Evaluation

Reflective diaries
User involvement
Seeking the whole truth
Objective assessment
Research report
Collaboration
Joint training
In my
experience
Making learning
meaningful
Expressive arts
A P O T E N T C O M B I N A T I O N
ISSN 1368-2105
vlNTER oo+
http://www.speechmag.com
How I use
music in
therapy
My top
resources
School aged
children
Winter 2001 speechmag
Reprinted articles to complement the
Winter 2001 issue of Speech & Language
Therapy in Practice
Putting parents perceptions first.
(October 1989, 5 (5))*
Linda Banks explains how the therapist-parent relationship
can get off to a good - or bad - start. She argues that
the first visit is a momentous occasion and deserves our
fullest consideration.
New skills are needed in adult mental
handicap. (January 1989, 4 (5))*
With the return of adults with learning difficulties into
the community, Susan Dobson found that skills needed
in this field had to be re-assessed.
Drake music project strikes the right note
for communication. (Nov/Dec 1995, 5 (1))**
The Drake Music Project aims to enable disabled people to
make music through technology. Adele Drake, Diane
Paterson and Leon Clowes describe their work.
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 and try out our search facility.
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From Speech Therapy in Practice*/Human
Communication**, courtesy of Hexagon Publishing, or
from Speech & Language Therapy in Practice***
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READER OllERS
vn vorkng
wth Dysphaga
The caseloads of speech
and language therapists
are increasingly includ-
ing work with clients
with dysphagia. This
practical text by Lizzy
Marks and Deirdre
Rainbow is suitable for
a range of client
groups including those
with acquired neuro-
logical disorders and
those with learning
difficulties.
Reflecting current practice in the UK, the contents
include subjective and objective assessment, tra-
cheostomies and ventilators, and legal, health and
safety and ethical issues. Multidisciplinary working is
discussed, as is training other professionals.
Working with Dysphagia normally retails at 35.00
but Speechmark Publishing Ltd (formerly Winslow
Press) is making FIVE copies available FREE to lucky
readers of Speech & Language Therapy in Practice.
To enter, simply send your name and address marked
Speech & Language Therapy in Practice - WWD offer to
Su Underhill, Speechmark, Telford Road, Bicester, OX26
4LQ. The closing date for receipt of entries is 25th January
and the winners will be notified by 31st January.
Working with Dysphagia is available, along with a
free catalogue, from Speechmark, tel. 01869 244644.
Congratulations to Angela Abell, K. McGuigan, Miss
R. Surridge and Ellen Hesketh who won
Speechmarks The Selective Mutism Resource
Manual in an Autumn 2001 reader offer.
Also to Mrs Linda Robinson, Helen E. Bruce and K.
McGuigan (again!) who won Music Factory, courtesy
of Widgit Software, an offer in the same issue.
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Speech & Language Therapy in Practice is pleased to report that, in spite of increasing production
costs and minimal advertising revenue, subscription prices are being held yet again for 2002.
This means that:
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Inside cover
Winter 01 speechmag
Reader offer
A chance to win Working with Dysphagia from Speechmark.
2 News / Comment
4 Evaluation
Without the reflective diary and contemporaneous
records of discussions, the speech and language
therapist and the group leader would have only had
the option of feeling, Havent we done well?
(which could have occurred just because the very
large project had finally finished).
The shift away from one-to-one direct intervention
presents extra challenges when we try to
demonstrate effectiveness. Sue Dobson reports on
the value of a reflective diary for a feelings project
with adults with learning disabilities.
7 Further reading
User involvement, stroke, stammering / Parkinsons
disease, mutism, aphasia.
8 User involvement
... use of this method [a questionnaire] has the
potential to explain why some services are accepted
while others are declined, and by whom. In these
days of limited resources, it is hard to overestimate
the importance of maximising the uptake of services
provided and cooperation with therapy.
Evidence-based practice should
include evidence of the acceptabili-
ty as well as the effectiveness of
health care services. Margaret
Glogowska and colleagues found
out what parents thought of their
childs speech and language thera-
py, and how services could improve
as a result.
11 Research
report
There is clearly a need for a non
invasive, easily transportable system
which will be both well tolerated by
infants and allow objective and
simultaneous assessment of several
aspects of infant feeding.
Anthea Masarei and colleagues detail
the progress of the Great Ormond
Street Measurement of Infant Feeding (GOSMIF) which
provides objective assessment of babies fed via a bottle.
19 Reviews (cont. p24)
Voice, stammering, acquired disorders, semantics,
paediatric dysphagia, multiple sclerosis, child language,
language and literacy.
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2001 1
20 In my experience:
Making learning meaningful
The first time a teaching colleague asked me to get
involved in a maths lesson, I replied, Me? Me, who
struggled endlessly with maths at school? OK, so I got
a B grade at O level, but I never really totally
understood what I was doing! Now...I realise it is the
comprehension of mathematical language concepts
that gives meaning to the subject.
In a discussion which has relevance to our role whatever
the client group, Wendy Rinaldi shows how a language-
based approach to school curriculum subjects improves
collaboration with education staff and gives more
meaningful learning opportunities to children with
language impairment.
22Collaboration
By studying together with teachers, speech and language
therapists will be enabled to understand different
approaches to teaching methods and will also develop a
greater awareness of how children think and learn, while
teachers will gain a better understanding of speech, lan-
guage and communication needs and how intervention
can be used to help children overcome their difficulties.
Ruth Paradice explains what a new Joint Professional
Development Framework should mean for speech and
language therapists, teachers and children with
speech, language and communication needs.
25 How I use music in therapy
Using music in this way feels genuinely therapeutic as
it involves creating opportunities and offering time,
support and feedback. It demands
of the therapist the very
basic skill of really tuning
in and of being
fundamentally
facilitative...
Claire Finlay, Helen
Bruce and Wendy
Magee with Susan
Farrelly & Sophie
MacKenzie inspire us to
turn on, tune in and sing
out with all client groups.
Back cover
My Top
Resources
Audited benefits of
Johansen Sound Therapy
include improvements in
concentration, comprehension, reading and spelling,
and, in particular, in maximising the benefits of the
teaching and therapy they are already receiving.
Nicola Robinson and Camilla Leslie work with
children at primary and secondary school stages who
present with specific speech and language /
communication difficulties, with or without associated
difficulties with reading and spelling.
WINTER 2001
(publication date 26th November)
ISSN 1368-2105
Published by:
Avril Nicoll
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e-mail: avrilnicoll@speechmag.com
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Editor:
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Avril Nicoll 2001
Contents of Speech & Language
Therapy in Practice reflect the views
of the individual authors and not
necessarily the views of the publish-
er. Publication of advertisements is
not an endorsement of the adver-
tiser or product or service offered.
Any contributions may also appear
on the magazines internet site.
Contents
WINTER 2001
Cover picture by Paul Reid.
Thanks to Helen Gowland and
Duncan of Jordanstone College of Art
and Design.
See page 11.
www.speechmag.com
IN FUTURE ISSUES
PAEDIATRIC FEEDING AAC ETHICS IN DYSPHAGIA
AUTISM HEARING IMPAIRMENT CLINICAL EDUCATION
14 Expressive arts
Same people altogether - similar but different,
like being pals. The people helping too were
awfully good. That first year I wouldnt have
gone because at that time I was thinking I
would still be alright - doing a lot to try to help
myself. The worst thing was coming to, youre
not going to be the way you want - youve got
to change your heads way. Even now, its hard.
Avril Nicoll meets participants in the
Expression project, a collaborative venture in
printmaking involving people with aphasia.
She hears their unique and often surprising
stories about life, change, services, aphasia -
and speech and language therapy.
COVER STORY
Benefit
plea
A charity which supports families
who care for children with disabili-
ties and special needs is calling on
community health professionals to
help increase the uptake of benefits.
Contact a Family has found that
nearly half of all children and young
people with disabilities in the UK are
not receiving Disability Living
Allowance. The purpose of this bene-
fit - which can mean as much as
93.95 extra income a week - is to
meet the extra costs which arise
from having a disability. It is not
affected by savings and can be paid
on top of any other benefits or
income. The charity wants health
professionals in the community to
encourage parents to ring its new
helpline number to see if they are
eligible and to get a free informa-
tion pack.
Contact a Family Helpline,
freephone 0808 808 3555
(Mon-Fri, 10am-4pm);
www.cafamily.org.uk.
Conductive education
pioneer
The director of the birthplace and world centre of conductive education has died at home in Budapest.
In the late eighties, following the the BBC TV documentary Standing up for Joe, Mria Hri opened the doors
of the Peto Institute to foreign children and their families. She became a Trustee of the Foundation for
Conductive Education, the Birmingham-based national charity created specifically to bring Conductive
Education to the UK.
Conductive Education, an approach to managing children and adults with motor disorders such as cerebral
palsy, was developed in Budapest after the Second World War by Andrs Peto. Mria Hri was a medical student
who worked with Peto as an unpaid volunteer, and devoted her life to this work, increasingly as an educator
rather than a physician. After Peto died in 1967, she succeeded him as director and was chiefly responsible for
developing the role of conductors.
Andrew Sutton, Director of the Foundation for Conductive Education, said, Mria Hri grew up under
Fascism, qualified as a doctor under Socalism and steered the Institute
right through into Capitalism. She was a pragmatist and survivor. She
never married and leaves no surviving relatives. But there are now
nearly two hundred places around the world where conductors prac-
tise their craft and professional training courses in the UK, Israel,
Germany, Austria and the United States. That is her living memorial.
news
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2001 2
Black Sheep Press - an
apology from the editor
Black Sheep Press made two more
great Reader Offers in the Autumn
01 issue of Speech & Language
Therapy in Practice, for the CD Time
to Sing and Concepts in Pictures
material. Unfortunately, I printed the
companys old address. Mail re-direc-
tion ensured all entries arrived, but I
would like to apologise for my error
and to advise you of the new
address:
Black Sheep Press, 67 Middleton,
Cowling, Keighley, W.Yorks BD22
0DQ, tel. 01535 631346,
www.blacksheep-epress.com.
Society moves
The British Geriatric Society (specialist
medical society for health in old age) has
moved to Marjory Warren House, 31 St
Johns Square, London EC1M 4DN, tel. 020
7608 1369, www.bgs.org.uk.
Older people
misplaced and
forgotten
Older people with learning disabilities
are too frequently misplaced in nurs-
ing and residential homes for older
people which do not meet their needs.
According to research from the
Foundation for People with Learning
Disabilities, people with learning dis-
abilities are around 20 years younger
than other residents, staff have little or
no training in supporting them, and
there are few opportunities for daytime
activities, particularly outside the home.
David Thompson, GOLD (Growing
Older with Learning Disabilities) pro-
ject manager, said, Fifty per cent of
people with learning disabilities now
have the same life expectancy as the
general population, but services just
arent meeting their needs. Instead,
people find themselves cut off from
day services, with little opportunity to
maintain friendships and relationships
outside the residential home, which we
know to be a safeguard against abuse,
and often overlooked by specialist
learning disabilities services.
The research report recom-
mends a review of all place-
ments of people with learn-
ing disabilities in older peo-
ples homes by learning dis-
ability care management. It
also calls on local authorities
to hold registers of people with
learning disabilities, and services
to pay more attention to helping
maintain older peoples social net-
works and family relationships.
Misplaced and Forgotten, 10 + p&p,
Foundation for People with Learning
Disabilities, tel. 020 7535 7441, or
download it free from www.learning
disabilities.org.uk.
Disabled young people face social exclusion
Action for autism
The UKs leading autism charity intends to mark
its 40th anniversary in 2002 with its biggest cam-
paign to date.
Action for Autism will see the National Autistic
Society working to raise public awareness, taking
a lead role in encouraging integrated working
across agencies, and raising 4 million to support chil-
dren and adults with autism. Initially established in 1962 by
a small group of parents frustrated by the lack of appropriate
provision for their children, the Society provides education, care and sup-
port services for those with the disability and their families.
www.nas.org.uk
Not being listened to, having no friends, and finding
it difficult to go shopping, to the cinema or out club-
bing are some of the problems faced by disabled 15-
20 year olds.
Young disabled people interviewed for a leading dis-
ability charity also identified a lack of control over money,
feeling a burden and being harrassed and bullied as part
of their social exclusion. In a new report, Scope calls on
service providers and policy makers to tackle the issue as,
despite social exclusion being on the mainstream policy
agenda, the experience of young disabled people with
high level support needs is not generally addressed.
Richard Parnell, Head of Research and Public Policy at
Scope says, Scope wants policy and service providers
to look again at their policy and service objectives. We
want them to ensure that they go beyond the physical
and basic needs of these young people and take into
account their views and opinions on how they wish to lead
their lives if they are ever to achieve true equality.
That kind of life is 3 to individuals and aid users and 12.50
to professionals and organisations, tel. 020 7619 7341.
www.scope.org.uk.
Benchmarking
New benchmark statements for health care professions including speech
and language therapy will help in the design and review of education
and training programmes.
Covering both the academic and practice elements of health care pro-
grammes, the statements were drafted by groups including practitioners
and representatives of professional bodies. Benchmark statements repre-
sent general expectations of the attributes and capabilities that those
possessing a qualification should be able to demonstrate.
The Quality Assurance Agency for Higher Education reports that - as
work progressed on dietetics, health visiting, midwifery, nursing, occupa-
tional therapy, orthoptics, physiotherapy, podiatry, prosthetic and
orthotics, radiography and speech and language therapy - it became clear
that a common health professions framework was emerging.
http://www.qaa/ac/uk/crntwork/benchmark/nhsbenchmark/benchmarking.htm.
~
~
~
~
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2001 3
news & comment
A potent
combnaton
How many of us describe spending time being creative - whether through art,
music or movement - as therapeutic? In a profession so dependent on words,
turning to other methods of self-expression and communication provides
welcome relief. The actual doing enables us to say things we had previously
found difficult to put into words while, at the same time, words inform and
help us improve our creative skills.
This potent combination of expressive arts and words can be harnessed in
speech and language therapy to great effect and enjoyment for all
concerned, as is shown in How I use music in therapy (p.25) In the Expression
project (p.11) the creative process of printmaking allied with facilitated
discussion, at a time when they were ready to reflect, enabled the
participants to explore their aphasia and its implications, and describe this
verbally and non-verbally. Margaret Glogowska and colleagues (p.8) also
amply demonstrate how giving people an opportunity to reflect on services in
a way that is meaningful to them produces a wealth of information so these
services can develop in a user-friendly way. Sometimes changes needed are so
small or subtle that they can be incorporated very easily into our everyday
practice. At other times, as Anthea Masarei et al (p.17) have discovered, a
full-scale research and development project is needed.
Sue Dobson (p.4) and her key worker colleague ran a group with adults with
learning disabilities, with Sue as the speech and language therapist working
in a supportive but gradually less direct way. The key worker used a reflective
diary which proved useful for gathering qualitative information on outcomes,
and provided motivation for her to persevere. The collaborative aspect of the
approach to the group was crucial, particularly the speech and language
therapist continuing to do as well as to be involved in the reflection.
We so often want to work collaboratively but need to address this both from
a top down, strategic and a bottom up, clinical governance perspective. The
new Joint Professional Development Framework (p.22) seeks to provide an
impetus and a context for individuals to work more collaboratively but leaves
the creative detail to the individuals concerned. Wendy Rinaldi (p.20) suggests
an overall approach to working more effectively with teachers and several
ways of creating these opportunities, and this issues My Top Resources provides
some very specific practical ideas for working on language and literacy.
As loyal readers you already know that Speech & Language Therapy in
Practice values that potent combination of doing and reflecting. I am
delighted to tell you that subscription rates are again being held at their
current low level, and I look forward to your continued custom in 2002.
With best wishes for the New Year,
...comment...
Avr Nco,
Edtor
Knnear Square
laurencekrk
ABo +Ul
te/ansa/ax o++
;;(+
e-ma
avrncoQspeechmag.com
Earlybird
An innovative centre for children with autism
spectrum disorder and their families has entered
its fifth year with a new director.
Jo Stevens, who has taken over the helm of the
National Autistic Societys EarlyBird Centre, is a
teacher and licensed user of the programme
which she has been running in Lincolnshire.
The EarlyBird Centre continues to offer three
day training courses for teams of at least two pro-
fessionals wishing to become licensed users of the
programme. The centre has found this skill shar-
ing amongst teams of different disciplines and
agencies is an appropriate and effective way to
help parents cope with the pervasive effects of
autism spectrum disorder.
NAS EarlyBird Centre, 3 Victoria Crescent West,
Barnsley, South Yorkshire, S75 2AE. Tel: 01226 779218.
Technology in the community
A multidisciplinary team specialising in the assess-
ment of electronic technology for severely disabled
people is taking its service into the community.
Speech and language therapy, occupational
therapy and rehabilitation engineering staff making
up the core Compass team are from the Royal
Hospital for Neuro-disability, a national medical
charity. Assessments for communication aids,
computers, environmental controls and powered
wheelchairs for clients who require simple switches
to operate the equipment can now be carried out in
the community, nursing homes and other hospitals.
The Compass team can also draw on other services
at the Royal Hospital if extra help is needed with
setting up equipment or with support and training.
Details: Compass Project Coordinator Gary
Derwent, tel. 020 8780 4500 ext. 5237.
Speaking out about stroke
A new report shows how far health services have
to improve before they can be seen to provide a
reasonable stroke service.
Although treatment in stroke units reduces
death and disability by 25 per cent, the Stroke
Association survey found that only 22 per cent of
respondents were treated in a stroke unit. Further
difficulties arose over discharge and rehabilita-
tion arrangements.
The charity is now carrying out a survey of NHS
hospitals in England and Wales on their specialist
stroke services as the government does not collect
this information centrally. It plans to use evidence
of gaps to lobby for improvements.
Speaking Out About Stroke Services from the
Stroke Association, tel. 01604 623 933.
Implant improvements
Children receiving a cochlear implant are set to
benefit from a technique which reduces scarring,
psychological trauma and infection rates.
The Queens Medical Centre in Nottingham is
pioneering the insertion of a cochlear implant
through a small, 3cm incision behind the ear. The
childs hair can be pinned back while the opera-
tion takes place and there are no stitches to
remove afterwards.
evaluation
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2001 4
you want to
do ess hands-on
therapy
montor quatatve
change
share your enthusasm
or communcaton
evauaton
When
effectiveness
is hard to
prove
Changes in the way speech and language therapy
is delivered means therapists are improving their
skills in facilitating, teaching and joint working.
Although welcome, this shift away from one-to-
one direct intervention presents extra challenges
when we try to demonstrate effectiveness. Could
reflective diaries be a useful method?
Sue Dobson reports on a feelings project with
adults with learning disabilities.
here are considerably fewer speech
and language therapists employed to
work with adults with learning disabil-
ities since the closure of the larger
institutions and the advent of commu-
nity care (Dobson & Worral, 2001). This factor,
together with changes in working practices to a
more advisory / consultative role (Money, 2000),
has led to a difficulty in measuring the effective-
ness of recommended interventions.
An episode of communication intervention is
now usually delivered and led by the day-care
workers or residential staff in the community
(Purcell et al, 2000). The role of the speech and
language therapist has become more of a facilita-
tor, supporter, trainer, and joint planner of inter-
ventions rather than to deliver hands-on therapy.
This means the therapists concerned often have
difficulty in evaluating the outcomes of their
action, as they cannot control many of the vari-
ables that influence the delivery of the therapeu-
tic process. Communication is viewed in the con-
text of the perspective and influence of the com-
munication partners - staff, peers and significant
others. Interventions therefore have to focus on
influencing:
1. the staff group
2. the activity
3. how it will be organised and delivered
4. using an appropriate tool to evaluate its effect.
The programmes, therefore, do not lend them-
selves to standard evaluation packages or meth-
ods. Some detailed quantitative evaluations may
take longer than the actual delivery of the inter-
vention itself; the danger then becomes that the
programmes are rarely fully monitored or
reviewed. So, different styles of effective methods
of evaluation need to be explored.
This article concentrates on the intervention
offered to a lady with autism spectrum disorder.
The intervention, which spanned a twelvemonth
period, focused on her emotional distress and her
inability to express it in a socially acceptable way.
As a project, it included all her peers and aimed to
develop an evaluation method which would be
useful to all those participating - peers and staff.
Qualitative changes
The initial three month period of joint working
with the group of service users involved was a
matter of routine style of evaluation: joint plan-
ning of each session, end of session discussions,
and monitoring and recording of individual and
group outcomes against the stated aims and
objectives. The second stage, of monthly visits to
the group by the speech and language therapist
and generalisation of the service users skills, and
the final stage of monthly meetings and discussion
with the group leader, presented greater difficulties.
The main focus of the work - qualitative changes
in communication, social interactions and the
environment - was evaluated using a reflective
diary written after each session by the group leader.
This was supplemented by records of facilitated
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SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2001 5
evaluation
reviews of progress during the joint monthly dis-
cussions. Reflective diaries have become a com-
mon feature in accredited courses at universities
for nurses, therapists and social workers. They can
also be used in the personal development log of
registered speech and language therapists, and
are regarded as acceptable evidence within clinical
governance activities.
Our client, R, was 29 years old with severe learn-
ing disabilities and autism spectrum disorder. A
lot of her speech was echoing commonly used
staff phrases. She was very emotionally volatile
and often became distressed about disruptions in
her routine or her inability to obtain items about
which she was currently obsessed. When this
occurred she shouted using repetitive phrases.
When extremely distressed she abused herself by
throwing herself violently on the floor or against
walls. Her general demeanour was that of
extreme anxiety. She constantly prowled around
the day centre looking for things to collect and
making excessive amounts of noise. It was diffi-
cult to engage her in activities and she rarely
interacted with her peers. It was felt her lack of
adaptability and poor level of social
competence were major factors in her
continuing distress.
Rs key worker reflected on referring
her for speech and language therapy:
Id been poorly for quite sometime
and when I returned to work, I felt Id
lost touch with my group. One of my
students was bouncing off walls and
screaming, one was shouting and
interrupting over the top of everyone.
Two of my students were always in
tears and one hid others belongings just to upset
them. Another student scratched herself and oth-
ers until they bled and the final one was very
withdrawn.
The agreed years plan was to establish a discus-
sion group which focused on emotions and creat-
ed a feelings communication book for each stu-
dent (sample pages in figure 1). The first months
led to the following comments by the group
leader:
For weeks we have cut out happy arms, happy
eyes, happy bodies! Weve made lists of things
which make us happy, temperature charts about
how happy we are and what we would say and
when wed say it...Its evident that its hard work for
them to see from our faces what we are feeling.
Transition
In the fourth month the therapist stopped attend-
ing every group but remained in close weekly con-
tact with the group leader for discussion. She also
supported the making of charts, symbolic material,
or social stories about situations in the centre. The
group leader was recording at this time of transi-
tion in delivery of the planned intervention:
At the beginning I felt I was preaching. Now
some of the group are beginning to think this
work applies to them. If they miss a group theyre
saying Im sorry to let you down. I was worried
about some aspects of the emotions such as cross
and that it would cause me problems but its been
a realisation. Its allowed the group to wave feel-
ings that they have had to keep quiet about. They
feel what they say is important If one of them
misses a group the others are passing on the best
of what we did to let them know too.
Individual records also showed that R had spon-
taneously approached the group to apologise for
screaming. Other group members were interrupt-
ing less frequently or volunteering comments
without prompts. One of the more withdrawn
group members was getting materials out in
preparation for the group without being asked.
The group leader felt:
This work has given the group a lot of order
which we didnt have before ... they are staying
on the section and joining in more.
There were also records about how some emo-
tions seemed to cause more difficulty than others.
Sadness had posed particular problems. However,
when R was seen to be crying two days after the
session the group leader recorded:
She was so distressed she hardly
noticed when I sat next to her. I
said, Oh dear, you are sad. Whats
the matter, love? She answered
me very quietly saying, I want my
mum. After a bit she used a much
louder voice and said, Enough
now, much better now and gave
me a cuddle and got up and left.
Some feelings, such as tired,
seemed to affect the groups imme-
diate physical behaviour. R
wrapped herself in a blanket and went to sleep
when tiredness was the topic. They found those
feelings which had clear physical symptoms easier
to describe; for example, tiredness was described
in terms of yawning, aching legs, and difficulty in
keeping your eyes open. Certain sessions were of
more relevance to some of the group. When this
happened they showed greater interest, made
more comments and participated to a higher
degree than usual. One of the group who is often
seen as lethargic described tiredness as:
If you are tired you can look ill. You may feel
cross for no reason, get in a muddle and find it
hard to talk.
Another woman, who was seen as energetic,
showed a complete lack of interest in this topic.
On the day tiredness was discussed she increased
her rate of interrupting and talked over the top
of others to a point where they objected.
Throughout this time R had always been pre-
sent, but never sat at the table with the group.
She had usually been seated in a corner of the
room. She came to the table when it was her turn
and participated but then returned to her space.
The group had started in a small but quiet room.
R had found this too confining so eventually the
group returned to the larger, key worker section
which was less private and noisier. After the
At the beginning
I felt I was
preaching. Now
some of the group
are beginning to
think this work
applies to them.

Figure 1 Sample pages from feelings communication book.

evaluation
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2001 6
moves, the level of discussion improved. The
leader recorded in her diary:
It was as if home ground made it easier to
discuss sensitive topics.
They send their love
Despite distancing herself from the group physi-
cally, it became clear R was listening and process-
ing what was being discussed. The leader had
noted, when being loved had been the groups
topic, that love seemed to be equated by all par-
ticipants with presents, and that most of the
group had really failed to fully understand the
concept. However, two weeks later, R forgot to
bring her home-to-centre communication book.
When the group leader expressed her disappoint-
ment at this, R offered the alternative and con-
textually appropriate reply of, They send their
love. This script had been used within the group.
Later, during the groups discussion of mischief, R
approached the table when it was not her turn in
the discussion, took the group leaders plan for
the group, screwed it up and put it in the bin. She
then said, Only kidding. The group leader was
by this time making short notes at the end of
groups such as a very productive session.
A month before the group finished, the leader
was noting R was now joining in the group on
occasions when it was not her turn. Her comments
were recorded as calm, quiet and appropriate.
The group leaders reflections indicated that R no
longer seemed threatened by the situation and
that her general manner in the centre was qui-
eter, and she was less often seen to be upset. She
reflected:
Its almost full circle now and we still need to do
anger. They have never discussed what it looks
like or how it feels and although Ive discussed
anger as a side effect of a lot of the situations
weve discussed, theyve always avoided it Some
clearly struggle to see the difference between
angry, jealous and sad I think they are scared of
showing it or talking about it They are expected
to be happy, angry isnt acceptable.
The record for the last group talked about the
need to build up trust and feel safe within the
group before being able to say anything about
anger or say what they could do to help each
other in angry situations. The last entry in the
reflective diary listed what had happened to the
service users over the year. The lady who hid other
peoples things touchingly discussed her feelings
of how she couldnt enjoy life as she wanted
because of her medical conditions. The lady who
hit and scratched herself was able to say she
wished to leave the centre and, once in control of
her anger, was able to attend another centre. The
lady who was withdrawn started to say what she
didnt like. The student who cried most of the
time told the group how lonely she was, how too
much was asked of her, and how much she liked
praise. The service user who interrupted all the
time now has an awareness of it, and she does it
less frequently and is seen as being prepared to
listen to other points of view. Finally R who, to
start with,
was bouncing off walls finds it easier to express
herself... she repeats less and has much better eye
contact. She shows her sense of humour.
Spontaneous
R was recorded as using more spontaneous utter-
ances which were longer and had a higher level of
structure; for example, Louise, Look at me,
mince pie please, when a promise had been for-
gotten. She was also using a wider range of com-
municative functions. Prior to the group, most of
her utterances had been requests for objects or
immediate needs. Some of her utterances now
also reflected the work on scripts for communica-
tion of feelings and emotions, such as, Oh my
god, its David! on seeing someone she found
frightening.
The group leader felt
running the group had
been a great learning
experience but, best of all,
I feel I understand my stu-
dents better and the issues
that are important to them.
It was truly a communication
breakthrough for every-
one.
Her initial intention had
been to use the group
work to help her complete
individual communication
profiles for the group
members. She stated that
this group had enabled
her to understand and
describe the quality of
their communication and
their needs in much greater depth. In the group
leaders evaluation of the therapy service and its
support she described that in the beginning shed
been sceptical and unsure of what the planned
group was likely to achieve. All she had initially
wanted was to create good communication pro-
files for each service user in the group. However,
the value of having someone to share both the
frustrations and the real breakthroughs with had
been important. The support of having someone
to prepare the necessary material, create the com-
munication books and record the work from an
outside perspective had been helpful. Her feeling
was that, without this kind of support, the group
would have stagnated and fizzled out. Part of the
pleasure of running it and completing the inter-
vention was the excitement of sharing what the ser-
vice users felt, their achievements and the books
they had created.
Reflective diaries are most often used as a medi-
umfor staffs personal development. It seems, how-
ever, that they can also provide useful informa-
tion about the service users development. In the
case of this group, only measuring their perfor-
mance against the aims and objectives of the
intervention plan would have left a lot of the
qualitative changes unrecorded. How, for exam-
ple, do you define a sense of fun or an aware-
ness of hurting others feelings? The group
leaders regular record keeping in the form of a
reflective learning log for herself meant it was
possible to look back and compare her impres-
sions of how much the participants understood
and applied their new knowledge. Without the
reflective diary and contemporaneous records of
discussions, the speech and language therapist
and the group leader would have only had the
option of feeling, Havent we done well?
(which could have occurred just because the very
large project had finally finished).
This method of recording change also enabled
the inclusion of Rs peers progress in a lively and
interesting format. The log includes some heart
touching insights into the
frustrations experienced by
the participants in everyday
situations and the similarity
of the kind of everyday
annoyances which affect us
all. The group leader put it
in her final entry in the log:
/ have noticed a distinct
change in my relationship
with them, We have grown
closer and more trusting of
each other, student to stu-
dent and students to me. ...
Our sameness has modified
our behaviour. Although the
groups finished I can still
hear the work coming back
to me in the scripts we
planned together.
Sue Dobson is a specialist speech and language
therapist with the clinical liaison team at Horton
Park Health Centre, 99 Horton Park Avenue,
Bradford BD7 3EG, tel. 01274 228900, e-mail dob-
son@bcht.northy.nhs.uk.
Acknowledgement
Thanks to Linda Thresher, Bradford Social Services,
for making this study possible.
References
Dobson, S. & Worrall, N. (2001) The way we were
... Bulletin of the Royal College of Speech and
Language Therapists. May 589, 7-9.
Money, D. (1997) A comparison of three
approaches to delivering a speech and language
therapy service to people with learning disabilities.
European Journal of disorders of Communication
32 (4) 446-449.
Purcell, M., McConkey, R. & Morris, I. (2000) Staff
communication with people with intellectual dis-
abilities: the impact of a work based training pro-
gramme. International Journal of Language and
Communication Disorders 35 (1) 147-158.
Do I actively seek
useful methods of
evaluating everyday
practice?
Do I make use of a
reflective diary for my
personal and
professional
development?
Do I recognise that my
support can be as
crucial to a project
continuing as it is to it
starting?
Reflections
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2001 7
further reading
APHASlA
Yasuda, K., Nakamura, T. & Beckman, B. (2000) Comprehension and storage of four seri-
ally presented radio news stories by mild aphasic subjects. Brain Lang 75 (3) 399-415.
The present study investigated aphasic subjects ability to comprehend and store serially
presented discourse. Sixteen mild aphasic subjects, eight age-matched normals, and eight
younger normals listened to four serially presented radio news stories and a single radio
news story. Half of the aphasic subjects performed as well as age-matched normals in a sin-
gle-news-story comprehension task. However, they demonstrated a drastic deterioration
in performance when asked to listen to a series of four news stories. Age-matched nor-
mals, and aphasic subjects, to a lesser extent, showed an impairment in the comprehen-
sion and storage of the news story heard last in a series of four news stories. These results
were discussed in terms of the comprehension and storage resources of working memory.
lURTHER
READlNG
Ths reguar eature
ams to provde
normaton about
artces n other
journas whch may
be o nterest to
readers. The Edtor
has seected these
summares rom a
Speech 8 language
Database comped
by Bomedca
Research lndexng.
Every artce n
over thrty journas
s abstracted or
ths database,
suppemented by a
monthy scan o
Nedne to pck out
reevant artces
rom others.
To subscrbe to the
lndex to Recent
lterature on
Speech 8
language contact
hrstopher Norrs,
Downe, Badersby,
Thrsk, North
Yorkshre YO; (PP,
te. o+; (o8,
ax o+; (o.
Annua rates are
Ds (or vndows
,):
lnsttuton L,o
lndvdua Lo
Prnted verson:
lnsttuton Lo
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heques are
payabe to
Bomedca
Research lndexng.

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USER lNVOlVENENT
Dixon-Woods, M. (2001) Writing wrongs?
An analysis of published discourses
about the use of patient information
leaflets. Soc Sci Med 52 (9) 1417-32.
Much has been written about how to com-
municate with patients, but there has been
little critical scrutiny of this literature. This
paper presents an analysis of publications
about the use of patient information
leaflets. It suggests that two discourses can
be distinguished in this literature. The first
of these is the larger of the two. It reflects
traditional biomedical concerns and it
invokes a mechanistic model of communica-
tion in which patients are characterised as pas-
sive and open to manipulation in the interests
of a biomedical agenda. The persistence of the
biomedical model in this discourse is contrast-
ed with the second discourse, which is smaller
and more recent in origin. This second dis-
course draws on a political agenda of patient
empowerment, and reflects this in its choice of
outcomes of interest, its concern with the use
of leaflets as a means of democratisation, and
its orientation towards patients. It is suggested
that the two discourses, though distinct, are
not entirely discrete, and may begin to draw
closer as they begin to draw on a wider set of
resources, including sociological research and
theory, to develop a rigorous theoretically
grounded approach to patient information
leaflets. (141 References)
NUTlSN
Gordon, N. (2001) Mutism: elective or selective, and acquired. Brain Dev 23 (2) 83-7.
When a child does not speak, this may be because there is no wish to do so (elective
or selective mutism), or the result of lesions in the brain, particularly in the posterior
fossa. The characteristics of the former children are described, especially their shyness;
and it is emphasized that mild forms are quite common and a definitive diagnosis
should only be made if the condition is significantly affecting the child and family.
In the case of mutism due to organic causes, the commonest of these is trauma to
the cerebellum. Operations on the cerebellum to remove tumours can be followed
by mutism, often after an interval of a few days, and it may last for several months
or longer, to be followed by dysarthria. Other rarer causes are discussed, and also
the differential diagnosis. The so-called posterior fossa syndrome consists of mutism
combined with ataxia, cranial nerve palsies, bulbar palsies, hemiparesis, cognitive
impairment and emotional lability, but the post-operative symptoms are often dom-
inated by the lack of speech. The most accepted cause for the condition is vascular
spasm with involvement of the dentate nucleus and the dentatorubrothalamic tracts
to the brain-stem, and subsequently to the cortex. Diaschisis may be involved in
causing the loss of higher cerebral functions, and possibly, complicating hydro-
cephalus. The treatment of elective mutism is reviewed, either using a psychotherapeutic
approach or a variety of drugs, or both. These may well be ineffective, and it must
be remembered that the condition often resolves on its own. The former treatment
must concentrate on the training of social skills and activities of daily life and must
be targeted to both the child, the family, and the school. Also, all kinds of punishment
and insistence on speech must be discouraged. The drug, which seems to be most
effective, is fluoxetine. Discovering more about the causes of mutism due to organic
causes may well depend on studies using such techniques as magnetic resonance
imaging and single photon emission tomography. (42 References)
STROKE
Sundin, K., Norberg, A. & Jansson, L. (2001)
The meaning of skilled care providers
relationships with stroke and aphasia
patients. Qual Health Res 11 (3) 308-21.
Little is known about the reciprocal influ-
ence of communication difficulties on the
care relationship. To illuminate care
providers lived experiences of relationships
with stroke and aphasia patients, narrative
interviews were conducted with providers
particularly successful at communicating
with patients. A phenomenological
hermeneutic analysis of the narratives
revealed three themes: Calling forth
responsibility through fragility, restoring
the patients dignity, and being in a state of
understanding. The analysis disclosed car-
ing with regard to the patients desire,
which has its starting point in intersubjec-
tive relationship and interplay, in which
nonverbal communication is essentialthat
is, open participation while meeting the
patient as a presence. Thus, care providers
prepare for deep fellowship, or commu-
nion, by being available. They described an
equality with patients, interpreted as fra-
ternity and reciprocity, that is a necessary
element in presence as communion. The
works of Marcel, Hegel, Stern, and Ricoeur
provided the theoretical framework for the
interpretation.
STANNERlNG / PARKlNSONS DlSEASE
Shahed, J. & Jankovic, J. (2001) Re-emergence of childhood stuttering in
Parkinsons disease: a hypothesis. Mov Disord 16 (1) 114-8.
OBJECTIVE: To characterize speech patterns in patients with Parkinsons disease (PD) who
have a history of childhood stuttering. BACKGROUND: Childhood stuttering usually
resolves, but it re-emerges in some patients after stroke or other brain disorders. This phe-
nomenon of recurrent stuttering has not been characterized in childhood stutterers who
later develop PD. METHODS/PATIENTS: Twelve patients with a history of childhood stut-
tering that remitted and subsequently recurred were included in the study. A structured
interview was administered to seven patients, and six were able to answer questions
about childhood stuttering. The Johnson Severity Scale (JSS) (range 0-7) and a Situation
Avoidance Scale (SAS) were used to rate stuttering severity (range 0-15) and avoidance
(range 0-15). RESULTS: The mean age at onset of childhood stuttering was 6.2 years (range
5-10), the mean latency from the onset of childhood stuttering to adult stuttering was
46.1 years, and the stuttering recurred on average 5.9 years (range 0-21) after the onset
of PD. The stuttering characteristics in childhood and adulthood included repetitions of
sounds and syllables at the beginnings of words, blocks and interjections, physical tension,
and a worsening of symptoms with stress. The patients rated themselves as having mild-
to-moderate childhood stuttering by the JSS (mean 3.0, range 2-4) and mild-to-moderate
stuttering and avoidance by the SAS (mean stuttering score 5.3, range 3-7, mean avoid-
ance score 4.2, range 3-6). There was no apparent association between the severity of
childhood stuttering and the severity of PD, but those patients who had higher Unified
Parkinsons Disease Rating Scale scores tended to have more and worse symptoms of stut-
tering. CONCLUSION: Our patients provide evidence for the hypothesis that childhood
stuttering may re-emerge in adulthood with the onset of PD. (45 References)
user involvement
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2001 8
he need to involve clients in health
care decisions and the evaluation of
services is now widely acknowledged.
In recent years the participation of
parents in their childrens speech and
language therapy has increased. There has, how-
ever, been little attempt to investigate parents
opinions of the services they receive.
There have been some attempts to use clients
perceptions as a measure for audit (van der Gaag
et al, 1993; van der Gaag et al, 1998), but formal
measures of consumer satisfaction have rarely
been built into research designs evaluating treat-
ments for early speech and language delays.
When a randomised controlled trial to evaluate
the effectiveness of community-based speech and
language therapy for speech/language delayed
preschool children (described in Roulstone et al,
1999; Glogowska et al, 2000) was initiated, a
questionnaire was designed to investigate
parental views of the interventions. We hoped
that, by improving our understanding of why dif-
ferent people choose to accept or decline therapy,
we could gather ideas for planning services and
approaching parents in a way that would max-
imise uptake and cooperation.
The questionnaire was aimed at the parents of
159 pre-school speech/language delayed children
who participated in the randomised controlled
trial. The children were initially randomised to
receive either immediate treatment (Therapy
Now) or to watchful waiting for a period of 12
months before receiving therapy (Therapy Later).
The Therapy Now children received the same
intervention that would have been available to
them outside the trial. The parents of the Therapy
Later children were given general advice only but
could start receiving treatment for their children
at any point over the 12 month period if they
wished. All the children in the trial were re-
assessed at 6 months and 12 months post-ran-
domisation. The questionnaire was administered
at the 12 month re-assessment point, when the
childrens involvement in the trial ended.
Altogether, 147 parents participated in the survey
- a response rate of 92.5 per cent.
T
Evidence
based practice:
seeking the whole truth
Convenient
In the questionnaire, parents were asked to
respond to closed questions about organisational
aspects of the service. Open questions were also
included where parents could raise their own
issues. With regard to the location of appoint-
ments, usually the local community clinic, 140 par-
ents (95 per cent) found it convenient. However,
attendance was difficult for some, especially
when parents relied on public transport.
Appointment times were acceptable, with 133
parents (90 per cent) rating them as convenient.
However, in the open sections of the question-
naire, parents mentioned difficulties in attending
when they worked full-time. The time allowed for
the appointments was considered satisfactory,
with 126 parents (86 per cent) rating the length of
appointments as about right. (Routine data
available from the speech and language therapy
services being evaluated in the trial showed that
the length of sessions ranged from thirty minutes
to one-and-a-half hours). However, some parents
(4 per cent) considered the length of the appoint-
ment too long, particularly where the childs con-
centration span was short.
Parents were asked about the number of
appointments they had received. While 96 par-
ents (65 per cent) said the number of appoint-
ments was about right, 32 parents (22 per cent)
said they had received too few. Likewise, when
questioned on the gap between appointments,
103 parents (70 per cent) said the gap was about
right but 27 parents (18 per cent) said it was too
long. The responses of Therapy Now and Therapy
Later parents were compared in these areas but
no difference was found between the groups.
Routine data collected from the speech and lan-
guage therapy services involved showed that, on
average, Therapy Now children attended 7.7
appointments (the range was 0 to 17) during their
involvement in the trial and, on average, were
seen monthly (the range was from once weekly to
once every two months). Post-randomisation,
Therapy Later children were seen for re-assess-
ment after six months and for final re-assessment
after a further six months. The number and fre-
quency of appointments were major differences
between them. However, this suggested that,
even where children received intervention, par-
ents still did not feel that the amount of speech
and language therapy provision was adequate.
In the questionnaire, 130 parents (88 per cent)
responded that the therapist had given them an
explanation of their childs difficulty which was
helpful and 128 parents (87 per cent) felt that the
therapists understanding of the childs difficulties
had been good. Also, 132 parents (90 per cent)
found the therapists advice helpful and 135 par-
ents (92 per cent) said they were able to make use
of the advice. The open question on the question-
naire, What has the speech and language thera-
pist done? prompted a wide range of positive
responses from parents of both Therapy Now and
Therapy Later children, including helped the childs
talking, improved their confidence, given parents
guidance about helping, given parents reassurance
and increased parents understanding of the childs
difficulty. A few parents, again of both Therapy
Now and Therapy Later children, did not feel that
the therapist had done anything to help.
Feeling better
Parents were asked whether speech and language
therapy had made them feel better about their
child, themselves and the difficulties experienced
by the child. While 100 parents reported that
speech and language therapy had made them
feel better about their childs difficulties (68 per
cent), 50 parents reported that speech and lan-
guage therapy had made them feel better about
the child (34 per cent) and 27 parents reported
that speech and language therapy had made
them feel better about themselves (18 per cent).
Parents could give negative responses to the
above statements too, although few did. Parents
were also asked about how the child and the fam-
ily had coped with the communication difficulty
over the period of their involvement in the trial.
Broadly, parents of children in both groups
answered that the child and the family had coped
well with any difficulties and that positive
changes in the childs relating to others had
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SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2001 9
user involvement
Are you frustrated when people fail to attend
or seem ambivalent about their childs therapy?
As Margaret Glogowska and colleagues
discovered, better communication between
therapists and parents and more flexible services
could make a difference.
occurred.
Parents were questioned about their views on
changes in their childrens difficulties over the
course of the year. For 139 parents (95 per cent)
there had been improvement in their childs diffi-
culty, with five parents responding that the diffi-
culty had stayed the same or got worse. Of those
parents who felt that there had been positive
change in their child, 104 parents (71 per cent)
felt that speech and language therapy provision
had contributed to the change. All the parents
were also questioned about their perceptions of
the childs need for further therapy, with 103 par-
ents (70 per cent) feeling that their child contin-
ued to be in need of therapy.
The questionnaire showed that both interven-
tion strategies were acceptable to differing sets of
parents. Many of the Therapy Now parents (96
per cent) were happy with the help they had
received and attributed their childrens improve-
ment to the treatment: Made a great difference
with his speech as he can now use short sen-
tences; Improved my sons speech and put my
mind at rest. Some parents (56 per cent) of the
children who had waited for therapy had found
the monitoring condition satisfactory: I wasnt
terribly concerned so I wasnt too worried about
waiting; I didnt mind as I wanted to see how
my child developed on his own; It gave us
chance to use the advice given to help him. For
some parents, Therapy Later was the intervention
strategy they would have chosen for themselves.
This was particularly true where the family was
experiencing difficult circumstances. For example,
one mother found it increasingly difficult to bring
her child for regular therapy, as she was also car-
ing for a terminally ill relative at the time.
Another mother explained that postponing her
childs therapy would have made life easier for her
as she was heavily pregnant with a second child,
had no car and found using public transport to
attend clinic very inconvenient.
Therapy Later was not universally acceptable,
however, as these comments show: I thought he
was not talking as well as he should; We felt he
was falling behind because of his ability to com-
municate with other children; I was concerned
about him starting school. When asked what
immediate therapy could have done, 46 parents
(71 per cent) of Therapy Later children felt that it
would have helped the difficulty. When asked
how having therapy straightaway
would have made them feel, 33 par-
ents (51 per cent) reported that it
would have made them worry less
about their childs difficulty.
However, a further 20 parents (31
per cent) felt that therapy would
have made no difference to their
concerns and 3 parents (5 per cent)
felt that therapy would have caused
them to worry more about their
childs difficulty.
Helpful
When asked about the games and activities pro-
vided in therapy, 71 parents (87 per cent of those
who received intervention) rated them as good.
Likewise, rating the strategies given them during
the therapy sessions, 68 parents (83 per cent)
found them to be good. A number of parents
made comments in the questionnaire about these
aspects: I was provided with lots of pictures and
given advice of games to play; The games and
activities that we did with her were very helpful.
When questioned about what aspects of the ser-
vice they were particularly happy with, several
parents singled out treatment activities and being
able to carry these on outside the clinic: General
advice and worksheets given in order to work
with at home; The way I was able to encourage
him at home with our sheets we were given.
However, not all parents perceived the activities
as constructive and helpful - the most common
negative perception of parents was that they
wished something more specific could have been
worked on: I felt I was guided by the speech
therapist on what to or not to do with him. I
would have liked tasks to be more specific, ie.
work on this group of words and well see how he
has got on with them next time; No answers for
the problems. Never felt it was very positive or
reassuring. Thought it would be more construc-
tive than assessments. A number of parents
expressed dissatisfaction over the lack of informa-
tion given to them about what they could do with
their child at home: The guidance was long-
winded and applicable ideas were
few; Games/activities were very lim-
ited. I would have benefited from a
few more suggestions.
Overall, parents expressed positive
views about the organisation of the
services they received. Parents them-
selves often seemed to benefit from
the provision offered because they felt
something was being done and that
their concerns about their childs
development were being taken seri-
ously. They had the opportunity to dis-
cuss the emotional aspects of having a
child with a communication difficulty and receive
support. Also, they felt they were being given the
means to help the child themselves.
The questionnaire, however, revealed areas of
difficulty for parents which might affect their sat-
isfaction with the service and even influence
whether they were prepared to attend therapy.
These included practical difficulties with getting
to clinic, the need for flexibility in arranging
appointment times, and the parents desire for
more frequent appointments. Greater awareness
of these on the part of speech and language ther-
apist and providing the opportunity for parents to
discuss these issues with the therapist might help
to increase parental adherence to therapy.
The acceptability of watchful waiting to cer-
tain parents is also of importance for speech and
language therapists. The acceptability of defer-
ring treatment to some parents will come as little
surprise to therapists. They may well have encoun-
tered families who do not cooperate with therapy
offered because they do not appreciate the sever-
ity of their childs difficulties, or because they find
it difficult to organise their lives. On the other
hand, therapists may feel disappointed and
threatened by parents who, aware of the degree
of their childs problems, are not persuaded that
They had the
opportunity to
discuss the
emotional aspects
of having a child
with a
communication
difficulty
you want to
take account o users
vews
encourage uptake o
your servce
target mted resources
Read this
user involvement
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2001 10
therapy should be undertaken and prefer a
watchful waiting option.
Need for discussion
The questionnaire demonstrated that, even
where parents felt immediate therapy might help,
it was not always the intervention strategy of
their choice and would not have necessarily alle-
viated their concerns. However,
the choice to delay therapy
became more explicable in the
light of the explanations dis-
closed by parents on the ques-
tionnaire. This highlights the
need for discussion with parents
about what other events may be
currently happening or about to
happen in their lives which may
interfere with regular atten-
dance at the clinic and make
speech and language therapy
seem less of a priority in their eyes. Taking into
account family circumstances should help the par-
ent and therapists to determine the best course of
action, weighing up the needs of the child and the
rest of the family in a realistic and manageable
way. Even where a parent attends clinic regularly
and willingly, it should not be taken for granted
that the family is not under severe stress.
The comments of some of the parents revealed
a large perceptual gap between them and the
therapists they saw in the area of treatment activ-
ities. One parent perceived that the play activities
undertaken by the therapist with her child were
merely ongoing assessment and therefore did not
constitute treatment for her childs difficulties.
Clearly, what the therapist aimed to achieve was
not transparent to the parent. This highlights the
need for therapists to make explicit to parents the
therapy they give. Others complained of the lack
of specific, applicable ideas. They sometimes felt
that the ideas passed on to them by therapists
were common sense or what they were already
doing with their children, to no noticeable effect.
For this reason, a check from the therapist to find
out what parents were already doing to try to
help their child, what ideas they had gleaned
from books, magazines or other media, or what
advice they had already received from friends,
family and professionals might have avoided this.
The trend towards evidence-based practice calls
for evidence of the acceptability as well as the
effectiveness of health care services. The study
reported here investigated parents response to
speech and language therapy provision for their
children alongside a trial of the clinical effective-
ness of the intervention. While the randomised
controlled trial provided information about the
progress of the children in Therapy Now and
Therapy Later, the questionnaire was designed to
show the limitations and advantages of the two
intervention strategies and to investigate other
aspects of the service from the viewpoint
of the parents whose children participat-
ed.
As a means of evaluating the accept-
ability of speech and language therapy
services, the questionnaire should be
regarded in speech and language thera-
py as a valuable tool. As this report
demonstrates, use of this method has
the potential to explain why some ser-
vices are accepted while others are
declined, and by whom. In these days of
limited resources, it is hard to overesti-
mate the importance of maximising the uptake of
services provided and cooperation with therapy.
Margaret Glogowska and Sue Roulstone are
speech and language therapists at the Speech and
Language Therapy Research Unit, Frenchay
Hospital in Bristol. Rona Campbell and Tim J. Peters
are based in the Department of Social Medicine at
the University of Bristol. Pam Enderby is at the
School of Health and Related Research in Sheffield.
References
Glogowska, M., Roulstone, S., Enderby, P., &
Peters, T.J. (2000) Randomised controlled trial of
community-based speech and language therapy
for pre-school children. BMJ 321: 923-926.
Roulstone, S., Glogowska, M., Enderby, P. & Peters,
T. (1999) Issues to consider in the evaluation of
speech and language therapy for pre-school chil-
dren. Child: Care, Health and Development 25(1),
141-155.
van der Gaag, A., Glass, K. & Reid, D. (1993) Audit:
A manual for speech and language therapists.
London: College of Speech and Language
Therapists.
van der Gaag, A., McCartan, P., McDade, A. &
Reid, D. (1998) An audit tool for health visitors
and speech and language therapists working with
the pre-school population. Proceedings of the
Royal College of Speech and Language Therapists
Conference, International Journal of Language
and Communication Disorders, 33: 37-41.
1. Find out family circumstances and priorities.
2. Check what carers are already doing to help.
3. Discuss pros and cons of starting or delaying intervention.
4. Offer advice that is as specific as possible.
5. Make sure people understand what you are doing and why at every stage.
Five steps to better practice

Taking into
account family
circumstances
should help the
parent and
therapists to
determine the
best course of
action
Career initiatives
A pioneering cadet scheme is opening up a career
in speech and language therapy to more people
from black and minority ethnic backgrounds.
The Birmingham programme offers a new way
into the profession for people who may not
have followed a traditional route through edu-
cation, but understand the language and cul-
ture of the diverse communities living there.
The cadets, supported and mentored by quali-
fied speech and language therapists, start by
obtaining a Btec in speech and language thera-
py, an NVQ in therapy skill and higher level
study skills, before going on to the three year
speech and language therapy graduate course
at the University of Central England.
The cadet scheme is funded by the West Midlands
South Workforce Development Confederation
which is also targeting career break health profes-
sionals, including speech and language therapists,
with return to practice initiatives.
Following on from successes in Shropshire and
Staffordshire, the Confederation is now offering
a multidisciplinary six week, part-time test the
water course at Keele University, aimed at peo-
ple who used to work in the NHS. Course fees
and financial assistance are available, and flexi-
ble returns to work are emphasised.
Details of the Keele University course from June
Spencer or Tracey Allen, tel. 0121 415 2185.
Multimedia project
- request from
Communications
Forum
Are you working with communication-impaired
children within mainstream classrooms?
The Communications Forum has gained fund-
ing to develop multimedia training resources
for schools. These resources will be aimed
primarily at teachers working at key stage 2
within mainstream schools.
If you work in this area or provide training and
would like to comment on any of the follow-
ing points please contact me on 0191 413 1818
or e-mail me at KAREN@kdixon27.fsnet.co.uk
1.What training medium would your school/
department find most useful eg. video;
CD ROM?
2.What information would be of most
interest to teachers and therapists?
3.Are you involved in collaborative working
with teachers / speech and language
therapists in your area?
Let me know where and how.
4.Are you involved with training in schools?
I would like to hear from you.
5.Would you like to know more about the
project? Let me know.
Looking forward to hearing your views and
comments,
Karen Dixon
Project Manager
news extra...news extra...
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2001 11
research

(Braun & Palmer, 1985) to the development of

devices such as pressure transducers and manome-
ters used to measure intra-oral pressures generated
during sucking, fiberoptic cameras placed within
infant bottles allowing direct visualisation of
intra-oral movements during sucking, ultrasonog-
raphy, videofluoroscopy, cervical auscultation,
and oximetry (Braun & Palmer, 1985; Wolff, 1968;
Eishima, 1991; Bosma et al 1990; Newman et al,
1991; Vice et al,1990; Rogers et al, 1993).
Unfortunately, many of these techniques are not
readily transferable to the speech and language
therapy clinical environment. They often rely on
specialist staff with technical expertise and bulky
equipment from other departments. This may
require that the assessment be carried out within
the schedule for these departments. Timing (in
terms of feeding routine), requirements of the
assessment (such as positioning of the infant and
the food / substance being given) and environment
(for example, large noisy equipment) may be less
than ideal in providing a valid assessment of the
infants usual feeding pattern. In some situations,
an infant may require several of these assessment
procedures to provide a complete picture. Few of
these procedures can be carried out simultaneous-
ly and, as a result, the whole series of investigations
may be time consuming, intrusive and expensive.
Well tolerated
There is clearly a need for a non invasive, easily
transportable system which will be both well tol-
erated by infants and allow objective and simul-
taneous assessment of several aspects of infant
feeding without relying on the support and facil-
ities of other departments during the assessment.
The Great Ormond Street Hospital
Measurement of Infant Feeding (GOSMIF) has
been developed to address this need. The system
allows the therapist to video-record the infant
bottle feeding, enabling the therapist to subse-
quently evaluate behavioural aspects of the feed
using scales such as the NOMAS (Meyer Palmer et
al, 1993). At the same time, the therapist is able to
identify swallows using auscultation, to measure
intra-oral pressures generated during sucking,
and to record patterns of respiration.
At this stage in its development the system only
allows assessment of bottle fed infants. Whilst
breastfeeding is the recommended means of
feeding infants, a significant number of infants
who experience feeding difficulties are bottle fed.
Where the mother has been keen to breastfeed,
but this has not been possible, she is encouraged
to give her baby expressed breastmilk via a cup or
bottle.
Routine
The GOSMIF assessment can be carried out in the
infants home, on the ward or in the clinic as part
of their clinical assessment, ideally at the time of
a routine feed for the child. The infant is fed by
the mother or carer as per routine. For clinical
purposes, the child can be fed their usual milk.
However, for the purposes of research, we use 5
per cent glucose solution, allowing us to control
Into
the
mouths
of babes
Infant feeding is an emotive area at
the best of times so it vital that,
when difficulties arise, they are not
compounded or skewed by the
assessment process itself. With this
in mind, a research project has
developed a new assessment tool for
infants having difficulty feeding
. Anthea Masarei and colleagues detail
the progress of the Great Ormond
Street Measurement of Infant Feeding
(GOSMIF): An Objective Assessment
of Infant Feeding.
n recent years there has been an increasing
use of technology in the assessment and man-
agement of speech disorders - electrolaryn-
goscopy, fibreoptic nasendoscopy and elec-
tropalatography, for example, are all well-
established systems. However there have been few
recent advances in the application of technology
to the clinical assessment of infant feeding.
Feeding is a complex process which may be
adversely affected by many intrinsic, environmental
and health factors. Even in healthy, term infants
the physiological feeding process can be influ-
enced by a number of factors including:
maternal and child factors - bonding, skin-to-
skin contact after birth, and the level of sedation
or pharmacological pain relief the mother
required during labour and birth;
child factors - the infants behavioural state and
level of arousal;
feed factors - the type of breastmilk or formula
milk, its taste, consistency and fat content; and
equipment factors - the flow rate achieved with
breastfeeding or different types of nipples/teat
(Kron et al, 1966; Wolff, 1968; Crook & Lipsitt,
1976; Nysenbaum & Smart, 1982; Wolf & Glass,
1992). These factors are compounded and added
to when a baby is born with a physical difference
which interferes with its ability to feed efficiently.
The complex nature of feeding has resulted in
the development of many different assessment
approaches in an effort to understand and
analyse the process. These vary from the use of
structured observation scales such as the NOMAS
l
you want to
take technoogy to your
cents
mnmse harmu
eects o assessment
ncude objectve measures
n your evauatons
Read this
research
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2001 12
review screen (Figure 3(a)), it can be seen that ini-
tially during the feed the infant uses a continuous
sucking pattern (as one might expect with non-
nutritive sucking). He then settles into a pattern
of organised sucking bursts and pauses before
returning to a continuous sucking pattern, per-
haps related to fatigue. Also evident from the
summary screen is the high proportion of positive
pressure generation in contrast to the predomi-
nant negative pressure generation evident in the
healthy infant. The lower half of the screen
demonstrates a suck swallow ratio of 4;1 and 2;1.
The data analysis screen allows further analysis of the
strength of pressures generated. Figure 3(b) indicates
the point of greatest negative pressure generation
during the study, measuring at -9.96 mm H2O.
Figures 4(a) and 4(b) represent data collected from
the assessment of a three week old infant with Pierre
Robin Sequence with cleft of the soft palate,
2
/3 of the
hard palate and micrognathia. This infants airway
difficulties are being managed with a nasopharyn-
geal airway at this point. The data review screen
(Figure 4(a)) shows an initial continuous sucking
burst, then a period of sucking bursts and pauses of
varying length. Over the feed the sucking bursts
appear to become shorter and weaker, and towards
the end of the feed return to continuous sucking
(non-nutritive pattern). From the data analysis screen
(Figure 4(b)) it can be seen that the point of maxi-
mum negative pressure generation is -7.5mm H2O.
Objective
The GOSMIF is an easily transportable, non-inva-
sive system which allows objective, simultaneous
assessment of three aspects of infant feeding in a
natural and routine environment. We do not sug-
gest that the GOSMIF should replace the clinical
observation assessment but rather that it is used
as an adjunct to the feeding evaluation, as it pro-
vides objective data about several aspects of
infant bottle feeding. Preliminary experience sug-
gests that it is well tolerated by infants and their
mothers / carers. It provides objective data about
suck: swallow: breathe ratios and coordination.
Measurements of aspects of sucking such as pres-
sures generated can be calculated. Simultaneous
video-recording of the feeding process permits
the use of behavioural rating scales and reduces
the possibility of inappropriate conclusions being
drawn where there are artefacts in the data.
Anthea Masarei is Research Fellow in the Speech
and Language Therapy Department, John Veness a
Clinical Scientist, Biomedical Engineering
Department, and Dr Debbie Sell is Head of Speech
and Language Therapy, at Great Ormond Street
Hospital, London. Dr Angie Wade is Senior Lecturer
in Medical Statistics in the Department of Paediatric
Epidemiology and Biostatistics at the Institute of
Child Health, London. Sheena Reilly is Professor of
Paediatric Speech Pathology at Latrobe University,
Bundoora, Melbourne, Australia.
Acknowledgement
The GOSMIF was developed as part of a study
funded by ACTION Research and the Colin
Bramley Parker Memorial Fund. We would like to
thank them for their support. At this stage the
GOSMIF is being used for research purposes only,
but we are investigating the possibility of making
the GOSMIF available for sale.
References
Bosma, J.F., Hepburn, L.G., Josell, S.D. & Baker, K.
(1990) Ultrasound demonstration of tongue
motions during suckle feeding. Developmental
Medicine & Child Neurology 32:223-9.
Braun, M. A. & Meyer Palmer, M. (1985) A pilot
study of oral motor dysfunction in at-risk
infants. Physical and Occupational Therapy in
Pediatrics 5; 13-25.
Crook, C.K., Lipsitt, L.P. (1976) Neonatal nutritive
sucking: Effect of taste stimulation upon sucking
rhythm and heart rate. Child Dev 47:518-22.
Eishima, K. (1991) The analysis of sucking behaviour in
newborn infants. Early Human Development 27:163-73.
Kron, R.E., Stein, M. & Goddard, K.E. (1966)
Newborn sucking behavior affected by obstetric
sedation. Pediatrics 37;1012-6.
Newman, L.A., Cleveland, R.H., Blickman, J.G.,
Hillman, R.E. & Jaramillo, D. (1991) Videofluoroscopic
analysis of the infant swallow. Investigative
Radiology 26:870-3.
Meyer Palmer, M., Crawley, K. & Blanco, I. A. (1993)
Neonatal oral-motor assessment scale: A reliability
study. Journal of Perinatology 13:28-35.
Nysenbaum, A.N. & Smart, J.L. (1982) Sucking behav-
ior and milk intake of neonates in relation to milk
fat content. Early Human Development 6;205-13.
Rogers, B., Arvedson, J. C., Msall, M. & Demerath, R. R.
(1993) Hypoxemia during oral feeding of children with
severe cerebral palsy. Dev Med Child Neurol 35; 3-10.
Vice, F.L., Heinz, J.M., Giuriati, G., Hood, M. &
Bosma, J.F. (1990) Cervical auscultation of suckle
feeding in newborn infants. Developmental
Medicine & Child Neurology 32:760-8.
Wolff, P.H. (1968) The serial organization of suck-
ing in the young infant. Pediatrics 42:943-56.
Wolf, L. S. & Glass, R. P. (1992) Feeding and swallowing
disorders in infancy. Tuscan: Therapy Skill Builders.

Am I aware of the effect an assessment

procedure itself can have on performance?
Do I try to create a natural environment
to get the best out of people?
Do I ensure that factors which facilitate
normal communicationand eating /
drinking are considered when planning
for a client?
Reflections
for variables such as taste, texture and fat content,
which the literature suggests may affect performance.
The length of assessment can be adjusted to
accommodate the clinicians goals of assessment.
We routinely collect 5 minutes of data but poten-
tially more could be recorded dependent on the
memory capacity of the computer being used.
As can be seen in Figure 1 the GOSMIF incorpo-
rates a rigid feeding bottle, which is modified by
drilling a hole in the base, to permit fitting of a
pressure transducer. This measures pressure
changes which are generated within the bottle
during sucking. Unvented NUK medium flow
orthodontic teats are used, as the holes are laser
cut and are therefore consistent in size. The size
of teat used is matched as near as possible to the
size used routinely by the infant. Swallow sounds
are recorded with an accelerometer and micro-
phone unit which is taped on the infants neck
(Vice et al, 1990). A standard respiration band is
placed around the infants chest to allow monitor-
ing of respiration patterns.
As the infant feeds, the information is processed
by a specially written software programme and is
displayed on the monitor. The video data is stored
in the computer (and recorded onto tape if
required). The other data, including the sucking
pressures, swallow sounds, and respiratory trace,
is stored both graphically and on a spreadsheet
that can be readily accessed. Given the large size
of the data file, we suggest writing the data to CD
for storage purposes.
There are two screens available for analysis; the
data review screen and the analysis screen. The
results of the whole assessment are summarised in
this screen (Figure 2(a)). The respiration trace is
shown in red, the auscultation traces in blue and
green, and the sucking pressures in black. The test
can be replayed in real time, or sections selected
and frozen. The lower part of this screen expands
the selected data that is within the purple band.
To demonstrate this, Figure 2(a) shows a still of
data collected during assessment of a healthy 6
month old infant with no history of feeding diffi-
culties. The data review screen summarises the 5
minute 1 second test feed. The lower part of the
screen shows the 3.6 seconds within the purple
band expanded. This clearly demonstrates a suck:
swallow: breathe ratio of 1:1:1 occurring at approx-
imately one suck; swallow; breathe per second.
The analysis screen (Figure 2(b)) provides the
possibility of more detailed assessment and mea-
surements such as sucking strength and waveform
measures. This screen has two cursors which can
be manipulated, allowing measurements such as
sucking strength and duration of the suck to be
taken. For example, in Figure 2(b) (in the same
study of the above healthy infant), we can see
that, at this point in the study, he was generating
sucking pressures of -28.3 mm H2O and that the
duration of the suck was 737.9 msecond.
In contrast, Figures 3(a) and 3(b) show data col-
lected during the assessment of a new-born infant
(two weeks of age) with a complete unilateral
cleft of the lip and palate. Looking at the data
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SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2001 13
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cover story
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2001 14
[Speech and language therapists need] persis-
tence. Have to know that no matter how it dont
look very good, got to keep going and look at
ways of making use of words to look at how the
people look at words in their head, because weve
all got ways of looking at words.
Its nearly two years since Ron Devine had
his stroke. Like all the participants in the
Expression project, he has come a long way but
hopes to go much further. Three weeks into a new
job, Rons life - and that of his family - was turned
upside down when he took ill at the wheel of his
car not far from his home.
Rons daughter persuaded him to admit to me
that he hated speech and language therapy. He
remembers having to find one word and not liking
it, preferring the later homework such as puzzles.
I couldnt believe I couldnt do this. After a while
I thought, wait a minute, this has happened, so
you just have to do it. I didnt particularly like it
but thought it would do me good. Patsy [Rons
wife] kept me going. In the beginning, you can-
not tell people at all. Theres not enough speech
therapists to keep going until youre never going
to get any better! New people come through
needing the services.
Figure 2 (above) Ron Devine: A cup of tea
Ron demonstrates how quickly his wife, or other non-
aphasic people can say Lets have a cup of tea.
Figure 4 Limits on participation
Figure 3 Len Agley - Limits on activity
Figure 6 Len Agley: New Discoveries
Figure 5 Len Agley - untitled view of reading
Imprints
of the
mind
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2001 15
cover story
Early in 2001, six service users with aphasia, two speech and
language therapists, an artist and an illustrator teamed up to work
on an expressive arts project. The results have gone way beyond
what they envisaged and have the potential to benefit a far wider
group of people. Here, Avril Nicoll meets four of the participants in
Expression to hear their unique and often surprising stories about
life, change, services, aphasia - and speech and language therapy.
As a charge nurse with the
frail elderly, Ron was acutely
aware that standards of nurs-
ing care fell way below what he
would have expected. He
remembers being handed a
razor and being told to shave. As he was not
given a mirror, normally used an electric shaver
and had just had a stroke, the result was pre-
dictably bloody. Ron also felt the humiliation of
not being able to express something as basic as
needing the toilet, even if someone happened to
be around at the time he needed.
... went to go out of my bed ...and I forgot my -
my legs werenae working [laughs]. The reason
was cos they hadnt given me a bottle and Id
never seen anybody and when you canna - canna
talk so you canna tell them - if you see somebody
going zh-zh-zh-zh [gestures and sounds people
buzzing about all over the place], they canna stop
- theyve got to be able to see you before you can
say I need you - I needed the toilet, and I just
had to go out to try and get it - and I didnt!
Ron is pleased to learn that Ninewells Hospital
in Dundee is at long last to get a specialist stroke
unit. He contrasted his experience in Ninewells,
and the experience of other people
he knows, with the Centre for Brain
Injury Rehabilitation at Royal Victoria
Hospital, although he didnt at the
time agree with their assessment
that he had potential. Reflecting
on how his experience makes him view what hap-
pened when he was on the other side of the fence
as a charge nurse, Ron is very positive.
Actually, I think I thought I had been - because of
whats happened - that what I was doing now -
oh, the wrong way - that I had been nursing them
in the way that I would wanted to be. But you
have to have enough nurses to do it - and they
didnae have it at Ninewells. Even when you did -
phew - it was hello and cheerio. They didnt
know how to stop and listen what you need.
In contrast, the rehabilitation centre had an
individualised programme and activities were
organised for the whole day. At that time in a
wheelchair, Ron resented being so dependent on
other people for his mobility and found this had a
huge limiting effect on his communication and
ability to make decisions. He still finds it difficult
to believe that he could have made so much
recovery in his movement and talking given the
Figure 7 Helen Gowland: Dying to Whoosh
Figure 8 Madeleine Nedelec-Lamb: Heaven and Earth
extent of his initial difficulties.
Ron suffers a great deal of pain and continues to
find the reversal of roles with his wife hard to
bear. He works hard on his computer; figure 1
shows part of two descriptions, done a few
months apart, of how his stroke occurred.
Interestingly, Ron explains his aphasia using a
computer analogy:
I look at my screen, the screen that I get - and
I use this for everything but some people dont
have one. Some people think its in their chest and
they feel their words are stopped.
Figure 1 Ron - A Stroke Happens
- January 2001
I held taken to car and always I saw some-
where can to push to can path and him told I
going the ambulance and I going person still
me seating and but I forget some.
- April 2001
I found myself getting out of the car, unable
to do anything but stand there. Someone
came down the path of a house and called to
me, asked if I needed help and he helped to
pushed me against the car before I fell down.
o
you want to
work coaboratvey
know what users reay
thnk
hep peope express
themseves
Read this

cover story
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2001 16

Ron talks slowly but fluently, focusing carefully

on the point he wants to make and using humour
to help him deal with highly personal and emo-
tional issues. His illustrations in the Expression
project reflect his feeling of being present among
a group of people but not being part of the com-
munication, and his recognition that the greatest
difference between his communication now and
before his stroke is timing (figure 2).
Collaborative venture
Expression is a unique collaborative venture
between a group of service users with aphasia,
speech and language therapists, an artist, and an
illustrator. The use of art as a communication
medium following aphasia is growing (see, for
example, Sacchet et al, 1999) but the aims of this
project were far wider. Over five Saturday sessions
of printmaking at an art college, each lasting 5
hours, the group constructed new representations
of aphasia in order to:
1. make aphasia visible and more understandable
2. increase awareness of what it means to
have aphasia
3. show wide-ranging competencies of people
who have aphasia
4. address different aspects of identity (for
example; personal, social and collective.)
Taxis and lunch were provided and visual
reminders were posted and telephone calls made
between sessions. Visual and written summaries
of the workshops were also made to facilitate
communication about the sessions with family
and friends.
Ron had previous knowledge in that he had at
one stage been a printer, but Len Agleys
experience of art was confined to his school
lessons. Although he found them enjoyable, he
says he was very bad! Len admits to having had a
sense of fear about the proposed group but, hav-
ing discussed it with his wife, felt he would try it
and, if he didnt like it, he just wouldnt go again.
However, he immediately loved it, built up a
strong bond with the rest of the team, and says
they would all go to Expression anytime. Len ges-
tures expansively as he describes the feeling of
inclusion which came from participating.
Same people altogether - similar but different,
like being pals. The people helping too were
awfully good. That first year I wouldnt have gone
because at that time I was thinking I would still be
alright - doing a lot to try to help myself. The
worst thing was coming to, youre not going to
be the way you want - youve got to change your
heads way. Even now, its hard.
Len, who exudes a quiet strength, covered a
large area of North East Scotland as a service engi-
neer with Comet. He took ill when he was at a
customers house and seems to have been a victim
of a catalogue of health service failures. His fami-
ly feels very let down by the system and his wife
points out that, even now, as aphasia is a hidden
disability it is not afforded the same respect as
other more visible ones. Len would like the
Symbol
devised to
say Dont
speak so
fast
Figure 9 Illustrations by Christine Farrell
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2001 17
cover story
opportunity to tell his story to someone in author-
ity, and for them to listen and learn from it, so
that it never happens to anyone else.
It took a long time for Len to accept that he was
not going to be able to do all the things he did
before. This was a lonely time
for his family who had taken
that fact on board much more
quickly.
Its hard because, before that, I
thought I would do anything I
wanted to do. Squash, running,
bike - I can do it now, but Im
numb up my right side.
Speech and language therapy
lasted two years. Len believes
he could have gone further
with it but, in common with the
other participants interviewed,
is philosophical about it, recog-
nising that services are under
pressure.
Part of the Expression project involved the par-
ticipants keeping a sketchbook where they visually
recorded things of importance to them.
Suggestions for what they might collect included
magazine cuttings, postcards, photos, words,
colours and images as well as sketches, doodles
and collages of their own. The World Health
Organisation principles of impairment, activity,
participation and well-being provided a structure,
but had to be made meaningful.
Looking first at impairment, Len was asked:
What doesnt work? What it feels like? What feels
wrong? Why wont it work? Where does it feel
wrong? Adding red to a figure of a man, he
coloured the right side and around his head.
Around a postcard of someone holding their head
with a cloud-like question mark, lightning and
rain above it, and the question whats it all
about?, Len explains
I know what I want to say but it comes out all
wrong!
Why does my head hurt?
Why do I not feel my right arm or leg?
Limits on activity, on what Len can do, are in figure
3. Figure 4 shows his response to the participation
question; the restrictions on his life, involvement,
engagement and attainment. Trying to communicate
within a group causes confusion and alarm, as
does being one half of a phone conversation.
Lens humour comes through in pictures of his
faces associated with his football team Dundee
United - upset, depression and frustration! The
serious side to this is addressed by a picture of his
face in a box set apart from this, showing isola-
tion. Len goes to the games and is part of the
crowd - but not a participant in the same way he
was before.
Feelings are explored under the banner of well-
being, with Lens a mixture of the negative (helpless,
inadequate, frustration, emotional) and positive
(more relaxed, more time, accept illness, grateful
for help.) Reading and writing are skills he misses
greatly, as shown by the print in figure 5.
Lens print New Discoveries is also a mass of
allegory which very much reflects how Len felt at
that time. The ship Discovery (berthed in his home
town of Dundee) is pictured along with the
Discovery space shuttle. As Len
explains,
They didnt know what was gonna
happen with them. And same
as...Thats where I was before. And
that eh that changed now what I was
thinking. You were going up. And eh,
going up.
If you look closely at figure 6, you
will also see a lump on the head of the
person with the sad face to signify the
brain injury. Chris Kelly, artist on the
Expression team, comments that New
Discoveries may have a certain naivet
in execution, but the quality of the
final print is such that it becomes a
sophisticated piece of storytelling.
Ready to reflect
Chris explains how the sketchbook and the World
Health Organisation model provided a structure
and context for personal reflection by a group of
people who were ready to reflect. Getting things
out into the open stopped the aphasia from being
such a personal burden. Dealing with any example
of aphasia in a very public way meant that they
could be discussed by the group and worked up
into visual representations by the students and
illustrator Christine Farrell.
Having expected to find most of the partici-
pants experience of aphasia revolving around the
head and the spoken word, the facilitators were
surprised to discover aphasia was actually experi-
enced far more holistically. In the first
session, one of the speech and language
therapists presented a narrative of apha-
sia, that its like coming into a filing
cabinet and finding that a group of
thieves has played mischief and created
disorder. But as an example it was irrel-
evant, as they didnt identify with it - the
participants were more involved with
images of being outside of the conversa-
tion, whether due to mobility problems
or sitting amongst a group of people
who were not aphasic.
Helen Gowlands experience of
aphasia is not in her head at all.
Enthusiasm for life, hobbies, family, friends and
work bubbles over as Helen explains where the
feeling of whoosh! comes from (see figure 7,
Dying to Whoosh.)
I said, its right in here [points to heart] but you
just cannot...get it in here [motions up to mouth].
I know EXACTLY what I want to say. Well, its
much, much better now - because, if you say
something to me, or I want to say something,
youll say it and Ill know what I meant to say. But
I know its there [in me], but its in here [points to
heart], and this is why I not in here [points to
head], this is why Im not mad this is why Im say-
ing its in my heart, because its just here [points
to heart] or.. just wait a wee minute..[walks fin-
gers towards heart] it can be in there [other area
of chest] or there [other area of chest].
Helen is adept at using a variety of methods - writ-
ing the first few letters of words, asking for a model
of a word, finding key words in her book, asking for
time - to help with communication. Her aphasia is
the result of a brain haemorrhage and operation
two-and-a-half years ago.
I was a physiotherapist and I absolutely LOVED
being a physiotherapist - just fabulous. Like you do
as well [being a speech and language therapist].
And I got three girls, and a husband. And every-
bodys fantastic. And all of a sudden - I was sitting
at telly about 9 oclock and I was watching TV - Joo
-Jools Holland - and I love him - and thats the last
thing I know, I can remember.
Not allowed to enter rehabilitation until a
month later, Helen remembers a pretty awful
time. She hated sitting about in her night clothes,
and cried to get home, but her daughters had to
keep telling her she couldnt. Gradually Helen was
able to go home for three day weekends when
she enjoyed having a good laugh with her friends.
This continues with get-togethers for coffee and a
group of women meeting up every month for a
curry at somebodys house. When I asked whether
her friends had known anything about aphasia,
she said no and added,
In fact, neither do physios either. Because its com-
pletely different because physios are all about this
bit [points to body] and thats been hard for phys-
ios to think about whats happened.
Helen now takes a popular exercise session once
a week at a club for the elderly, cooks and sews,
and has new hobbies of belly dancing
and Tai Chi. She has recently started
counselling as she describes her speech
and language therapist as wonderful
but explains that, afterwards, you ask
what else? what about ME? Helen
believes there is insufficient speech
and language therapy which means it
cannot continue for as long as people
would benefit from it. She is now
active in the local Speakability group
which is planning to take its campaign
for more therapists to the Scottish
Parliament. In common with Ron,
Helen didnt much care for whats
that? naming tasks, but says
I love, Today were going to Edinburgh with my
daughter to get a _____ - MUCH better.
Two of Helens daughters are at university, one
at St Andrews, the other at Oxford. Helen is frus-
trated that these place names are particularly elu-
sive and, although she is rather concerned that
other people might get impatient, is persistent in
getting them from here to here through visuali-
sation so she can whoosh. Helen makes use of all
her senses to make up for things she cannot enjoy
If you
get the
opportunity
to see the
Expression
exhibition,
do go.
people get huge
enjoyment from
being creative.
Some naturally
gravitate towards
computers, paints
or pastels, and
colour or humour

her weight in gold and tells how John gave up his

career to look after her.
Happiness a lot easier to find since. I feel grateful
that I am almost chosen to be here and at least talk-
ing, not in the manner that I would like - I would
love more expressions to be able to... but, yeah. My
day isnt long enough. I used to be often bored
before, I was always keeping myself busy - proba-
bly too energetic, or too hyper. I think I just appre-
ciate being. Its hard - it takes me so long just to do
little things - its taken me so long to do little things
whereas before you would do them in a second.
Madeleine describes the relief of being in
respite care where she doesnt have to do what
seems like one task to us but means ten to her.
I didnt have to buy the food, I didnt have to pre-
pare the food, cook the food, I didnt have to set
the table, serve it, didnt have to - em - take the
plates away, I didnt have to wash up.
Madeleines print (Heaven and Earth, figure 8)
describes her struggle but says nice things to her
- her dad who died when he was 42 is up there, as
is her brother John who died at 50. Madeleine
herself nearly made it when she was 50.
Madeleine found it difficult to conceptualise her
picture, and to understand what she was meant
to be doing until it was actually finished.
Speech and language therapy is something else
Madeleine says she didnt understand until it was
finished. She would like to do more but with
something she is interested in and which inspires
her rather than words for words sake.
Madeleines father was with the Free French and
she remembers the language being spoken
around the table with onions and mustard, crusty
bread and good cheese long before these became
trendy. She would love to re-learn French, but is
finding she needs more help than the tapes and
books she has offer her and is further hampered
by the physical challenge of turning pages.
Madeleine has ongoing problems with reliability
of transport which severely restricts her indepen-
dence and ability to take part in groups. She is
participating in the local Speakability group but,
in addition to transport issues, finds the level of
paperwork a problem. For so many daily living
tasks she feels she needs just a little extra help.
She hopes to get a computer again in the future
so she can make use of facilities such as e-mail
which is far easier for her than writing and fold-
ing a letter, putting it in an envelope, sticking a
stamp on it and posting it.
Madeleine sets high standards for herself. She
likes to have notes to compensate for the memory
difficulties she finds so debilitating and frustrating
to read, and to use several different words to
describe the richness of her experience. She under-
stands why people say och, I forget things too but
is eloquent in explaining what she really needs.
Often I dont talk because...FAR too fast - not
clear enough or slow enough. I need words
repeated. If I was in a discussion NOW, I would
love to express myself better - would love to do it
the way I did before. [I need] one-to-one, very
cover story
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2001 18
Do I know how the therapy I
offer makes people feel?
Do I appreciate that a
communication difficulty is felt
more holistically by clients?
Do I prioritise people for therapy
at the right time for them?
Reflections
as much as before; for example, by smelling books
she cannot read. She can manage recipes but
important tools such as shopping lists are an
ongoing problem. Although her spoken words are
firmly in and around her heart, Helen doesnt
have a strong sense of where written words are -
she just doesnt know.
Helen had tried a Chest Heart and Stroke group
but she didnt like the noise and found the volun-
teers overbearing. In contrast, she describes
Expression as
Absolutely fantastic, the most wonderful thing
Ive done. Start with something small - shape,
colour, a little bit more, realise oh! I can do a bit
more than that.
The grading of the printmaking skills from basic
to more complex was overseen by Christine
Farrell. Her previous experience, including a resi-
dency working with women and children at the
Transport Museum in Glasgow, has shown that
people get huge enjoyment from being creative.
Some naturally gravitate towards computers,
paints or pastels, and colour or humour, depend-
ing on their age, individual preferences and
mood.
Excitement of the moment
Monoprints were done by drawing on paper that
was on top of glass covered in ink. When the
paper was pulled back, the image was in reverse.
In contrast, lino cut is a block print with ink
applied to a surface that has been cut. The design
and print workshop at the art college has old,
cast-iron presses and a history and smell associat-
ed with it which increase the excitement of the
moment when the finished article is revealed.
The physical element of the process - the balance
required to pull the press, the fine control to cut
the lino - was enjoyed by all participants.
Madeleine Nedelec-Lamb is unable to
use her right arm following her stroke but is par-
ticularly persistent. A facilitator held the lino and
turned it every time to ensure she made the cuts
away from herself, using the weight of their hand
to prevent the lino from slipping. Madeleine
describes Expression as
Probably the best help Ive ever experienced in
that field. Well, for a start, I didnt know what I
was doing. I still didnt know what I was doing.
The others knew what they were doing but
werent able to express things clearly, but I didnt
know why I was there, what I doing - I knew I
wanted to do it because they were nice to you -
they had time - you were not a burden - its like
you were a normal person, you werent a burden.
Of the four participants interviewed, Madeleine
has the most spiritual approach to a life which has
not been easy. She has persistent pain from arthri-
tis and headaches but has learnt peace and
patience, and found her determination not to
give up comes from being a mum to her sons,
James Paul and John Michael. She is very grateful
for all the support she has from her family. For
example, she describes her own mum as worth
clear, slow, not in a hurry, not getting job done
and on you go. Cos everybody is in a hurry and -
eh - its far easier for me if things are slower.
Power
The Expression project has enabled all these par-
ticipants to communicate their experience of
aphasia. At every stage, facilitators were enthus-
ing, encouraging, observing, discussing and tak-
ing notes. By turning the power over to the par-
ticipants to create something unique reflecting
their personal experience (examples in figure 9),
the possibilities are infinite. Over the next few
years, Christine Farrell plans to extend this work
with other people with aphasia so that it will ben-
efit a wider audience. She envisages a package of
illustrations being produced to be used by speech
and language therapists with people with aphasia
and their families at different stages of the
process of coming to terms with it.
If you get the opportunity to see the Expression
exhibition, do go. The enthusiasm, inclusion, con-
fidence and humour associated with it is there for
all to see, and the bond between the facilitators
and participants mutual.
As Madeleine says,
I couldnt believe how nice they were. They said
we had benefited them - wow! It made you feel
so - youre not a number, its like youre a person
again - and they had the time for you.
References
Sacchet, C., Byng, S., Marshall, J. & Pound, C.
(1999) Drawing together: An evaluation of a ther-
apy programme for severe aphasia. International
Journal of Language and Communication
Disorders 34 (3).
Acknowledgement
Avril Nicoll would like to thank Christine Farrell,
illustrator, Chris Kelly, artist and Laorag Hunter
and Lynsey Paterson, speech and language thera-
pists for their assistance in gathering information
for this article. Special thanks go to Len Agley,
Ron Devine, Helen Gowland and Madeleine
Nedelec-Lamb, Expression participants, for shar-
ing their very personal experiences so that others
with aphasia may benefit - it was a privilege to
meet you all.

SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2001 19

reviews
REVIEWS. . . . . . . . . .
r e v e w s
Hippety-hop, Hippety-hay (Growing with
Rhymes from Birth to Age 3)
Opal Dunn
Frances Lincoln
ISBN 0-7112-1195-7 6.99
Hippety-hop, Hippety-hay is a very special
rhyme book to which we can say HOORAY!
Written for parents/carers by language special-
ist Opal Dunn, it offers a treasure chest of
quirky rhymes and useful advice on how, when
and why we use rhymes.
Cheerfully illustrated, the book is presented
in three developmental sections. Each contains
a user-friendly introduction on child develop-
ment, and a wide choice of short, easy to
remember rhymes. Nearly all have accompany-
ing actions and are aimed to be included in
daily routine; for example, bathing, nappy
changing.
Useful to recommend to parents/carers and for
those involved in Sure Start projects, and handy
in clinics for encouraging early phonological
awareness skills. Undoubtedly value for money.
First Words - Babies Start Here!
Bill Gillham
Frances Lincoln
ISBN 0-7112-1564-2 10.00
This simple vocabulary book is written for
parents/carers to help in the quest to get
their children to learn new words. However
the words included have been identified
through ground breaking research, reveal-
ing the most productive first words a child
can learn; for example, cat, teddy, biscuit.
Coincidentally, they are what weve been
suggesting to parents to model in early lan-
guage play for quite some time.
The book includes an attractive set of
theme based composite pictures, such as
party time, which can be used for a range of
children for picture matching, vocabulary and
sentence building. It does not actively encour-
age verb development, which parents often
forget about. Its certainly nothing new, a lit-
tle pricey and - being paperback -could easily
be destroyed by a two year old in clinic!
Speech and Language disorders in Multiple Sclerosis
Ed. Bruce Murdoch & Deborah Theodoros
Whurr
ISBN 1 86156 100 8 25.00
The first chapter of this book gives an excellent review of
the neuropathophysiological basis as well as the various
clinical presentations of multiple sclerosis, and current
medical intervention.
Divided into two main sections, it first focuses on the
motor speech disorders frequently associated with mul-
tiple sclerosis, and gives a detailed account of the physi-
ological findings in relation to the subcomponents
involved in speech production.
The second part provides interesting information about
the less reported language disorders associated with mul-
tiple sclerosis, with case histories used to illustrate their
complexity and variety. In particular it focuses on the
effects on naming ability as well as other higher level lan-
guage functions, and contains a chapter on treatment.
Overall, an excellent book for therapists working with
this client group.
Caroline Jeffries-Shaw is on maternity leave having
worked recently as a locum speech and language therapist
in the area of adult neurological impairment.
Semantic Processing - Theory and
Practice
Ed. Wendy Best, Karen Bryan & Jane
Maxim
Whurr
ISBN 1 86156 185 7 19.50
This book gives a detailed insight into
the current models of semantic process-
ing as well as their application to spe-
cific client groups. The chapters on
Alzheimers and semantic dementia
were an interesting inclusion.
This is an ideal book for a clinician
working in the field of acquired disor-
ders, or students with a specific interest
in this area.
The chapters are in-depth and so the
book is more appropriate to be used as
a guide for clinical cases rather than to
be read straight through. At 19.50 it
represents good value for money.
Fiona Dunn is a speech and language
therapist working for North Glamorgan
NHS Trust.
Jays Observational Assessment of
Paediatric Dysphagia
Judi Hibberd & Jeanne Taylor
Details: see www.quest-training.com or
contact Jo Frost on 0121 628 2813, e-mail
jo@quest-training.com
175; additional copies 25 each
This is a package which thoroughly covers
the whole process of paediatric dysphagia
from referral to treatment. The authors pro-
pose its use with children of two years and
over but it is appropriate to use with
younger children. The assessment is
designed for use by speech and language
therapists who have undertaken post-regis-
tration dysphagia training.
The assessment is in an easy-to-read for-
mat which includes instructions on each sec-
tion. Lack of space could be an issue if there
is a need to note additional information.
The current price of 175 is value for money.
Kim Armstrong is a speech and language
therapist with Yorkhill NHS Trust in
Glasgow.
Voice Disorders and their Management (3rd ed).
Ed. Margaret Freeman & Margaret Fawcus
Whurr
ISBN 1 86156 186 5 25.00
This excellent addition to the current literature is great
value for money and a must for all speech and language
therapy (and ENT) departments. Presented in an easy-to-
read format, it would be valuable for therapists at all lev-
els of experience, as well as students. The range of subjects
covered is broad, with useful chapters on voice problems
associated with dysarthria and in children.
It is a particular pleasure to have chapters written by such
a range of eminent voice professionals, and to have such a
good review of up-to-date voice management techniques
with a comprehensive reference list.
The detailed and instructive chapter on the
Multidisciplinary Voice Clinic is essential reading for any
teams considering setting up their own.
More detail on the specific therapy techniques would
enhance the book, but the reference list guides you to more in-
depth reading.
Vanessa Hayward is Head of adult speech and language
therapy at Prince Charles Hospital, North Glamorgan NHS
Trust.
Hooray!
CHILD LANGUAGE
Nothng new
CHILD LANGUAGE
lnterestng normaton
MULTIPLE SCLEROSIS
A partcuar peasure
VOICE
Easy-to-read ormat
PAEDIATRIC DYSPHAGIA
ln-depth gude
SEMANTICS
Clair Brookes is a speech and language therapist working in paediatrics for Barnsley Community
and Priority Services NHS Trust.
in my experience
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2001 20
n my consultative work, I am increasingly
receiving reports from all concerned of dis-
satisfaction in a model of speech and lan-
guage therapy service delivery that is based
upon the therapist writing individual pro-
grammes that are usually implemented by the
teacher or learning support assistant and moni-
tored by the therapist. In some cases, speech and
language therapists see children for assessment
only; in others, they may be involved initially in a
hands-on capacity for a set period -
for example, of six weeks or half a
school term. Across the professions,
an alternative is being sought to
enable children with language
impairments to access a meaningful
learning experience at school. At the
same time, teachers need approach-
es that can be used integral to their
teaching practices within the
national guidelines for literacy,
numeracy and other curriculum sub-
jects. There is some evidence that
using a language-based approach
across the curriculum may provide
an effective way forward (Moats &
Lyons, 1996 ; Ofsted, 1996, 1997; Rinaldi, 2000 ).
Speech and language therapists have an impor-
tant role: to help teachers see the value of lan-
guage-based approaches, and to take part in
implementation. However, to do so, speech and
language therapists need a greater awareness of
the subjects in which they are to be involved; that
is, to develop a subject perspective to add to the
language perspective they have already acquired
in their initial training and subsequent work experi-
ence. This can appear a somewhat daunting
prospect, and perhaps cause a sense of embarking
upon foreign territory. The first time a teaching col-
league asked me to get involved in a maths lesson,
I replied, Me? Me, who struggled endlessly with
maths at school? OK, so I got a B grade at O level,
but I never really totally understood what I was
doing! Now, having been involved in developing
maths programmes for language impaired children,
I realise it is the comprehension of mathematical
language concepts that gives meaning to the subject.
Language impaired children can do well in areas
that require mathematical or visual skills, but the
language concepts can be problematic to the
extent where their progress is significantly impeded.
It is only by delving into the subject matter that
speech and language therapists can see:
i. exactly how a language focus can enable access
to the subject, and
ii. how important it is.
Speech and language therapy involve-
ment in curriculum subjects may appear on
first consideration to be beyond our pro-
fessional remit, but I find teachers highly
value specialised input that enables pupils
to make progress in curriculum subjects.
Speech and language therapists need to
communicate how therapy that explicitly
focuses upon aspects of language such as
phonology, grammar, conceptual/vocabu-
lary knowledge, and communicative inter-
action will contribute to curriculum sub-
jects, either directly or by facilitating
access.
Language basis
A language-based approach stems from the
premise that all curriculum subjects have a lan-
guage basis. Every lesson, including literacy and
numeracy hours, can be subdivided into a lan-
guage-based component (where language knowl-
edge and skills are focused upon explicitly), and a
broader learning experience (where the language
knowledge/skills are applied). For example, in
mathematics, language-based teaching of size
and measurement concepts can feed into more
practical measurement tasks, enabling pupils to
complete these tasks with greater understanding.
In English (speaking and writing), skills of lan-
guage organisation can be applied to creative
story telling / writing activities. In science, the
vocabulary and associated vocabulary relating to
Access
all areas
l
you
are dssatsed wth
ndrect therapy
programmes
want deas or
coaboratve workng
pan to set up a pot
project
Read this
We know that
language is
fundamental to
learning, but struggle
to integrate our aims
with those of other
professionals. In a
discussion which has
relevance to our role
whatever the client
group, Wendy Rinaldi
shows how a
language-based
approach to school
curriculum subjects
improves
collaboration with
education staff and
gives more
meaningful learning
opportunities to
children with
language impairment.
teachers
highly value
specialised
input that
enables pupils
to make
progress in
curriculum
subjects
point 2 above and
figure 1). You may
need to refer to
N a t i o n a l
Curriculum docu-
m e n t a t i o n .
Consider also which teachers in the childs school
are likely to want to work with you on this project.
This will be an important consideration, and may
actually determine which subject you choose.
4. Get together with this member of staff and look at
how you might implement this way of working, ini-
tially for a pilot period, to be jointly reviewed.
Having worked for around 15 years as a speech
and language therapist in the public and voluntary
sectors, Dr Wendy Rinaldi has now set up her own
publications and consultancy business, Learn-
Communicate. She works mainly as an author
and advisor to teachers, speech and language
therapists and educational psychologists on vari-
ous aspects of special educational need.
References
Moats, L.C. & Lyons, G (1996) Wanted: Teachers
with knowledge of language. Topics in Language
Disorder 16 (2) 73-86.
Ofsted (1996) Inspection report nos 17504 18257.
Meadowbank School, Cardiff
Ofsted (1997) Inspection report nos 125461. The
Park School, Woking, Surrey
Paulger, B and Bowen, J, (2001) Experimenting
with Language. Speech and Language Therapy in
Practice (Spring).
Rinaldi, W.F. (2000) Language Difficulties in an
Educational Context. London: Whurr.
In 2002, Wendy Rinaldi will be running introductory
courses on implementing a language-based
approach collaboratively across the curriculum.
Speech and language therapists will be invited to
attend with a teaching colleague. For more infor-
mation please write to Learn - Communicate, 18
Dorking Road, Chilworth, Surrey GU4 8NR, or tele-
phone 01483 458411.
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2001 21
in my experience
concepts of matter and forces can enable stu-
dents to have a fuller understanding of scientific
experiments. The approach can also be used to
help students understand and retain body process
sequences such as breathing, digestion
and movement. Non-academic subjects,
such as physical education and music,
can also be viewed with a language
focus. Commonly, these have been seen as
practical subjects where there is no need
for specialist involvement. Certainly
children can enjoy these subjects at an
experiential / practical level; however, it
only takes a few moments observing a
lesson, and hearing teacher instructions
and class group discussion, to realise the
language basis. Language concepts of action, space
and movement predominate in physical education;
in music, the language concepts include volume,
rate, pitch, and length of sound.
Rinaldi (2000) details the language-based
approach and how it may be implemented across
the curriculum, and figure 1 summarises the lan-
guage areas that chiefly enable access to particu-
lar curriculum subjects. Three other key principles
are: cumulative organisation (learning is linked at
skill/knowledge level and at activity level in order
to be cumulative); multisensory methodology;
and metacognition (pupils are aware of their
learning and its application) (Rinaldi, 2000).
There are many ways in which a model like this
can be implemented. For example,
1. Speech and language therapists can jointly plan
with subject teachers and provide the language-
based component, with the subject teacher pro-
viding the broader learning experience.
2. Speech and language therapists can jointly plan
with subject teachers and jointly provide the lan-
guage-based and broader learning components.
3. Speech and language therapists can jointly plan
with subject teachers and learning support / therapy
assistants. The delivery of the language-based
and broader learning components can be shared
amongst the team.
The main objective of joint
planning is to dovetail as close-
ly as possible the language-
based and broader learning
components. The
planning dialogue
can also give speech and language ther-
apists the greater subjective perspective
I referred to earlier, whilst the subject
teacher and learning support assistant
gain a greater language perspective.
Another way for speech and language
therapists to develop a greater subject
perspective is to become familiar with
national curriculum documentation,
and to see this documentation as an
essential part of their resource bank.
Shifts of thinking
A language-based approach requires shifts of thinking
and practice - from teachers to a greater language
perspective, and from speech and language thera-
pists to a greater subject perspective - and these
shifts take time. Initially, pilot projects may be
undertaken, perhaps involving a particular class
group and one subject only. Endorsements by
Ofsted (for example, 1996; 1997) and reports of suc-
cessful implementation (Paulger & Bowen, 2001)
are encouraging signs that this approach could pro-
vide a very exciting forum for collaborative practice.
So how about giving it a go? A few suggestions
for getting started on a pilot project are:
1. Focus on one school age child in your caseload (or
a small group of children in the same class group).
2. From your assessment, identify a priority area in
the childs language profile, and match it with
associated subjects; for example, phonology (literacy);
concept / vocabulary (maths, science, humanities
etc.); grammar / syntax (English); interactive com-
munication (English or PSE); pragmatic compre-
hension (English or PSE); language selection /
organisation (English - speaking or writing).
3. Consider which subject your language focus will
chiefly contribute to (recommendations given in
A language-
based approach
requires shifts of
thinking and
practice...and
these shifts
take time
Wendy Rinaldi
Figure 1
Note 1: Language skills contributing to English will also enable pupils to take part more
effectively in group discussion, creative speaking and writing tasks across the curriculum
Note 2: Interactive communication skills also contribute to PSE (Personal-Social Education)
LANGUAGE AREA
Interactive communication
skills
Language organisation /
Relevance
Contextual meaning
Grammar
Phonology
Language concepts /
vocabulary
SUBJECT
English (speaking/
listening / literacy)
Maths (including
Numeracy),
Science, Humanities,
Music, Art, PE, PSE.
Do I recognise when a client
has the ability to do an activity
but is prevented from accessing
it by language problems?
Do I give sufficient priority to
joint planning in my
collaborative ventures?
Do I cover language concepts
and the broader learning
experience when planning
intervention?
Reflections
I CAN, the national educational charity for children with speech and language
difficulties has been funded by the Department for Education and Skills to
develop a framework of joint training for speech and language therapists
and teachers. Ruth Paradice explains what this should mean for therapists
working with children with speech, language and communication needs.
collaboration
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2001 22
he need for collaborative training for
speech and language therapists working
in educational settings is well recog-
nised. The Royal College of Speech and
Language Therapists has set professional
standards for therapists providing services to edu-
cation (RCSLT, 1996). These state that the service
will involve a high degree of shared knowledge,
skills, expertise and information among all those
involved with the child (p.54). Therapists are
expected to work in a consultative way within
schools so that education staff can incorporate
the aims of therapy into the broader curriculum.
In addition, a joint working
group of the Departments for
Education and Employment, and
Health (DfEE/DoH, 2000) made a
number of recommendations to
promote collaborative practice
and learning.
The Department for Education
and Skills has funded I CAN, the
national educational charity for
children with speech and lan-
guage difficulties, to develop a
Joint Professional Development
Framework. The aim is to facili-
tate collaborative training,
enabling teachers and speech
and language therapists to develop a shared
understanding of their professional skills, knowl-
edge and expertise so that they will be able to use
these more effectively to raise the attainment lev-
els of children with speech, language and com-
munication difficulties.
The structure of the framework was agreed fol-
lowing consultation with primary stakeholders
including professional bodies, voluntary organisa-
tions and individual teachers, speech and lan-
teachers and speech and lan-
guage therapists is built into the
structure. Both groups are
expected to undertake work
together and share their exper-
tise, particularly in carrying out
practical classroom-based activi-
ties. By studying together with
teachers, speech and language
therapists will be enabled to
understand different approaches to teaching
methods and will also develop a greater aware-
ness of how children think and learn, while teach-
ers will gain a better understanding of speech,
language and communication needs and how
intervention can be used to help children over-
come their difficulties. Other potential benefits
arising from joint training include:
breaking down professional barriers by greater
understanding of each others roles
awareness of the complementary nature of the
roles of teacher and speech and language therapist
an understanding of the difficulties and
constraints inherent in the role of teacher and
speech and language therapist, and an awareness
of how these constraints may be overcome
through development of collaborative working
practice
sharing of professional expertise.
Every key area contains suggestions for practical
activities, called practice in partnership. Each is
linked with a specific learning outcome within
each key area, so the completion of each practice
in partnership task demonstrates that the linked
learning objective has been achieved. (Figure 2
gives an example taken from one of the key areas
of the core level of the framework). The sugges-
tions are not intended to be prescriptive or limit-
ing. It would be entirely possible for individuals
T
guage therapists and parents.
The framework consists of three
levels - foundation, core and
extension. These are organised
hierarchically, each building on
the knowledge, skills and exper-
tise gained in the previous level.
The foundation level is a gen-
eral introduction and is intend-
ed for those who know very lit-
tle about speech, language and communication
needs. It would be relevant to speech and lan-
guage therapists working with children in an edu-
cational setting for the first time,
or those returning to practice
after a career break. The core is
aimed at those who may be
already working with children
and wish to develop their skills
and professional expertise more.
The extension level is for profes-
sionals who want to gain a deep-
er understanding of the theoreti-
cal underpinnings of their prac-
tice and who may wish to study
for a postgraduate qualification.
The three levels are further
divided into a number of key
areas. The relationship between
the levels and key areas is shown in figure 1.
Each of the key areas contains detailed learning
objectives which have been designed to be used
by professionals to audit their training needs,
highlighting areas of strength as well as areas
where further development would be beneficial.
Active collaboration
As the main aim of the framework is to foster col-
laborative practice, active collaboration between
active
collaboration
between
teachers and
speech and
language
therapists is built
into the structure
you want to
mprove your
coaboratve workng
have an organsed but
exbe approach to
contnung proessona
deveopment
be n a stronger poston
to meet cents needs
Read this
Putting
partnership
vast majority of
teachers and speech
and language thera-
pists were in favour
of joint training and
were prepared to
devote time to it.
We hope that the
Joint Professional
D e v e l o p m e n t
Framework will
increase levels of col-
laboration between
teachers and speech
and language therapists in a bottom-up approach.
This, coupled with changes in policy that will enable
health services and education authorities to work
more closely together, should put both professional
groups in a stronger position to meet the needs of
children with speech, language and communication
difficulties. Ultimately it is hoped that this will raise
levels of attainment and enable children to reach
their potential as full and active members of society.
Ruth Paradice is the project manager for the Joint
Professional Development Framework. If you
would like to receive more information, please
contact I CAN, 4 Dyers Buildings, Holborn,
London, EC1N 2QP, tel. 0870 010 4066.
References
Department for Education and
Employment/Department of Health (2000)
Provision of speech and language therapy services
to children with special educational needs: Report
of the working group. London: DfEE.
Royal College of Speech and Language Therapists
(1996) Communicating Quality 2: Professional Standards
for speech and language therapists, London: RCSLT.
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2001 23
collaboration
to devise alternative activities as long as the link
to the appropriate learning outcome is clear;
however, they must be included as they form the
basis of the collaborative aspect of the framework.
Each task/experience should demonstrate collabo-
ration with an individual from a different profes-
sional background; wherever possible, this will be
a teacher and a speech and language therapist.
Key element
Practice in partnership is a key element of the
framework for a number of reasons. It is the
method through which active collaboration
between professionals is achieved because all the
activities are designed for teachers and speech and
language therapists working together. It is also
important in ensuring the flexibility of the frame-
work; the suggested activities could be undertak-
en as part of an organised course or as part of dis-
tance learning packages. Alternatively, individual
professionals might choose to meet the criteria of
each unit through different forms of continuing
professional development. For example, other
ways of meeting the practice in partnership crite-
ria for each of the key areas could include:
attendance at stand-alone workshops/ training
programmes
secondment to another situation relevant to
learning experience
working with a colleague who has specialist
knowledge
stand-alone distance course
carrying out independent reading/research.
Although there is a recognised need for joint
professional development for teachers and speech
and language therapists, there is no unifying
structure that brings training together. Market
research carried out for the project demonstrated
that existing training was patchy and was often
provided on an ad hoc basis. It
is therefore envisaged that,
over time, the framework will:
provide a coherent structure
that will bring together
training currently offered by
universities, voluntary
organisations and other
providers
be used by training
providers to modify existing
courses to reflect the
structure of the framework
be used by purchasers of
training to audit existing courses
provide a clear pathway for training.
It is difficult at the moment to gauge the effect
of the framework on speech and language thera-
pists. The training outlined in the framework is
not mandatory, but it is hoped that teachers and
speech and language therapists will use it to
structure their continuing professional develop-
ment. The Royal College of Speech & Language
Therapists has been represented on our project
team and steering group, and the framework will
certainly fit in with its annual continuing profes-
sional development log. Individual teachers and
speech and language therapists will be able to see
areas where further professional development is
required and target appropriate courses or expe-
riences to fill the gaps in their knowledge, skills or
expertise. They may choose to take on additional
training, either by attending a suitable course, or
by engaging in one or more of the activities
described. The choice will be up to the individual,
but the framework sets out what professionals
need to know and will therefore provide a
means of auditing professional development.
Research carried out for the project found that the
Figure 1 Joint Professional Development Framework
Figure 2 Practice in Partnership example
Core Level
The Special Educational Needs Context, past, present and future developments in speech,
language and communication needs
Learning outcome
Specify relevant health and education legislation and describe how it has influenced current practices in Special
Educational Needs, with particular reference to the speech, language and communication needs of pupils.
Suggestion for Practice in Partnership
Identify one factor from current government Special Educational Needs policy that has necessitated local
change for both the speech and language therapy service and the education service. Describe how this has
altered the educational opportunities within speech, language and communication needs.
into
practice
Do I devote the necessary
time to joint training with
other professionals?
Do I keep abreast of
government initiatives and
see how they will impact on
my practice?
Do I reflect a range of
continuing professional
development activities in my
personal log?
Reflections
Joint Professional Development Framework
FOUNDATION
level
CORE
level
EXTENSION
level
Speech, language
and communication
difficulties:
implications for
education.
The SEN context.
Developing language
and communication.
Identification,
assessment and
intervention.
Effective teaching
and therapy.
Social, emotional
and behavioural
development.
Language,
communication and
interaction.
Teaching, therapy
and assessment.
Working in the
educational system:
management of
change.
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2001 24
reviews
REVIEWS. . . . . . . .
r e v e w s
WASSP: Wright & Ayre Stuttering
Self-Rating Profile
Louise Wright & Anne Ayre
Winslow
ISBN 0 86388 275 7
24.95
Dissatisfied with existing assess-
ments of stuttering, many of us
have attempted to devise our own,
so WASSP is a welcome addition.
The manual is short, easy to read
and includes a laminated copy of
the rating sheet and summary
profile for photocopying.
WASSP consists of five internally
reliable sub-scales which consider
the overt, covert and social dimen-
sions of stuttering: behaviours,
thoughts, feelings, avoidance, and
disadvantage. Clients rate them-
selves pre- and post-therapy using
a seven point scale. They also note
down their aims / expectations
and summarise what they feel
they have achieved. Different
coloured highlighter pens show
the change.
WASSP was developed as a long
term outcome measure with over
40 clients on a workplace stutter-
ing course for British Aerospace.
All were aged 18 or over,
although the authors suggest it
could be used with some 14-18
year olds. It can be used by spe-
cialist and generalist therapists
with clients with different types
and severity of stuttering, and
whatever the therapy approach or
nature of service delivery. It is sim-
ple and only takes about five min-
utes for the client to complete.
In addition to attempting to
measure client perception of
change in a very visual, compre-
hensible way, this user-friendly
tool can also be used as a basis for
discussion of therapy aims, evalua-
tion and planning. As Renee Byrne
says in her introduction, it is an
essential tool for clinicians working
with clients who stutter, and it
will certainly be used routinely in
our clinics now.
Moira E. Little is Lead speech and
language therapist (Adult
Services) for The Lothian
University Hospitals NHS Trust.
Clicker Animations
Requires Clicker 4 and includes a site licence
Crick Software
49 (Clicker 4 costs 90)
Many teachers and therapists are familiar with
Clicker 4; this add-on is a valuable and engaging
resource for client and therapist.
Animations is potentially useful for various aims
in language and literacy from single words to sim-
ple sentence level. For example;
introduce verbs, since the essential element of
movement is presented
distinguish verb and noun
gain and keep attention - depending on your client.
The program also includes features such as
ready-made sentences, talking stories and
word/picture match. Different symbol sets are
offered within the Clicker 4 program: you can pre-
pare a simple sentence containing sleep and bed
and produce these different pictures above the
relevant words. Some common verbs are not pre-
sented (eg. push; fall). Past tense is not marked by
a symbol - but in certain stories you can stop the
animation with a click.
As with many flexible programs it is necessary to
familiarise yourself with Animations in order to
make your selections.
Emily Ball, Ann Farquhar and Carole Kaldor, on
behalf of the speech and language therapy team
at I CANs Meath School.
Care worker training
Two speech and language therapists are behind a new
training pack to help care workers communicate with
people with learning disabilities.
Anne Hancox and Janice Davies have been developing
the total communication pack since 1995 with the Home
Farm Trust, and any profits will be used to fund further
research and training. It includes trainers notes, a work-
book and a CD. Split into two levels, the material is for
two one-day courses or for individual study and revision.
Communication Skills Training Pack 79 + p&p from
Communication Matters, tel. 0870 606 5463,
www.communicationmatters.org.uk www.hft.org.uk.
Storytelling
Keith Park, author of Interactive storytelling: a multidis-
ciplinary plot in the Summer 01 issue, has advised us of
an online article about storytelling (to include people
who are deafblind).
www.tr.wou.edu/tr/dbp/current.htm
Chatback
A new software programme aims to help school aged
children with articulation difficulties by letting them
hear and see the difference between sounds in words.
Chatback enables pupils to listen to words or sounds, to
copy what they hear and to hear their efforts played
back to them. A mouth shapes the words and sounds on
screen, and a graphic representation is also created as
the sound or word is produced. The pupils can work on
their own and compare their own efforts with the pro-
gramme or a model recorded by a teacher.
Chatback is 52.29 from Xavier Educational Software
Ltd, University of Wales Bangor,
http://xavier.bangor.ac.uk/; demo at
http://xavier.bangor.ac.uk/xavier/Chatv2/index.htm.
Developmental coordination
disorder
A dyspraxia / developmental coordination disorder
teachers starter pack will shortly be available online.
Produced as part of a Scottish Executive-funded project,
the pack has been sent to every primary and nursery school
in Scotland. Project partners Afasic Scotland and the
Dyspraxia Foundation are also planning a parents pack.
Understanding and supporting children affected by dys-
praxia / DCD in the early years - see www.talkingabout-
dyspraxia.org.uk
Fragile X reports
The Fragile X Society has produced reports of confer-
ences held in Birmingham and Glasgow.
Living with Fragile X looked at different therapies and
strategies known to be helpful to children and adults
with Fragile X and their families (sensory integration
therapy; aromatherapy; music therapy; coping strate-
gies; Sleep Scotland.) Adult Living covered supporting
social opportunities and encouraging relationships; cir-
cles network; choices in accommodation; Camphill
Communities; living in the community; a familys experi-
ence of living in the community.
Details: 53 Winchelsea Lane, Hastings, East Sussex TN35
4LG, www.fragilex.org.uk.
..resources..resources..
Essenta too
STAMMERING
Vauabe and engagng
LANGUAGE AND LITERACY
Acquired Neurogenic Communication Disorders -
a clinical perspective
Ed. Ilias Papathanasiou
Whurr
ISBN 1 86156 111 3 24.50
This book is based on the collation of presentations
at a 1998 South East SIG in Adult Neurology study
day by distinguished clinicians such as Robert Wertz,
Renata Whurr, Sally Byng and Kathryn Yorkston.
Eight easy-to-read and stand alone chapters
cover aphasia, dysarthria and apraxia. The editor
states that the book aims to provide an overview
of the wide spectrum of approaches used to define
and describe acquired neurogenic communication
disorders, not only from a simple theoretical, but
also from a clinical perspective. And that is exactly
what it achieves.
A good resource to have in any department for
the inexperienced and experienced therapist, pro-
viding updated clinical and research information.
Natalie Vanderlinden is a speech and language
therapist with North Glamorgan NHS Trust.
Theoretca and
cnca perspectves
ACQUIRED DISORDERS
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2001 25
how I
l use musc
n therapy
Athough what we oer s
very derent rom musc
therapy, speech and anguage
therapsts can use musc as a
therapy too. But do we make
the most o t'
Nusc has unversa appea
crossng a ages, cutures and
backgrounds. lt s one o the
most basc ways o estabshng
shared nteracton. lt can be
un, memorabe, camng or
rousng, emotve and
attenton-grabbng - and
everyone can partcpate.
Our three contrbutons
expan why we shoud say,
thank you or the musc.
Claire Finlay was working until
recently for Epsom + St Helier
NHS Trust. She is currently on a
career break with her own
young children.
Helen Bruce works with adults
with learning disabilities for
Grampian Primary Care NHS
Trust, and also practises as a
clinical aromatherapist.
Dr Wendy Magee is a state
registered music therapist and
Head of the Music Therapy
Department, Susan Farrelly is a
Specialist Speech and Language
Therapist and Team Leader on
the Profound Brain Injury Unit
and Sophie MacKenzie is a
Senior Specialist Speech and
Language Therapist at the Royal
Hospital for Neuro-disability.
you want
condence to use musc
a shared anguage wth
cents
to enjoy your work
Read this
s
e
e
w
w
w
.
s
p
e
e
c
h
m
a
g
.
c
o
m
in
s
id
e
fr
o
n
t
c
o
v
e
r
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2001 26
how I
y interest in using music in therapy developed
following Wendy Prevezers I CAN course (well
recommended), and her residential weekend
course. I was then fortunate to work closely
with a colleague already using music in an interactive way with
young clients with profound and multiple learning disabilities.
My own young children, and the various music groups and tod-
dler groups we attend, have provided further inspiration - with
lots of ideas to copy and adapt. There is also a huge range of
CDs, videos and audio tapes commercially available which can
provide ideas, remind you of tunes and bring you up-to-date
with what toddlers are currently into. Fun Song Factory, The
Wiggles and Tweenies Song-Time videos are all worth looking
at and are usually available in libraries.
I have used music in a variety of therapy settings - in com-
munity clinic language groups, in a multidisciplinary group
for preschool special needs children, in a special school and in
one-to-one therapy with children with severe learning disabil-
ities. Singing and a few basic instruments (drums, shakers,
chime bars, bells) is all that is required. I dont have a partic-
ularly good singing voice but it seems to be sufficient and I do
try to use my voice with conviction and reasonable volume.
Some investment in one or two good quality instruments is
worthwhile - a cymbal that produces a pure, clear ringing
tone, or a drum that really resonates focuses attention and
acts as a signal in a way the toy shop versions cant match.
Whatever the client group, beginning a session with a hello /
welcome song is good practice. This is a familiar device for any
child who attends a toddler or playgroup. Singing together is
a friendly experience. I aim to convey a sense of warmth and
welcome. The song signals the start of the session, focusing
minds and stilling fidgeting bottoms. A hello song can name
all the children individually, requiring a response (verbal or non-
verbal) as they hear their name, or can issue a general hello.
Tune in
Musical activities help to build early language skills in a fun
and relaxed way, with a built-in feeling of reciprocity and
mutuality. Listening skills, attention and joint attention skills,
eye-contact, turn-taking, initiating, copying, anticipating and
basic vocabulary building can all be addressed through the
simplest action song. Adding a few basic instruments, and
one or two stock-in-trade puppets or soft toys, creates added
interest and allows you to ring the changes. The therapeutic
value lies in the therapists ability to tune in to the needs of
the children. We can slow the pace or gradually increase it as
the child becomes competent. We can emphasise key words
to advantage, we can halt and create gaps for the child to fill,
and we can abandon or repeat parts. We can add signs and
gestures, essentially manipulating the song or action rhyme
to suit our therapy goals. Many children in clinic language
groups will have been part of singing sessions at playgroup
or nursery, but may have been unable to participate due to
the speed or complexity of the tasks. In therapy we can pro-
vide a rewarding and fun musical experience. Well-known
action songs such as The wheels on the bus or Ten fat
sausages can be easily adapted to make them suitable for
therapy sessions, and have the benefit of being mainstream.
Using well loved action songs in a more facilitative manner
is a good start in bringing music into therapy sessions. In
addition to this I use my own made-up songs and rhymes to
encourage specific skills, for example this rhyme to work on
pointing with young children and also to encourage eye-con-
tact and awareness of peers. Chanting with a slow and
emphatic rhythm, and wiggling my index fingers, we sing:
Heres my pointy fingers
one and two
Point to me and point to you.
Be brave
and
sng up!
are lnay uses
musc to tune n
to young chdren
- and nds t un,
beratng and
eectve.
Heres my pointy fingers
What can they do?
Point to me and point to you.
I also use songs as commentary on a childs actions or behav-
iours - flexible songs which allow me to follow rather than
lead and which encourage not just participation but initiation,
still within a predictable and repetitive framework. For
example, I may use a box of simple toys and offer it to a child
to choose one. To the tune of Pop goes the weasel, I then
sing, Its Tobys turn to choose a toy. If he selects a brush and
pretends to brush his hair, I would then sing something like
brush and brush and brush your hair. Another song of this
type, to the tune of Skip to my Lou, simply comments on
actions the children make. This may be something uninten-
tional at first, such as, Scratch, scratch, scratch your nose -
Scratch your nose like Kirsty, or, later, a deliberate contribution
such as, Stamp, stamp, stamp your feet .... like Martin.
Non-directive
Songs and instruments can enhance many typical language
group activities. Blowing bubbles can be accompanied by a song
such as bubbles, bubbles everywhere to the tune of Twinkle,
Twinkle, Little Star - or rolling a ball, or building a tower.
Similarly, I sometimes invent a short song for sitting down or
joining hands. Singing along to these simple tasks makes the
language that accompanies them more explicit, key words are
repeated many times, more time is created for the child to
process, and a non-directive fun atmosphere is maintained.
In work with very young children with severe and complex
learning difficulties, singing and musical instruments can be
brought into episodes of intensive interaction (Nind &
Hewett, 1994). For example, sharing an instrument (a drum
or a triangle), or perhaps with a shaker each, I play with the
child. I might provide a simple commentary, or use my voice
to imitate the sounds the instrument makes, or set up a
rhythm or a turn-taking routine. My aim is to establish a rec-
iprocal, pleasurable interaction. The episode is taskless, and
I attempt to sustain it by offering carefully calibrated
responses and sensitive reflective feedback.
Holding or stroking a child and singing can provide a sen-
sory experience which can help to engage with those children
who are hard to reach. This could involve rocking a baby /
child in my arms and singing, to the tune of Rock a bye
baby, a simple and repetitive song such as rocking and rock-
ing and rocking together. I could then stop unexpectedly,
wait for a response from the baby and resume, interpreting
any signal as a request for more. I can vary the pace, volume
or intensity. I can replace a side-to-side motion with a for-
ward and back motion. In later sessions I might move on to
further verses such as nodding, looking and waving.
Slight changes are made within a familiar framework. This
scaffolding facilitates extension into new learning.
Using music in this way feels genuinely therapeutic as it
involves creating opportunities and offering time, support
and feedback. It demands of the therapist the very basic skill
of really tuning in and of being fundamentally facilitative,
and is a conduit for a pre-verbal child to communicate.
Using music in therapy is fun, liberating, and effective. Take
a deep breath, be brave - and sing up!
References
Nind, M. & Hewett, D. (1994) Access to Communication.
David Fulton Publishers, London.
Resources
Details of Wendy Prevezers I CAN course A Musical Approach to
Developing Communication from The Training Administrator,
tel. 0870 01 7088, e-mail training@ican.org.uk
N
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2001 27
how I
he aim of music therapy is not simply to teach peo-
ple to play music or sing; rather, it is to use music to
encourage change in behaviours, skills and quality
of life through a developing musical relationship.
However, the use of music in therapy is open to all who enjoy
and are interested in music.
My use of music in therapy dates back to 1994, and has taken
its lead from clients own needs and strengths. At that time I
was working in a challenging behaviour project for 12 clients
with severe challenge to the service. The ethic of the project
was to attempt - within a properly resourced facility and in a
framework of ongoing evaluation and teamwork - to offer a
change of regime, approach and opportunity to these clients.
Up to this point, they had been spoken of mainly in terms of
their problem behaviours, so most came with frightening stories
attached. For many reasons their treatment had centred around
reactive rather than proactive methods: drugs; seclusion; and
programmes to eliminate their challenging behaviours. None
had effected significant change in the individuals.
In the initial stages, we focused on analysing client behaviours
and interaction, using observation and videoing to assess
their communicative function. We looked at the significance
that each problem behaviour had for each client within various
environments. It was very important to consider that, at this
stage, it would be quite unethical for us to attempt to remove
any problem behaviour without having a more positive
behaviour to replace it with.
I asked the following questions:
1. How do I work on anxiety - a common denominator which
blocks so much communicative potential and opportunity?
2. How do I shift the emphasis away from the problems a person
presents, to the difficulties they experience and the messages
they are trying to get across using these behaviours?
Information on person to person - establishing contact
and communication with people with profound learning
disabilities - is useful (Caldwell, 1996).
3. How do I best convey communication assessments and
total communication training theory into positive
communication practice for staff who are at the coal face
in terms of having to implement all team action plans?
4. How do I use the clients plusses, such as behaviours and likes,
and introduce the ethic of compliments given and received?
In my experience what we term the Gooding method has
good effect. This involves immediate, precise feedback to the
client using the word good ____ followed by the action being
praised, using whichever communication system is appropriate.
5. How do I facilitate the group of staff / clients with a programme
in the context of everyday living routines for genuine, embedded,
life learning (see Henderson & Crowhurst, 1991; Dobson et al, 1999)?
6. How do I help the group dynamic in each house at a basic
A
heang
orce
Nusc has
opened up new
opportuntes or
Heen Bruces
adut cents wth
earnng
dsabtes and
ther carers.
fun level - more ease, rather than disease (see Jones, 1990)?
7. How do I help increase shared understanding and empathy
with the individual? Video observation and analysis is a
useful means of gaining insight into the reasons underlying
the behaviour of concern, particularly using the Scottish
Project in Viewing Interaction Positively approach
(www.dundee.ac.uk/psychology/SPinVIP/welcome).
Discussion with key nursing staff and team members
involved in daily living / interaction groups followed, and
music was reported as a definite like for all clients. Indeed,
music could provide answers to all seven queries.
Priorities
A staff brainstorming session pinpointed priorities and we trialled
an eight week block of sessions using music to facilitate these. The
resulting programme (figure 1) for three clients was led initially
by the speech and language therapist along with an assistant and
key worker, and was to be modelled to all relevant project staff
and rolled out to the other clients. Key signing / symbols were:
music; relax; slowly; quiet; start; stop; hello; goodbye.
Good short-term responses to music with this group of
clients led to it also being used as a vehicle for body aware-
ness and touch communication sessions.
Long term carryover has been most apparent in the area of
listening to music to reduce anxiety. Seven years on this is still
valued by clients and staff, and the daily after-lunch session is
a sacred no callers allowed time.
It is apparent that some clients can self-calm or be assisted
to calm by listening to music and to express themselves more
freely through music. Music can truly provide not just a shared
language but a bridge to better shared understanding and,
for the client, an ability to form a new identity as a more able
communicator and - on occasions - the lead player. As Marvin
Gaye so rightly said, Music is the healing force of the nation.
References
Caldwell, P. (1996) Getting in touch - ways of working with
people with severe learning disabilities and extensive support
needs. Pavilion.
Dobson, S., Stanley, B. & Maley, L. (1999) An integrated com-
munication and exercise programme in a day centre for adults
with challenging behaviours. BILD Feb/March.
Henderson, R. & Crowhurst, G. (1991) On the job training for
residential staff. Mental Handicap 19.
Hooper, J. & Lindsay, W. (1992) Improving the quality of life
through music - a case study. BIMH.
Jones, S.E. (1990) INTECOM. NFER-Nelson.
Recommended reading
Nind, M. & Hewett, D. (2001) A practical guide to intensive
interaction. BILD (ISBN 1 902519 63 9).
T
Figure 1 - Programme
1. Relaxation
Previous behavioural relaxation methods had been attempt-
ed with some clients, but with poor carryover. The techniques
demanded a degree of concentration and attention and the
requirement to watch and imitate had proved so great it
had actually increased distress.
Could listening to relaxing music provide a viable alternative?
Self calming had been observed in certain clients in response
to listening to particular music, and it was important that staff
should learn from the techniques used. Hooper & Lindsay
(1992) found music was as successful as relaxation training in
reducing anxiety.
The signing and symbols for relax and slowly were taught
prior to - and linked with - the relaxation music. There was a
short relaxation session to start and a longer one to finish
each session. The emphasis was on active relaxation, not sleep.
2. Social greetings / farewell
This was a problem area for many clients and it was important
to highlight how it could be done. So, after the relaxation at the
start, we worked on greetings using signing, and singing
Hello+name with an emphasis on the intonation. After the
relaxation session at the end we finished with Goodbye+name.
3. Exploring
Each client selected an instrument and explored it along with a
staff partner, before playing it and turn-taking with their partner.
4. Giving the clients more of a voice
A few clients enjoyed using their voice for pleasure in singing,
making sounds to indicate needs and express emotions, and
using intonation patterns as conversation on a one-to-one
basis with staff. We extended this by using musical instruments
along with voice in one-to-one dialogues within the group.
An emphasis was placed on using the clients own resources -
face, body, voice,movement, touch, rhythm.
5. Silence
Appropriate periods of silence are very difficult for some
clients. Each episode of sound had silence before and after
it.
6. Start and stop / finish
These difficult concepts for most clients were taught
throughout the session, and clients were introduced to
conducting.
7. Compliments
Praise was given and received throughout sessions whenever
appropriate as a reward.
8. Emotions
Music was used for labelling / expressing emotions - happy
and sad initially, angry at a later stage, and moving on from
there as appropriate to individual needs.

Figure 1 - Ts music therapy assessment

T was referred to music therapy by speech and language ther-
apy and occupational therapy at six months post injury. As the
result of an accident she had been brain damaged and pro-
foundly disabled physically and communicatively. She was non-
verbal and the team had not established any reliable system of
yes or no. At the time of referral, she was reported to be
vocalising fairly constantly in what seemed to be a distressed
manner, but no pattern to her vocalising had been established.
The team was unsure whether her vocal sounds were related
to her environment, or were due to internal pain or confusion.
The goal of the music therapy assessment was, therefore, to
contribute toward the multidisciplinary team establishing
some understanding of her crying patterns, and whether these
were related to stimuli in her auditory environment.
All music therapy sessions are recorded, which allows me to
respond in the moment to the patients sounds and listen back
afterwards to analyse what has gone on in the non-verbal
interaction. Initially I listened carefully to her sounds; both the
musical elements of her vocalisations, and also the emotional
expression. For example, I listened to the dynamics of her cries
and how these fluctuated. I listened to the pitch and melodic
contour of her cries. I listened to the duration and articulation
of her cries: were they short, sharp, stabbing cries or long,
legato cries? These are all the musical elements. Most impor-
tantly, I listened to the emotional communication in her cries.
Were her vocal sounds calm, interactive and related to the
musical sounds I offered? Or were her vocal cries expressions
of distress, emotional or physical pain, or anger?
After the first step of listening, I reflected Ts sounds. That
is, I picked up on the musical and emotional expression of
her sounds and repeated them back to her. At first this may
have been simply mirroring her sounds, but it quickly
moved on to more than imitation, by extending and devel-
oping her vocal sounds. I tried to match the emotional
intensity of her sounds. This was done possibly through
vocalising, but also often used the added dimension of a
piano to add some sort of harmonic structure. This helped
to enhance and support the experience. For example, if Ts
cries were distressed and expressing frustration, I used dis-
cordant harmonies to provide a supportive structure for her
to vocalise with. The aim of this was to empathise with her
emotional expression. The aim behind using music in this
way was not to calm her down but to communicate with
her using her own means, saying, I can hear you and I can
understand that this is what you mean and how you feel.
Within the assessment sessions I noticed that, in immediate
response to my mirroring Ts sounds, she paused briefly in her
crying to listen. Often this would then be followed by an
increase in the intensity of her crying / vocalising. Together we
could build in intensity - using a wider range of pitch, getting
louder, changing the timbral quality of both of our vocalisa-
tions, and changing the length and articulation of our
vocalised phrases. From our interactions during the assessment
sessions I was able to establish that T was using her vocalising
in a communicative and interactive way in these sessions. This
was confirmed by her response in one session to a humorous
musical gesture (a sudden bass note plonked at the end of a
phrase.) In immediate response to this, T laughed. Taken by
surprise, I offered another differing humorous musical gesture.
Her response was similar. She did not sustain this response, but
it indicated important information to us that her vocal expres-
sive responses were at times related to what was going on
around her. This is something her family had been reporting,
but which had not been observed by many members of the
team in more formal assessment situations.
Meeting with Ts family enabled us to develop an under-
standing of the role music had previously played in her life.
This helped us to think about what music therapy interven-
tion may mean to her now. Her family told us that she had
previously played instruments and sung on a daily basis as
part of spiritual worship. This suggested to us that music
might have a very deep and personal meaning for T, and
might be touching her in ways we couldnt possibly observe.
+. Share nteracton whch does not depend on spoken anguage.
. lsten, mrror, scaod, repeat and extend communcaton through musc.
. lnd out the meanng o musc to the cent and ther amy / carers.
(. lnvest n one or two good quaty nstruments and sng wth convcton and voume.
. Adapt we-known songs to therapy goas.
. Pan and share sessons wth a musc therapst.
;. Engage wth cents and tune n to ther needs by adaptng pace, voume, start / stop, and pausng.
8. Use musc to set a tone (wecomng, reaxng, energsng, humorous).
,. Record sessons to mprove assessment and pannng.
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2001 28
how I
t the Royal Hospital for Neuro-disability, we have
the privilege of being able to work closely with a
music therapy colleague. We do this through joint
goal planning, shared therapy sessions, and run-
ning therapy and assessment groups together.
Identifying communication abilities in patients who are diag-
nosed in a vegetative or minimal conscious state requires skilled
assessment, particularly observational assessment by a multidis-
ciplinary team. To access communication abilities, the therapists
working with the patient need to be creative in providing
opportunities for communication to happen. This can be very
difficult when the patient has a very limited repertoire of behav-
ioural responses. Music provides an alternative medium which
can provide these important opportunities for shared interac-
tion but which does not rely upon spoken language. In this way
subtle responses can be identified and developed. In figure 1,
Wendy Magee demonstrates how music therapy assessment and
an understanding of the meaning of music to one client, T, was
crucial to the multidisciplinary assessment process.
Using a musical framework for communication opportunities
has proved invaluable in speech and language therapy inter-
vention with this client group. The non-verbal patient is given
an environment where interaction can and does take place,
and the therapists are able to identify and build on responses
which might otherwise not have been elicited. In this way,
music therapists and speech and language therapists have
been able to pool their expertise and experience to the benefit
of the minimally conscious and vegetative patient.
reatng
opportuntes
Nany aduts at the
Roya Hospta or
Neuro-dsabty
have been
dagnosed as beng
n a vegetatve or
mnmay
conscous state.
Nusc therapy s
an essenta
eement o the
mutdscpnary
approach to
assessment o
ther
communcaton
abtes.
A

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EVENTS
9-12 January, 2002
BETT - The Educational Technology Show
Grand and National Halls, Olympia, London
Includes Special Needs Village.
Ticket Hotline 0870 429 4574
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2002
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London* / Nottingham** / on-site in the UK***
Details: Jeremy Fisher, tel. 020 8291 1758, e-mail
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12-19 May, 2002
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Ncoa Robnson
and ama lese
are speech and
anguage
therapsts
workng n
Ndothan and
East lothan
respectvey. Both
work wth a
paedatrc
caseoad, n the
man wth chdren
at prmary and
secondary schoo
stages who
present wth
specc speech and
anguage /
communcaton
dcutes, wth or
wthout assocated
dcutes wth
readng and
speng. Ths
seecton o
resources reects
ther nterest n
ookng at a broad
range o approaches.
. onnectons
This is a new discovery thanks to a
colleague in our department! Very
reasonably priced, it is a wonder-
fully versatile therapy tool for the
slightly older child. A hexagonal
board is divided into small hexagons
on which are placed hexagonal
cards with pictures or words.
Blanks are also available. The aim
is to cross the board by placing
your cards next to one another
but, in order to place a card, you
have to state the connection with
the adjacent card. The connection
can be of any nature, but has to be
explained by the child.
Connections Board (1.99), Picture
Association and Word Association
Games (6.25 each) and Blank
Hexagons (1.99) from Philip and
Tacey, North Way, Andover, Hants
SP10 5BA, tel. 01264 332171.
;. Phonoogca Awareness
Tranng
This highly structured tool for working
with children who are having diffi-
culty with the early stages of litera-
cy development uses an onset and
rime approach. The child is asked to
select letters from the top of the
worksheet to make words using the
four rimes below; for example, -in,
-ay, -et, -all. A reading list and sentence
dictation sheet corresponds with each
worksheet, only using words with
rimes so far covered. Each worksheet
provides scope for revision as well as
introducing one or two new rimes. The
built-in repetition enables the child to
achieve a good degree of success
which is good for self-confidence.
Available from: Educational Psychology
Service, County Hall, Aylesbury, Bucks
HP20 1UZ. Price for different levels of
PAT is from 19.50-25.00 inc. p&p.
+. oour odng
Based on aspects of the Sunnybank Scheme developed by
speech and language therapist Jennifer Reid, this has proved an
invaluable approach for children with phonological awareness
difficulties. Sounds are classified according to where in the
mouth they are made and are allocated a colour - red for lip
sounds, blue for tongue sounds (corresponds to the colour of
the veins under the tongue), yellow for back sounds (you need
a torch to see the back of your mouth) and black for vowels.
Colour Coding can be used with a wide range of children with
difficulties ranging from phonological production to written
language problems, and can easily be integrated with other
approaches being used in therapy or at school.
See Scottish Office Education Department (1999) Support
for Learning: Special Educational Needs within the 5-14
Curriculum. Part 3 (vii) Developing the 5-14 Curriculum for
Pupils with Language and Communication Disorders.
. SAN-
With four sections looking at a childs
ability to process words and sentences
presented in different auditory envi-
ronments, this assessment is invaluable
for those interested in auditory pro-
cessing difficulties in children (or
adults). Words are presented to right
and left ears through headphones for
the child to repeat. The auditory envi-
ronments represented are filtered
words - words that sound muffled -
background noise, and dichotic listening
for words and for sentences. This
assessment really helps to identify at
what level children with a variety of
language difficulties are failing and to
plan ones therapy accordingly.
SCAN-C: Test for Auditory Processing
Disorders in Children (revised 1999) by
Robert Keith is 125.37 from the
Psychological Corporation, tel. 0208 308
5750, www.tpc-international.com.
(. Arrow
Arrow was developed by Colin Lane, ini-
tially for use with hearing impaired indi-
viduals. The self voice has been found to
be a powerful teaching tool - much
more powerful than listening to some-
one elses voice. In Arrow, the childs
voice is recorded using a modelling
technique; that is, the child imitates the
therapist but only the childs voice is
recorded. By using sophisticated record-
ing methods the child can subsequently
hear themselves, often for the first time,
using correct syntax, phonology and so
on. Arrow is currently used mainly by
teachers for children with literacy difficul-
ties, but there is considerable potential
for more widespread use by speech and
language therapists with all client groups.
Dr Colin Lane, The Arrow Priory Annexe,
Little St Mary Street, Bridgewater,
Somerset TA6 3EL, tel / fax 01278
446261.
. Vsuazng and Verbazng
Nanci Bells programme has proved a
valuable resource for working on both
receptive and expressive language
skills. Children of all ages who have dif-
ficulty visualising incoming auditory
information can benefit from developing
visualisation skills to support both com-
prehension and verbal expression.
Feedback to the child is always positive
and helps to shape the childs language
without resorting to repetition of the
therapists model and without being
judgmental. Nanci Bells book gives
clear guidelines with many practical
examples of how to implement each
level from picture description to creat-
ing images of words, sentences and
finally whole paragraphs.
Visualizing and Verbalizing for Language
Comprehension and Thinking is 44.95
from Winslow Education and Special
Needs catalogue, tel. 0845 921 1777.
. Johansen Sound Therapy
When looking to address the underlying auditory processing
difficulties many language disordered children have, we find
there are few tools available to us which tackle the problem
at a sufficiently fundamental level. Johansen Sound Therapy is
one type of Auditory Integration Training and is well placed
to do just that. Children listen at home to specially recorded
music, customised to their individual needs, for 10 minutes each
day over a period of about 9 months. Audited benefits of
Johansen Sound Therapy include improvements in concentration,
comprehension, reading and spelling, and, in particular, in
maximising the benefits of the teaching and therapy they are
already receiving. The approach has had favourable results in
many countries and further research is being planned in the UK.
Further information, including training courses, from Camilla
Leslie, 10 Kingsburgh Road, Edinburgh EH12 6DZ, e-mail:
camillamleslie@hotmail.com.
8. omprehenson Nontorng
Training in this intervention programme
enables listeners to evaluate their own under-
standing of incoming messages and respond
when they become aware of a problem with
comprehension. The children who most need
to ask for help are those who are least aware
of when they do not understand, and rarely
act to facilitate their interactions.
Comprehension Monitoring is based on a pro-
gramme developed by Dollaghan & Kaston,
with specific goals set for good listening and
thinking, and detecting unclear speech -
whether accoustically deficient, inadequate in
content, ambiguous, contradicting or impossible
to carry out. Focusing on messages that are
too complex or long, or contain unfamiliar
vocabulary or too vague words, encourages
the children to see themselves as active partic-
ipators rather then passive responders.
Dollaghan, C. & Kaston, N. (1986) A compre-
hension monitoring program for language-
impaired children. JSHD 51; 264-271.
,. Scae Oueston
By placing a cross on a line at a point between 1 and 10,
with 1 representing the hardest, worst scenario and 10 the
best, most successful point at which the pupil would like to
be, a scale question enables the therapist / teacher and
pupil to focus on general goals. Change can be measured
over time using a positive, forward-looking, practical tech-
nique. This idea comes from a basic philosophy known as
Solution Focused Brief Therapy and fits well into approaches
where therapist and pupil develop solutions to difficulties
together.
Solution Focused Brief Therapy was co-developed by Steve
de Shazer and Insoo Kim Berry. See www.brief-therapy.org.
+o. ooured ubes
Small coloured cubes provide a clever way of tackling phono-
logical awareness, and in particular phoneme segmentation
for spelling, without provoking the resistance pupils can
often bring to a perceived spelling task. By representing each
sound in a word with a different coloured brick (same sound
same colour, though not colour coded as such) the more dif-
ficult sound combinations, such as in CC and CCC blends
(bump, flag, string) can be made more tangible for pupils.
This training transfers to greater accuracy of regular spellings
through improved auditory perception and effective use of
strategies related to listening and talking. Twenty four cubes
(such as lego), with four each of six colours, is sufficient.
MY TOP RESOURCES