ISSN 1368-2105

SUMMER 2000

http://www.speechmag.com

Training
A client-centred approach

Intensive Therapy
Changing trends

Inclusion
A model of good practice

Differential diagnosis
Avoiding inappropriate treatment

In My Experience
Personality traits

My Top Resources
Bilingual children

Reader Offers
Win special needs software Win aphasia software

How I manage transitions

service children, special needs, adult neurology

C O P I N G

W I T H

C H A N G E

Speech & Language Therapy in Practice

The Summer 2000 speechmag website includes:
Reprinted articles
Clinical Focus on Dysfluency: Should all adults be treated? (Armin Kuhr, 1 (1), November 1991)** Clinical Focus on Education: Should teachers have more training in language development? (Ann Locke, 1 (4), August 1992)** Using the Alexander Technique in Voice Therapy (Carol Harris and Sheila Pehrson, 2 (3), May 1993)**
All from Speech Therapy in Practice* / Human Communication** , courtesy of Hexagon Publishing.

a report on the 8th Annual Meeting of the Dysphagia Research Society, USA from Lisa Hurst and Paula Leslie It can be quite an aggressive forum at which to present but world experts are in attendance and available for discussion. This is the cutting edge of research and such a concentration of focused ideas can be very motivating. Quality of light - Kim Talbot shares her experience of working at Arohanui Special School in New Zealand Occasionally, I forget that challenges are good and a challenge from a colleague - and particularly a parent - can throw me off guard. Short articles / conference reports / comments for the speechmag site are welcome.

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

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Contents
2 News / Comment
www.speechmag.com
SUMMER 2000
(publication date 29th May) ISSN 1368-2105 Published by: Avril Nicoll 33 Kinnear Square Laurencekirk AB30 1UL Tel/fax 01561 377415 e-mail: avrilnicoll@speechmag.com

Summer 2000
14 Inclusion
We make no distinction between the role played by the specialist language teacher and the specialist speech and language therapist. Both professionals work collaboratively in the special school setting, so it was an obvious step to work together on the implementation of the new model. Sarah Gill and Julia Ridley share a model of good practice for partial integration of children with speech and language impairment into a mainstream secondary.

4 Training
The objectives of our training were To enable staff to: carry out an assessment of their clients communication skills identify their clients communication strengths and needs formulate a booklet describing how their client communicates create a more positive communication environment develop an individual plan for improving their clients communication. Tracey Moore and Amanda Irwin describe how their client-centred approach to staff training is leading to long-term improvements in communication in a day care environment for adults with learning disabilities.

18 In my experience
After talking with a parent, professionals are often aware that a child is quite tense or anxious. The danger is that we register this fact as if it were simply another of their traits - and fail to acknowledge that the tension or anxiety is very often responsible for the traits. Patricia Sims believes the time has come for a change in direction for childrens speech and language therapy.

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Production: Fiona Reid Fiona Reid Design Straitbraes Farm St. Cyrus Montrose Printing: Manor Group Ltd Unit 7, Edison Road Highfield Industrial Estate Hampden Park Eastbourne East Sussex BN23 6PT Editor: Avril Nicoll RegMRCSLT Subscriptions and advertising: Tel / fax 01561 377415 Avril Nicoll 2000 Contents of Speech & Language Therapy in Practice reflect the views of the individual authors and not necessarily the views of the publisher. Publication of advertisements is not an endorsement of the advertiser or product or service offered. Any contributions may also appear on the magazines Internet site.

7 Reader Offers
Win Laureate software and Personalised Advice Booklets for Aphasia (PABA).

20 Diagnosis
Early and precise diagnosis is of major importance in the management of Paradoxical Vocal Cord Movement. It allows for rapid intervention, maximising potential benefits and minimising surgical and medical treatment for asthmatic symptoms, thus reducing risks and side effects (Goldman, 1997). Yifat Raz and Paul Carding find a path through the maze of this poorly understood condition.

8 Intensive therapy
Therapy has been directed increasingly at the whole person, with encouragement to change thinking as a starting point for altering not only speech but patterns of communicating. Latterly, visualisation, neuro-Iinguistic programming (NLP) and hypnotherapy have been used to expand thinking and control mind and body as part of speech management. Rosie Sage reports on the Apple House Courses which have been helping stammerers for over 32 years.

24 Further Reading
25 COVER STORY
Hearing impairment, dysarthria, dysfluency, dysphagia, bilingualism.

How I manage transitions

Probably the most fundamental factor in facilitating a successful transition between services is active communication between services and clients. Three contributions coming from armed service children (Dawn Synnuck), special needs (Fiona Johnstone and Gillian Welsher) and adult neurological (Anne Whateley) perspectives consider how we can smooth the path of change.

30 My Top Resources
A small grant from our Trust and assorted shopping trips later, we have the first trial version of photographic object and action pictures featuring activities and dress which reflects the local community. Carol Stow and Sean Pert work with bilingual children.

Cover picture by Caroline Hutcheson. See page 25, How I manage transitions. Photo posed by model.

12 Reviews
Deafness, cancer, phonology, voice, adult neurology, education, AAC.

IN FUTURE ISSUES

APHASIA MORE ETHICS STAMMERING VOICE EARLY FEEDING PSYCHIATRY FRAGILE X PROGRESSIVE NEUROLOGICAL DISORDERS

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2000

news

A quality

A speech and language therapy service in Belfast is the first to be accredited by the Royal College of Speech & Language Therapists. The new Signed-up to Quality scheme involved the speech and language therapy department of the Royal Hospitals Trust being assessed across 73 administrative and clinical standards. The department was commended in a number of areas including clinical care, technology for treatment of patients, audit and conference presentations and publications. Service manager Christine Hayden says, The scheme was timely in that it provided the department with a framework for a total service evaluation which met the Trusts Clinical Governance agenda. The peer review aspect was important, in particular the standards relating to clinical care. The award adds to the Charter Mark and Royal Recognition awards received by the department within the last year.

service

Parkinsons campaign
A campaign aims to increase the number of Parkinsons Disease Nurse Specialists in the UK. The Parkinsons Disease Society is concerned that only 64 such staff are employed in the UK and believes 240 are required if there is to be a nationwide and equitable service. The nurses provide a link for people with Parkinsons and other health and social care professionals. They can give information on drugs, monitor therapies, provide education and training and offer essential emotional support. The PDS now has a freephone Helpline staffed by nurses with a specialist knowledge. It is open from 9.30am-5.30pm. PDS, tel. 020 7931 8080, Helpline 0800 800 0303.

Invisible aid
Experts believe an invisible hearing aid implanted into the mastoid is set to replace conventional hearing aids altogether. The Totally Integrated Cochlear Amplifier (TICA) is coupled directly to the middle ear bones, avoiding the need for a loudspeaker. Even its batteries are implanted, making it completely invisible and suitable for water activities without any special precautions. The TICA and Vibrant Soundbridge, a semiCarol Bird of Walsall, West implantable hearing device for Midlands, the first person in the UK to have the Vibrant the middle ear in use for just Soundbridge implant. over a year, will be among developments reviewed at the 3rd International Symposium on Electronic Implants in Otology and Conventional Hearing Aids in Birmingham from 31 May - 2 June, 2000. www.otology2000.com

Evidence based stroke care

New national clinical guidelines for the treatment of people with stroke emphasise the importance of client-centred, seamless care with specialist management and an agreed terminology. The guidelines have been developed by an Intercollegiate Working Party following a damning report on stroke care from the Royal College of Physicians in 1999. Claire Gatehouse, chief speech and language therapist at Northwick Park Hospital, represented the Royal College of Speech & Language Therapists on the panel. The guidelines make it clear that Untrained clinicians may misdiagnose the cause of abnormal communication. Accurate diagnosis is essential to guide and inform the team and the family. A speech and language therapist is the most competent person to assess a patient with abnormal communication. Recommendations include the assessment and provision of appropriate alternative or augmentative communication aids, and there is a list of what to consider when preparing local guidelines. Evidence based practice is given priority, and tables of evidence include the natural history and management of dysphagia. The Stroke Association welcomed the guidelines, believing they provide a detailed framework which will make it easier for hospitals to introduce organised stroke care leading to a massive reduction in the levels of death and disability from stroke. See full text at: www.rcplondon.ac.uk/ceeu_stro ke_home.htm or order a copy of National Clinical Guidelines for Stroke (22 inc UK p+p) on 0207 935 1174 ext. 254. For The Stroke Association, tel. 020 7566 0317.

HRH The Princess Royal opening AbilityNet Scotland.

I CAN go for it
A challenging programme of fundraising events for the year 2000 is planned by the national educational charity for children with speech and language difficulties. I CAN go for it is seeking volunteers to scale Mount Etna in September and to undertake a nine day jungle trek in Guyana in November. At any time of the year, the charity is looking for people to make a 10 000 foot sky diver or solo parachute jump. A registration fee of 250 is payable for the overseas events and a minimum amount of sponsorship must be raised. For an information pack, tel. Hannah Bence or Kate Gannon on 0870 010 40 66.

Access for all

A charity dedicated to improving access to technology for disabled adults and children has opened its first centre in Scotland. AbilityNet staff assess peoples needs at home, school or in the workplace and provide adapted computer equipment, training, technical support and awareness education for carers, professionals and employers. A free national helpline has had an increase in use of more than 30 per cent in the past year. The organisation now has offices in Warwick, West Byfleet, Malvern, Liverpool, Reading, York and Edinburgh. It works in association with partners from public, private and voluntary sectors. Freephone 0800 269545, www.abilitynet.co.uk

Partnership for Scope

The national disability organisation whose focus is people with cerebral palsy has benefited from a campaign at this years Education Show. The British Educational Suppliers Association (BESA) used various methods to encourage educational suppliers to support Scopes work in education. Scope runs seven special schools for children whose educational needs cannot at present be met by mainstream education. It also operates a School for Parents network which helps parents in preparing preschool children for mainstream and special school. BESA supports Scopes campaign for equality in education for disabled children. The Education Show ran from 23-25 March at the NEC Birmingham. Scope, tel. 0171 619 7200.

Speakability
Action for Dysphasic Adults has been renamed Speakability. At a House of Commons reception to mark the change, the charity called for greater access to speech and language therapists, recognition that loss of language can be severely disabling and access to appropriate support for language disabled people. A quarter of a million people in the UK have aphasia. Speakability, tel. 020 7261 9572, helpline 080 8808 9572.

SPEECH & LANGUAGE THERAPY IN PRACTICE

SUMMER 2000

news & comment

Software for phonology

A research project aims to develop and evaluate software for children with phonological difficulties. Subjects recruited to the Hear IT - Sound IT project based in Bristol will be aged between four and eight years, attend mainstream schools and have receptive language within normal limits. In the final phase of the study, the children will be randomly allocated to one of two groups - those receiving standard therapy and those receiving standard plus computer therapy. Details: Yvonne Wren, research speech and language therapist, e-mail yvonne@speech-therapy.org.uk

...comment...
Avril Nicoll, Editor 33 Kinnear Square Laurencekirk AB30 1UL

Afasic Abstract
The charity representing children and young adults with communication impairments is bringing information about new developments in research and practice to professionals and parents. Three year funding for the twice yearly Afasic Abstract, edited by Professors Julie Dockrell and Geoff Lindsay, has come from the Department of Health. Each broadsheet will be distributed to schools, speech and language therapy services, GP surgeries and educational psychology and specialist teacher services and can also be accessed on the web. Afasics other plans for this year include expanding the Helpline service, training additional volunteers, appointing development workers across parts of the UK not currently covered and developing Afasics website and corporate image. Afasic, tel. 020 7841 8900, Helpline 08453 55 55 77, www.afasic.org.uk

Moving on
Clients are often moved on in the sense of having their therapist or placement changed - but do we help them move on mentally? The three contributors to How I manage transitions point out how difficult change is for everyone, and how much more so for people with communication difficulties who dont have the strategies to make sense of it. A key message of Julia Ridley and Sarah Gills article is that support must be given before, during and after a real life event for it to be effective. We should therefore plan therapy to include adequate preparation of the client, specialist assistance during the event and time afterwards to catch up, reflect on and reinforce what has been experienced. As they have realised, it is not only the client but staff who are able to move on professionally as a result. In a different setting, Tracey Moore and Amanda Irwin have also found a way of helping carers take responsibility for developing their clients access to communication. Reading the reprinted articles on the speechmag website (http://www.speechmag.com), we see how the profession is moving on by building on what has gone before. Carol Stow and Sean Perts top resources draw heavily on their enthusiasm for computers. Given the increase in information available via the web and software for therapy, the profession has to continue moves in this direction. Constant change can be threatening, but less so if it is evolution rather than revolution. In her report on the fluency courses at the Apple House, Rosie Sage comments that the treatment, while not being controversial, is curious because of its longevity. Therapists there built on their earlier understanding of stammering and fluency control techniques, over time incorporating the importance of communication with an audience and ways of tackling the real life implications of a stammer. Patricia Sims has moved on from traditional speech and language therapy approaches to looking at anxiety and tension as an underlying cause of various childhood disorders. The interplay between the physical and the psychological is also explored by Yifat Raz and Paul Carding. The authors stress the importance of the multidisciplinary team working effectively to avoid clients going round in circles and receiving inappropriate symptomatic treatment. The new multidisciplinary stroke guidelines from the Royal College of Physicians also attempt to address this (see news, page 2). They were developed in response to qualitative research with the people who know how clinically effective we are being - the clients and their families. By facing up to rather than ignoring unpalatable facts about the service we offer, clients, families and professionals have the opportunity to move on in every sense.

tel/ansa/fax 01561 377415

e-mail
avrilnicoll@speechmag.com

Child care
The strategic body representing everyone working with children up to eight years is promoting involvement of men, people from ethnic minorities and people with disabilities. The Early Years National Training Organisation is undertaking a case study survey to show how children can benefit by being cared for by these groups. Overall, the bodys aim is to raise the standard of care and education of young children by identifying training needs and facilitating provision for high quality training for the Early Years sector. Early Years NTO, tel. 01727 738300, e-mail enquiries@early-years-nto.org.uk

Autism action
Autism Awareness Week from 15th May aims to raise the profile of autism and Asperger syndrome among the general public. Led by the National Autistic Society, the title of this years campaign is Action for Autism. Details: NAS, tel. 0171 833 2299.

Office for Wales

The Parkinsons Disease Society has opened its first Welsh office in Pontypridd. There are an estimated 6000 people with Parkinsons in Wales where the society has 15 branches. In addition to improving the speed and level of support for families and carers, the office will allow the society to respond to the local cultural and political landscape. PDS Wales Office, tel. 01443 404916.

SPEECH & LANGUAGE THERAPY IN PRACTICE

SUMMER 2000

training

Making an
The success of therapy often depends on the staff or carers we work through, and training significant others therefore has to be a speech and language therapy priority. The frustration comes when what is taught does not translate into a long-term change in practice. Tracey Moore and Amanda Irwin describe how they have addressed this with a client-centred approach in a Social Education Centre.

impact
Tracey Moore and Amanda Irwin

Read this if you want to ensure communication action plans are maintained motivate carers interest in communication change staff behaviour to improve a clients communication

s speech and language therapists working with adults with learning disabilities, we are frequently faced with a surge of referrals from a Social Education Centre. Even after setting up several communication groups, many clients remain who need individual communication action plans. In the past we have spent many hours assessing these clients and meeting with a large number of staff on a one to one basis, discussing similar issues, only to find the action plans discarded inexplicably a few months later. We were desperate to find an alternative way of working with this particular client group and service providers. As a department, we see training significant others as a priority. We also recognise that the success of our interventions depends on the staff/carers we work through, and we needed to take into consideration the large number of referrals we receive, our limited resources and the demands already made on staff within the Social Education Centre environment. Other speech and

language therapists working in day care environments may be interested in our project, particularly in the light of the limited number of published assessment and training packages in this field.

Ownership
Our aim in developing the package (table 1) was to: 1. increase staff follow-up of individual communication action plans by involving staff throughout the process of assessment and programme planning to develop ownership of the action plan ensuring action plans are realistic and achievable by giving staff responsibility for developing them raising staff awareness of communication difficulties and their consequences to help them understand the need for intervention 2. help staff identify changes within the environment which would benefit all clients. The importance of creating a positive communication environment for people with learning dis-

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2000

training

Table 1 - Training Package Sessions 5 x 1 hour workshops at weekly or fortnightly intervals. 1 x 3 hour 30 minute workshop (session no. 4). Table 2 - Examples of action identified by staff Teaching Style Interactive sessions involving discussion of key topics and staff feedback of assignments completed between sessions. Each staff member to select a client with a communication difficulty to work with throughout the course. 1. to develop guidelines regarding the use of key phrases, Makaton signs and objects of reference with their chosen client 2. to use objects to help the client anticipate what is going to happen next, for example: giving the client a cup to let him know it is time for coffee assisting client with her apron to let her know dinner is being prepared 3. to enable the client to use objects to initiate, for example a tape to request that music is put on 4. to obtain pictures of activities so the client can be shown what is going to happen next 5. to develop a communication book to encourage initiation of / engagement in interaction and provide a means of requesting an activity if s/he is unable to express it verbally 6. to identify / document Makaton signs client already knows 7. to inform other members of staff of the Makaton signs to use with the client 8. to introduce new Makaton signs (list of signs identified) 9. to include client in a Makaton group 10. to organise Makaton training for staff 11. to reinforce an appropriate greeting such as shaking hands 12. to assist client to choose own snack / drink at the snack stop.

Objectives

To enable staff to: carry out an assessment of their clients communication skills identify their clients communication strengths and needs formulate a booklet describing how their client communicates create a more positive communication environment develop an individual plan for improving their clients communication.

Topics

1. Assessing communication: what we need to consider when assessing communication methods of communication assessment 2.The importance of consistent interpretation of communication behaviours and the development of a communication booklet to encourage this 3.Categorising a clients communication with regard to strengths and needs 4.Observation of staff-client interaction - identification of good partner skills 5.Choices: comparing the number, quality and types of choices we make with those made by people with learning disabilities increasing the number of choices available within the Social Education Centre environment 6.Using objects, pictures, symbols and signs (Makaton) to create a positive communication environment 7.Formulating a communication action plan to meet an individual clients needs. Course participants to present completed communication action plan to significant others. Therapist to offer support should they wish to implement a similar programme in their environment.

Involvement Of Significant Others

abilities is widely recognised. Our professional standards state: Building an environment that is conducive to good communication is particularly significant to this client group. It must be recognised that developing improved physical surroundings, personal circumstances and appropriate communication used by carers will significantly benefit the clients communicative success. (Royal College Of Speech and Language Therapists, 1996, p.134.) The importance of increasing the knowledge and skills of significant others is frequently identified within the literature. Cullen (1988) stated ...in order to change the communication skills of the clients, it may be essential to first change the behaviour of staff. The package was presented to the Social Education Centre manager clearly stating the aims of the approach and the commitment

We were desperate to

find an alternative way of working with this

particular client group and service providers.

required from staff, and the managers agreement was obtained. Van der Gaag and Dormandy (1993) state the success of any training initiative depends upon securing and maintaining the support of the management (p.143). Staff members were nominated by the manager to represent each of the clients referred for input. Nine staff attended the course - three practice supervisors, four day centre officers and two care assistants. Each selected one client to work with throughout the training period. We recommended that staff chose a client with whom they worked on a regular basis. When designing the course we planned to hold six sessions - five one hour sessions and one three and a half hour session. However, due to the ther-

apist being off sick for a long period during the course, an extra session was held to reorientate staff. Staff put forward many suggestions for improvements within their day to day practice to enhance the communication of their chosen client and other service users. These were written up in the form of action plans (see examples in table 2). The course was evaluated qualitatively through notes kept by the speech and language therapist following each session, feedback forms completed by staff on the final session and an interview with staff six months after the course to review the progress of the action they had identified during the course.

Support
Many issues were highlighted as the course progressed, for example: Staff needed more support in developing their action plans than we anticipated. Some staff appeared anxious about being asked to complete assessments and a communication action plan. We felt this was

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2000

training

Table 3 - Most frequently identified advantages 1. having the opportunity to discuss clients communication skills / needs with others (five staff) 2. being involved (three staff) 3. an increased awareness of the need to consider how we communicate with client (two staff). Table 4 - Most frequently identified disadvantages 1. insufficient time to complete assignments (four staff) carry out recommendations made on the course (three staff) 2. time-scale (due to therapist being off-sick) (three staff). Table 5 - Improvements in working practice

Barbara Maltby, course participant

I use more objects of reference and Makaton. Weve set up a Makaton group and are reinforcing the use of Makaton in everyday practice. If I cant communicate one way, I try something else - for example, demonstrating using objects, making use of touch, Makaton. Were more aware of the need to provide choices for dinner. Im more aware of the non-verbal behaviour of clients. It has sharpened my practice and brought to my attention different methods of communication.

Yvonne Collins, course participant

Chris Barnbrook, course participant

Lyndon Rogers and Ruth Powell, , course participants

possibly due to the terminology used rather than the task itself. There was a poor response to the letter to significant others inviting them to attend a meeting to discuss the communication action plan. Only one out of nine responded, although the therapist was also aware of one other carer who made direct contact with the staff member concerned. On the final session, staff were asked to list the advantages and disadvantages of the course (tables 3 and 4). Seven of the nine course participants were interviewed six months after completion of the course. (Six of the nine staff were still working at the Social Education Centre, one had moved to another Social Education Centre, one had retired and one was on maternity leave.) The action plans had been passed on by two out of three of the members of staff who were no longer at the Social Education Centre. Staff were continuing to work on action plans for eight of the nine clients studied during the course. The interviewees were asked if their day to day

Staff needed more support in developing their action plans than we anticipated.

practice had changed since attending the course. One member of staff reported that she had less contact with special care clients now due to managerial responsibilities, but she felt she was possibly more aware of how other staff are interacting. One member of staff didnt feel her practice had altered as Im always aware of the need to improve communication. Five members of staff identified ways in which their working practice had improved (examples in table 5). The training package we developed was very successful. Positive feedback on the course was obtained from staff and many excellent ideas were put forward for improving the communication skills of clients and creating a positive communication environment within the Social Education Centre. In eight out of nine cases communication action plans were being continued six months after the course, according to staff reports, and an increase in staff knowledge was noted by the speech and language therapist following the course. Additionally, positive working relationships developed through the implementation of the programme.

Modifications to the course in the future will include: 1.Reconsideration of the terminology used to describe the course - that is, the use of words such as assessment. 2.A formal agreement with managers prior to the course to ensure: Staff will be given time to complete assignments. Staff will be supported in carrying out their action plans following the course. Staff selected will be working with their client for the foreseeable future. 3.Modifications to the course content to meet the needs of Special Care clients. 4.Reconsideration of how significant others could be involved in the project to provide a consistent approach for the clients. 5.Meetings with staff during and following the course to provide further support and guidance. It may also be useful to consider using video recordings during the course particularly when discussing how staff can support clients communication. This will raise issues of an ethical nature and will therefore need careful consideration. Although the course appeared to be very successful, the evaluation methods used were limited.

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2000

training

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

Win Laureate software

Laureate software, developed in the USA by Dr Mary Sweig Wilson to complement her Linguistic Hierarchy, is now available in the UK. Speech & Language Therapy in Practice has a single user copy of First Words I, First Words II and First Verbs to give away FREE to a lucky reader, courtesy of Rompa, the UK distributor. These computer programmes are recommended for children and adults with special needs who need to master essential early vocabulary, for example, those with language learning disabilities, developmental disabilities, physical impairments, visual impairments, hearing impairments and autism. They provide highly-structured tutorial training of 100 early developing nouns and 40 verbs. There are six levels of direct instruction and a variety of features allowing you to customise lessons. Record keeping is automatic. To enter, simply send your name and subscriber number / address marked Laureate to Avril Nicoll, 33 Kinnear Square, Laurencekirk AB30 1UL, tel. 01561 377415, e-mail avrilnicoll@speechmag.com by 14th July, 2000. The winner will be drawn randomly from all valid entries.
1. Entrants must subscribe personally or as one of a department to Speech & Language Therapy in Practice, and only one entry per subscriber number is allowed. 2. Entries must be received by the editor on or before 14th July, 2000. 3. The winner will be randomly selected from all valid entries. 4. The winner will be notified by 21st July, 2000. 5. The winner will have access at work to suitable computer hardware. 6. The winner will be required to review the prize for Speech & Language Therapy in Practice by a date agreed with the editor.
COMPETITION RULES:

To provide more conclusive evidence further measures would need to be obtained, for example: measures of staff behaviour before and after the course, such as mean length of utterance, or frequency of use of augmentative methods of communication changes in client communicative behaviour, for example an increase in initiations.

Moulded
Since the initial project, the training package has been repeated in several daycare placements with similar success. The project has also been implemented in residential homes. Although many positive comments Do I ensure were obtained managers of care from staff, the therapist felt that staff are fully the project was behind training less successful in initiatives? these environments and staff Do I encourage appeared to have staff to take more difficulty responsibility for taking responsibility for devising developing their action plans. This own ideas? perhaps supports Van der gaag and Do I amend the Dormandys 1993 training I offer statement that It according to the is important that recipients needs? training is moulded as closely as possible to the individual care staff and the contexts in which they work. Our evaluations suggest this method of working is an effective approach for use within the Social Education Centre and other day care environments. It has resulted in increased staff awareness and knowledge and this has had a direct impact on both the clients studied within the training programme and other clients with whom staff work.

Reflections

Laureate Learning software will run on most modern PCs, for example, anything from a 486 with Windows 95. Recommended levels are Windows 98, Pentium processor and 16MB RAM. The programmes normally retail at 199 each or 389 for all three. A FREE demonstration CD ROM and further information is available from Rompa, tel. UK local rate 0845 3000 899 (01246 505 151 from outside UK) or http://www.laureatelearning.co.uk

Win

Personalised Advice Booklets for Aphasia (PABA)

COMPETITION RULES:

Tracey Moore and Amanda Irwin are specialist speech and language therapists, Adult Learning Disabilities, for Dudley Priority Health NHS Trust (Thanks to Prof. Margaret Bamford for support and advice).

PABA is a new software package incorporating the latest theoretical and practical approaches to aphasia. It contains advice on the specific nature of the language impairment and helpful strategies which can be selected for each client according to their needs. Personal information such as family, friends, interests and work can be printed from information provided by the family on the carers questionnaire. Gender sensitive text and graphics are selected automatically. Once the therapist has decided on content, the booklets can be generated by an assistant or secretary in under 10 minutes. The result is a cost-effective, professional looking booklet tailored to each individual client. Speech & Language Therapy in Practice has a copy of PABA to give away FREE to a lucky subscriber courtesy of its developers, the speech and language therapy department and medical illustration services at Glasgow Royal Infirmary. To enter, simply send your name and subscriber number / address marked PABA to Avril Nicoll, 33 Kinnear Square, Laurencekirk AB30 1UL, tel. 01561 377415, e-mail avrilnicoll@speechmag.com by 14th July, 2000. The winner will be drawn randomly from all valid entries.
1. Entrants must subscribe personally or as one of a department to Speech & Language Therapy in Practice, and only one entry per subscriber number is allowed. 2. Entries must be received by the editor on or before 14th July, 2000. 3. The winner will be randomly selected from all valid entries. 4. The winner will be notified by 21st July, 2000. 5. The winner will have access at work to suitable computer hardware. 6. The winner will be required to review the prize for Speech & Language Therapy in Practice by a date agreed with the editor.

References
Cullen, C. (1998) A review of staff training: the emperors old clothes. Irish Journal Of Psychology 9, p309-323 cited in Chatterton, S. (1999) Communication Skills workshops in learning disability nursing. British Journal Of Nursing 8 (2). Royal College Of Speech and Language Therapists (1996) Communicating Quality 2. RCSLT. van der Gaag, A. and Dormandy, D. (1993) Communication and Adults with Learning Disabilities. New Map of an Old Country. Whurr Publishers.

PABA will run on most modern PC and Macintosh computers. Demo versions of the software can be downloaded from http://www.medill.co.uk. It normally retails for 240 + VAT. PABA is available from Medical Illustration Services, Royal Infirmary, Glasgow, G31 2ER, tel. 0141 211 4692.

Previous winners... Congratulations

to Neil Thompson who won the Boardmaker software courtesy of Mayer-Johnson in the Winter 99 issue of Speech & Language Therapy in Practice. Neil will review the software in a future issue. The winner of the five audio taped translations of Does Your Young Child Stammer? courtesy of the British Stammering Association in the same issue was Ann Adams.

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2000

intensive therapy

Reaching the parts S

photo courtesy of the British Stammering Association, tel 020 8983 1003

Dysfluency is as much a social problem as a personal one. For therapy to succeed, it must help clients interact effectively in spite of any continued dysfluency. According to participants, courses at The Apple House in Oxford over the past 32 years have addressed this successfully. How? Rosie Sage reports.
tammering has intrigued man for centuries. Laotze mentioned this interruption of speech rhythm in a poem 500 years BC. The Bible (1611) proclaims the blessings of the glorious kingdom, The tongues of stammerers shall speak plainly. Contentious treatments have included whistles beneath the tongue, leeches on the lips, leather chest straps and elk oil. Dysfluency has resulted in many management philosophies such as self-help, psychotherapy, behaviour modification, speech education, mind control, medication and surgery. Six common treatments were ranked by Andrews et al (1980) in order of effectiveness: prolonged speech, gentle onset, rhythm, airflow, attitude therapies and systematic desensitisation. The conclusion was that techniques can be beneficial and compare favourably to others in health sciences. Most therapy programmes now contain elements of teaching the person who stammers to modify dysfluency as well as reducing fear and avoidance behaviour. Therapists work to change attitudes and build self confidence and communication skills in a range of informal and formal activities. However, efficacy studies are victims of accountability, looking only at outcomes of specific processes and procedures as evidenced in calculations of percent dysfluency. Although used as a progress measure, it encourages teaching to the test, ignoring complexities of internal and external changes taking place in and after treatment. Studies generally lack client views and the question of whether treatment works is limited to measurement of dysfluency in clinical rather than normal situations. (Andrews & Harris, 1964; Bloodstein, 1987; Peters and Guitar, 1991; Webster, 1996) indicate 50-70 per cent of people who stammer show a genetic pattern. 2. Precipitating factors include upsets, illnesses or losses that activate existing biological weaknesses. 3. Perpetuating ones, such as insecurity, stress and unsuitable demands facilitate development of stammering behaviour. Presently, little can be done about predisposing and precipitating factors. Perpetuating factors, however, offer hope. Cooperative approaches between parents and professionals now exist, so lessening chances of dysfluency becoming established in infancy. Therapy has taken a broader approach, concentrating less on speech and more on a relationship with an audience. This has led to a communicative focus with opportunities to develop a wider range of skills and change mental attitudes. In addition, brain scan techniques are pinpointing neural activity and show how the electrical circuitry is altered so biochemical movements are understood. Webster (1996) describes this in relation to fluency and non-fluency behaviour. Present work, under Professor LeDoux at the Center for Neural Science, New York University, holds promise. Certain connections between nerve cells within the amygdala, at the brain base, become strengthened when someone learns to fear. The rate at which nervous signals flow through the brains fear centre is raised, so increasing intensity of emotion. This confirms the importance of control methods in managing dysfluent speech. The treatment reported here is curious because of its longevity. Gerda Wilson managed adult fluency problems at the Apple House from 1966 1998. Part-time input from Sylvia Davey, a noted voice specialist, was available from 1976. Research took place in 1997-1998 to evaluate a unique treatment experience before retirement of both therapists as follows:

others dont

Read this if you are interested in: how therapy trends are changing getting clients views relating theory to practice

Offering hope
Three factors regarding dysfluency are mentioned in the literature. 1. Predisposing ones are hereditary. Researchers
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intensive therapy

A) Audit of course activities as a record of theory and practice. B) Four client case studies to present real life issues of individuals and families. C) Questionnaire to 25 per cent of past clients to elicit information on course satisfaction. D) Communication profile and follow-up of participants on a 1997 course. E) Course rating.

easily controlled. Beasley (1876) suggested dysfluent speakers: Learn the art of speaking. This will induce self-respect, calmness and confidence. Although improper use of articulators as the cause of dysfluency is not implied, its involvement is suggested. Work on voice dynamics and the rhythm of an utterance is part of the process of learning to communicate effectively.

A) Audit
Fluency courses began at Warneford Hospital, site of Oxford University Institute of Psychiatry, as research by Dr Seymour Spencer, Consultant Psychiatrist, and Catherine Renfrew, Chief Speech Therapist, in 1964. Psychotherapy and drug treatment for people who stammered was unsatisfactory and a method targeting speech fluency was more appropriate. The aim was to replicate work of Andrews and Harris (1964) using syllable-timed speech, giving each word-part equal emphasis. The method proved positive for dysfluent speakers. Ten-day intensive courses were set up and 800 plus adult clients have been treated. Over time, other methods of shaping talk have been introduced. Therapy has been directed increasingly at the whole person, with encouragement to change thinking as a starting point for altering not only speech but patterns of communicating. Latterly, visualisation, neuroIinguistic programming (NLP) and hypnotherapy have been used to expand thinking and control mind and body as part of speech management. Each course is tailored to meet the specific needs of each client group of eight people, from a framework of five core principles:

2. Communication Opportunities
Avoidance behaviour has cumulative effects with speaking skills underdeveloped for a range of situations. Participants are prepared in role plays to try speaking activities such as enquiring about train times. They alter performance from group/video/audio feedback before tackling real talk outside the Apple House. Prose, poetry, play readings as well as talks, discussions and question and answer sessions facilitate effective communication.

To deal with learnt responses and negative feelings, the client is helped to think differently before changing behaviour. Using relaxation, visualisation, neuro-linguistic programming and hypnotherapy, they free unhappy experiences stored unconsciously and develop positive self concept and control. When relaxed, the mind can create, with visualisation enabling a person to face angry and miserable feelings, leading through this process to less threatening forms. The experience allows the brain to develop whole notions (Bell, 1991) as well as critical and creative thinking to understand the totality of the problems and different ways in which they can be solved. Participants vouch that to think better is to feel better, speak better and be better.

5. Maintenance Activities
Nine intensive, consecutive days begin changes but these must continue if fluent speaking is to be attained. Monthly follow-ups offer further practice and support for as long as is needed. Supervision is vital, as research suggests 50 per cent of people undergoing treatment will relapse after a year (Garvin-Cullen, 1990). The Stammer Trust provides links through a newsletter and social events, establishing networks for those who want them. Therefore, the aim is to help the person present themselves confidently and clearly to others. Attention to speech alone is useless. The new fluency is an aid to a better life - but how? It is not just going out and speaking competently but understanding how the fluency and good feelings it generates can help towards a new way of communicating and living whilst maintaining and improving this. The client needs help in rearranging their life and communicating more effectively. But who can best judge the quality and effectiveness of a particular treatment and by what criteria - objective external evaluators or subjective internal participators? There is growing consensus that clients are the most informed, fair judges of their experiences and this study design reflects this view.

3. Group Support and Influence

The forming, storming, norming, conforming and performing processes of group interaction help participants come to terms with difficulties and find ways of dealing with these based on others experiences. The therapist provides activities, monitors performance, encourages and reproves it if necessary and, although their presence may prevent the emergence of a leader, there is continual opportunity for individuals to use initiative. The Apple House does not have the feel of a taught course and participants describe a family atmosphere in surroundings which demonstrate value, care and consideration for everybody. The setting helps relaxation and enjoyment of the course. The Stammer Trust works to provide resources which have included renovating and equipping the Apple House.

1. Speech Education
Participants are introduced to speech control methods: slowed speech below normal rate; prolonged speech by lengthening long vowels; syllable-timed speech from altering timing patterns; slow onset, soft contact speech by gliding softly onto words and airflow techniques releasing breath then word. A technique other than prolonged speech (more unnatural than the other methods) is chosen as the start for normal talk. Speech emphasis is reinforced when participants describe their stammer: tongue and jaw shoot forward, lips pout in a sucking action, words muddle, panic sets in, tongue feels too big, lack of breath, muscles tense everywhere, words catch in the throat, powerless, idiotic sensations, sounds forced out, mouth dries, choking feelings. Descriptions suggest speaking occurs with the tongue forming the anterior wall of the throat. The larynx drops to allow for this as in the infant sucking pattern. In adult speech, the tongue and Iarynx drop back and down as the styloglossus muscle strengthens to suspend the tongue backwards and upwards for greater mobility in talking. Voice work strengthens this muscle so the tongue is in a better position and dysfluency more

efficacy studies are victims of accountability, looking only at outcomes of specific processes and procedures

4. Attitude and Behaviour Change through Therapy

Participants think of themselves as stammerers and this construct is reinforced by families, friends and work colleagues. A person who is dysfluent does not produce a normal response in communication exchanges so cannot experience positive feedback. They may describe a holiday incident, producing a hesitant, incoherent account resulting in their listener looking away embarrassed, or anticipating and supplying words not uttered freely. When faced with a repeat they anticipate the struggle and expect to perform badly. So, a person with dysfluent speech may avoid certain sounds, words, phrases, topics and unpleasant experiences such as using a telephone. Allowing others to speak for them, circumlocution or complete silences are strategies employed.

B) Case studies
Four cases were chosen at random from Apple House records to present individual views of the courses. Two subjects attended in the 1960s and the others during the 1990s. Three were male and one female to reflect the reported gender ratio for dysfluency. Participants were asked the same six questions over a two hour period, including How do you think about your stammer? and How has the course helped you to communicate more successfully? Answers suggest that, in spite of initial lack of success in reducing the stammer and continual negative experiences, it is possible to progress personally and achieve good jobs. Dysfluency may prohibit a career dependent on constant speaking.

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Table 1 - Satisfaction with communication skills The Communication Skill 1. Listening attentively 2. Chatting informally with people you know 3. Reading easily with quick understanding 4. Using a wide vocabulary 5. Understanding large amounts of spoken information easily 6. Writing in logical order and to the point 7. Spelling accurately 8. Using gestures to support words 9. Using facial expression to support words 10. Using voice with variety and interest 11. Making eye contact with listeners 12. Pronouncing speech sounds easily 13. Expressing spoken ideas clearly and in order 14. Giving spoken instructions and explanations 15. Using the telephone confidently 16. Speaking at a proper rate with pauses 17. Chatting informally with people you do not know 18. Discussing ideas in formal setting (eg. a meeting) 19. Speaking with a fluent rhythm 20. Talking formally as in giving a speech Table 2 - How the course has helped Summary of answers

Table 3 Course rating No. responses No. positive % positive Rating Value ranging from 0 (dissatisfied) 146 131 89.7 to 10 (very satisfied) 147 131 89.1 146 146 147 148 148 146 146 146 147 147 146 148 147 147 147 148 147 148 124 123 121 118 115 108 92 92 92 90 87 87 75 69 66 66 62 50 84.9 84.2 82.3 79.7 77.7 74.0 64.4 63.0 62.6 61.2 59.6 58.8 51.0 46.9 44.9 44.6 42.2 33.8 0 1 2 3 4 5 6 7 8 9 10 Total

Frequency

1 1 0 4 2 4 6 22 44 42 30 156

The late Sylvia Davey

Table 2a - How the course has not helped Summary of answers No. of Percentage responses Specific situations dealing with strangers and formal settings Still need help with formal communication skills Non-specific situations still cause trouble Still experience relapses 23 16%

No. of responses Percentage 98 44 32 32 32 30 22 20 15 14 66% 30% 22% 22% 22% 20% 15% 14% 10% 10%

Self confidence Learning techniques and how to adapt them Understanding the problem Greater self awareness Aware of aspects of talk and communication Support of group Awareness of the importance of slowing down Reduction of anxiety Acceptance of the stammer Introduced to a range of communication activities

15

10%

12

8%

12

8%

Helen wanted to be a television presenter but ended up a dress designer and Paul wished to lecture but decided the Civil Service was a better option. Most people adjust aims because of circumstances and the interviewees show ability to do this successfully. The course reduced suffering. Robert suggests he is now cured although sometimes dysfluent. Misery has gone and the stammer is no longer a dominant issue. He suggests people feel that fluent speech leads to instant happiness but this is rarely the case. Many problems are bound up in a stammer and must be tackled for a successful outcome. John mentioned that the Apple House course got to the parts that others didnt and all four subjects suggested this was the reason it had worked for them. They felt the Apple House offered a total approach in contrast to previous treatments that mainly targeted fluent speech with less emphasis on personal and social issues.

course) for a binary rating: happy / unhappy, to provide a general impression. Table I records satisfaction with communication skills, ranging from 34-90 per cent, with an average rating of 65 per cent evenly spaced across age groups. In the first 10 rankings, 80 per cent refer to non-verbal and 20 per cent to verbal skills whereas in the bottom half the reverse is the case. Formal communication brings most trouble but this is probably the case for everybody. Section 2 required comments on how the course has helped (most significant in table 2). There are roughly four positive comments to each negative one. Section 3 requested views on how the course has not helped (most significant in table 2a). Section 4 used an interval scale I - 10 to rate the course.

attitude at the six month stage. Cases A, B and D were experiencing difficult circumstances at this time which undermined their performance. Their profiles confirm this when compared with C and E. Since data suggests a year post-treatment that respondents feel happier about communication skills, information indicates attitude changes before behaviour.

E) Course Rating
Table 3 reports course rating and frequency values. An 81 per cent level of satisfaction, with 89 per cent of replies clustering in the 7-10 band, suggests high success when compared with other health service treatments which deem a 65 per cent rating as excellent. The crucial outcome for participants is increased self-confidence (66 per cent). The fact that 42 per cent of respondents are still unhappy about fluency is less important. As Robert (a case study) reminds us: The first and most important thing to do for someone who stammers is to cure the unhappiness and instil confidence. Three per cent reported no improvement in fluency although feeling better about coping with life.

D) Profile and follow up

One aim was to find a method to measure change but the project timing only allowed 12 clients to be monitored. A profile, comprised of 40 statements representing a range of positive and negative views about how a subject felt about themselves and their communication, was used and rated true or false. Test-retest reliability was at a 0.9 level. Five out of a possible twelve subjects completed a pre/post course and six month follow-up profile. They present very different profiles, with initially subjects A and E showing almost exact opposites in negative / positive views. Over the group, the six month period demonstrated an increase in positive views and a decrease in negative ones. The time of greatest change was during the course, but there was a steady increase in positive

C) Questionnaire
A four section questionnaire was sent to 200 (25 per cent of) past participants. Six were sent to a random sample of the 25 clients on average each year (192). Seven were sent to the first and last four years to make up the sample of 200. A 79 per cent return rate, with an even response across years, was achieved. There was a variability of responses within and across years with a tendency for satisfaction to increase a year post-treatment, so this could be a useful point to evaluate. Age is not a significant factor in predicting successful outcomes. Section 1 presented 20 communication skills (selected after an exercise on the January 1997

Answer in interplay
Why is the Apple House course successful? The answer may lie in the interplay between the neurology and psychology of stammering. Webster (I996) suggests high right brain activation in those who stammer (reverse of normal state) is linked with fear. This overflows to the left hemisphere and interferes with the supplementary motor area organising speech movements. Fox (1996), whose imaging techniques showed intense activity in the

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It is vital to confront questions of social expectation if there are to be competent communicative exchanges.
Gerda Wilson (centre) Group Therapy - photo courtesy of the British Stammering Association

right brain of those who stammer, reinforces this view. Such an explanation suggests it is possible to control speech function successfully in two ways: 1.Reducing right brain activities by overcoming fear and anxiety which in turn means less interference with the left brain supplementary area. 2.Counteracting left hemisphere inefficient control of speech motor movements by slowing and simplifying utterances to bring them within the systems capability. Apple House courses operate on these principles. Therapists help a person believe they can speak fluently and reduce fear by showing them how they can achieve this by altering the way they think and speak. This is followed by opportunities to develop communication skills and practise control techniques. Underpinning this is the understanding of each persons leaning style, affecting how messages and methods are constructed. Although a theory of right brain interference with left brain speech action suggests control management, the speech pattern that results is different to the norm. In a contrived situation a person may not feel the stress of communicating in a new way and at a slower rate. In real life, with pressure to conform to the speaking format of others, the use of control techniques generates stress that may send right brain activity soaring. This is a problem for some, who are dragged back into old stammering routines by social pressure. Dysfluency is as much a social problem as a personal one. It is vital to confront questions of social expectation if there are to be competent communicative exchanges. Successful therapy helps clients become effective interactants with others in spite of stammering responses that occur in conversation. Those who have long experience of the Apple House courses mention how therapy has broadened to consider social communication in more detail. Questionnaires confirm multi-level involvement in speech and communication acts. One respondent elaborates: When I reflect on my stammer I view it as a disturbance of thinking as well as speaking performance. My thoughts seem as tangled as my tongue. Non-verbal difficulties are also apparent with 37 per cent reporting problems with eye contact, 36 per cent feeling they do not use appropriate facial expressions to support meaning and 37 per cent suggesting inadequate use of voice to speak expressively.

Crucial aspect
However, when a person becomes fluent they assume a new persona. Changes occur which must be possible to identify. Why is it that people who stammer are, in general, fluent for 75 per cent of the time? Looking at periods of fluency may be as useful as examining dysfluent phases. More indepth study of a number of cases, investigating personal and interpersonal issues, could precipitate new directions in management and provide clearer understanding of fluency and non-fluency patterns. Relapse is a crucial aspect. There needs to be comparison of clients who make excellent progress with those whose gains are not as satisfactory. Research and experience suggest biological and psychological differences in those who stammer but ways of identifying and classifying these need more detailed attention. The Apple House uses a wide range of techniques to manage personal and social problems, but it should be possible to isolate core elements in behaviour and target them in different ways. For example, is one stress reducer (neuro-linguistic programming or hypnotherapy) more effective than another for clients showing particular profiles? Are some components more suited to self-organised learning than others? Breathing techniques seem more difficult to acquire than slow speaking. Would video/audio tapes and written guides provide useful aids? There is much in the daily grind that bears you down and bowls you over but, for most, Apple House therapy is a pivotal experience. Comments from the questionnaires include: There was a light at last at the end of a tunnel; I can talk at conferences and am 99 per cent fluent; It gave me dignity and a knowledge of what to do; I was taught to believe in me; I did not see it as a fluency course - it was a way of improving my life; It brought calm and peace. Helen (a case study) says My stammer gave me the feeling of having one leg. I was like someone in a wheelchair, fairly handicapped. Now I can speak without stammering it is as if Ive grown another leg and can go out wearing short skirts. The challenge for us now is to use this knowledge and target help more precisely.

The Stammer Trust Report of Fluency Courses at the Apple House, Oxford (1966-1998) (ISBN 0 9534807 0 4) price 5 plus 2 postage & packing is available from Ruth Thomson, The Farm House, Blakesley, Towcester, Northampton NN12 8RB. Cheques made out to the Stammer Trust.

References
Andrews, G. and Harris, M. (1964) The Syndrome of Stuttering. London: Heinemann. Andrews, G., Guitar, B. and Howie, P. (1980) Metaanalysis of the effects of stuttering treatment. Journal of Speech and Hearing Disorders 287-307. Beasley, B. (1876) The Beasley System. London: W.J. Ketley. Bell, N. (1991) Visualizing and Verbalizing. Paso Robles CA 93446: Academy of Reading Publications. Pub. by Winslow Press in the UK. Bloodstein, O. (1987) A Handbook Do I appreciate on Stuttering. the importance of Chicago: National Easter Seal Society. the historical Fox, P. (1996) A PET context of therapy study of the neural I am offering? systems of stuttering. Nature 382, Do I take account p.382. of the social Garvin-Cullen, A.J. (1990) The relationimplications of ship between locus communication of control and the difficulties in effectiveness of post remediation treatment planning? activities on the Do I provide maintenance of flulong-term support ency following short-term intento ensure gains of sive behavioural therapy are therapy for stuttermaintained? ing. PhD Thesis. Health Science, New York University. Peters, T.J. and Guitar, B. (1991) Stuttering: An integrated Approach to its Nature and Treatment. Baltimore: MD: Williams and Wilkins. Webster, W. (1996) Some keys to understanding stuttering and its management. Speaking Out 17 (3) London: The British Stammering Association.

Reflections

Rosemary J. Sage is based at the University of Leicester.

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reviews

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

Of little use to speech and language therapists
DEAFNESS
Hearing Attitudes in Rehabilitation Questionnaires (HARQ) Dr Richard Hallam The Psychological Corporation 72.50 The HARQ is intended for use in Audiological Rehabilitation Clinics. This questionnaire for adults with acquired hearing loss attempts to measure attitudes towards, and beliefs about, hearing loss and its consequences. The purpose in constructing a questionnaire that assesses attitudes is derived from an assumption that this form of self report is most likely to be useful in the prediction of a range of behaviours such as avoidance of social situations - and therefore will give a prediction of possible outcomes to rehabilitation. The questionnaire covers both cognitive and affective elements. Questions have been framed bearing in mind that self perceptions are requested, and not self reports, on the amount of disability, handicap or emotional distress caused by the hearing loss. It has not been designed to measure a persons coping strategies for hearing loss, but is designed to give a prediction of outcomes following rehabilitation, and a measurement of attitude changes through time. When I first saw it, I was intrigued. Here was a questionnaire which could predict who would benefit from rehabilitation - amazing! However, the more I looked at it, and the more I tried it out on a few patients, I came to realise it is of little use to speech and language therapists. There is nothing complicated about it, and the manual is easy to read, but the conclusions should be well known to professionals working in the field of acquired hearing loss - that, following diagnosis of hearing loss, people who receive counselling along with their hearing aids will become better hearing aid users. Experienced therapists working with adults with acquired hearing loss will be able to predict the outcome to rehabilitation through careful case history taking, and by asking questions similar to those in the HARQ. However, for therapists who are new to the field of acquired hearing loss, this could be useful as a guide to the kind of questions to ask. This questionnaire is designed primarily for audiologists to help them decide who will be good hearing aid users. In the current climate of outcome measures and efficacy of treatment - and given the cost of hearing aids - it could be useful for the audiologists to have another tool to add to their assessment battery. There might then be fewer hearing aids kept in kitchen drawers and handbags. Susan Howden is a senior specialist speech and language therapist with Tayside University Hospitals NHS Trust.

Ideal for busy clinicians

PHONOLOGY
Phonological Awareness Screening Pack / Phonological Awareness Activities Handbook Alice Peters and Lynne Kemp From Kathleen Sharkey, tel. 01382 462857. 10.00 each or 15.00 for both, cheques to Dundee City Council The real plus point about these eminently practical booklets is the cost. At 15.00 they are good value for money with lots of photocopiable worksheets ideal for busy clinicians to use as handouts. Essentially designed for preschool children and early primary readers, they could be used with older children at a lower developmental level. The first booklet provides a range of informal assessment tasks of phonological awareness, the second corresponding intervention activities. The booklets assume purchasers have a clear understanding of phonological awareness and can make their own judgements about developmental progression and why some areas have not been included. There is a very brief theoretical introduction but the focus is essentially practical. Black and white pictures are provided for the screening assessment but the purchaser needs to cut up and laminate. In the second booklet, the equipment and materials needed are listed but not provided. Many good ideas are presented which are applicable to the primary school child. Both booklets are easy to read and well presented. They would be a positive addition to the resource library of therapists working in schools, clinics and nurseries and are particularly valuable to those new to this area. Angela Hurd is a senior lecturer at the University of Central England and a practising clinician.

A lucid account
EDUCATION
Speech/Language Therapists and Teachers Working Together (A Systems Approach to Collaboration) Edited by Elspeth McCartney Whurr ISBN 1 86156 124 5 19.50 Elspeth McCartney has edited a most user-friendly book. She sets her work in the context of the legislation and working practices that teachers and therapists have had to take into account. It not only mentions things I have found myself, but gives many practical solutions. I have no hesitation in recommending it to teachers and therapists at all levels of experience. It is a lucid account of working methods, sympathetically set against the recent history of both professions, helping promote an understanding of their likely perspectives. To the experienced, the pitfalls of collaboration are highlighted, and solutions offered that have been researched in various educational settings. To the inexperienced, preemptive wisdom is available. It is very readable with all terms defined and practical, with the sound knowledge base of experienced therapists and special needs teachers. Caroline Windham is a specialist speech and language therapist working in a Language Development Centre within a First School in Norfolk and collaborating daily with teachers.

Interesting and comprehensive

CANCER
Communication Disorders in Childhood Cancer Bruce Murdoch Whurr ISBN 1 86156 1156 25.00 This offers an excellent review of current research into speech and language disorders associated with posterior fossa tumours and acute lymphoblastic leukaemia, including the effects of surgery and central nervous system prophylaxis. There is a range of interesting case studies and a comprehensive battery of published assessments is recommended - including a number of physiological assessments - which may not always be readily available in a therapy clinic. There are detailed references at the end of each chapter and a clear index. This book would be a valuable addition to both paediatric acute and community speech and language therapy departments and especially to students and clinicians who are becoming familiar with this caseload or who are looking for research projects. It is packed with accessible data and is good value for money. Angela Hawthorne is a speech and language therapist in paediatric neurology at Newcastle upon Tyne General Hospital.

Useful timesaver
PHONOLOGY
Total Phonology Lisa Abba, Sara Ayub & Vicki Selwyn-Barnett Winslow ISBN 0 86388 204 8 44.50 A lot of work has gone into devising this assessment and intervention programme. The assessment section is neat, covering production, auditory discrimination and a quick screen of phonological awareness which I found helpful with older children. The drawings are clear and the programmes useful for some children as they stand, and lending themselves to adaptation for others. The section on parent workshops would be a useful framework for the less experienced clinician. This would be a relevant additional resource for therapists covering busy schools or clinics where a clearly explained and well presented off the shelf package would be a useful timesaver. Margaret Rooney is a community speech and language therapist, Amber Valley, with Southern Derbyshire Community NHS Trust.

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reviews

Advice for an increasing challenge

EDUCATION
Supporting Young People With Language Impairments in Secondary Mainstream Schools - A Practical Guide Anita Marks and colleagues (Cheques payable to) Worthing Priority Care NHS Trust ISBN 1 902131 004 16 inc. p+p Available from Speech & Language Therapy Service, Trust HQ, Arundel Rd, Worthing BN13 3EP. This pack, designed for speech and language therapists and special educational needs coordinators (SENCOs), consists of a series of photocopiable information sheets and proformas. Of these, the strategies with a functional focus (chapter 3) have the most universal and practical application, particularly Quick problem solving ideas for the classroom. Other useful sheets focus on memory strategies, self help and lists of vocabulary. This resource presents much needed advice to address an increasing challenge. Based on the practice and philosophy used in Worthing, it would be useful as a starting point for addressing specific local needs. I am not certain it would be suitable for SENCOs as many of the activities need a speech and language therapist for effective implementation. It would benefit from being more attractive and user friendly, with tighter editing, plain English and positive rather than negative wording to describe students and their needs. It puts emphasis on educating school staff in speech and language therapy terminology, assessments and activities. A more functional, strategies-based emphasis would have allowed for better use of limited teacher time and led to more realistic expectations of students with communication difficulties. Elaine Hirst works for Nottingham Community Health NHS Trust with children with specific language impairment who attend mainstream schools.

Look no further
VOICE
Manual of Voice Treatment (Pediatrics Through Geriatrics) Second Edition Moya L. Andrews Singular ISBN 1 56593 998 0 42 For the student or less experienced clinician this manual provides comprehensive and accessible information about the nature of voice disorder, intervention selection strategies and treatment approaches across the age range. The application of theory to practice is well illustrated with case studies. This second edition admirably reflects recent progress in voice research in its upto-date clinically relevant references. Useful appendices include assessment forms, therapy materials and treatment outcome scales. However there is an inevitable bias, with no reference to certain voice facilitation techniques practised in Europe. If your department needs a central resource about voice, look no further than this volume in the Clinical Competence Series. However, experienced and specialist clinicians are unlikely to find topics covered in adequate detail. Linda Heggie is a specialist speech and language therapist (Voice) with Sandwell HealthCare NHS Trust.

...RESOURCES...RESOURCES...

Expressing views
A package from the University of Stirling allows people with motor neurone disease to express their views about quality of life issues using pictorial symbols, even if they have no speech or limited hand control. Have I got views for you! 25, tel. 01786 467645, email joan.murphy@stir.ac.uk As the telephone is an often overlooked resource for people with communication difficulties and their carers, the University has also developed a workbook and video package as a practical tool to help people with communication difficulties use the telephone more effectively. Dont Hang Up costs 35, details as above.

Software for dyspraxia

Dyspraxia drills on CD ROM developed in Australia are now available in the UK. A set of two CD ROMS provides multimedia cues for 531 consonant/vowel and consonant/vowel/consonant words covering 19 consonant sounds in initial position. There is also a print option for 20 colour photographs of consonant articulatory position. Designed for adults with dyspraxia, it may also be suitable for children. Dyspraxia Drills on Disc, 90 + 5 delivery + VAT for single copies from Gordon Russell, Propeller Multimedia Ltd, tel. 0131 446 0820, http://www.propeller.net/react

Well worth having

ADULT NEUROLOGY
The Sentence Processing Resource Pack Jane Marshall, Maria Black, Sally Byng, Shula Chiat, Tim Pring Winslow ISBN 0-86388-207-2 54 As most current psycholinguistic assessments are aimed at single word level, this pack is a very useful addition for therapists working in aphasia. It consists of two assessments - The Reversible Sentence Comprehension Test and The Event Perception Test - and a handbook. The tests are easy and quick to administer and the handbook written in an easy-to-read format. It discusses both production and comprehension of sentences and the final chapter neatly follows on by covering therapy for sentence processing skills. The three volumes are held in a neat, portable container which is light to carry. At 54, definitely value for money and well worth having. Lynda McLean is a speech and language therapist for Fife Rehabilitation Service within Fife Primary Care NHS Trust.

Catalogues
Two Winslow catalogues for 2000 cover Health & Rehabilitation and Education & Special Needs. Free from Lynn Smith, tel. 01869 244644, e-mail lyns@winslow-press.co.uk

Technical and complex

AAC
Augmentative and Alternative Communication: New Directions in Research and Practice Filip Loncke, John Clibbens, Helen Arvidson, Lyle Lloyd Whurr ISBN 1 86156 143 1 50 This book came out of developments in education, clinical psychology, speech synthesis, sociology, engineering, psycholinguistics and speech-language patholody. In many parts it is difficult to read due to its highly technical language and complex concepts. I felt this book was written primarily for researchers and for presentations at conferences. It is expensive to buy at 50.00. The contributions came from all over the world but the main emphasis was American. Unfortunately, I did not find that it related to any of my clinical work. Ann Gosman is a speech and language therapist with Orkney Health Board.

Spellmagic
Self-sticking letters provide an alternative way of helping children learn about letters and sounds. Spellmagic letters are supplied with a holding board and a pupils spelling board. Samples and details from: Adhere Industrial Tapes, tel. 01206 210999, www.spellmagic.co.uk

The latest version of a low cost text to speech aid promises a dramatically improved textreader window with higher quality voices. Further information on textHELP! ScreenReader 4.0, tel. 02894 428105, e-mail info@texthelp.com

Text reader

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2000

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inclusion

Reshaping opp s p
Read this if you need to improve collaborative working support clients real life experiences match therapy to current legislation
Photo courtesy of I CAN, the national educational charity for children with speech and language difficulties, tel. 0870 010 40 66

In the G

inclusive

implicat

practice

approac

he debate concerning inclusive or segregated education for children with special educational needs has been raging for many years. The present view is that, for a child to flourish in adult life, he needs to have some experience of being educated alongside his peers (see Green Paper on Special Educational Needs, 1997). However, the Green Paper goes on to say that special schools will continue to play a vital role as part of an inclusive local education system and it would be unrealistic to expect mainstream schools to have the resources or expertise to cater for children with complex needs on a fulltime basis. Our model of partial integration of children with speech and language impairment from a special school into a mainstream secondary therefore has a solid foundation in current legislation. It is an effective starting point to meet the childs curricular needs more effectively with an additional benefit of disseminating good practice between the two educational institutions. The aim of this model is not full-time integration but to provide special school children with the opportunities to use language in real situations and access the curriculum through specialist teachers and language support. The integration process is much more than providing individual support to the child only; the emphasis is on dismantling the barriers to their learning and access to mainstream school life by reshaping the teach-

ing and learning opportunities rather than a focus on changing the child (Thomas, 1997). The head teachers of the special school and mainstream secondary school concerned are both members of a Local Authority working party on inclusion and were the driving force behind this new initiative and the implementation of this model. We make no distinction between the role played by the specialist language teacher and the specialist speech and language therapist. Both professionals work collaboratively in the special school setting, so it was an obvious step to work together on the implementation of the new model. Three year 7 pupils (box 1) from the School for Children with Speech and Language Impairment are currently involved in the integration programme. They form part of the first cohort in this newly established department for secondary aged children with speech and language impairment within the special school. Children A and B attended the special school during the primary phase and were also educated within the nursery attached to the school. Child C attended a mainstream

We felt lessons with a strong visual, practical element that did not involve lots of reading and writing - areas of difficulty for all of the children - would be the most valuable.

school until the age of eight when he transferred to the primary phase of the special school. All of the children had previous mainstream experience of one afternoon per week with support from a classroom assistant. The children have average and above average non-verbal skills and it was felt all three would be able to handle and benefit from the different demands that would be placed on them within the mainstream environment. However it was decided this would be with full-time language support from specialist professionals who were well-known to the children, namely their class teacher and their speech and language therapist. Children A and C integrate for two subjects, Design & Technology and Science. Child B integrates for Design & Technology. Each subject area involves two one hour sessions per week. The specialist speech and language therapist acts as the language support within the Science lessons whilst the specialist language teacher supports the children in Design & Technology. We felt lessons with a strong visual, practical element that did not involve lots of reading and

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inclusion

portunities, haring good practice

writing - areas of difficulty for all of the children - would be the most valuable. It was also important that the teachers who would be involved in the process should have a genuine interest in special needs. Marshman and Miller (1994) state how the attitude of the teachers in the host school is crucial. The subjects of Science and Design & Technology seemed to fulfil both criteria. The children had all shown some aptitude in both subjects and staff thought they would gain a lot from specialist teaching and having the opportunity to work in fully equipped Science laboratories and a state-of-the-art Design & Technology suite. The process began with a meeting with the mainstream Special Educational Needs Coordinator (SENCO). This was followed by a meeting with the Heads of Departments to discuss the classes and to look in detail at the intended Schemes of Work. A further meeting was given over to a discussion of the childrens individual difficulties in more depth. Within the mainstream lessons, particular areas of language difficulty and strategies used to support the children have been identified (box 2). On returning to the special school, the children work on the new vocabulary in more detail, having it reinforced across subject areas. An example of this is words encountered in a Science lesson such as carbohydrates, protein, solid, liquid and acid which can all be reinforced within a cookery session. The children have lots of opportunities to build up correct semantic links between new vocabulary. In addition, children with articulation difficulties are given opportunities to practise saying the words in various settings. The speech and language therapist runs a group that focuses on ambiguous language used within the mainstream. This is an opportunity for the group to discuss any phrases they did not understand and increase their semantic knowledge. The teacher and therapist work together with the children on the Talkabout scheme (Kelly, 1996) which targets conversation skills and helps the child deal with pragmatic difficulties. Both these groups reflect work done by Miller and Roux (1997) who claim the child needs to be aware of his own strengths and weaknesses so he can identify when and how his understanding breaks down in order to ask for appropriate help. The mainstream experience helps the child see the language in action, occurring in a naturalistic environment. The children write up any work they did not have time to finish. This is important since, without time being given for this, they may be unable to keep up with the pace of the mainstream lessons. Time to do this needs to be built in to the weekly timetable at the planning stage. The integration process was reviewed as it completed its first year. This took the form of interviews with the mainstream teachers, general discussion with pupils A, B and C and observations from the special school team.

Green Paper on Special Educational Needs (1997), the Government emphasises the importance of

e education wherever possible. For some children this will mean partial integration, but what are the

tions for them and their teaching / therapy staff? Sarah Gill and Julia Ridley share a model of good

e, where language-based teaching in a special school is combined with a more content-based

ch in a secondary mainstream setting.

Positive experience
The main point from all elements of the feedback is that integration is viewed as a positive experience for all concerned. Both the Science and Design & Technology teachers said they want the integration to continue and expand each year and would welcome the children in their classes. One teacher said he saw it as a personal challenge for them to achieve GCSEs in year eleven. The other teacher mentioned an awareness of how he had changed his teaching style to accommodate the children by decreasing the amount of written work and putting the emphasis on oracy. He also described how he is more aware of the need to adapt Schemes of Work so they are more accessible for children with special educational needs. Some ambiguity persists around the teachers perception of children with speech and language impairment. They mentioned two children who attend mainstream with significant language difficulties and some visually impaired children when asked about their experience of working with speech and language impairments. The latest statistics from Afasic state that speech and language difficulties affect 1 in 10 of the school population. In consequence, a mainstream teacher could expect to encounter three children each lesson who exhibit some difficulty with speech and language. The SENCO shows an awareness of the need for whole school in-service training, dedicated to speech and language impairment within the

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inclusion

Box 1 - The Children Child A Child B Child C Male Female Male 12:7 years 12:2 years 12:O years comprehension and pragmatic difficulties and attention problems comprehension and pragmatic difficulties expressive language including dyspraxia, comprehension and pragmatic difficulties

Box 2 - Mainstream strategies

Attention

It is encouraging to see a change in teaching style within the mainstream school...the teachers are now more aware of the level of language they use

The children are encouraged to listen and are taught the skill to look as though they are listening.

Comprehension
Complex instructions or descriptions are broken down into smaller units and any ambiguous language is explained in a more literal way. Any new vocabulary is described and the augmentative sign system, Paget Gorman Signed Speech, is an additional tool used to aid comprehension within the classroom.

Expression
The Special School teams role is to help the children to organise their thoughts into coherent sentences and give them strategies to pronounce words. Very occasionally we have had to act as translators.

Organisational Skills
The children are reminded to think things through before acting on them as well as being told to think about how to organise themselves for work. In addition they need prompts regarding the importance of recording results after they have done experiments in Science.

Social Skills
The teacher/therapist is seen as a facilitator whose role is to help bridge any possible communication gaps between the children and the mainstream children or teacher. Our children may have to be prompted to reply when someone speaks to them as well as being reminded about how one speaks to adults. Pragmatic difficulties are dealt with as situations arise.

Literacy
The teacher/therapist reads any information the child has difficulty with and checks it is understood. If the child does not understand, the work is discussed using simple language and Paget Gorman Signed Speech.

mainstream school. She says she appreciates the opportunity to talk to different professionals in the field about particular concerns she may have about some of the mainstream children. All the teachers interviewed commented on the childrens enthusiasm and eagerness to learn.

A proper school
When questioned, the children from the special school showed a particular interest in the features of the mainstream school that differ from the special school, such as the size of the site, the uniform and the coke machine. They talked about these in a positive manner and one child said these things made it a proper school. Two of the children were able to give a rationale for the presence of the special school staff, namely to help them understand what the teacher was saying and also to do sign language so they were able to understand. All three children said they would like to go there for more subjects. In discussion, the special school team finds it particularly valuable to have the experience of working with normal 11 year olds which helps give a measure for the development and progress of the children from the special school and prevents feelings of isolation. It is useful to see different styles of teaching with a variety of teachers who have different backgrounds and subject spe-

cialisms. On a practical level, the link between the schools has helped the fledgling special school department build up resources and expand the curriculum to possibly include more demanding objectives for the children. It is hoped this will have the effect of raising the standards of the children in the special school. It is encouraging to see a change in teaching style within the mainstream school. Observation within the lessons shows that the teachers are now more aware of the level of language they use and give the children more time to reply to class questions.

Inherent problem
However, practical difficulties have arisen that will form part of the development plan for the coming year. Social integration and forming friendships are problems that tend to be inherent in children who exhibit pragmatic difficulties: The increased demands on social communication skills, including the jokes, chat and gossip, so important for the development of relationships in adolescence may impact particularly on pupils who experience language and communication difficulties (Miller and Roux, 1997). Child C has made friends essentially because he lives near the school and meets his friends at a local karate club. The other two children come

from another borough in London and it is more difficult to meet with children after school. It is hoped that lunch times and break times can be spent within the mainstream school as well as the special school children being invited to go on out of school excursions with their mainstream peers. Another practical difficulty is that the two schools are more than a mile apart which means impromptu meetings and chats do not happen. The team feels this lack of opportunity to meet formally and informally on a regular basis is an obstacle to progress and needs to be addressed in the future. Moreover the two schools have different timetables with a much shorter day at the special school. This restricts the number of subjects our children can attend since they are not at school for the first and last period of each day and, in addition, their lunch times do not coincide. On completion of the first year, the reviews for this model have been favourable. Both schools remain fully committed to the integration of pupils A, B and C and would like to extend the model to include more subject areas and more pupils each year. As a consequence of the good relationships developed between the professionals involved, the special school team is developing an assessment and in-service training package to help the mainstream school identify and address the needs of the mainstream children within their

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inclusion

Reflections

for children with speech and language difficulties? Do I allocate time before, during and after a clients real life experience to maximise the benefits? Do I understand the importance of multidisciplinary collaboration in overcoming practical problems?

school who have speech and language impairments. The model is much more than a child with special needs dipping in to subjects and operating in a vacuum without becoming part of the mainstream environment. The value of highly qualified and experienced specialists being the people who give language support to the children cannot be overestimated. It is the authors belief that being able to offer the mainstream teacher support with other children, adapting work sheets and Schemes of Work and generally being around to give advice, makes the relationship between the schools truly reciprocal and does not increase the workload for the mainstream school. This is an important factor these days when teachers and Do I recognise the resources are so stretched advantages of and time is at specialist support a premium.

model also lends itself to a longitudinal study to see whether the children are able to sustain the progress they have made in these subject areas in the long-term. Such a study could look in detail at more precise measures of progress such as test results and continuous assessments to compare the childrens progress with that of their mainstream school peers. A further area of research considered by the authors is an examination of the attitudes of mainstream peers towards the special school children since the constraints of this review have prevented an analysis of their views at this time. Their opinions are vitally important since they add another dimension to the model which may have an impact on its ultimate success or failure as a long-term venture. Sarah Gill is a specialist speech and language therapist with Forest Healthcare Trust, East London and Julia Ridley a specialist speech and language teacher, Whitefields School and Centre, Walthamstow, East London. The address for correspondence is Ms. J. Ridley, 13 Broadmead Road, Woodford Green, Essex IG8 0AX.

A message from the Chair of the British Aphasiology Society

The British Aphasiology Society is a national interest group for professionals interested in aphasia.We have been in existence for about 10 years, aiming to further the development of study in this area, in particular 1. encouraging greater awareness of advances in the study of aphasia among professionals 2. encouraging research 3. promoting the interests of people with aphasia 4. drawing upon the expertise of people with aphasia. Membership is open to all professionals concerned with aphasia, although our predominant membership is speech and language therapists. Members enjoy a quarterly newsletter which provides updates on BAS events as well as other aphasia related conferences and courses, reviews of books and therapy resources, literature listings and general information on whats new. We run a biennial conference and a biennial therapy symposium. Costs for members are always reduced. Last year a successful conference was held in London, and in 2001 it will be in Exeter. This year it is the turn of the therapy symposium which is to be held in Glasgow, September 6-7, 2000. The aim is to allow in-depth presentation and discussion of therapy, more than would be possible in standard conference formats. We also run a variety of study days which cover issues relevant to the practising clinician, and their theme is always led by the suggestions of members. We offer conference support to members, as well as student prizes which encourage and reward excellent projects and essays in the field. BAS aims to work alongside people with aphasia, constantly drawing on people who are able to contribute first hand to furthering an understanding of what is involved. BAS also offers educational and / or vocational bursaries to individuals with aphasia who may need to finance a course or programme as part of their rehabilitation or efforts to develop new skills. Further information: www.bas.org.uk or from Julie Morris, BAS Chair, Dept of Speech, Newcastle University, Queen Victoria Road, Newcastle upon Tyne, NE1 7RU, e-mail Julie.Morris@ncl.ac.uk Details of the therapy symposium from Susan Booth or Angela Moar, tel. 0141 211 4819, email Speech.Therapy@gri.org.uk

Equal value

The model values both environments equally and can be seen as a good example of the type of educational practice outlined in the Green Paper mentioned earlier. The children with speech and language impairment need specialist work at the special school to address their complex language needs and to teach them in small groups where their confidence and self-esteem can be fully developed. The staff in the special school have an overview of the childs learning and developmental level that would not be possible were they exposed to ten or more subject teachers in the mainstream school on a full-time basis. However their language needs should not be seen as an obstacle to them having equal opportunities to access specialist resources and teachers, and to work beside their peers in a stimulating educational environment with an emphasis on what they can do rather than what they cannot do. With careful planning and a common sense of direction and purpose from the participating schools, this type of model can work. It needs to be reviewed annually, especially at the end of Key Stage 3 as the children consider their options. The

Acknowledgement
We would like to thank the teachers from the mainstream school for their help and support throughout the year as well as the children for their insights into integration.

References
Department for Employment and Education,1997: Excellence for all Children - Meeting Special Educational Needs. London: HMSO. ICAN (undated) Secondary speech and language resources. London: ICAN. Kelly, A. (1996) Talkabout - A Social Communication Skills Package. Winslow Press. Marshman, A. and Miller, C. (1994) Integration of a pupil from a language unit into the host school: a case study. Child Language Teaching and Therapy 10 (3). Miller and Roux, J. (1997) Working with 11-16 year old pupils with language and communication difficulties in the mainstream school. Child Language Teaching and Therapy (13) 3, 228-243. Parkes, J. (1990) Integration from a language unit: a qualitative study. Child Language Teaching and Therapy 6, 160-172. Paget Gorman Signed Speech (1990) Paget Gorman Society. Thomas, G. (1997) Inclusive Schools for an Inclusive Society. British Journal of Special Education 24 (3).

Contacts:
Afasic is at 69-85 Old Street, London EC1V 9HX, tel. 020 7841 8900, www.afasic.org.uk The Paget Gorman Society is at 2 Dowlands Bungalows, Dowlands Lane, Smallfield, Surrey RH6 9SD.

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in my experience

A change
Read this if you are interested in the effects of anxiety and tension find a diagnosis is not always discrete are treating symptoms rather than causes

direction
A
s a profession we have developed elaborate procedures for testing and measuring clients and the process can be quite a time consuming affair. Yet at the end of our assessments, how well do we understand the children and their problems? We are well aware of certain conditions - specific language impairment, dyspraxia, autism, dyslexia, attention deficit hyperactivity disorder or stammering, for example - and we have amassed facts about these. Armed with some facts about the child and facts about his condition, we proceed to advise and treat. The problem with this approach is that the connection between the childs behaviour and his difficulties is not thoroughly considered. Unless I understand what is causing the behaviour, I cannot properly understand the conditions for, when I look more closely, I discover the symptoms of the conditions are actually the behavioural traits or are related to them. And if I am unaware of the cause of the behaviour, my therapy - however well intentioned and devised - can be inappropriate and even reinforce a problem. No matter how complex and sophisticated my assessments and treatment programmes become, they remain essentially simplistic if I have failed to address the underlying causes. A comparison of the lists of symptoms for the various developmental conditions illustrates that the signs or symptoms are all traits which can be related to tension or anxiety, and which overlap throughout the various conditions in what appears to be a haphazard manner. Whether we label a child dyslexic, autistic, dyspraxic, or say that he is suffering from attention deficit hyperactivity disorder, specific language impairment or Tourettes syndrome, really depends on his particular traits and the degree to which they are manifest or dominant.

in

Does the way we assess and diagnose our clients distract us from the cause of their behaviour? Patricia Sims calls on us to look more closely at the role of tension and anxiety to avoid inappropriate treatment of childhood communication difficulties.

Switch off
People often take for granted the existence of physical causes where there is no evidence for them and there is a tendency to shy away from psychological considerations. There is, for example, increasing evidence to show that the brain of somebody with dyslexia behaves differently from that of a person who does not have dyslexia (Paulesu et al, 1996) but, rather than being the cause of the problems, the differences may be an effect of an underlying causal factor - they may be a manifestation of a problem. Paulesus teams work suggests dyslexia is a problem of disconnection, with certain brain areas working separately but not together. Donna Williams, who suffers from autism and experiences shutdowns in thinking, views her frequent inability to process for meaning and significance and her delayed or unsatisfactory responses as a problem of poor connection too (Williams, 1996). My observations and enquiries lead me to believe that anxietyrelated switch-offs and programmed involuntary shutdown can be responsible for problems with connection and are implicated in both dyslexia and autism. Similarly, convulsions can be psychogenic (Lancman et al, 1994), as may be strabismus or squinting (Douche et al, 1990). Likewise, allergies are initially a form of hypersensitivity and overreaction, and biochemical imbalances can have an emotional basis. We should also bear in mind that clumsiness may originate from inattention, tension, impulsive behaviour and poor spatial and / or poor kinaesthetic awareness. These factors may at least contribute to the early pro-

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in my experience

Box 1 - A theory of stammering based on a consideration of personality traits Repetitive behaviour increases with tension and anxiety. Once we acknowledge that repetitive behaviour, like fears, is common in childhood, we can view stammering more clearly. Children can be repetitive in any aspect of their behaviour. They may suck their thumbs persistently, they may repeat questions and encourage adults to repeat themselves or to give predictable responses, they may develop tics, rituals, be repetitive with food, clothing and so on. With raised levels of tension, which may well be within normal limits, it would be baffling if some children did not repeat sounds and syllables. block and a struggle. The behaviour becomes conditioned to, or triggered by, certain feelings and circumstances and the patterns of stammering reinforce themselves. I have known adults who like to stammer, in spite of wishing to be rid of the affliction. The release of tension after a struggle can be pleasurable and addictive. In these cases, the stammer would not be being maintained by conditioning alone.

Some Implications for Therapy From Repetitions to Stammering

Compulsive behaviour, like other behaviour, lies on a continuum. When it is severe we speak of obsessive-compulsive disorder. Yet below this level lies a range of compulsive activity and thought. We must appreciate that our childrens repetitions can become compulsive, albeit often mildly so. Stammering is habitual, conditioned, repetitive and spasmodic behaviour, with some aspects of it akin to tics and their compulsive qualities. It begins with simple repetitions of sounds and syllables which become habitual and compulsive in some children. When the child attempts to pass on to the next syllable or word, he is at the same time programmed or needing to continue the repetitions - his brain is receiving conflicting messages. He therefore experiences a 1. A full enquiry into the childs personality traits is of importance and action should be taken to reduce tension, whenever or as far as possible. 2. It is not difficult, in the light of this approach, to see that the Lidcombe Programme is valuable (Onslow et al, 1997). The children are given special attention, praise and support from parents and therapist. The repetitions are inhibited in their early stages; they are corrected in a particular and sensitive manner. Stammering therefore originates in commonplace childhood tension and anxiety which is frequently within normal limits. It is simply the case that habitually repeating words and syllables has more scope for complications than do many other traits, such as ardent thumbsucking.

Reflections:
gramming of unrefined or dyspraxic motor responses which might persist as a persons norm (rather as problems can persist when strabismus is treated late because the childs brain has become fixed in its behaviour). It is vital that we enquire fully into a childs personality traits but it is equally important that we properly appreciate their significance and effect on development. After talking with a parent, professionals are often aware that a child is quite tense or anxious. The danger is that we register this fact as if it were simply another of their traits - and fail to acknowledge that the tension or anxiety is very often responsible for the traits. And the traits themselves can be responsible for many of the speech, language and social difficulties, the dyslexia, and the behavioural problems we meet on a daily basis (Sims, 2000). To improve my efficiency and job satisfaction, I found it necessary to devote a generous amount of time to enquiring into traits during an initial appointment and to devise a Personality Check List which I use as a tool. This is a list of questions based on approximately 40 tension or anxiety-related traits. For some children it is necessary to go into greater depth than for others, but the check list is always useful as a memory jogger. By the end of the initial session parents have learnt a lot about their children and are delighted to have an improved understanding of their problems. The children will frequently leave the room in a cheerful state. They have enjoyed having their fears and anxieties aired without criticism while they played, perhaps having contributed to the discussion. They are relieved to know that other children feel and behave just like them; maybe they will no longer have to pretend to be brave. Parents have not been made to feel that anything abnormal has been discussed. They appreciate that tension or anxiety is normal and essential to us all but that individuals differ in the degree to which they possess it and the manner in which they display it, and there is an understanding of how it can give rise to problems in development - even when it is within normal limits. This approach has huge implications for testing, treatment, and research. It has altered my therapy and given me confidence in it, and has helped me devise a preventative and remedial method for dyslexia (Sims, 2000). It has also led me to contrive a theory of stammering (box 1). The year 2000 perhaps calls for a change in direction. Give this more holistic approach a try. Patricia Sims has worked principally within the NHS. She is now an independent speech and language therapist and a specialist in the treatment of dyslexia.

People often take for of physical causes where there is no and there is a

granted the existence

evidence for them

tendency to shy away from psychological considerations.

Do I focus on Lancman, M.E., Asconap, J.J., physical Graves, S. and Gibson, P.A. (1994) Psychogenic seizures in causes rather children: long-term analysis than of 43 cases. Journal of Child considering Neurology 9, 404-407. psychological Onslow, M., OBrian, S. and Harrison, E. (1997) The ones? Lidcombe Programme of early Do I feel stuttering intervention: methcomfortable ods and issues. European Journal of Disorders of discussing a Communication, 32, 231-250. childs Paulesu, E., Frith, U., personality Snowling, M., Gallagher, A., traits with Morton, J., Frackowiak, R.S.J. and Frith, C.D. (1996) Is develtheir parent? opmental dyslexia a discon Do I take a nection syndrome? Evidence holistic view from PET scanning. Brain 119, of the clients 143-157. Sims, P.M. (2000) Reasons and I see? Remedies. Barnstaple: Mortimore Books. Williams, D. (1996) Autism: An Inside-Out Approach. London: Jessica Kingsley.

References
Douche, C., Barral, A., Winter, R., Dezard, X. and Zenatti, C. (1990) Les strabismes secondaires des troubles psychologiques. Bulletin des Socits dOphtalmologie de France 90, 59-61 & 64.

Patricias Personality Check List and more detailed explanations of the approach and therapy are given in her book, Reasons and Remedies, which is available from bookshops at 12.95. Readers of Speech & Language Therapy in Practice may purchase copies direct from Mortimore Books, PO Box 156, Barnstaple, EX33 1YN at 10.95 each (inclusive of postage and packing).

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diagnosis

The story of Ruth...

Read this if you could improve onward referral / multidisciplinary work have an interest in counselling have voice clients who are not responding to therapy

Ruth is a 34-year-old nurse. She is married and has two young children. She was referred to ENT by her GP with a 12-year history of recurrent inspiratory stridor, unresponsive to antiasthma therapy. During her first meeting with the consultant, Ruth described herself as hyperactive and hard-working. Ruth had seen chest and allergy specialists and had been admitted to hospital on nine occasions for emergency treatment to relieve breathing difficulties. The attacks were sudden, although they sometimes appeared to be preceded by a sore throat. Symptoms consisted of respiratory distress, stridor on inspiration and a feeling of discomfort in the throat. She had experienced mild depression in early adulthood, which was treated with antidepressant medication for a period of 12 months. This treatment was stopped by the GP after Ruth reported her mood had improved. Testing during asymptomatic periods revealed no allergic responses, normal measurements of lung volumes, and variable performance on flow-volume loop testing. Psychiatric assessment pointed out anxious tendencies, but not enough to warrant psychotherapy. Testing during an attack revealed limited inspiratory lung capacity but no evidence of broncho-constriction. Other tests which yielded normal results included chest X-ray, biochemistry investigations, blood gas measurements and a neurological assessment. Fibreoptic bronchoscopy, which had to be performed under general anaesthesia due to hypersensitivity, showed normal appearance of the larynx and bronchial tree. Direct laryngoscopy revealed the stridor was due to narrowing of the glottis, as a result of vocal cord adduction during inspiration. When the lungs were passively inflated, without any inspiratory effort, this paradoxical movement of the vocal cords during inspiration was reversed. The ENT consultant referred Ruth to the speech and language therapist. During the initial interview, the therapist allowed Ruth to talk about her situation in detail and to explore her feelings, without making suggestions or giving advice in the process. The therapist communicated full attentiveness, empathy and acceptance and offered Ruth treatment, during which she explored her self-concept and talked about her relationships with various family members. In addition, Ruth learned diaphragmatic breathing and relaxation. Although the speech and language therapist had undergone basic training in person-centred counselling, she did not feel adequately qualified to further explore Ruths psychological issues. After several therapy appointments, she shared this feeling with Ruth and suggested onward referral to a counsellor. Ruth agreed to this suggestion. The speech and language therapist liaised regularly with the counsellor, and the treatment outcome was good. Today, Ruth is better equipped to cope with her anxieties concerning life stressors and is continuing to improve her self-esteem and relationships with family members, particularly her mother. She works part-time and has undertaken a postgraduate course. Her symptoms gradually reduced in severity and frequency, and she learned to control them by using breathing and relaxation techniques.

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SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2000

Photo posed by model

Outof the maze

diagnosis

Asthma which does not respond to treatment may not be all it seems. Yifat Raz and Paul Carding find a path through the complex differential diagnosis and management of paradoxical vocal cord movement, outlining the speech and language therapy role in the multidisciplinary team.
he literature on Paradoxical Vocal Cord Movement (PVCM) is heterogeneous and somewhat inconclusive. Although the factors underlying PVCM are not yet fully understood, greater awareness of the condition is likely to prevent inappropriate treatment. Patients who suffer from PVCM may present to GPs, chest physicians, ENT physicians or allergy specialists with asthma-like symptoms which are resistant to conventional treatment. PVCM is found predominantly in women aged between 20 and 45. Children, men and elderly cases have also been reported (Goldman, 1997). On clinical examination, patients are found to have wheezing or stridor originating from the larynx. Direct laryngoscopy during an attack shows vocal cord dysfunction (Collett et al, 1983). PVCM is frequently misdiagnosed as asthma since both PVCM and asthma attacks are similar in that they begin and end suddenly, produce distressing shortness of breath and create respiratory stridor (Gallivan et al, 1996). Antiasthma therapy, including high doses of corticosteroids, is ineffective and may cause side effects of steroid toxicity such as puffy face, weight gain, depression and psychosis (Lacy and McManis, 1994). During an attack of PVCM the typical laryngeal presentation consists of adduction of the anterior two thirds of the true vocal cords, possibly with adduction of the ventricular folds, with a diamond-shaped chink in the posterior portion of the glottis. Spirometry during symptomatic periods usually reveals a pattern of extra-thoracic upper airway obstruction for the whole respiratory cycle or, more commonly, only on inspiration. In some cases, the obstruction has been considered severe enough to warrant emergency intubation and tracheotomy (Lacy and McManis, 1994). Paroxysmal (sudden onset) spasms of the larynx are sometimes thought to be the result of a laryn-

Yifat Raz

Although the main presenting complaint is inspiratory stridor, Serving the purpose symptoms may vary The aetiology of PVCM is unknown. A explanation suggests the to include expiratory neurological pathway of suggestion, mediated by the vagus nerve, is activated, producstridor, coughing, ing a change in laryngeal muscle tone, thus lowering the threshold for stimuli dysphagia, and to produce vocal cord spasm (Gallivan et al, 1996). However, PVCM is most musculoskeletal commonly explained by psychogenic factors, usually of the conversion reactension (Sette et al, 1993).

geal reflex response. This reflex arc consists of an afferent (sensory) pathway, carried by the superior laryngeal nerve, and an efferent (motor) pathway, carried by the recurrent laryngeal nerve. This has been demonstrated through electrical stimulation of the superior laryngeal nerve which brings about repetitive excitation of the recurrent laryngeal nerve, which in turn causes prolonged adduction of the vocal cords through stimulation of the thyroarytenoid and lateral cricoarytenoid muscles and inhibition of the posterior cricoarytenoid muscle (Loughlin and Koufman, 1996). Although the main presenting complaint is inspiratory stridor, symptoms may vary to include expiratory stridor, coughing, dysphagia, and musculoskeletal tension (Sette et al, 1993).

Yifat Raz working with a patient

tion type. Conversion (or somatisation) reactions can produce various manifestations including perceptual, motor, sensory, and linguistic impairments (Corren and Newman, 1992). According to this psychogenic explanation, the abnormal laryngeal movement has served or continues to serve the purpose of enabling the patient to avoid confrontation with an unpleasant life situation or emotion, and gives them the opportunity to receive attention and sympathy (Christopher et al, 1983). Several psychiatric diagnoses have been associated with PVCM, including depression, anxiety, obsessive-compulsive disorder and borderline personality disorder (Corren and Newman, 1992). Another important aetiological factor is gastroesophageal or laryngopharyngeal reflux. The full laryngeal implications of reflux are not clear; however, it is known that it can lead to asthmatic and laryngopharyngeal symptoms such as dyspho-

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diagnosis

Box 1 - Speech and language therapy options

Information
Provide reassurance that the stridor is real and acknowledge potential fears and anxieties. Explain how the laryngeal and respiratory mechanisms work. The initial technique of informing the patient about the nature of their problem is of major importance, as it is likely to influence their therapeutic response. The initial phase should be non-threatening for the patient. They should be made to feel understood and safe. Patients who perceive their diagnosis as its all in your head are highly likely to resist therapy (Aronson, 1990). Therefore, the therapist should ensure that the patient is allowed to enter therapy without having to openly acknowledge there may be a psychological component to their condition. 3. The patient can be taught to exhale, then to allow inhalation to follow effortlessly and passively. Help the patient develop the attitude that their breathing does not have to be actively performed but is part of a natural physical process that can be trusted (Martin et al, 1987). 4. Additional useful therapy techniques include Voicecraft, the Alexander technique, laryngeal manipulation and massage.

Counselling
Enable the expression of emotions and memories to an empathetic, non-judgmental and genuine listener. The therapist should treat the disorder with respect and recognise patients potential for achieving insight and change (Aronson, 1990). Therapy should aim to remove or alleviate the cause and achieve better adjustment of the patient to his difficulties by gaining insight into the connection between the symptoms and their aetiological, precipitating and maintaining factors (Elias et al, 1989). The results of symptomatic voice therapy are good only if the patient is ready to stop the pattern and deal with the underlying problematic issues that are causing it. In cases where the patient is not ready to face the underlying problems, improvement is usually limited (Butcher et al, 1993).

Symptomatic relief through direct voice therapy

In addition to relief of primary symptoms, therapy also addresses secondary symptoms which may result from the condition because forceful vocal cord adduction often leads to voice strain, vocal fatigue, hoarseness, nodules, polyps or ulcers (Gallivan et al, 1996). Treatment aims to reduce strain on the phonatory mechanism through promoting a good breathing pattern, relaxation and selfawareness. Treatment also aims to prepare the patient to voluntarily control an attack when it occurs. Useful strategies include: 1. Diaphragmatic breathing to direct attention away from the larynx, give the patient a different focus for respiratory effort and avoid laryngeal tension. The patient concentrates on pushing the lower abdomen out on inspiration, and utilising the lower abdominal muscles for support during expiration. Teaching the patient to focus their attention away from the larynx during exhalation interrupts their tendency to feel unable to breathe (Martin et al, 1987). 2. Wide open throat during breathing, tongue lying flat on the floor of the mouth, releasing the jaw gently and using diaphragmatic breathing (Martin et al, 1987).

Psychotherapy
Some cases require detailed psychological therapy from a suitably qualified clinician. The speech and language therapist who has not undergone additional training in this area might consider onward referral to mental health services. The timing and appropriateness of such referral is important. If done prematurely, it may increase the chance of treatment refusal or rapid relapse (Aronson, 1990). Useful psychological interventions include personal construct therapy, cognitive behaviour therapy, analytical psychotherapy such as Jungian analysis and hypnotherapy.

nia, dysphagia and globus pharyngeus (Gallivan et al, 1996). Laryngopharyngeal reflux is closely linked with paroxysmal spasms of the larynx. This claim is supported by clinical findings that anti-reflux drug therapy leads to significant relief in PVCM attacks (Loughlin and Koufman, 1996). In most cases the GP or ENT consultant investigates any reflux problem and offers appropriate treatment. The speech and language therapist should ask the patient if s/he suffers from acid reflux, heartburn or indigestion and enquire about any medication. In some cases it may be appropriate for the speech and language therapist to discuss the relationship between the two conditions with the ENT consultant, who may then investigate and offer treatment as necessary. A definite diagnosis can only be achieved through detailed case history taking, speech systems examination, direct visualisation of the vocal cords and flow volume loop measurements, all of

the management of PVCM is not the sole responsibility of the speech and language therapist. It requires close multidisciplinary cooperation to achieve efficient and effective practice.

which show the characteristic pattern of PVCM (Brown et al, 1988). The timing of stridor within the respiratory cycle is a critical diagnostic criterion. Typical asthmatic airflow obstruction occurs mostly on expiration (Goldman, 1997). Stridor and wheezing can arise for a number of reasons and at several anatomical sites along the respiratory tract. It is therefore crucial to consider all possible sources in a patient who either presents with atypical clinical features or does not respond to conventional asthma therapy. Atypical asthma features include: absence of symptoms during exercise and sleep; poor response to aggressive drug therapy; normal arterialalveolar oxygen gradient; normal pulmonary function shortly after a severe attack; negative histamine challenge test (no bronchial hyperactivity to inhaled histamine); and flattened flow volume loop on inspiration, normal or depressed on expiration (Freedman et al, 1991).

Similar
PVCM can be mistaken not only for asthma. It often appears similar to adductor spasmodic dysphonia which is characterised by vocal cord

spasms, laryngeal elevation, rigidity, and reduced thyrohyoid space. Adductor spasmodic dysphonia is thought to be a neurological disorder of central motor processing. Such patients almost never have all the typical characteristics of PVCM. Similar to adductor spasmodic dysphonia, adductor laryngeal breathing dystonia - a rare disorder characterised by inspiratory stridor, normal voice and cough, dysphagia and adductor spasms of the vocal cords - can also be mistaken for PVCM; however, its diagnosis is supported by the finding of dystonia in other parts of the body and associated respiratory dysrhythmia. Both adductor spasmodic dysphonia and adductor laryngeal breathing dystonia are highly resistant to speech and language therapy, psychotherapy and drug therapy. They are successfully treated with botulinum toxin injections - which confirms their neurological origin - unlike PVCM which does not respond favourably to botulinum toxin injections (Gallivan et al, 1996). PVCM therefore must be differentiated from bronchial asthma, laryngeal oedema, adductor spasmodic dysphonia, adductor laryngeal breathing dystonia, mechanical upper airway obstruction (for example, lung cancer, laryngeal cancer or inhaled foreign bodies), and neurological lesions such as vocal cord paralysis (Goldman, 1997). PVCM may be on a continuum, with co-existing

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diagnosis

Reflections
Do I conduct a full speech systems examination when there is any doubt about diagnosis? Am I careful with the timing and manner of suggesting a psychological component to a problem? Do I ensure clients have access to specialist assessment and treatment when appropriate?
asthma, dysphonia and globus pharyngeus. The importance of a thorough speech systems examination cannot be overemphasised, even when the disorder seems to be confined to the larynx. Such examination may disclose the beginnings of a neurological disorder (Aronson, 1990). Early and precise diagnosis is of major importance in the management of PVCM. It allows for rapid intervention, maximising potential benefits and minimising surgical and medical treatment for asthmatic symptoms, thus reducing risks and side effects (Goldman, 1997). Typically, the professionals involved in the diagnosis and treatment of PVCM include the ENT consultant, respiratory medicine specialist, allergy specialist, speech and language therapist, GP, psychiatrist and psychologist. Some cases require additional involvement from a neurologist, counsellor, psychotherapist and paediatrician. The specific role of each professional depends on the dominant aetiological factors in any individual case. The speech and language therapist has an important role in the diagnosis and treatment of PVCM. However, it must be noted that the management of PVCM is not the sole responsibility of the speech and language therapist. It requires close multidisciplinary cooperation to achieve efficient and effective practice. until the aetiology of the condition is clearer, a number of different surgical, pharmacological, behavioural and psychological treatment programmes all remain viable options. Evidence of treatment effectiveness will help to clarify the underlying aetiology. Yifat Raz is a speech and language therapist at Kaplan Medical Centre, Rehovot, Israel and Paul Carding head of speech and language therapy at the Freeman Hospital, Newcastle Upon Tyne.

RESOURCES...RESOURCES...

Opening doors
Books developed for adult literacy projects may be of use to therapists working with adult clients with neurological disorders. The Open Door series consists of six original or adapted works from Irish authors such as Roddy Doyle and Patricia Scanlan. 4.99 each from New Island Books, Dublin, tel. (+353 1) 298 9937, e-mail brooksid.iol.ie

Textphones worldwide
A software system designed to allow textphones from many different countries to communicate with one another is being introduced in the UK. Ultratec believes its V.18/T marks the beginning of universal compatibility for textphones around the world.

References
Aronson, A.E. (1990) Clinical Voice Disorders: an interdisciplinary approach. Fifth Edition, Thieme, New York. Brown, T.M., Merritt, W.D. and Evans, D.L. (1988) Psychogenic Vocal Cord Dysfunction Masquerading as Asthma. Journal of Nervous and Mental Disease 176 (5), 308-310. Butcher, P., Elias, A. and Raven, R. (1993) Psychogenic Voice Disorders and Cognitive Behaviour Therapy. Whurr, UK. Christopher, K.L., Wood, R.P., Eckert, R.C., Blager, F.B., Raney, R.A. and Souhrada, J.F. (1983) Vocal Cord Dysfunction Presenting as Asthma. The New England Journal of Medicine 308, 1566-1570. Collett, P.W., Brancatisano, T. and Engel, L. (1983) Spasmodic Croup in the Adult. American Review of Respiratory Disease 127, 500-504. Corren, J. and Newman, K.B. (1992) Vocal Cord Dysfunction Mimicking Bronchial Asthma. Postgraduate Medicine 92 (6), 153-156. Elias, A., Raven, R., Butcher, P. and Littlejohns, D.W. (1989) Speech therapy for psychogenic voice disorders: A survey of current practice and training. British Journal of Disorders of Communication 24, 61-76. Freedman, M.R., Rosenberg, S.J. and Schmaling, K.B. (1991) Transgenerational Psychosomatic Respiratory Symptoms: A Case Illustration. Journal of Family Psychotherapy 2 (1), 17-25. Gallivan, G.J., Hoffman, L. and Gallivan, K.H. (1996) Episodic Paroxysmal Laryngospasm: Voice and Pulmonary Function Assessment. Journal of Voice 10 (1), 93-105. Goldman, J. (1997) All That Wheezes is Not Asthma. The Practitioner 241. Lacy, T.J. and McManis, S.E. (1994) Psychogenic Stridor. General Hospital Psychiatry 16, 213-223. Loughlin, C.J. and Koufman, J.A. (1996) Paroxysmal Laryngospasm Secondary to Laryngopharyngeal Reflux. Centre For Voice Disorders of Wake University, USA. Martin, R.J., Blager, F.B., Gay, M.L. and Wood, R.P. (1987) Paradoxical Vocal Cord Motion in Presumed Asthmatics. Seminars in Respiratory Medicine 8 (4), 332-337. Sette, L., Pajno-Ferrara, F., Mocella, S., Portuese, A. and Boner, A.L. (1993) Vocal Cord Dysfunction in an Asthmatic Child: Case Report. Journal of Asthma 30 (5), 407-412.

Thickened drinks
Therapists managing dysphagia in the community may be interested in new options for thickened textures. Resource ThickenUp can be mixed quickly with hot or cold food and liquids without altering their flavour and without thickening over time. Thickened Squashes, orange or lemon flavour, come in re-sealable bottles as two ready prepared consistencies of syrup and custard. Thickened drinks, apple or orange, are also available in syrup and custard consistencies and come in ready to use single serving cups.Details: Novartis, tel. 01403 210211.

Positive conduct
A resource for schools may be of use to speech and language therapists working with older children. Described as a positive sanction which makes them think, topics in the Conduct File include bullying and teasing, rudeness to an adult and behaviour during excursions. Photocopiable sheets allow the young person to read about others in a similar situation and respond to questions, guiding them through the process of examining their own behaviour and what effect it has had upon others and themselves. Details: JDJA Education Ltd, PO Box 4067, Poole, BH13 7YR, www.conductfile.co.uk

Effective treatment
Speech and language therapy combined with psychotherapy is reported to be the most effective treatment for PVCM, reducing the severity and frequency of attacks in many and achieving reversal of inappropriate tracheotomy or intubation. Where appropriate, the speech and language therapist can apply the following treatment guidelines: information, symptomatic relief through direct voice therapy, counselling and psychotherapy (box 1). The combination of symptomatic voice therapy with psychological approaches seems to be an appropriate intervention for PVCM. However,

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further reading

further reading further reading further reading further reading further reading

This regular feature aims to provide information about articles in other journals which may be of interest to readers. The Editor has selected these summaries from a Speech & Language Database compiled by Biomedical Research Indexing. Every article in over thirty journals is abstracted for this database, supplemented by a monthly scan of Medline to pick out relevant articles from others. To subscribe to the Index to Recent Literature on Speech & Language contact Christopher Norris, Downe, Baldersby, Thirsk, North Yorkshire YO7 4PP, tel. 01765 640283, fax 01765 640556. Annual rates are Disks (for Windows 95): Institution 90 Individual 60 Printed version: Institution 60 Individual 45. Cheques are payable to Biomedical Research Indexing.

further reading...

DYSARTHRIA
Lapco, P.E., Forbes, M.M., Murry, T., Rosen, C.A. (1999) Laryngeal botulinum toxin A for spastic dysarthria associated with cerebral palsy: a case study. J Med Speech Lang Pathol 7 (1) 63-8. A 34 year-old woman with the diagnosis of cerebral palsy, presented with severely compromised articulation and dysphonia due primarily to spasticity. Her voice was characterised by uncontrollable loudness, harshness and a staccato-like quality. Overall intelligibility with unfamiliar listeners was 40 per cent; with familiar listeners it was 60 per cent. A decision was made to treat her with intralaryngeal botulinum toxin A (btx A) injection following a course of speech-language therapy, based on the rationale that her severe laryngeal spasticity, although of different aetiology from spasmodic dysphonia, might respond to btx A and become less strained and strangled. Btx A injection was followed by additional speech and language therapy, which was used to address the articulatory problems of her speech disorder. Following treatment, the patients voice became more fluent, quieter, and the staccato-like quality diminished. This improvement lasted for approximately two and a half months. Her intelligibility improved during that time and she was able to use the telephone for the first time in her life. Her intelligibility increased to 85 per cent at the single word level and 94 per cent for sentences with familiar listeners. Voice changes were documented with videoendoscopic, aerodynamic and spectrographic records and showed significant changes in voice quality and temporal dimensions. Btx A therapy was the primary basis for the change in the patients voice. This was followed by a more precise identification of the articulatory deficit, which allowed specific phonemes and temporal patterns to be targeted in speech intelligibility and voice quality improved enough to facilitate oral communication and telephone use. Further trials of btx A as an adjunct to traditional treatment of spastic laryngeal mechanisms due to cerebral palsy are warranted.

DYSFLUENCY
Yairi, E., Ambrose, N.G. (1999) Early childhood stuttering I: persistency and recovery rates. J Speech Lang Hear Res 42 (5)1097-1112. The divergent developmental course of stuttering with its two major paths, persistency and spontaneous (unaided) recovery, has been a focus of scientific attention because of its critical theoretical, research and clinical perspectives. Issues concerning factors underlying persistency and recovery and their implications for early intervention have stirred considerable controversy among scientists. In light of the intense interest, the scarcity of direct essential epidemiological data concerning the magnitude of the two paths and the timing of recovery is problematic. Most past studies have used retrospective methodologies. The few longitudinal studies have been severely limited in scope or objective data. The purpose of the investigation reported herein is to study the pathognomonic course of stuttering during its first several years in early childhood with special reference to the occurrence of persistent and spontaneously recovered forms of the disorder. Employing longitudinal methodology with thorough, frequent periodic follow-up preschool children who stutter have been closely followed for several years from near the onset of stuttering. In this, the first of three related articles, we present findings regarding the current stuttering status of 84 of these children, who have been followed for a minimum of four years after their onset of stuttering. The data indicate continuous diminution in the frequency and severity of stuttering over time as many children progressed toward recovery. Our findings lead to conservative estimates of 74 per cent overall recovery and 26 per cent persistency rates. The process of reaching complete recovery varied in length among the children and was distributed over a period of four years after onset. Detailed analyses of phonological and language skills pertaining to differentiation of the developmental paths of children who persist and those who recover are presented in the two other articles in the series (E. P. Paden et al, 1999 and R.V. Watkins et al, 1999).

DYSPHAGIA
ODonoghue, S., Bagnall, A. (1999) Videofluoroscopic evaluation in the assessment of swallowing disorders in paediatric and adult populations. Folia Phoniatr Logop 51 (4-5) 158-71. Videofluoroscopic swallow studies (VFSS) are often considered the gold standard technique to assess dysphagia. Despite this status, unanimous agreement has not been reached regarding the protocol for this procedure. Review of the literature reveals two main schools of thought. The first advocates a uniform, standardised protocol used with all patients. The second argues for functional, tailor-made studies, which aim to elicit a sample of swallowing representative of typical feeding patterns. This paper reviews the literature on VFSS methodology and evaluates the applicability of protocols to the paediatric population. Broadly speaking, adult protocols tend towards uniform procedures, whereas paediatric studies aim to be more individualised and tailor-made. Clinical recommendations based upon VFSS are examined in the light of validity and reliability issues. The need for standardisation of the VFSS procedure is highlighted. The question is raised whether it is possible to achieve uniformity and consistency between clinicians and still perform patientcentred, tailor-made VFSSs, which are truly representative of a patients swallow function. It is revealed that dysphagia specialists should achieve greater consistency in the VFSS procedure before claiming to be implementing a gold standard technique.

BILINGUALISM
Gutierrez-Clellen, V.F. (1999) Language choice in intervention with bilingual children. Am J Speech Lang Pathol 8 (4) 291-302. This article examines assumptions underlying the selection of a language for intervention with bilingual children with language disorders and reviews the literature. The rationale for the use of a bilingual approach in intervention is presented. It is shown that (a) bilingual input does not retard language development in general, (b) learning in one language involves interrelated processes in the other for both typical and atypical learners, and (c) transfer of skills to a second language by children with limited proficiency in English can be facilitated by mediation in the native language. It is concluded that intervention in children from a minority language background should be provided in the language(s) spoken in the home while the child is in the process of learning English as a second language at school.

HEARING IMPAIRMENT
Mody, M., Schwartz, R.G., Gravel, J.S., Ruben, R.J. (1999) Speech perception and verbal memory in children with and without histories of otitis media. J Speech Lang Hear Res 42 (5)1069-79. Two groups of children, with (n = 7) and without (n = 7) first-year histories of otitis media, were participants in a longitudinal study that included periodic audiological and medical evaluations during the first year of life. At age nine, these children were tested on a series of speech perception and verbal short-term memory tasks using stimuli of varying degrees of phonetic contrast. Although the otitis-positive group performed less accurately than the otitisfree group, the pattern of errors was the same for the two groups. The performances of the children with and without positive histories of otitis media were negatively affected by an increase in phonetic similarity of the stimulus items. The two groups, however, did not differ on identification or on temporal-order recall when the speech sounds were differentiated by multiple features. These findings provide evidence of subtle, long-term effects of early episodes of otitis media on phonological representations and on working memory.

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cover story

manage
Read this if you want to understand more about change minimise the effects of change on clients and families improve communication with clients and other services

transitions
Photo posed by model

Dawn Synnuck (nee Moffat) is professional lead for speech and language therapy with the British Forces Health Service in Germany.

Gillian Welsher and Fiona Johnstone are speech and language therapists with the Community Team Learning Disability, Sanderson Centre in Gosforth. They would be interested in hearing from other speech and language therapy departments who offer a preschool transition service.

Anne Whateley is the principal speech and language therapist for adult services in South West London Community NHS Trust.

Change is not made without inconvenience, even from worse to better. Richard Hookers point has particular resonance for those who lack the communication skills which help most of us make sense of and come to terms with change. As speech and language therapists, do we think enough about preparing our clients for change and supporting them through the process? Here, three contributors describe how they manage different types of transition: the constant change experienced by children of service personnel, from preschool community paediatrics to a school special needs team and for adults with acquired neurological problems moving between acute, rehabilitation and community services.
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cover story

C
Perpetual transition
Children of service families experience more change than most. Dawn Synnuck explains how this influences assessment, therapy and training of others as well as the transfer process.

hildren of service families are in perpetual transition, with constant change in home life, location, country of residence, nursery / school and the people around them. The length of posting for a family averages between six months and three years for serving soldiers and families, but could be longer for civilian support personnel. The British Forces Germany - Health Service employs a team of nine speech and language therapists to provide service to all British forces employees and families stationed in garrisons within Northern Germany. This includes some isolated detachments in Holland, Belgium and Southern Germany. Therefore whilst the caseloads are relatively small compared to the UK (average 80), the geographical distances covered are very large. The British Forces Germany - Health Service is split into five regional primary health care teams of which the speech and language therapist is an integrated team member. As a speech and language therapy team we are constantly evaluating the service we provide through clinical audit, statistic collection and outcome measures. We realise the importance of immediate therapy intervention to ensure support and advice is provided whilst the family is in one place and we make all transitions within speech and language therapy to and from the UK as problem-free as possible. Following referral, an appointment is offered within eight weeks for assessment and two weeks for an urgent referral. We try to keep waiting lists for therapy to a minimum as children have often been referred in the UK but - before they reach the top of waiting lists, or just following initial assessment - they move on to another posting. Our aim is to provide appropriate intervention as soon as possible and to ensure the child and family have access to ideas to facilitate the childs communication. Parent training and the use of Hanen is a vital part of our work. Thus, even when they move around the world, the family will have some strategies to use to help their child. When postings to the UK arise, we make the transition as smooth as possible by: 1. establishing who the receiving health trust and speech and language therapy department will be 2. contacting the receiving department by telephone 3. sending recent reports to the receiving department 4. providing parents with up-to-date reports 5. ensuring copies of reports are with medical notes and education notes 6. providing the family with a programme and / or activities as appropriate until the UK appointment can be arranged. We are not allowed to forward casenotes. However, for more complex cases, we will provide a prcis of the past intervention.

Promotional / Trade Courses - anything from one to six weeks away from home. One soldier may experience all three within a year. This causes various degrees of disruption, going from two-parent to single-parent family life and alternating between the situations. Children experiencing communication difficulties may show the greatest effect due to poor understanding of what is going on and the constant changes they are experiencing. We encourage both parents to attend appointments wherever possible and are well supported by the forces in this request. This facilitates the fathers understanding of the childs communication difficulties and includes him in the remediation process as much as possible. During sessions, especially assessments, we note if the father is away, has just gone away or has recently returned as it can be a significant factor in the childs behaviour and attention. We also try to assist with transport getting families to and from appointments as this can be difficult if a mother has young children and does not drive. As well as the caseload population constantly moving on, the spouses of soldiers who work in the kindergartens or crches, as class assistants in school or as nurses are perpetually moving on. We have therefore developed training packages presented on a rolling programme in each region to ensure new staff can be booked into the next session to make them aware of our service and how to work with children with communication difficulties. Close liaison with health professionals and education is required to ensure the children and families access a complete service as quickly as possible when they are referred. Children who present with specific and complex difficulties are integrated into the mainstream schools and nurseries as much as possible. Support is provided and there are resource units in the regions. The speech and language therapists work very closely with Service Childrens Education and the Advisory Teachers for Special Needs. If specialist resources are required, for example, assessment at the Nuffield Centre or videofluoroscopy, the therapist will be involved with making a case for the family to be sent to the UK for assessment.

Compassionate posting
In some cases it is necessary for the family to return permanently to the UK. This is only in extreme circumstances where the level of provision required by the child / family is greater than can be provided by Service Childrens Education and / or British Forces Germany - Health Service. The therapist will attend a case discussion along with all involved with the family, including the Forces Families Officer. This discussion may result in a compassionate posting to the UK being requested. The Forces culture is unique and remains a British pocket within Germany. Most children adapt very well to their transient life style, but we must maintain awareness of the effects this can have on children with communication difficulties and their families.

Third Culture
Speech and language therapists must be aware of the additional factors that can and do affect the childrens behaviour and day-to-day living. The Child Guidance Team organised a course, Third Culture Kids, to increase professionals awareness about extraneous factors having influence on the childrens outlook, behaviour and social skills. This refers to children who live, and are often born, outside the country of their and their parents nationality, and have to cope with moving around in various cultures other than their own. The majority of families we see have one parent, usually fathers, away from home a great deal. This may be due to an Operational Tour - usually six months away (with a possible two weeks rest and recuperation during the six months back at home) Army Exercises - up to six weeks at a time, training away from home

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

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cover story

he step from preschool to school provision leads to a major change for the child, family and services involved. For children with learning difficulties and their parents, the changes can be even greater and more confusing. In Newcastle, children with a learning difficulty are transferred from the paediatric speech and language therapy team to the department of communication within the Community Team for Learning Disabilities (CTLD) when they start school. This transfer means the child will be allocated a new speech and language therapist and may be placed on the waiting list. It also means there is access to a multidisciplinary community team specialising in learning disability. Intervention with the child moves from the clinic setting to a more community-based approach, with

Excerpts from an All About Me book

the emphasis on the home and school environment. Starting school means the child and family also have to cope with the uncertainty of how the child will manage in new situations without their family, and how the child with a communication difficulty will express their needs, wants and feelings to the new network of professionals involved. To address some of these issues, our department developed a protocol to help smooth the transition period: 1. A meeting between representatives of both paediatric and CTLD speech and language therapy to discuss the children being transferred. 2. A parent meeting during the summer holidays to a) explain our service and how it differs from the paediatric service. b) gather initial information about the family and their child. c) discuss their past involvement with speech and language therapy and their expectations of the new service. While two therapists run the parents meeting, other therapists and assistants / students spend time with the child and possibly their siblings. Information gathered from the parents meeting and direct observation of the child give us a general overview of the childs and familys needs. This enables us to build up our own picture of the childs communication skills and an idea of the level of intervention required when they start school. 3. Parents are invited to complete an All About Me book about their child which accompanies the child into school to give staff initial information about family, likes / dislikes, communication skills and personal care (see example). 4. The child is allocated a therapist before starting school to ensure appropriate intervention. We continue to look at ways to develop our service. Last year we invited professionals from CTLD to attend part of the parents meeting, including community nurses, a clinical psychologist and a physiotherapist, people who may have future involvement with the child. Parents were able to find out more about their services and how they work. We also want to achieve earlier referral of these children to improve the organisation of meetings and preparation of the All About Me books.

Taking

care of

you

A department in Newcastle has developed a protocol to ensure a smooth transfer of children with learning difficulties from preschool to school services. For Fiona Johnstone and Gillian Welsher, early contact with the children and their parents is vital.

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cover story

Commitment,

and coordination
In South West London, speech and language therapists and their colleagues have been acting on recent practical research findings to make transitions easier for clients who have suffered a stroke. Anne Whateley tells us how.

cooperation

hange is difficult for all of us but especially when it comes as a result of a sudden, devastating event such as stroke. Not only are there physical changes to cope with - paralysis, sensory loss, language impairment - but it is likely that patients will have to make a number of other transitions during the course of recovery. These might include being admitted to hospital, transferring to other units for rehabilitation either within the same hospital - for example to a stroke unit - or elsewhere - for example to a tertiary rehabilitation unit - and returning to either an old or new home. The challenge for all health and social service professionals is to ensure these transitions are as stress free as possible for both the person and their family and that they receive continuity of care throughout their rehabilitation and beyond. Studies examining the experiences of people who have received healthcare often identify the apparent lack of coordination between services as being a significant problem (see for example Parr et al, 1997; Royal College of Physicians, 1999). Over the past few years, the adult speech and language therapy teams along with our multidisciplinary colleagues in South West London have begun to develop practical ways to address these concerns.

patients can be easily identified through the liaison meeting. The perhaps less obvious value of meeting regularly - the eyeball to eyeball contact - is that individuals from different services gradually become more familiar with each other, usually leading to improved dialogue and increasing the chances of easier communication through other mediums, such as over the phone. This also leads to improved knowledge of the nature of the various services that can be transmitted to patients and carers, reducing the level of misinformation and misunderstanding which, unfortunately, happens so often.

Common understanding
Successful transitions can only happen when there is a common understanding of the patients needs and how those needs might be met by different services. For several years, the local adult speech and language therapy teams across community, tertiary and acute settings have met at least four times a year with the specific aim of looking at particular clinical issues from their own perspectives. Topics have included: discharge and prioritisation, dysphagia management and counselling. By discussing these issues in the context of each part of the service it has been possible for us to: develop a core understanding of our respective roles in the patients journey through the services improve our knowledge of the different services, so that we can better inform patients and carers; for example, we are about to review the written information that is provided adopt and understand common terminology, for example for cognitive-communication disorders create a regular forum for sharing and debating ideas on therapy and management identify skills and special interests within the teams, which can be accessed with ease, often leading to joint management sessions pre-admission / discharge. Forums such as those described can help to dismantle the barriers between services which frequently hinder patient care, encouraging us to communicate more effectively and to be more focused on facilitating the patients transitions. However, in order to withstand the staff and service changes which are inevitable within any service, there needs to be long-term commitment, cooperation and coordination from managers and therapists across the services to support and participate in such initiatives.

Active communication
Probably the most fundamental factor in facilitating a successful transition between services is active communication between services and clients. To improve this locally, representatives from the local community teams, tertiary rehabilitation centre and acute hospital meet fortnightly to identify, at an early stage, patients who will be making the transition between services. This can buy valuable time for preparations to begin for the transition prior to discharge, preventing the And when I got home there was just nothing.... experience (Royal College of Physicians, 1999). Preparations may include: Pre-discharge visits, where a therapist from the receiving community / rehabilitation team can visit the patient whilst still in hospital to introduce and provide information about the team and what will happen on returning home. It is often possible to arrange an initial out-patient / domiciliary appointment at this time with a named therapist. During these in-reach visits, valuable information can be exchanged with the in-patient staff both in terms of progress to date and in keeping each other up-to-date about services. Attending the discharge case conferences at the rehabilitation centre with the same benefits as above. In this way patients and carers - who participate in the meeting - are able to see the link between services, and hopefully this reduces some of the anxiety that is inevitably felt on discharge. Allocating time slots in advance for patients who are just about to be discharged, so they do not have to wait unnecessarily for rehabilitation to continue. Conversely some wish to have a break before recommencing, and these

References
Parr, S., Byng, S., Gilpin, S. & Ireland, C. (1997) Talking about Aphasia. Open University Press. Royal College of Physicians (1999) Stroke Rehabilitation: Patient and Carer Views. RCP Publications. (See also the news item Evidence based stroke care on page 2 for details of the multidisciplinary guidelines produced as a result of this report.)

PRACTICAL POINTS
1. Transitions include a change in service, therapist, other professional, home environment and family life. Waiting for the change can be stressful. 2. A clear, regularly updated, multidisciplinary transfer policy / protocol is necessary. 3. Transitions need attention before, during and after the event. 4. Communication (face to face, over the telephone and written) with clients, families and other professionals is vital if transitions are to run smoothly. 5. Qualitative research provides information for improving services, particularly at times of transition. 6. Professionals need a clear, mutual understanding of services available to prevent misinformation being given. 7. In-reach visits should be considered as well as out-reach when a client is moving from one environment or service to another. 8. Visual aids such as communication books may be helpful.

28

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2000

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MY TOP RESOURCES
Carol Stow
1. Bilingual assistant
When working with clients from a Pakistani background our bilingual assistant Zahida Warriach is an invaluable resource. Sessions flow smoothly, allowing more information to be elicited and - with an accurate case history and detailed mother tongue assessment - we are more likely to reach an accurate diagnosis. We work with rather than through Zahida. She not only provides rapid and accurate translations but invaluable cultural and religious information, which helps us to understand and empathise with our clients and their carers. As an experienced speech and language therapy assistant she has insight into both the clients viewpoint and that of the therapist. All potential barriers are lifted allowing us all (therapists, assistant and carers) to focus on the needs of the bilingual child rather than parents feeling isolated from the therapy process by cultural barriers.

is a speech and language

4. National SIG Bilingualism
This group of the Royal College of Speech & Language Therapists meets at least twice a year with meetings rotating around the country. An invaluable forum for hearing the latest research and discussing current issues as they occur in clinic, the meetings also offer an opportunity to share ideas about resources and get support from other therapists working with bilingual clients. Contact Sheila Anderson, Speech & Language Therapist, Keighley Health Centre, Oakworth Road, Keighley, West Yorkshire BD21 1SA. Annual fee 5.

8. Bag Books
These unconventional books (actually a set of pages in a box) were developed for use with children with severe special educational needs or with visual impairment. Each page is a sturdy A3 sheet with a real object attached so that children can participate in the action as the simple story unfolds. Used in the groups we run, we find children love the repetition as each one takes it in turn to carry out the action - for example using the real dusters to clean the chairs in anticipation of Grans visit. One book in the series, The Party, is specifically multi-cultural, describing a Hindu celebration - but we use them all, to much hilarity when Gran arrives, apparently wearing her new tweed shalwaar kameez! Bag Books, 60 Walham Grove, London SW6 1QR, 30 plus p&p.

therapist who specialises in working with bilingual children. With her colleague

Sean Pert,
she sees bilingual children both individually and in groups in a community clinic in Rochdale. Both are involved in research projects with Newcastle University.

5. British Library Reading Room

We visit the British Library reading room at Boston Spa at least once a year. Its an excellent and completely free resource which allows access to all the latest research. Each person can request ten journal articles or books by ordering them in advance and a further six whilst there. A day in peace and quiet with no phones to answer getting new ideas for clinic can be revitalising for a stressed therapist. The Reading Room, The British Library, Document Supply Centre, Boston Spa, Wetherby, West Yorkshire, LS23 7BQ.

2. Internet
We make extensive use of two Internet facilities: the World Wide Web and e-mail. The World Wide Web is a treasure trove of information - some of which needs judicious sifting. We have our own web site and get many interesting contacts from people around the world who visit it and then contact us via e-mail for further information. When carrying out research we use e-mail extensively to make contact and then correspond with fellow researchers. On one occasion, when editing an article for publication, we were using e-mail to pass suggestions back and forth rapidly to meet a deadline, blissfully unaware that our coauthor was in Hong Kong that weekend. http://www.speechtherapy.co.uk

9. The right kind of mango and a small aubergine...

Whilst there are excellent picture materials available for use in community clinics, our client group do not recognise many of the items. Some pictures reflect a culture and lifestyle of which they have little or no experience; for example, they are reluctant to name a burger as it is an item most of them are not allowed to eat. We therefore decided to tailor our equipment to the everyday experience of our clients. A small grant from our Trust and assorted shopping trips later, we have the first trial version of photographic object and action pictures featuring activities and dress which reflects the local community. We are collecting user comments to improve further the picture materials we use, but the photos appear to be eliciting more spontaneous language - and the right kind of mango is now recognised. This material will possibly be published in future. For further details contact Carol or Sean at Baillie Street Health Centre, Rochdale OL16 1XS.

6. Velcro board
We run group sessions for children and find a Velcro board invaluable. It provides a focal point onto which real objects and picture materials can be fixed and, in this way, we can encourage one child to act out an action with rag dolls and real objects, whilst another constructs the appropriate sentence using laminated picture stimuli. The children love standing up and being teacher. Velcro board from T.F.H. 76 Barracks Road, Sandy Lane Industrial Estate, Stourport on Severn, Worcestershire DY13 9QB, 39.

3. RAMP
The Rochdale Assessment of Mirpuri (wth Punjabi and Urdu) Phonology is a phonological assessment we developed to meet the needs of our main population group. A total of 59 words are elicited using 35 brightly coloured and culturally appropriate pictures. The data obtained can then be transferred to detailed analysis sheets allowing a complete phonological assessment of mother tongue abilities. Preliminary standardisation data obtained using the assessment indicates that some realisations previously considered to be errors are in fact normal processes in this client group. A CD ROM version of the assessment is particularly enjoyed by our older clients who love the opportunity to use a computer. RAMP (ISBN 0 9534337) is published by Sean Pert, 31 Gilbrook Way, Badger Hollow, Rochdale OL16 4RT, 75 plus p&p.

10. Video camera

We have a video camera in our clinic and frequently use it to record ourselves and students working with children. Used in a supportive way, this allows students to observe, monitor and - following constructive analysis - modify their clinical performance. By recording children demonstrating a range of speech and language abilities we ensure we have a library of different video clips which we use to teach a wide range of people including special educational needs coordinators, health visitors and other members of our profession. We always obtain written parental consent after giving a careful and detailed explanation in the mother tongue of why we wish to use the video and, contrary to many peoples expectations, its very rarely that we get a refusal.

7. Computer and laminator

We use a computer to produce high quality colour picture materials and worksheets both for therapy activities and to encourage carryover in the home environment. Laminating equipment makes it more attractive and long lasting so it is costeffective in the long run. We use Boardmaker to make target SOV or SVO strips for the children to check their output against when describing pictures or activities on the Velcro board (see no.6). The ability to produce the best possible equipment gives the message that we value the clients and see bilingualism as an advantage, not a difficulty. Boardmaker - UK distributors are Cambridge Adaptive Communication, Don Johnston Special Needs Ltd, Inclusive Technology and SEMERC. See also www.mayer-johnson.com