computers

This is IT
Julia Wade and Sarah Woodward

With the range of software for people with aphasia limited, Julia Wade and Sarah Woodward use an evaluation protocol to check out packages designed for other markets. So, have you embraced the age of information technology? Or is IT still just a pronoun in capitals? Whatever your level of experience and client group, read on to wise up to the potential of computers.

hatever we as therapists feel about them, computers are here to stay. We are increasingly being asked about the possibilities of using a computer in therapy. But how does a busy clinician keep abreast of new software that becomes available so as to be able to respond to this in an informed and informative way? And, given that software resources specific to individual client groups are limited, could we be borrowing more from what is available to other client groups? Software reviews which evaluate the potential for application in speech and language therapy do exist. Wren (2001a; 2001b) provides a review of software for working with children which was carried out as part of the Hear IT, Sound IT project to develop software appropriate for working on phonological difficulties in children. The Software Evaluation Booklet produced by the Aphasia Computer Team (1999) at the Speech and Language Therapy Research Unit at Frenchay Hospital reviews software appropriate for people with aphasia. It covers some of the most widely known software such as INTACT, REACT, Parrot and Bungalow (see resources) as well as some recreational and word-processing software. The evaluation process involved people with aphasia giving their views. Therapists often report frustration at the limited choice and quality of specialist aphasia software available, not to mention the cost. The number of software titles designed specifically for aphasia therapy, though growing, is still limited and is small compared to the number designed for the education sector in general. This article therefore draws attention to the fact that software designed for other groups may nonetheless by useful to people with aphasia. We review a limited selection of seven titles (My House, Smart Start English, Speech Sounds on Cue, Jigsaw, Co:Writer, Clicker 4 and Out and About), none specifically designed for users with aphasia, and demonstrate in what ways these may be useful to them. There is a risk in any evaluation that the software reviewed is quickly superseded. We hope that our explanation of our evaluation protocol will enable readers to apply evaluation procedures independently, thus keeping abreast of innovation. In reviewing non-specialist software, we want to encourage readers to think broadly when it comes to software resources. The task of systematically reviewing software taken from such diverse categories as therapy software, word processing software and recreational software is a challenging one and inevitably results in distilling information to a summary. However, 10 questions were borne in mind when developing the evaluation protocol:

1. What language tasks are targeted?

Software may target auditory language comprehension, written language comprehension, speech sound production, word processing skills or visual skills. Just as with conventional therapy programmes, it is likely that you will get most from the software by picking and choosing aspects suitable for individual clients.

Read this
if you want to keep abreast of information technology open up new opportunities for clients offer therapy at both impairment and functional levels

2. What is the intended client group and what other client groups may benefit?
Some software (for example, My House) has been designed primarily for children and uses cartoon type drawings, but may be useful with other client groups. If you have reservations regarding the suitability of software for adult clients, demonstrate it, explaining it was designed for use by children as well as adults, and let the user decide whether it is acceptable or not. Even if aspects of the software are clearly appropriate, you may need to select and leave out those that are not. Certain parts of Out and About, which is designed for people with learning difficulties, are appropriate for people with head injury but will not necessarily be appropriate for people with aphasia following a stroke.

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Figure 1 Summary of evaluations

Package

My House series

Smart Start English

English as a foreign language software designed for any learner to work on English language skills Stroke, head injury, learning difficulties

Speech Sounds on Cue

Speech and language therapy software designed for work on dyspraxia Dyspraxia

Jigsaw
Software for doing jigsaws on the computer for all ages

Co:Writer
Adapted word processing software designed for all ages who need some help with their writing Stroke, head injury, learning difficulties

Clicker 4
Adapted word processing software designed for all ages with limited literacy skills Stroke, head injury, learning difficulties

Out & About

Speech and language therapy software designed for the learning disabled for work on all areas of auditory language and memory Stroke, head injury, learning difficulties

Description of Speech and Task/Software language therapy

software designed for children to work on auditory comprehension Stroke, head injury, learning difficulties, developmental language Laureate Learning

Appropriate client groups Supplier

All

AVP 34 W95, soundcard, SVGA video card

Propeller Multimedia 90 W95, soundcard

Crick software 30 W95

Don Johnston 149 W95, soundcard

Crick software 90 W95, soundcard

Semerc 59 (20 home licence) W95, soundcard

Price 129 (single licence) Hardware requirements

W95, soundcard

Level targeted Mod Visual interface *** Feedback * on error Presentation *** of results Menu ** customisation possibilities Authoring 0 component Input device MKTS
= = = = none poor good excellent Ratings key: 0 * ** ***

High ** *** * 0 0 M
Input device key:

Low *** 0 0 0 0 M
M K T S = = = = mouse keyboard touchscreen switch

Low-mod *** * N/A 0 *** MKTS

Mod-high * N/A N/A N/A N/A MK

Low-mod ** N/A N/A N/A *** MKTS

Low-mod *** *** *** *** 0 MK

3. What are the hardware/software requirements of the therapy software and cost of the software/extra user licenses? i) Hardware/software
If the software uses sound output, the computer will need a sound card and speakers. Many recently produced software packages will only run on Windows 95 or later and may at some point become incompatible with future versions of Windows.

5. How clear is visual presentation?

In Co:Writer, an assistive word processing package, several windows need to be open simultaneously and users can be confused as to which window they are working in. As a result they may need support and facilitation for longer before being able to use the software independently. However, in Speech Sounds on Cue, information on screen is limited to a visual demonstration of the lip shape that corresponds to the target sound and the letter that corresponds to this sound. Users therefore need fewer demonstrations before they are able to use the software independently. We used a simple three star rating system to indicate clarity of presentation with one star indicating poorest and three stars greatest clarity.

ii) Software costs

Costs vary tremendously. It is worth considering whether you are likely to want to install the software on a persons home computer or just use in clinic - and examining the price structure for multiple user licenses. For example, the cost of My House is 129 for a single user license, 449 for the 5 user license, and 645 for a 35 user licence, a price structure clearly favouring large scale use in schools over home usage. By contrast, for the software Out and About a single user licence costs 59, additional user licenses are available at 10 each and the recently introduced single license home user of 20 has allowed cheaper access for use at home.

strategy by the user. Trial and error is possible in My House when the instruction is simply repeated taking no account of the nature of the error. In most software, a maximum of three incorrect responses is allowed before the target is demonstrated so, even where no informative feedback is given, the user knows the correct response will be revealed after three attempts. In Jigsaw no information is given as to why any attempt at placing a piece of the jigsaw might be incorrect and the piece is simply removed again. In Speech Sounds on Cue the users attempts are not recorded therefore no feedback on production is given. This question does not apply to the adapted word processing software because there is no predetermined correct answer.

6. Does the software provide intervention and feedback for incorrect/correct responses?
In Out and About the feedback given relates to the nature of the error made. For example, the response No, you need to find something to wear when its hot is given when the user has mistakenly selected an overcoat to wear in hot weather. Smart Start also has some exercises where the feedback relates to the error made, such as, No thats the banana, you want the apple. This encourages linguistic processing of feedback rather than a repeat trial and error

7. How are the results recorded and presented?

Ideally the number of correct responses will be presented graphically in a form accessible to the non reader, as in Out and About and Smart Start. My House also gives the response time in seconds but all feedback is in the written word which is a far less use-friendly medium for people with communication impairments. Out and About also reports the time taken to complete the activity and whether a prompt has been needed. The recording and presentation of results does not apply to the adaptive word processing software as the purpose of this software is simply to facilitate

4. What level of ability does the user need?

This is a very gross categorisation to act as a general guide. We have used a three point scale of low-moderate-high. We felt some of the software reviewed could be appropriate for a broad range of ability depending on how it is used.

p.16

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Figure 2 Case example

Background
J, a 73 year old lady who had a left cerebrovascular accident about 18 months ago, was referred to the second author who provides a Computer Assessment and Training service from Frenchay Hospital to support clients and therapists in using computers in therapy. She has aphasia and dyspraxia, which have severely affected her spoken and written output. She is ambulant around the house, but needs a wheelchair to get about for longer trips. She has good functional use of both her hands.

Communication history
Js levels of comprehension are compromised in formal assessment but rarely affect her social and functional communication. Her speech is very limited and the few words she has are often difficult to understand due to her dyspraxia. Her writing is restricted to initial one to three letter spelling. She reads well at sentence level. She is an active participant in all communication settings.

Software we looked at
1. REACT (specific speech and language therapy language programme): We looked at using this for work on reading comprehension, spelling and whole word sentence building. 2. Co:Writer (word prediction package): We examined this to see if J could use her initial letter spelling and whole word reading to generate some of her own writing. 3. Clicker (supportive writing tool): We considered using this for work on sentence building skills in a functional way (writing cards and letters). 4. WAPS (basic keyboard familiarisation): We looked at this to see if it would help J practise finding her way around the keyboard. With help from the local speech and language therapist, we put together a therapy programme using a combination of three of these software packages (WAPS, REACT and Clicker) which J would find motivating and of immediate functional use. The aim was for her to improve skills on some packages while putting these new skills to functional use, for example when writing cards and letters. Long-term, we will review progress with spelling and sentence structure with a view to introducing the fourth package (Co:Writer). We set up a loan computer at Js home and trained J and her husband in operating the various packages. We left a folder with detailed, user-friendly, step by step, picture supported instructions for them to follow.

Current communication
J is a very sociable, confident and effective total communicator. She rates well in terms of communicative competence and uses her various strategies to respond, ask questions, initiate new topics and indulge in general banter. However she obviously has frustrations. J uses a combination of spoken single words augmented with lots of clear, functional gesture; pointing; use of a communication book; use of a diary; use of a dictionary; and writing (initial one to three letter spelling). She has excellent levels of attention and concentration, and demonstrates good potential for new learning.

Speech and language therapy input

When J was first referred, she was working on improving her writing at a single word level, improving her reading at paragraph level and increasing her speech output.

Outcome
J and her husband quickly became familiar with the operation of the computer and the layout of the keyboard. J was able to find her way in and out of the software packages and the various exercises we had set her with ease. J and her husband only needed one session of two hours to be using the computer independently (bearing in mind NO previous experience). This was followed by four home visits each lasting 11/2 hours. Within a month they were eager to purchase their own computer and three months after they had first set foot in the computer assessment and training service they were fully set up with their own PC (personal computer) and printer. J now uses the computer daily for: working on her spelling and sentence building skills writing her Christmas (and now starting on her Easter) cards writing to her family who live far away carrying out new hobbies such as making cards and playing games on the computer. (J and her husband have now purchased various software packages themselves which they have figured out how to use with minimal help.) J and her husband have also attended free IT lessons at the local library to boost their skills and confidence. J feels extremely proud of her achievement given her age, lack of previous experience and language difficulties. She has mastered something without difficulty that others, without any language impairment, are still challenged by. She feels it has helped her work independently on certain skills thus giving her more therapy. She also feels it has opened up new pastimes for which she is grateful given that, like many people in her situation, a lot of her previous hobbies such as gardening and cooking are now impossible to realise.

Previous computer knowledge

J had never used a computer before and indeed was extremely nervous about doing so. Her husband felt similarly. Her speech and language therapist had some limited experience of using computers, but did not feel certain of how to introduce them into Js therapy.

Reason for referral

J was referred to us by her speech and language therapist because she appeared to have so much potential and was so eager to try everything possible to increase her communication abilities.

Js aims:
to learn how to use a computer to then use the computer to work on the same areas as in speech and language therapy sessions, independently to increase leisure opportunities to improve written output.

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word processing. No score representative of accuracy rate is given in the Jigsaw software.

8. Does the software allow the therapist to customise the menu options available to the user?
My House gives the option of an exploring or a testing mode for the user and allows customisation of response time. Smart Start does not allow any customisation so the full suite of exercises is always available to the user. Out and About has a totally customisable menu facility so that anything from one to eight exercises can be made available.

Frenchay Hospital, Bristol, BS16 1LE or at www.speech-therapy.org.uk. Wren. Y. (2001a) Software and Speech - a review of software in phonology therapy. International Journal of Language and Communication Disorders 36 supplement, 487-492. Wren, Y. (2001b) Childrens software evaluation for Hear IT - Sound IT Research Project. Available on request from the Speech and Language Therapy Research Unit, Frenchay Hospital, Bristol, BS16 1LE or at www.speech-therapy.org.uk.

REVIE
PAEDIATRICS

HELPFUL KEY POINTS

Speech and Language Therapy (The Decision-Making Process when Working with Children) Edited by Myra Kersner and Jannet A.Wright David Fulton Publishers Ltd. ISBN 1-85346-668-9 25.00
This book addresses the everyday decisionmaking processes that speech and language therapists face when assessing and managing children. It starts by describing a framework for the processes involved, which is then applied to different work settings and a variety of client groups. Working with other professionals and parents is also included. Each chapter covers a different specialism and is by an expert in that field. They provide clear details with helpful key points. Terminology is clearly defined and learning outcomes highlighted. It is especially relevant to and a useful reference point for students, newly qualified therapists, plus returners (and anyone supervising them). A valuable addition to any speech and language therapy department. Philippa Fieldson is a returner working as a speech and language therapist for Worcestershire NHS Trust.

Resources
Bungalow Software, see www.bungalowsoftware.com. Clicker 4 from Crick Software, 35 Charters Gate, Quarry Park Close, Moulton Park, Northampton NN3 6QB, tel. 01604 671691, www.cricksoft.com. Co:Writer from Don Johnston Special Needs, 18/19 Clarendon Court, Calver Road, Winwick Quay, Warrington WA2 8QP, tel. 01925 241642, www.donjohnston.com. INTACT from Aphasia Computer Team, Frenchay Hospital, Bristol BS16 1LE, tel. 0117 918 6529, www.speech-therapy.org.uk. My House series by Laureate Learning Systems, Inc. From Rompa, Goyt Side Rd, Chesterfield, Derbyshire, tel. 0845 3000 899, www.laureatelearning.co.uk. Parrot Software, see www.parrotsoftware.com. REACT and Speech Sounds on Cue from Propeller Multimedia Ltd, PO Box 27028, Edinburgh EH10 6WD, tel. 0131 4460820, www.propeller.net. SEMERC, Granada Learning Ltd, Granada Television, Quay Street, Manchester M60 9EA, tel. 0161 8272927, www.semerc.com. Smart Start English from AVP, School Hill Centre, Monmouthshire NP6 5PH, tel. 01291 625439, www.avp.co.uk.

9. Does the software have an authoring component to allow the clinician to create their own exercises?
This allows the flexibility of targeting material that is personally relevant. Jigsaw lets the therapist use scanned or digital photos. Clicker 4 allows for personalised words, phrases and pictures to be inserted into the users grid from which users then select relevant items to build up sentences in a separate word processing window.

10. Does the program allow for different input devices to be used?
My House, Jigsaw and Clicker 4 can all be accessed by people unable to use a keyboard or mouse (that is, using a touchscreen or a switch). A lot of people with any kind of upper limb weakness will find a tracker ball easier to use than a mouse. The summary of evaluations is in figure 1 (p. 14). It shows that, as in conventional table-top therapy, no one therapy activity is sufficient to target any individuals needs, and activities become most effective when functional gains are the main goal. The case example (figure 2, p.15) illustrates how different software can be used concurrently by one person with aphasia to target their language difficulties at both impairment and functional level. Both authors are speech and language therapists working for North Bristol NHS Trust at Frenchay Hospital. Julia Wade (tel. 0117 918 6529, e-mail julia@speech-therapy.org.uk) works in the Speech and Language Therapy Research Unit, investigating use of computers in aphasia therapy. Sarah Woodward (tel. 0117 970 1212 ext 2241, e-mail comptraining@lineone.net) provides a Computer Assessment and Training service from Frenchay Hospital to support clients and therapists in using computers in therapy.

APHASIA

A WELCOME RESOURCE

During a course run by the second author and Alex Davies in June, many delegates expressed an interest in forming a Computer SIG. This could provide a useful forum for the exchange and brainstorming of ideas and equipment. If you would be interested, contact us: Sarah Woodward, tel. 0117 9701212 x 2241, e-mail comptraining@linone.net Alex Davies, tel. 0117 9754834, e-mail alex.davies@north-bristol.swest.nhs.uk.

Phonology Resource Pack for Adult Aphasia Sarah Morrison Speechmark ISBN 0 86388 228 5 85.00
This will be a welcome resource to all therapists who like to offer psycholinguistically motivated impairment therapy. The pack consists of five ring bound A4 booklets providing a substantial body of therapy exercises aimed at developing the phonological skills of people with aphasia. Most exercises are rhyme judgement tasks based either on pictures or written words. Others involve homophone judgement and a degree of phonological segmentation. There are no syllable number judgement exercises (the sales blurb describes the pack as being comprehensive, always a dangerous claim!) The pictures are line drawings presented in a gently humorous style and photocopying is permitted. The generous appendix allows for preexercise familiarisation and the consistency of format between exercises makes it easy to use. Therapists working in an outpatient or rehab setting will certainly get their moneys worth. Jon Hunt and Lauren Caris are speech and language therapists with North Bristol NHS Trust.

Reflections
Do I need to invest more time and resources in computer based therapy? Do I consider how therapy materials designed for one client group can be adapted for another? Do I encourage clients to take advantage of community education opportunities?

Acknowledgement
To Alex Davies and Jane Mortley for their contributions to the Software Evaluation Booklet and the evaluation protocol on which our evaluations were based.

References
Aphasia Computer Team (1999) Software Evaluation Booklet. Available on request from the Speech and Language Therapy Research Unit,

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