RFfS project can make a con-

tribution to the much Jarger

project of creating sensitive,

imaginative an d responsive

services for everyone.

Greater sensitivityProfessionals themselves need support an d

training to bring about the difficult

changes needed for parents an d children to

benefit from greater sensitivity at the time

a child's disability is recognised. This is

why the project is so concerned to influ-

ence professional training and has put so

much energy into devising and offering an

appropriate training model. The working

group realises that parents' experience and

. .... .......... .. ..continued on page 23 .. .

RESOURCE UPDATE. _.RESOURCE UPDATE. . .RESOURCE UPDATE. . .

Change ofpublisherAphasia - A Social Approach

by Lesley Jordan and WendyKaiser is now published byStanley Thomes, price£15.50 + £2. 75 p+p. Itreviews aphasia services inBritain and considers theimplications Of differentmodels Of disabilityfo raphasia services. It providesa ramework fo r developingprofessional practice.Tel. 01242 228888.

AutismA reference point on autismand guide to further resourcesfo r parents, teachers, CPs andother health professionalshas contributions f romleading practitioners. (TheAutistic Spectrum - aHal]dbook 1999, £6 + p&p.)A booklet aims to give practicaladvice and tips on how todeal with common behaviourproblems in young childrenwith autism. (It can get better- a guidefo r parents andcarers, £5 + p&p.)80th from the NationalAutistic Society,tel. 0171 903 3595,[email protected]

Reading and writing skillsThe therapy programme Reading Again using audio tapes andbooklets to aid the recovery of everyday reading skills following a

stroke or head injury is most suited to those with moderate language impairment. It includes work on shopping lists, postcards andappointment letters. A sample package is available.Author and speech and language therapist Sue Lakin has also produced a resource file Letter-by-Letter Dyslexia which includes a casediscussion, information gathering activities, activity ideas and adviceand photocopiable worksheets. Profits are donated to Action forDysphasic Adults. Details and prices from Sue Lakin, tel. 01159254593.

learningdisabilitiesA practical guide illustrated bycase studies explains techniquesfor communicating with peoplewhose behaviour is challenging

or displays autistic features.Person to Person by PhoebeCaldwell with Pene Stevens is

£79.95 +pap rom PavilionPublishing, tel. 01273623222.

EthnicminoritiesA book from Age Concern aimsto improve service provision toethnic minority elders. Theparticular needs of Black, Asian,Chinese and Vietnamese andJewish, Polish and Turkishcommunities are considered,Caring fo r Ethnic Minority Elders: aguide by Yasmin Alibhai-Brown,£74.99 from Age Concern, tel,

01Bl 765 7203/B.

Carers - strokeStroke: a carer's guide aims to explainthe range of services and supportavailable while pointing readers toother sources of reliable informationand help, It particularly concentrateson the most vulnerable times such as

onset and adjusting to life at home,From the Stroke Association, tel.0171 5660300, fl . For bulk

orders, tel. 0171 5660313,

Child languageA charity has worked with EastKent speech and language therapists to produce a series of 12booklets for parents and carers.Titles include Making sense of

language, Helping your child toconcentrate, Learning position

words, Learning the's' soundand Putting two words together.From AFASIC, tel. 0171 236 6487,£1-£2 each or £12 .50 fo rfull set.

Carers - childrenParents Of a child with adisability or special need are

being offered practicalpointers on the kind of

advice, information andemotional support that theycan access. A directory Oforganisations at the end of

the guide leads carers tofurther help and advice suitedto their individual needs.There are approximately onemillion parent carers in theUK. Financial and housingproblems are common.Caring for your child is freeto carers from CarersNational Association, tel.

0171 490 8824 or Contact aFamily, tel. 0171 383 3555

Different strokesEach year over 10 000 peoplein the UK under the retirementage have a stroke. A charity,Different Strokes, formed bya group Of younger strokesurvivors aims to provide aninformation pack beforedischarge from hospital, acounselling service andadvice and information oneducation, work and benefits.Different Strokes, tel. 0171

2496645,http://www.strokes.demon.co.uk

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRINC 1999 21

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PARTNERSHIP

Figure I Excerpts from RFTS Template of Good Practice

I . Valuing the child

Th e ch ild is central to th e situation . In the case o f diagnosis during the early months. it is va lua ble fo r th e baby to be present

when being discussed, and responded to in a w ay that reflects that the child is valued. fo r example by using the child's name.

In some circumstances either parents or professiona ls ma y not feel that it is appropriate. advisable or practicable fo r the baby

or child to be present; it is then all th e more impol-tant that language and the manner o f commun icating should reflect

respect fo r th e child. Discussions about the child should have a positive focus. Predictions about the child's future should be avoided - no on e can claim to know what any chlld's capabi lities will prove to be.

2. Respecting parents Professionals should demonstrate respect, understanding and war mth in their manner towards parents.

Honesty on th e part o f professionals in sharing information with parents, and acknowledging th e limitations o f professional

knowledge. is essential if respect fo r parents is to be conveyed effectively. An y uncertainty should be shared.

Plain understandable language accessi ble to th e parents should be used in giving explanations that w ill build up parents' con

fidence to handle th e situat ion. They need ample opportunity to ask questions and explore the situation, a process which

should also allow professionals to check whether parents have fully undel-stood what they have been told.

3. Initial concerns

If it is the parents w ho are concerned about their child. their concerns should be treated seriously and responded to quickly

and honestly. Available information should be shared and its limitations acknowl edged ..4. H ow to tel l Fam ily circumstances var y enormously.

Decisions as to how parents are told about a child 's disabi lity are best made on th e basis of the team 's knowledge of each

individual family.

Th e varying cultural needs o f families with different ethic backgrounds need to be care fu lly and sensitively taken into account

and accommodated.

a. Who should be there?

Parents report that they wo uld prefer no t to be alone when told . T he y generally say they would prefer to be told together.

However. this cannot be taken fo r granted. Fo r example. a child may live with only on e parent. Fo r th is or m any other re asons the parent being told may need the support o f a fnend or relative. rather than the other parent.Arrangements should take these possib ilities Into account.

There w ill be occasions when sharing the concern with only one unaccompanied parent cannot be avoided. In these ci rcumstances it is particularly important that professional support should include en suring that arrangements are made that

take into account th e pa rent's needs for support and practical help immediately follow ing the discussion (eg. how will the

parent ge t home /) . When on ly on e parent has been told separately, arrangements need to be made for one of the professional team to tell the

other parent as qUickly as possible, with th e agreement o f th e parent who already knows.

b. Which staff should be involved

Parents' vulnerability and right to pr ivacy should be respected by ke eping th e number o f people involve d at th e t ime of being

told to a minimum .. Th e family' s general practitioner should be informed o f th e situation immediately, and provided with the notes of the disclosure meeting and w hatever other infol-mation is necessary. c. Tuning in to the parents

Respecting parents' reactions to th e news Once again, parents' neactions var y enormously and cannot be predicted.

Professional s shou ld respect pal-ents' individua l reactions and attempt to be aware of them and respond to them appropr iately and supportively.

Some parents w ill need immediate support from a team membel- as they may be in a state o f shock and do no t want to

be left alone.

Others ma y wa nt to be left alone fo r a w hile, and will need to be given space. The opportunity to meet one o f th e profes

sional team again before going home is known to be valuable in these circumstances.

Follow-up contact (preferably with the same team member) should always be made immediate ly on the parents' return

home w ith early contact w ith community teams planned and guaranteed.

d. The need fo r privacy

Most parents say that pr ivacy is Important to them at the t ime o f learning about their child's disability...

e. Written information

Parents should be given notes immediate ly after the meeting to clarify what wa s said fo r future reference. These should be

available in th e language appropriate to th e parents...

A telephone number should be given so that parents can ask further questions as necessary. 5. Practical help and information

Parents' Information needs wi ll vary... Pamphlets should be made available. both about the child's conditio n and about practical help...

Contact with another parents (o r parents' group) should be offered and made available when the parents indicate they

would like such contact.

The needs of parents who se fir st language is not English must be taken into account throughout all these processes.

Legislation states that parents should be pu t in touch with relevan t voluntary organisation s. Parents value the help they have

received in this way, bu t many repor-t that this information was not given to them or only found by chance . Collaboration

between professionals and vo luntary organisations should ensure that parents benefit fully from th e help available through

the vo luntary sector:

Figure 2 - Summary of activity

Since it began in 1994, th e RFTS Working Group has created;

• a Template o f good practice to support professionals in getting to grips with the problems

• a training resource pack

• a CD-ROM and video

• national networks toSUPPOl

-t loca l initiatives and share experience• training and dissemination activities across th e whole country

• an 'audit document' to help professionals review progress

• severa l conferences.

22 SPEECH & lANGUAGE THERAPY IN PRACTICE SPR ING 1999



HIP

Referenceserspectives are most powerfully

(1) examples:onveyed by parents themselves.

• Survey of Disability in Britain,imilarly, the positive value and

Report 6 (1989) OPCS.ontribution of disabled people is

• Determinants of Parentalemonstrated as well as communi

Satisfaction with Disclosure ofated by disabled people themDisability, Sloper, P. and Turner,S.elves working with professionals

in Developmental Medicine andn these issues. In view of this, RFTS

Child Neurology, (1994) 35, 815ecruits and supports parents and

825.isabled people to work as trainers

(2) examples:n these issues. 'Pilots' of this train

• Cunningham, e.e. and Davis, H.ng model have proved very success

(1985) Early Parent Counselling.ul. There is a 'rolling programme'

• JUPp,S. (1992) Making the Rightf professional training in some

areas and we are planning training

and induction programmes for disabled

people and parents of disabled children to

ensure a supply of 'trained trainers' to

carry on the work.

In addition to training needs, Health

Authorities and Trusts usually do not haveexplicit policies and procedures on this

issue. The RFTS campaign urges that all the

organisations that may have an input at the

time of diagnosis and disclosure should

work with staff and parents to devise and

adopt clear polices and procedures of

which everyone is made well aware.

Imagination and inrtiativeAs a framework for devising such mea

sures, the RFTS team wrote a Templare of

Good Practice, highlighting the main

underlying issues that have to be consid

ered and taken into account in policies

and proced ures. (See figure 1 on page 22

for excerpts.) It is a guiding framework, not

a strict reci pe; the RFTS project accords

professionals the same respect and autono

my that should be offered to parents.

Imagination and initiat ive are called for

and we do not want to iron out these rare

and invaluable qualities by being over-pre

scriptive. 'Ownership' has to be local.

The latest addition to the resource pack is

the audit document. The group produced

this to help staff to review progress in

achieving the RFTS objectives.

The whole of the complex project - its prin

ciples, networks research base, strategies,

databases - are drawn together in an inter

active CD-ROM, which includes a RFTS summary and presentation section which is

also available on video. Both the video and

the CD-ROM are training tools adap table for

use interactively according to the specific

needs of the wide range of people involved.

These resources are also capable of being

edited and re-issued as the project develops.

A highly successful conference in London in

June 1997 brought together over 200 parents

and professionals from all parts of Britain to

celebrate three years' progress and to plan

future strategy. Further local conferences and

training events have 'spun-off from the orig

inal conference in Birmingham, Manchester,

Northampton, Somerset and Durham, with

others due in 1999. As with the rest of RFTS

activities, all of these conferences are organ

ised in partnership with the voluntary and

professional bodies that make up the RFTS

consort.ium.

A summary of the work to date of the RFTS

project is in figure 2. The project addresses

the structural and organisational factorsthat have inhibited the development of

good practice at the time when parents first

learn about their child's disability. It also

confronts the attitudes an d values that

make life more difficult than it need be for

disabled children (and adults) and their

families. We are confident that there has

already been some success in reaching a

wide range of the people wh o can 'make a

difference'. We are even more confident

that there is still plenty of work to be done

and a long way to go before we get it com

pletely RIGHT FROM THE START.

Anne Leonard is Research Officer for Scope, 6

Market Road, London N7 9PW, tel. 0171 6197100, http://www.scope.org. uk/

Start. Opened Eye Publications,

Hyde, Cheshire.

• Breaking The News (1992) North-West

Training an d Development Team.

• Shared Concern (1987) SOPHIE and the

King's Fund.

Resources

The RFTS CD-ROM is f30. The video pre

sentation part of this is available for £20

on video tape and the Report, Template

an d Audit document are available as a

Resource Pack for £ 10, cheques payable to

Scope (RFTS). Contact Scope's Library an d

Information Unit, 6 Market Road, London

N7 9PW, tel. 0171 6197100 for more infor

mation.

Conferences

• Late March 1999, Bradford details

from Scope's Wakefield office 01924

366711.

• Wednesday 5 May, Eiland Road

Stadium , Leeds - details tel Rena Martin,

Family Fund Trust, 01904 550007.

• Wednesday 26 May, Durham County

Cricket Club Ground, Chester-Ie-Street

details tel Debbie Mackie, Mencap, 0191

4870444.

Acknowledgements

The Family Fund Trust generously under

took the administration of two of the

northern conferences. Th e Joseph

Rowntree Foundation also magnanimous

ly contributed bursaries to fund parents'attendance. •

\ Answers~ ~ i l i i ~ . I I i ~ M I ~ ' ~ \ \ - " ' i I i i i - Working collectively, networking, ensuring~ • • ~ i i N M t ; J continuity and valuing all concerned is~ vital.

. ~ . l t l i l i f i . ( i l I t 1 M ~ Good communication based on mutualM ~ M . M . M ~ I f i I M . ~ respect is the foundation for partnership.

w . I t ~ ~ . l i f i f i i M M i l M ~ N M N i t a The good practice at the time of disclosureM i " " ~ • •n••W i ~ also applies to the provision of s e n s i · ~ i v e ,imaginative and responsive services.

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 1999 23

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HEARING IMPAIRMENT

Calderon , R. and Low, S. (1998) Early social-emotiona l, language,and acad

emic deve lopme nt in children with hearing loss. Families with and withoutfath ers. Am Ann Dea( 143 (3) 225-34.As a group, children with signi(tcant hearing loss are at greater risk than other

L.

(1)

FU IITHER R E A D ~

' f u r t he r r e ad i ng . . .This regular feature aims to provide information about articles in other journals whichmay be of interest to readers.The Editor has selected these summaries from a Speech & Language Database compiled byBiomedical 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 contactChristopher Norris, Downe, Baldersby, Thirsk, North Yorkshire Y07 4PP. te l. 01765

640283, fax 01765 640556 .

Annual rates areDisks (forWindows 3.I,can run on Windows 95): Institution £90 Individual £48Printed version: Institution £60 Individual £36.

Cheques are payable to Biomedical Research Indexing.

children (or outco mes (or below their poten tJOl, despite the institu tion o( various

educational approaches at increasingly ear/,er ages Resea rch suggests some

bene(tts o(early intervenuon (or dea( children and their {amilies . However, there

remains a paucity o( re search in to how (am ly variables may affect child out

comes. The present study investigated the effect o( paternal presence or

absence on the social-emotional, language, and academic outcomes o( 22 dea(and hard o{ hearing children ages 43-83 months. The children hod graduated

anywhere (rom 9 to 47 months earher (rom on early interventio n program {or

dea( and hard o{ hearing children 3 years o{ age or younger Results indicated

that children whose (other is present have slgm(tcantly better academic and lan

guage outcomes than those without a (othe r presenL Possible explana tions (or

the {tndings are discussed, as well as imp /icotions o{ these (tndings (or services

offered by ea rly intervention programs .

BRAIN INJURY

McHenr y, M. (1998) The ability to effect intended stress fo lowing traumatic bra in inlury. Brain Inj 12 (6) 495-503.

This study was designed to explore the production o( word stress (ollowlng trau

matic brain inj ury (fBI). Ten subjects wi th TBI and ten ma tched normal controls

produced a sentence with stress elicited on different words. The difference

betVleen stressed and unstressed productions o{ the some word was colcula ted{or In tensity, (u ndamental (re quency and duration Subject's intensity range, (un

damental (requency range and vital copacity were also obtained Na ive listen

ers judged which word was stressed within each sente nce. Individuals with TBI

were signi(tcantly less accurate conveying intended stress compared with normal

controls. IndiViduals with TBI produced significantly less difference in durauon

between stressed and unstressed words. There was no correlation {or either

grou p between percentage change In intensity. {undamenta l (requency, or dura

Uon and the related phys iological range. Durauonal cont rol requires subtle phys

iological adjustments that individuals Wth TB I may be unable to accom plish .

Furthe r, compensatory strategies may place excessive cognitive demands on the

spea ker. Thus, he producuon o( stress contrasts me1'j not be amenab le to ther

apeutic intervention. Rother, listeners may be required to rely on context to in(er

intended stress.

SEVERE APHASIA

Cunningham, R(1998) Cou nse llin g so meo ne with severe aph as ia: an exp lo

rative case study Disabl/ Rehabil 20 (9) 346-54.

PURPOSE: To exp lore a counselling approach (or a clienl HN, with a severe

aphaSia. /v1ETHOD The principles o( Personal Construct Therapy were used

Therapy (s ix sessions) was started and finished by HN producing a repertory

grid Sessions were pauent-/ed but the In(ormation (rom the repertory gnds was

used to help (aCi litate the process. Each session was Video taped RESULTS:

AnalySISo( thera py sessions revealed HN was (o llowng a pattern, i( erratic. He

used good conversational strategies to control the less structured sessions .The

thera pist was dominant when the repertory grids were produced Statisucal

analysis o{ the repertory grids was mainly nonsign ificant but there was a shift

{or the (Inal gnd to a greater variety o( and more posluve responses. General

Im provement in comprehenSion Via s also noted CONCLUS ION: A counselling'

approach with someone With severe aphaSia IS poss ib le. Using a repertory gridwas a use{ul tool (or understanding HN better It seemed to initiate HN to diS

cuss things o(Importance. The changes seen in him could have been due to on

Im provem ent in confidence as a commvnicator. This stud/ has implications (or

how we can enable people with limited language to adop t to their situations.

24 SPEECH & LA NC UAGETH ERA PY IN PRACT ICE SPRIN G 19 99

VOICENixon , C.W, Morri s, L.j., McCavitt, AR, McKinley, R.L ., Anderson, TR,

McDaniel, MP. and Yeager, D.G, (1998) Female voice com munications in high

Ie els of airc raft cockpit no ises- Part I: spectra, levels, and microp hones.

AVia Space Enwon Med 69 (7) 675-81HYPOTHESIS. Female produced speech,although more intellig!l)/e than mole speech in

some noise specrro. may be more vulnerable to degradation by high levels o{some mil

ltary aircraft cod<pit noises. The acoustK:: teotures o( (emale speech are higher In fre-

~ e n c y , icM'er n p o w e and appear me re suscepoble than mole speech to m a s k i ~ by

some o( these military fiOlSeS Ctm-en military voice communic(l(jon systems

'vere optimised (or the mo!e voice and ITl0' no adequately accommodate the (emale~ e in these high level nOises METHODSThis oppbed swdy i()<l€stigateci e intelligi

bility' o( (emale and mole speech produced in menoise Spec!m of f()(J r rruhrary O l r a acockpits at I€vels ranging {Tom 95 dB o I15 dBThe expetJmefltal subjects used sum-dard flight helmets and headsets, noise-cancelling microphones, and military r o u ~voice communications systems during the measurements .RESULTS: The ! I ~ I i of

[emale speech wos lower than that o( mole speech (or all experimental conditions,

however. d/ferences were small and insignificant except at the highest levels o( the

cockpit roises.lntelligibility fOr both genders varied with a i r c r a ~ noise spectrum and leve .

Speech In elllglbllil!/ o( both genders was acceptable dvring normal crUise noises o(all

(our aircra{1, but Impravements are required in the higher levels o( noise created during

a i r c r a ~ maximum operating conditions . CONCLUSIONS The intelligibility o( (emale

speech was un accepwbie at the highest measvred noise level or I 15 dB and may con

stitute a problem fOr other mif tary !Motors. The inte/iiglbility degradation due to the

nOise con be neutraised by use o(on available, I proved noise-cancellmg microphone,

by the application o( current oaNe noise reduction technology to the personal com

munlc(l(jon eqUlpm en4 and by the development o( a voice commvnico tions system to

accommodate the speech prodtKed by both (emale and mole avia tors.

LANGUAGE DEVELOPMENTUkra ine tz, TA ( 1998) Stickwriting stories: a qUick and easy narrat ive repre

senta ti on st rategy Lang Speech Hear Serv Schools 29 (4) 197-206.Narrative is on important target o( language intervenuon. However. orol narro

IJves are difficult to remember. reVle v,: and revise because 0 their length and

complexity, Writing is an option, b r So{!en ;NS' ating (or both student and clm

ICian,Th is arode Introduces a notatIOnal system co iled pictography can be

usefUl (or remporanly preseniJI1g ,1f)( (o nte'lL Children represent the characters,

settings, and sequences of ocoons wrth simple, chronologicaly or episodIcally

or an,sed stick·flgUre drmvmg;.As a qUick and easy representa tionalstrategy, pic

tography i- o.ppf'lcn e to both indlvid 01 language IntervenlJon and Indusive

dassroom serungs, This arode describes bene(lts observed in narraUve Interven

(IO, doong (aCilltation o( a time sequence, Increased length and qualiy. and ag ~ a t (ocus on narratJve content rather than on the mechaniCS o( Writing

DYSPHAGIAPochaczevsky, R. (1998) The chewable barium tablet slow tracki ng of oral

and pharynge al swa llow ing dys funct ion.) Clin Gastroenterol26 (4) 32/ -1Dysphagia can be due to oralor pharyngealdys(ur;ction as well as to oesophageal

causes. Oral and pharyngeal disturbances, howe'fer, are more common in okkr

people becavse o( their attendant risks o( laryngeal, trachea l, and pulmonary aspl

mUo n.To guide any dietary prescrip tions it is Important 10 es tablish whether the

patient con best tolerate liqUids, (oods, solid chewable boluses, all, or none o(

these. It therefore becomes important to supplement liquid barium swallOWing

studies with and chewable boluses mixed with banum. Here I deSCribe the

novel in troduction o(chewable barium tablets in conjunction 'Mth routine swallow

Ing studies . Chewabie barium tablets, i( used proper/y, are sa(e, supp ly needed

information, and can shorten the evaluation o( oral and pharyngeal dysfunctionstudies. Becavse o( the granular appearance o( the tablets, aspirati'on due to this

solid chewable bolus can be distinguished trom liqUid aspiration. Moreover. i( the

barium tablets are S\¥ollowed whole, they can help delineate oesophageal stIic

tures i( the oral and pharyngeal phases o( swallOWing are normal.

L. (1),

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Howlwork ·

assislaKate Richards is the speech & language therapy

service manager for North Warwickshire NHS

Trust, based at Brooklands in Birmingham, tel :

0121 3294943.

Lorraine Kelly-Atherton is a speech and language

therapist in Cardiff.

Irys Lindsay is a speech and language

therapist with Yorkhill NHS Trust in Glasgow.

H OW l...

There are over 500speech and languagetherapy assistants in theUK. The work they carryout, the training andassessment they undergoand the relationship theyhave with speech andlanguage therapists WIll

vary across services anddient groups. Theopportunities andchallenges posed bymultidisciplinaryteamsare also present forspeech and languagetherapists working withassistants. Here, threetherapists suggest howthe conbibution of

assistants can bemaximised. Training andassessment thecomponents ofagoodworking partnership andthe kinds oftasks and

responsibilities assistantscan take on are eotNdered

SPEECH & lANGUAGE TIiERAPY I PRAcnC PRiNG 1999 25



HOWl . ..

u n d e r s t a n ~assistants

advocate

K a r e ~ r d s ~ ~ w ~ ~ ! T d v ~ m e f u rassistants p'repares them qUICklyand effectively for h e ~ chaDenges of

the wO rKpla<."e.Training for speech and language therapists'

is available in many guises. The

essential on-the-job development many of us

remains at the core of any training pro

gramme for assistants and should continue to be so. T he skills and

knowledge acquired in this way can now be recognised by formal

assessment under the Scottish/National Vocational Qualification

(S/NVQ) (Level 3) Programme. There are, in addition, any num

ber of structured courses which can contribute to the underpinning

knowledge required by the S/NVQ (Level 3) assessment standards

and also contribute to individual and departmental needs.

The BTEC programme offered at Brooklands is one such structured

format. It is unusual however in its extent and depth. The BTEC is

a course of study and is offered on a day-release basis over 40 days

but also promotes the shared, lifelong learning approach byencouraging students to undertake 'Home Based L e a r n i n g ~The course is at Level 4 and, having been developed, tutored and

administered from the outset by speech and language therapists,

provides not only a comprehensive knowledge base but also the

majority of the underpinning knowledge required by the speech

and language therapy units in the new S/NVQ III award. Ou r

intention is that, from day one of the course, students can take

away information and skills which immediately translate i nto prac

tical application in the workplace.

Learning quicklyOne of the key questions I am asked is "how can I train myassis

tant in all the areas of speech and language therapy - I need her to

understand quicklyl " There isn 't an easy answer here as we all

learn so differently, but the BTEC is as near to answering the practical issues as we could achieve as a group of therapists. We too

needed newly appointed assistants to learn new skills quickly. The

lectures cover all areas of speech and language therapy work and all

client groups ranging from large incidence language disorder

groups to small incidence forensic services. All contributors to the

course are speech and language therapists or associated specialists

such as teachers and psychologists. They are briefed to adopt a facil

itative approach to teaching and to point out the relevance of their

subject to all client groups so, for example, students learn about the

systems of the body such as the Circulatory system, but it is presented

alongside the disorders arising from difficulty with the circulation

system, such as cerebrovascular accident. This whole context

approach means that students never lose sight of the client and that

the compartmentalising of human communication disorders into

that which is relevant only to certain age groups, is challenged; for

example, students learning about language development are asked

to consider why this is relevant to adults with a learning disability.

Confident communicatorsAssessment on the course is ongoing and looks at group interac

tion as much as formal assignments. Again the emphasis is on how

we learn and develop as communicators as much as how we devel

op as therapists and assistants. The dreaded word 'assignments'

does still engender a kind of terror, however past students have

remarked "Why was I worried" or "It really helped me to focus on

communication" - isn't hindsight wonderful? The process of

preparing the assignment and presenting it is also practical and not

that fearsome. Students are given skills which will enable them to

confidently report back or present client needs in a number of sit

uations in the work place. The final part of the course enables

them to extend presentation skills to include group situations such

as career conventions / parents' evenings. It is therefore the total

approach to communication and to the joint role of therapist and

her assistant which has proved to be so successful for the students.

The course allows us to start off together as therapist and assistant

and to progress to problem solving and then to joint planning. The

Whole issue of communication difficulties and how to help through

both direa methods and alternative service delivery models is also

addressed. I have found the course to be a learning exercise for

myselfand the other tutors - we always want more time and so do the

students. This, I hope, is a positive sign and plans are afoot to create

'the next level' of structured learning to enable assistants to move on.

Distance no objectAs busy practitioners we are always grateful for assistant colleagues

who can 'hit the ground running' - is there ever time for any other

option? The Brooklands BTEC recognises this and its whole struc

ture is aimed at maximising every learning opportunity, from creating a portfolio to preparing assignments, but the one difficulty is

location. Many people contact us interested in the course but can

not access it due to distance. It is however now possible for other

speech and language therapy departments to offer this course. The

route we have established means centres can register their students

through us at Brooklands, so don 't let distance put you off.

There are five units which constitute the course:

• anatomy and physiology

• social development

• behavioural science

• communication

• workplace systems and practice.

These units are integrated throughout the lectures into learning

objectives. This means that students cannot complete one unit, get

accreditation and leave. The whole course must be completed. It is an entry requirement that assistants must be working within a

speech and language therapy department or very closely with the

department. Students from local education authorities or social

services are only accepted with the agreement of the local speech

and language therapy services manager, and only if they have regu

lar contact with a supervising therapist.

Evaluation is through

• ongoing course input and contribution

• three formal assignments

• portfolio development - home based 'tasks'

• attendance.

Each student must have a speech and language therapist supervisor

who attends for three meetings per year or stays in touch by tele

phone. Feedback sheets are completed by speech and language

therapy supervisors as well as students.

Sense of ownerShipThe course offers a thorough 'backcloth' to communication diffi

culties and the role of the speech and language therapist and

speech and language therapists' assistant. The standards and

importance of our professional body, the Royal College of Speech

& Language Therapists, are stressed throughout. Improved mutual

understanding across agencies is always a result of the course as

participants come from a number of backgrounds. Students not

only gain study skills and confidence but also a sense of ownership;

it is up to them to keep in contact with their supervisor and up to

them to maximise their learning. This in itself helps in the work

place where the therapist is not present all the time.

Our experience has shown that structured learning, iflinked strong-

Iy to the workplace, can provide speech and language therapists'

assistants with the knowledge and skills they require to meet exacting speech an d language therapy standards. This complements our

role as clinicians and widens the opportunities for our clients

• BTEC awarding body has IIOW combined with London Examinations and is known as Edexcel Foundation - the awards themselves are unchanged.

26 SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 1999



H \ I

Speech an d language therapists

impart advice to a variety of pro

fessional groups and ' their' assis

tants. However, the relatively

recent awareness an d acceptance

of the need to train our own

assistants has led us to focus on developing

good working practice. There are some key elemen ts of wo rk-

ing together which, if made explicit, can enha nce the wo rki ng rela

tionship to the benefit of therapist, assistan t and c.lient.

Personal experience gained from working with a varierv of carers

and professional grou ps is invaluable and the work of Carl Rogers,

Bernstein an d Geo rge Kelly is useful in providi ng methods to

understand th e perspective of staff for whom we are responsible.

Approach to supervisionSpeech and language therap ists do not have as long a histoty of super

vision as do professionals such as social workers (Thompson 1996).

The supervision of an assistant who does not hold a speech and lan

guage therapy qualification requires a different approach than , for

example, the sup ervision of a speech and language therapy student or

newly qualified therap ist (Kimbarrow 1997). It is significa nt that the

assistant may not have the same theoretical knowledge, nor the

means to gain that knowledge. However my assistant, Samantha

Lomax, has an NN EB qualification and has worked in state nurseries.

She was at a school for PMLD children for a year before being

appointed as a speech and language therapy assistant there with me

as her supervisor. The service is jointly funded by Cardiff NHS Trust

and Cardiff County Council Education Department; Sam is an

emp loyee of education and I remain with the health service.

Sam 's knowledge of chi ld development proved invaluable as ashared baseline. She has ten sessions and I have two. We do not

have day-to-day contact so need to be clear about the parameters

of supervision. Planned sessions promote co llaboration and can

include a teacher or other staff member. They provide a source of

co nfidence, training and reassurance regarding issues related to

clients in particular and to the school in general and include:

• discussion of specific cases / disorders

• planning objectives

• sourcing materials

• reviewing actions taken to date

• sharing concerns.

Negotiation and planning It is important that we are clear about the use of time management

as this can prevent mistakes and misinterpretations on the part of

colleagues. We are fortunate that the head teadler has been sup

portive and willing to discuss issues related to improving the service.

Specific procedures are necessary and advisable and might include:

1. an agreed fo cus for the service, in our case the lower school. This

takes into account Sam's experience and tacitly acknowledges the

greater potential fo r change in the you nger group. Through focus

ing on a timetabled caseload, Sam has achieved an excellent rap

po h as a basis for individual programmes, an d would advocate this

as a positive way to ensure job satisfaction.

2. regular discussion with class teachers (speech and language ther

apist and assistant speech and language therapist , or speech and

language therapist alone) seeking their views on prioritisation and

suitability of children for one to one work; listening to their obser

vations about the children and fostering a two-way exchange of

views and information .

3. the provision of written short term objectives. In our case thattends to be three or four objectives which might include pre-verbal,

skills, turn-taking, choice or early vocabulary. Targets are retained

for a term and modified or changed if little progress is made. Some

targets are taken from the curriculum, from individual ed ucation

plans or devised by the speech and language therapist.

4. A multipurpose record form has been devised which captures

data such as baseline or emerging skill on entry, attendance, areas

targeted for treat ment and a section for the assistant to write com

ments after each treatment session . This is copied for Annual

Reviews and the child's file and updated termly.

5. our timetable is on the wall of each dassroom we are involved with

and updated termly. Supervisory sessions are noted on the timetable.

Positive, genuine and reassuring In a busy school of children with challenging behaviours and com

plex comm u nication disorders, feeling of helplessness could pre

vail. Person al qualities such as

• a positive attitude

• a genuine interes t in the client group

• a sense of humour

• good communication skills

• a reassuring, war m approach

• enthusiasm, interest, motiva tion, initiative, adaptability, flexibility

together with an ability to modify language at an appropriate level

an d a confidential and professional attitude to colleagues are all

highly desirable.

The speech and language therapist's awareness of the particular

learning style and cognitive attitude of her co-worker is also impor

tant (Furnham , 1992). Periods of active hands-on experience are

facilitated via client contact, and reflective observation aided by joint

sessions. The discussions help to conceptualise the next stage which

is recorded in note form before being transferred to the reco rd form.

Need for training and supportA degree of maturity and fairness is essential on our part as is an abil

ity to work cooperatively, which requires self confidence and seOJrity

about our own skills. An awareness of certain issues, in our case those

surrounding assess ment, feeding and alternative and augmentative

communication, is essential to ensure that professional assistants do

not get drawn into areas which require post-graduate training.

Sam contributes comments an d observations on her caseload

while referring any other queries to me. Future development might

include additional sessions to satisty the ever present need for the

consultative role of the speech an d language therapist. Assistants

should be aware of selvice development issues but need not be too

deeply involved. Training is an issue which can be partially

addressed by in-house education courses, in our case on chal.leng

ing behaviour and health and safety. Sam has also attended a Royal

College of Speech & Language Therapists ' SIG in Autism study day.

Although a small group of assistants in our district are e mployed by

health and have different pay an d conditions to Sam's, they could

be a source of support for her in the future . We should be aware

that assistants are a minority group wh o are vulnerable and require

protection and empowerment. We need to support their need for

access to a variety of equipment and recogn ise their achievement.

A long association , as clinician and ma nager, with the specialism of

learning disability affirms my belief that we need new an d inn ova

tive approaches to overco me inherent diffi cu lties with recru itment

and retenti on of staff. The lure of working with an assistant

brought me back in 1997 to the school where I sta rted my career

many years ago. Comparing then and now, th e outcome has been

positive and beneficial to myself and the children on the caseload.

References

Thompson, N. (1996) A Guide to Effective Practice in the Human Services. McMillan.

Furnham, A. (1992) Personality at Work. Routledgt'.

Kimbarrow M. (Fall , 1997) ASHA pAI-44 .

SPE ECH & LANGUAC E R A P Y IN PRACllCE SPRING 1999 27



HOWl . .

andIrvs I)r:ldsav's department ~ ~ wot1<iru!'with assistants for several years.Sne lists h ~ kindS of respombilitiesand tasrcs they take on

COMMUNI I Y CHILO HULl H SeRVICES

The main emphasis of ou r assistants' work has always been the sup

port of therapeutic practice in any setting, in any model of delivery,

with individual speech and language therapists or within shared

discipline group activities.

Yorkhill NHS Trust in Glasgow is a discreet Paediatric Trust. Assistants

in speech and language therapy have been employed since before Trust

status and their roles have evolved and developed over these years.

Developing expertiseAssistants have been given training by ou r own speech and lan

guage therapists, learning about general expectations an d require

ments within the department and also about particular speCialist

areas and how the assistants can best support the clinicians . This

has been done through varied programmes of in-service, presented

in the Trust's training centre, including presentations from col

leagues outwith speech and language therapy.

Much of the assistants' knowledge is, howeve r, acqui red by on-site

lea rning. They develop expertise in adapting to each situation as it

arises and eventually to anticipating the requirements of the clinician

by way of accommodation set-up, materials needed and the level

of privacy required for some interviews.

Home visitsFor the many clients wh o requite domici.\iary visits an assistant's

presence can be extremely beneficial. The assistant can spend time

with th e child while the therapist concentrates on parent / carer

discussion or, while the therapist offers an activity to the child, the

assistant can observe therapist / child interaaion an d can comment

at a Iater case discussion.

Whether in school, nursery, clinic or home an assistant can be most

helpful during assessment. S/ he becomes familiar with the formal

test presentation and can help with placing the toys, presenting thequestions or transcribing responses. During informal assessment,

the assistant learns the aims being targeted an d can produce requi

site pointers to assess particular skills.

Recording interactionThe assistants become skilful in the use of camcorders. They work

unobtrusively to record child / parent / therapist interaction. These

records are so valuable to the therapist for later analysis and dis

cussion an d they can be used for discussion with the parents too.

Much use of this skill has been made throughout the Hanen

Programme. The assistants can carry out all the video recording

required at the various stages an d the parents get to know them and

are pleased to welcome them into their homes.

Supporting groupwork

Speech an d language therapy in Yorkhill Trust now puts greater

emphasis on group work than ever before. The assistants' input has

become an important part of this work. They themselves build an

awareness of how they can best help in the groups, as well as carrying

out aaivities - games, worksheets, stories -as requested by the clinician.

The assistants are able to guide and support the children to respond

at the level of comprehension being targeted. They can encourage

the children to wait and listen, to wait for the ir turn and to maximise

their attempts at achieving the aims of the session. Clinicians and

assistants build a bond and an understanding which promote joint

working to the benefit of the clients an d their families.

In addition to eight assistants, Yorkhill Trust employs two bilingual

co-workers. Their work is similar to that of assistants but it is also

expanded to cover knowledge and use of the language and culture

of many bilingual families. These co-workers link with the assis

tants at meetings every two months. At these meetings they discuss

matters particularly pertinent to their jobs. The head of service often

attends so that she can hear at first hand how the ass istants and co

workers feel their work is fitting in to the whole department's aims

and objectives. All assistants and co-workers are having the oppor-

tunity to gain Scottish Vocational Qualifications (SVQ). All are also

members of the MSF Union and have their own representative at

Trust-wide union meetings.

The assistants' current job description is on e planned an d discussed

by the assistants themselves, supported by a senior clinician. Th e

Key Re sult Areas put all the emphaSis on the job being on e of sup

port to the clinicians' therapeutic interventions.

Integral roleNew recruits hear from an assistant already on the staff about the

expectations of the work. People in this job find it varied an d challenging bu t never boring. Retention of staff can be difficult because

the financial rewards are not high. However, on e assistant left to

train as a nurse an d two others have gone to study speech an d lan

guage th erapy. The role of the assistants is still evolv ing but they are

now integral to the staff complement in speech and language

therapy as they expand their range of skills to continue to support

clinicians' input to their client group.

ResourcesInformation on the Hanen Programme from Anne McDade. Hanen UK /

Ireland Co-ordinator, tel. 0141 9465433, e-mail uk_ireland@hanen .org

Details of MSF from Membership Services, MSF Centre. 33·37 Moreland

Street, London EClY 8SS. •

Background• 1980s - assistants begin to be employed more frequently by speech andlanguage therapy departments. Training and assessment is informal.Gradually more formal structures emerge, for example from 1he

A s s o c i a ~ o n of Speech & language Therapy Managers.• 1996 - a Royal College of Speech & language 1herapists' survey findsassistants make up nearly 10 per cent of the speech and languagetherapy workforce (RCSLT B u l l e ~ n ) .

• 1997 - formal N/SVQ assessment awards for assistants introduced.Assessors must be speech and language therapists and must assess theassistants consistenHy over ~ m e . BTEC training is developed atBrooklands and elsewhere.

• 1997 - the Royal College of Speech & language Therapists sets up anAssistant Network. Benefits include a quarterly newsletter and directory

of network members. For further information, contact Jenny Pigram on01716136415.

Practical points1. the focus of an assistanYs work should be onsupporting therapeutic p r a ~ c e

2. assistants can provide invaluable help with homevisits, assessment, videaing and group work

3. the best training is on-the· job, supplemented bystructured, p r a c ~ c a l courses of study

4. assistants should be encouraged to develop ascommunicators

5. planned time together to exchange viewspromotes collaboration and confidence

6. an agreed focus and caseload gives job satisfaction

7.a supervising therapist needs to be mature,confident and secure

8. planned contact with other assistants issupportive.

Speech and language therapy assistants - subscribe 10 Speech &Language Therapy in Practice for only £15! Tel 01569 740348.

28 SP EECH & IANGUACETHERAPY IN PRACTICE SPR INC 1999









IMPORTANT NOTICE Subscribers should contact the publisher if they have not received their magazine(s) within two weeks of the publication date.

Tel: 01569 740348

EVENTS ASLTIP 'Clinical ExceJlelll;e' Day, Saturday 6 March 1999

Speakers include Tessa DuffY of Symboland Sheila Ryan ofThe Learning Journal.

This event at Robinson College. Cambridge,is free to ASLTlP members, £45 to non-

members and includes lunch .The Association of Speech & LanguageTherapists in Independent Practice wouldwelcome prospective independent therapiStsat this eventDetails from Gail,ASLTIP Office

Manager, tel. 01630 655858, or theAssociation's web site,http://www.aidaweb.co.uk /asltip/

Estill Voice Training Systems

Courses in Voice C r a ~ (Anatomy &

Physiology, Level One and Level Two) with Jo

Estill will be held at the Uverpool Institutefor Performing Arts from 6- I I April 1999.Future courses planned include Voice Skills

for Speech Therapists and Safe Belting.Details from : Felicity Blair, EVTS UKAdministrator. 0 181 463 0543.

I CAN training centre

Courses in Summer 1999 include ADIHD,autism, cued articulation, IndividualEducation Plans, developing thinking skills,developmental cognitive neuropsychology.

dyspraxia, effective staff development,Hanen and speech and language targets.Booklet I details from The CourseAdministrator, tel. 01932 820470.

International Scientific Centenary Conference

Organised by the Stroke Association, thisevent from 13- I4April 1999 is aimed atall involved with research or stroke careand includes a presentation from

Profession Pam Enderby.Details: Stroke Association, tel. 01715660300.

British Aphasiology Society

The BAS Conference will be in Londonfrom 13 -15 September, 1999. (Detailsfrom Hetty Lynn , tel. 0171 477 8288.)

A study day on the evaluation of therapywill be held in Harrogate on 15 April1999. (Details from MargaretRobinson, tel. 0 1423 553604 .)

Contributions to~ e e c h &LanguageTherapy in Practice:

Contoa Ihe Editor (or more InfofTT'GtJonand Ior tD dlSQJSS your plansPlease note:• orrides must be or rroctJcal use 10

clinlC/ans• use case examples IJnd list use(ulresources• lengrh is genemlfy around 2500 words•

supPlycopy

011 disI<

,rpoSSIble• keep statistIcal mformanon andreferences 0 a mlntmum

• photographs Clnd illustrations WII/

be returned

£40 authorities (sin Ie subscription)

£15 students I assistants I unflaid

:, or more - £18 each

Special offer for personal subscribers Introduce a colleague* to Speech & Language Therapy inPractice and you both get an extra issue - free!The new subscriber fills up theIr details on the form and pu u your nom e in the 'recommended by'space. Once their payment has been received, they will ge t 5 copies for the price of 4 In their firstyear's subScription, and you will be notified thot your subscription period has been moved on bythree months.

So, tell a ll your friends the advantages of a personal subscription to Speech & Language Therapyin Practice. Remember . you will ge t an extra Inu e for every new subscriber you bring/no

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.ds Centre e should.cation AI hat e'leryon I am

communi ource t rfe sa'ler.\ . . local res much a I to Sarar\ere IS a and is 'Iery nd ideas the

esS to h ughts a ho haSha'le aC

Crefer my t 0 co_ordinatOr. w them il'to

able to he centre translate ....bo\

2. Care an d Responsibility

Training Breakaway Techniques

There are times when my 'breakaway'

training is invaluable. and there have

been times when being able to hold a

pe rson safely has been necessary.

However the greatest value is knowing

tha t, if the going gets tough, I w ill be

able to deal with the situation. This

makes me more relaxed when work

ing with an individual who is known tohave aggressive outbursts.This in rum

has a positive effect on the cl ient.

which usually results in less outbursts.

. de l' , t hoW to I sy,,'r\ aSIIng nd \<.nOw . " systemS . passtechl'ology a . t referencln" mmunicauon

. I oblec onal cOpra

ctlCa. etables I pe

rsd thiS in

\<.s I um \<.s goO .boO d sO on . roduces 10

0, e what we

ports an thing that p and carers us . the baCI<.

As e'lery hat clientS nding up Ineans t d lesS e

tUrn m with lesS an've them

gl boards .of cup

'0.Th e Mountains ofSnowdonia

I live on the ed ffa ' ge 0 SnOWdonia not

r ,rom the foot f S 'I'k 0 nowdon , and II e to .escape to the hills as often as

I can. lIke all jobs thes d

and language therapyeha;sb'epeechmo d Comena re an more stressful. I am fortu_

te that my Stress reliever is m

orlessj'USt 'd oreOUtSI e the door: Ik 'the hills helps me to . ' a 109

get It all intperspective and re-char e 0

teries, giving more g my bat. energy to k

With the cl ' worlents and h I

that th . any c a lengesey may bnng.

• •Tool BoX I box. full of

, have a red rubbery things.

materials whit chains (no wondervibrating balls. and et a reputation!).that "m startlOg to g u h it. and

to rummage thro gClients 10'le of in itiating incerac-

'

love the challenge withdrawn

I who aredo n with C lents I bo x often. ,d difficult. My little red to O

does the t rick.

_,II, ;_ f t Points

much of my work is involved in skill tranS"

and training others - creating an awareness

the presenting challenging behaviour

associated with a communication difficulty.

P i ' I I I S 8 I ~ t i l l l ! concepts in an interesting and fun

is difficult. so the activities presented In

- . · _ ~ . f t file' makes my life so much easier.

leave the training sessions saying that they

enjoyed themselves - my only hope Is thatalso learn something!

Points Sue Thurman, Kath Stewart,Jane

MvToDResources

Gwenan Roberts is PrincipalSpeech & Language Therapist fo r

the Learning Disability ServiceforYmddiriedolaeth lechyd

Cymuned Gwynedd. She dividesher clinical time between work

with the Additional Support Team(Challenging Behaviour) and

Community Support Servicesacross the counties of Conwy,

Ynys Mon and Gwynedd.As the area is predominantlyWelsh speaking, she works

through both Welsh and English.She works with school age

children and adults with learningdisabilities.

sUPPOrt WOrkers - Additiona lupportTeam (Challengin Beh .

Working as part f h g ilVIour)backup of some eO tile team. I have the

Xce ent suppo t kers. who thankfull I r Wor •individuals tha t y ee that the majority of

present With h IIbehaViours have a . c a engingty of one descriPtiocommunJcation difficul.Th ' n or another:

ey Will question wh h ' .

follOWing comma d et er an ind,vidual is. n s or Simply h 'Information fro ' . gat erlng

m sItuatIonaltoo are frustrate d wh cues, and theyWords that ha en they hear the

unt us all .. He deverything I say!". un erstands

As they are able to spend mo .carer dIre time with

s an c ients, they can be dto implement s t r a ' epended Onand t tegJes, set up rOUtines

o carry out an 'I may make I . Y recommendations

re atlOg tocommunication.

t h Wales I• • ,..at,,,I'' ' ' lG Nor . < J ' "

S - . h Le anlnbWit .th bothI wor\<. WI st r o u ~ ha5

R <kbOUI," Special Inte;er

creating

resource 0 I can turn.- .... .. . ds that be

neW fne n ems torna'dng s eha'liour se with speech

d" at present, . reasinglywo r . being Inc earns.

therapIsts mbers 01 t

. ortant me S\G toas Imp fortUnate as a which

been . . ng days. I~ c e \ l e n t t ~ I ~ ~ e r therapiSts Is to

roe in awe 0 0 w much thered me of ho h West SIG •

rern1n Wales I Nort

of North 70 I081teL 01352 -

Stass Publications, 44 North Rood,

tlbnfl!lartd. Northumberland, NElO 9UR, tel

I - 822316, price £36. . )~ __ ' " " ' : ~ ___ ~ 6. Personal

Co Plan COtntnuni .. . . . . . .- . : : ~ . : ; ; u i s t i C . in Aphasia ropriate

(PSychO\lng processing 0 ha'le app the

1 : ~ ~ ; n ~ of : I ~ ~ : f e ~ r e d c ~ ~ : : ~ e : ; e t : : ~ ~ : ~ a t isA of the Indl'l ctatiOns 0 d misunde beha'liours.Many C1e sl<.ills , SO e){pe misinterpret )( challenging.. n needed.langua" ho often e comp e t is o" e nd

I n d i ' l i d u a ~ S w ~ o can d i s ~ l a y ~ ~ ; i s t i C a s ~ e ~ s ~ ~ ~ client g ~ o u ; s : s s _said, an more comp e){ no t designe 0 ho s behind t e athway.ihus, a PAlPA IS rm . the et es t input p 0-

AlthOUgh the d in itS pure . ~ i ' l i d u a \ ' s strong nd se t up appr

Workers I fi mpleting this catIon. d 'Ind th prOfile . hIn iVidua/'s h at I can get Wit carers /

they a t t r i b u ~ allenging b e h a v i o ~ / . o o ~ Picture of u P P o r tcornrnun' . some of th IS VieWed OW anth ICatlon skill e behaViour . and Wheth

e PCP I s. s to di((j I erassert hima/so highlights wh h ICU ties With

herself b et er an .are interpre ' Ut dOin indiVidual i .The ted as ina g So throu h s trYing to

t h i n : : ~ ~ e s s of o m p l : ~ ~ ; ~ ~ i a t e behavi!ur:methods Which

w Ut an individ ' e PCP allo .

Documents

Speech & Language Therapy in Practice, Spring 1999