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WinTh e winner
of the Winter
98 reader
offer of React
Th
Speech & Language T herapy
in Practice has a coPY ofTheTest of Pretend Play (ToPP).courtesy ofThe PsychologicalCorporation. This new assessment no rmally retails for£31 2.23.To enter, all you have to do isfind seven three-letter realwords using the letters of theword 'P LAY'.The winner willbe picked randomly from allcorrect entries. Send your listwith your nam e (and,if youknow it, your subscriber number) to Avril Nicoll. Speech &Language Therapy in Practice.FREEPOST SC0 2255.
STONEHAVEN AB39 3ZL*or e-mail toavriinicolI@sol.co.uk.Please note t he winner willalso be required to rev iew the
ToPP or provide a case study
based around it for th eAutumn 99 issue.
• For readers outside the UK.the address is Lynwood Cottage,High Street, Drumlfth/e,Stonehaven A839 3YZ.
eader Offer
Test of Pretend Play by Vicky Lewis and JillBoucher is designed to be used by professionals working with young children, Including speech and language therapists.
It can assist with assessment and diagnosis and provides a framework for observing and gaining qualitative Information from structured and free play.
Administration time is 45 minutes and the age range I to6 yean.
In addition to finding ou t whether a child can incorporate several symbolic actions into a meaningful sequence, the three types of symbolic play are assessed: • substituting on e object for another object or per
son• attributing an Imagined property to an object orperson• reference to an absent object, person or substance.
Th e kit contains tw o versions of th e assessment, on enon-verbal, the other for children who have sufficient~ m p r e h e n s l o n .The ToPP has been co-normed with th e Pre-schoolLansua. Seal.3 (UK) assessment to enable direc tco mparison.
Competition ru les:I. Entrants must sub-scribe to Speech &Language Therapy inPractice and only Qneenlty is allowed per sub-sc,r/ber number.2. Entries must be received
by the editor on or before
31st March 1999.3. A person nominated bythe ecfltor will randomlyselect the winner from all
correct entries , but w ll
not know who the
entrants are .4. The winner WIll benotified by 6th AprH 1999.5. The winner will provide
eIther a review of theToPP or a case studybased around It 10
Speech &LanguageTherapy In Practice byllnd June 1999.
TIle Tesc ofPretend PlGy Is ovallable (rom The Psychological CorporotJon.Foots Cray High Street. S/clcup. Kent DAI4 5HP. tel. 0181 308 5710.
software
from
Propeller
Multimedia is
Laorag
Hunter with
her entry:
We have
people and
PCs ready
for aCtion
who want-
Really
Easy to use
Adult
Configured
Tasks
Laorag will
review React
in a later
issue.
Reader O ffi
Sienificantly improvedThe-Reynell Developmental Language Scales III (RDLS III) The University o(Reading Edition Available from NFER-Ne lson, £375 + VAT
Th is third vers ion of the Reyn ell is intended 0 follow current thinking on
language developmen t and . o quo te from the ma nua l, "to reflect a devel
opme ntal logic In terms of lingu istic structure".
We were mildly perturbed wh en the very fam iliar black exec utive brref
case arrived in the office - wel"e the conten ts going to be simi l r to the
o her vers ions l Would we still go through bu ilding the fence. men ding
th e bed (wi th o ~ a p or blu-tack) and tying the limb back on the dol r.We we re however de lIghted with the co ntents, wh ICh are modern.
attractive and of sturdy quality It would also seem that rep laCing indi
vidua l items ISnot going to be a problem.
This vers ion ISso different to he first ones. t hat careful reading of the
manual is essential before emb arking on any test ing. The chapterson the
des cnp Ion of the sca les and the admin istration of them are well laid out
and easy to read. There ISno precise ceil ing for aband on ing the tes t and
th erapists have to use their own discret ion to some exte nt. A strong
magnifying glass and ruler are recomme nded for read ing th e percentile
and stand ard score tables.
The first t ime we admin is ered the test was a nightmare. We couldn 't
remem ber whic h boxes he toys went back in and a certain amount of
manua l dexterity was reqU ired getting teddy to wave a nag,whilst hold
ing a bi ro and keep ing the chi ld's atten tion. After only a coup le of
attempts, admi nistratIon be came organ ised and s ick and th e clear record
bo oklet was easy to use. Once a th erap ist IS fami lIar with the test it
shou ld take between 20 and 30 minutes. The ch ildren clear ly fo und the
toys interesting and in ost cases enjoyed the test. The switching from
objects to pictures a d b ck again was useful in holdi ng children's atten
tion.W hen testIng with the expressve section we we re left with the fee l
ing that he taskswere very difficu lt for the ch ildren and hat thewscores
would be poor However this was not the case and age equivalent levels
were accw·ate.Sconng the test is straightforward and compares we ll to other assess
me nt s.The test provid es a range of scores . including age equivalent. stan
dard and percen tIle scores wh ich are invaluable when comp lirng repor ts
fO I- th e Loca l EducatIon Authority. The quan.ative informa ion prOVided
has also been useful and the record bookJet has section head ings which
are elpful wh en inte rpret ing a ch ild's pe rformance.
Overal we feel thiS is a significan tly improved assessment and shoul
become part of any paedlatrrc speech and language therapist 's diagnos
tic krt. If someone cou ld tell us how we cou ld w in another 20 for our
Depa rtment we wou ld be most gratefu ll
Barbaro McLennan is Head or speech and language therapy and ErmlyMcA rdle a PinCipal speech ond language therapist wich Wi I and WestCheshire Community (NHS) Tust at S( Carhenne's Hospital, Brkenhead(-hiS rev'ewel-s wen ths }sseS,f"Ylent In a ccrnpet,tlor n A ItJmn 98
S,llE: of 5Deecn & Lansjage I heldDY 111 Practl e)
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Further Reading 24
& ~ e e c hguage
TheraJ)in Pm ice
www .sol.co.uk/s/speechmag
SPRING1999(publication date 22nd
February)
ISSN 1368-2105
Published by:
Avril Nicoll
Lynwood Cottage
High Street
Drumlithie
Stonehaven
AB393YZ
Tel/fax 01569 740348
e-mail : avrilnicoll@sol.co.uk
Production:
Fiona Reid
Fiona Reid Design
Straitbraes Farm
St. Cyrus
Montrose
Printing:
Manor Group Ltd
Unit 7, Edison Road
Highfield Industrial Estate
Hampden Park
Eastbourne
East Sussex BN23 6P T
Editor :
Avril Nicoll RegMRCSLT
Subscriptions and advertising :
Tell fax 01569 740348
©Avril Nicoll 1999
Contents of Speech & language
Therapy in Practice renect the views
of the individuol outhors and not nec-
essorily the views of the publisher.
Publicotion of odvertisements is not
on endorsement of the advertiser or
product or service offered.
Any contributions may also
appear on the magazine's
Internet site.
Cover picture:Epilepsy - a speech andlanguage therapist's gu ide .
Picture from St Piers
School
~ ~ C O N T E N T ~ S ~ ~ Parent / professionalews/
Comment 2 partnership . 20
Epilepsy is the commonestserious chronic neurological conditionin childhood. Linda Edwards illustrates why special careduring assessment and flexibility in therapy is neededin specialist, mainstream and community settings.
There are problems in the way
COVER STORYEpilepsy 4
Nasality 9Sarah Moore and Anne Hardingsuggest how generalists andspecialists can collaborate toprovide effective therapy for
children with nasality problems.
Dysphagia 12Continuity of patient care and theprovision of food of appropriateconsistencies are perennialchallenges in dysphagiamanagement. Penny Gravil! reportson the experience of one hospitalover an eighteen month period.
Reviews 16VOice, genetics, audiology,aphasia.
Leaming throUghdrama 17Having covered Beginnings andEndings in Part I of her article onusing drama in therapy, here inPart II Myra Kersner demonstratesthe versatility, flexibility andcreativity of the main body of thework, the Middle.
SUMMER '99 will be published on 31st May 1999
IN FUTURE ISSUES• working with older children • Communicate • stammering
• rhyme • new assessments • Top resources - brain injury
Language development, hearingimpairment, brain injury, voice,dysphagia, severe aphasia.
How 1work withassistants 25Three therapists offer their viewson training and assessment, thecomponents of a good working
partnership and the kinds of
tasks and responsibilitiesassistants can take on.
My TopResources 30Gwenan Roberts chooses tenthings she could not do without
in her work with clients withchallenging behaviour.
parents aretold abouttheir child'sdisability.AnneLeonardfrom Scopeexplainshow RightFrom TheStart is
working tomake a difference byensuring aconsistentapproachbased on
best practice.
SP EECH & LA NGUAGE TII £RAPY IN PRACfl CE SP ill G 1999 1
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NEWS & COMMENT
Crossing specialisms In How I work with ass i'stants, Kate Richards describesthe training for assistants developed in her Trust: "thecompartmentalising of human communication disordersinto that which is relevant only to certain age groupsis challenged; for example, students learning about
language development are asked to consider why thisis relevant to adults with a learning disability:Clinicians adopting th is attitude benefit from cross-fertilisation of ideas and a wider range of experiencethan they would get from being tightly focused on aspecialism or diagnosis.Just think, then, what opportunities Myra Kersner's childdrama activities would also provide for groups of peoplewith dysphasia, dysarthia, dysphonia, dysfluency andlearning disabilities, indeed for any group needing torehearse and practise communication skills in a realSituation. Sharing a diagnosis with parents is one suchsituation where all professionals can improve theirskills according to the Right From the Start project.Excerpts from the template of good practice give us
food for thought. What measures do we take to checkpeople are alright once they get home? When do weever give people time alone to think over what wehave said? How often do we make it easy for peopleto ask more questions? User involvement is a trendyterm. The challenge for us is to respond to it.Penny Gravill's work in developing a system for dysphagiamanagement in a neurosciences unit meant gettingfeedback from nursing staff about how well the systemwas working and then making amendments as aresult. Frustrating and time-consuming? - certainly. Butnecessary for the system to function effectively and animportant part of any process of change.Dysphagia teams are a relatively new development
compared with those for cleft palate. However, amajor shake-up in cleft services means specialists andgeneralists are going to have to spend more time oncollaboration. Sarah Moore and Anne Harding providevery clear suggestions as to how this can be achievedalong with the latest thinking and resources.In her comprehensive and enlightening article onepilepsy, Linda Edwards also passes on experiencegained as a specialist. Her enthusiasm is catching, andit is clear she finds it "a fascinating challenge to try tofollow the path through the maze, and an endlesslyrewarding opportunity to offer some, often hugely
appreciated, help."Whatever new things are goingon in any area of the profession,
we want to bring you news of
them - where else would youhave heard about Gwenan
Roberts' red tool box? So, keepyour ideas, feedback and articlescoming to the magazine that ismaking a difference.
Avril Nicoll
Editor
Lynwood Cottage, High Street,Drumlitllie, Stonehaven AB39 3VZ
tel/ansa/fax 01569 740348
e-mail avrilnicoll@sol.co.uk
Centre's achievementsThe success of The Speech, Language an d Hearing
Centre's early intervention philosophy is detailed in
its annual report.
In addition to an outstanding OFSTED report an d
the launch of an Outreach Training Programme, a
Department of Health funded research project
showed good progress was made at the Centre by
children with speech and language delay and autistic
spectrum disorders. The Centre has also established
a number of partnerships. Working with the National
Deaf Children's Society, it will develop familly
workshops for recently diagnosed deaf babies.
The Speech, Language and Hearing Centre, rei. 0171 383 3834.
Education eventOver six hundred exhibitors at The Education Show
1999 will include those specialising in special needs.
Seminars will include raising literacy standards and
the underachievement of boys.
The Education Show nms from 11 - 13 March 1999,
NEC Birmingham. Ticket Hotline 01203 426549.
; : ~ ! ~ e e C a S ~ ~ \ ~ ~ ~ K , an organisation of
professionals working to help people keep their
voices healthy and to communicate effectively, has
been awarded charitable status.
As the next step, the Network hopes to start a
refereed journal. Details of this from Lesley Hendy,
tel. 01223 836175.
Practical interactive study days for potential network
tutors are planned for 29 March in London and 24
April in Edinburgh. VCN, tel. 01926864000.
Screening reviewThe report Screeni ng for speech and language delay: a
systematic relliew is now available from National
Coordinating Centre for Health Technology
Assessment, Mailpoint 728, Bolderwood, University
of Southampton, Highfield, Southampton S016
7PX, tel. 01703 595586,
http://www.soton.acuk/Nhta/htapubs.htm
SIGNALONG move
The SIGNALONG group has moved to The
Communication and Language Centre, Chatham
Historic Dockyard, Chatham Maritime, Kent ME4
417, .
Nel'" publications include National Curriculum
Science, KSI (Life Processes & Living Things ) an d
Signs for Literacy Strategy. Collections ofYelY
Important People and This is Mel are planned and
individual core vocabularies can be produced on
request.
Details. 01634 819915.
Web updateThe National Autistic Society has a n ev>,ly designed website
which includes specific information ro r professionals.
hup: //www.oneworld.org.autis m_ lI/,;
Winslow Press aims to crea t a Uniqlle ce n tre of
information, news, discLission groups an d resource
materials for everyone invo lved in rehab ilitation an d
educational special needs \\' Lh its site. n on-line
catalogue and Therap\' \\ 'eekJ ;' are included.
hItp://www.II'inslow-pres '. [(1 .II I;
SPEECH & LANCUACE THERAPY IN PRACfICE SPRINC 1999
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." ,
oo
. :"0u.r:on
W".r:U )
o5J:c..
Alan Hewitt, Chair of the
Action for Dysphasic
Adults working group on
the Disability
Discrimination Act
(1995) presents the
group's report to the Minister
for Education an d Employment, MargaretHodge. Sue Gilpin of the working party and Ruth Coles, ADA
Director, look on.
The Minister has agreed to include language impairment in depart
mental documents where appropriate. She suggested evidence col
lected from individual cases would help establish the specific needs
of people with dysphasia when being considered for benefits.
Details of the repoTt 'Open Hole the Stony Wall' from ADA, tel. OJ 71
261 9572. ADA also has a range of merchandise for sale including pens,
badges and t-shirts.
Primarycare for
Parkinson'sA guide to recognising
and managing
Parkinson 's Disease in
primary care has been
distributed to every CI '
in the UK.
Produced mai nly by GPs
for CPs, in association
with the Parkinson's
Disease Society, the
guide promotes onward
referral to specialists an d
members of the multi
disciplinary team. Each
GI' has on average less
than three people with
Parkinson's an d is the
first person seen by
people experiencing the
symptoms.
Details: PDS, tel. 0171 931
8080.
Rare disordersAn awareness week has
focused attention on rare dis
orders.
Initiated by the Rare Disorders
Alliance - UK an d co-ordinated
by Contact a Family, the chari
ty which supports families
who care for children with dis
abilities an d special needs, the
campaign highlighted the need
for research into rare condi
tions and information-sharing
across the world .
Of the 15000 children born or
diagnosed \vith a disability
each year, at least 1200 will
ha\'C on e of more than 5000
differing rare disorders. The
main problems these children
face include late diagnosis, lit
tle patient-friendl y informa
tion. contact with other fami
lies an d awareness of the con
ditions and expertise among
professiona'is. Research into
rare disorders suffers from
severe limitations including
poor statistical collection and
scarcity of subjects.
Rare Disorders Alliance - UK
c/o Contact a Family
tel. 0171 383 3555
e-mail rda@cafamily.org.uk
Efforts to improve communication
between doctors an d patients with
leaming disabilities have been recog
nised with a national award.
Professor Sheila Hollins of St
George's Hospital Medical School
used actors to role play people with learning
disabilities during drama workshops for medical students. She
has also produced practical resources for patients and their car
ers. A series of 17 picture books includes 'Going to the Doctor',
'Going to Out-Patients' an d 'Michelle Finds a Voice', the latter
co-authored by speech and language therapist Sarah Barnett.
Accepting the BUrA Foundation Communications Award from
Professor James Watson, Professor Hollins said she believes that
if future doctors can acquire the skills an d positive atti.tudes nec
essary to communicate with people with learning disabilities
then they will find it easier to communicate with the majority
of their patients.Books Beyond Words cost fl O each from the Royal College of
Psychiatrists, tel. 0171 235 2351 ext 146.
People's PanelFindings of a national panel to
research the effectiveness ofgovernment services haveimplications for speech andlanguage therapy departments.The People's Panel of over 5000randomly selected people has be(71
set up to help generate ideas on
how services in the public sectorcall be improved. The first waveof research found that
• the services which members feelare most important to them are GPs
and NHS Hospitals respectively
• in general, the better a serviceis at keeping people informed, thehigher its satisfaction rating
• heart disease and strolle are themost important health-relatedissues for possible futuregovernment campaigns, afterdrug misuse and cancer• nine OlH of ten people wouldlil1e a one-stop, 24 hour telephone
illj(mnation line on governmentservices that is answered personallyra ther thun electronically
• Iline per cent of the panel areconnected to the Internet at home
• the use of new technologyappeals to 65 per cent in the 16-
34 year age group 17w only 25per cent of the DUeT 65s .The Panel is open to all publiclyfunded bodies and will be el.'aluated
over the next three years .
Details: http :/ /www.service
first. gov.uk/panel.htm
- - - ~ - - - -
New discussiongroupEasyspeak is a new e-maildiscussion group which aims to
bring together people interested in
children 's communication difficulties and to provide another forumfor links between practitioners in
education and health services.Anyone with Internet access can,
at no cost, join the list of memberswhich is managed by CarolMiller of the University of
Birmingham's School of Education.The mailing list software is on a
computer at the BritishEducational Communicationsand Technology Agency (BECTa) ,and you can send on e ('-mailmessage to reach everyone, orrespond individual/y.To join , send an e-mail as follows,without adding any further textor a subject line:
To: majordomo@ngfl.gov.uk
Subject:
Subscribe easyspeak
Your request to join will beacknowledged and you will besent an introducto ry file giving
more details about the list andhow it operaCEs.Details: http ://www.becta.org. . sencoor e-mail c.j.miller@bham.a· uk
SPEECH & LANGUAGE THERAPY IN PRACTICE SPRlNG 1999 3
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EPILEPSY
Epilepsy' -a speech and
langua -e
Epilepsy is the commonest
serious chronic neurological
condition in childhood( I),
affecting 5- lOin everyI ,(xx) children(2). tt
signposts the possibility of
some disturbance of brain
function which has the
potential to affect
communication, and
indicates the need for special
care during assessment and
flexibility in therapy
Linda Edwards takes acomprehensive look at
epilepsy in four parts - the
condrtion rtself, effects of
medication, assessment and
therapy - to demonstrate
the implications fo r
specialist, mainstream and
community settings.
therapi sguide I.The eoileptic
contJrtJon
T
e most dramatic impact of
epilepsy on our practice is also
the rarest - that it may be the
speech and language therapist
wh o is the first to identify
symptoms of epileptic disorders. The best
known example is the rare Landau-Kleffner
syndrome (acquired epilepsy and aphasia),
which presents most commonly between
three and eight years. Almost half of these
children show language problems first.
with regression of language after a period
of normal development. It may start with
an acute or gradual loss of verbal compre
hension, followed by phonological errors,
prosodic disturbances or paraphasias, pro
gressing in the severest cases to an auditory
agnosia(3)(4). Language symptoms may
fluctuate markedly, while behavioural
problems and autistic features may appear.The electroencephalogram (EEG) shows
abnormal discharges in one or both tem
poral lobes, especially during sleep,
SPEECH & lANGUAGE THERAPY IN PRACTICE
although up to a third of these children do
not have recognised seizures.
Voice suspicions earlyThe prognosis for language recovery, as
with acquired auditory disorders rather
than acquired aphasia(S), seems better in
older children. It may also be bener where
deterioration of comprehension happens
more suddenly(6). Con trolling the epilep
sy does not directly improve language but
recovery may be related to how long the
abnormal EEG discharges continue(7), so
there is good reason to voice any suspi
cions early. Where recovery is incomplete,
special educatio n may be required. Speech
and language therapy will combine audito-
ry / phonological training with visual sup
plements such as signing. symbols, written
language, colour coding or articulatory
cueing.
Other epilepsy-related disorders may first
present to the speech and language thera
. pis!. The EEG in one of the commonest
epilepsy syndromes in children - benign
partial epilepsy with centrotemporal
spikes, characterised by hemifacial motor
SPRING 1999
seizures often related to sleep - looks like
that in Landau-Kleffner syndrome.
Intermittent drooling. phonological dis
turbance, dysarthria or oromotor dysprax
ia lasting days to weeks may occasionally
occur(S). These temporary disturbances
reflect the site of the epileptic focus and
can occur without visible seizures(9).
Most seizures controlledFar more commonly, the therapist sees a
child wh o is already being treated for
epilepsy. Many children will have few if
any seizures, and minimal disruption to
their lives or education. With progress in
anti-epileptic medication in recent years,
up to sa per cent of people will have their
seizures well controlled. However, this is
not always the case. The therapist will want
to ask parents or teachers: Does he have
seizures in the daytime? Ifso, what do they
look like? How long do they usually last] Is
any help ever needed? This way, a seizure in
a session can be recognised (not always aseasy as it sounds) and reported . If a child
does have a majo r seizure, these are almost
always self-limiting and very little interven
4
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EPILEPSY
tion is actually required. You should:
• cushion the head from hard objects
• not move the child (unless in danger), or
restrict movements
• not put anything between the teeth,
including your fingers• turn the child into the recovery position
when any jerking is over
• stay with the child and be reassuring
until s/he is fully recovered
• look ou t for any incontinence which can
be distressing afterwards.
Other types of seizure are less immediately
recognisable, panicularly complex panial
seizures which can look at first like pur
posive behaviour, for example repeated
picking at the clothes. These also should
be identified and reponed.
Developmental
and acquiredThe impad of epilepsy on ou r practice is of
course wider than the small chance of a
seizure during a session. Epilepsy may occur
at any age, resulting from trauma, infection
or other cause, or it may arise spontaneous
ly, perhaps with a genetic predisposition.
Depending on age at onset, a child with
epilepsy may present with a developmental
or an acquired communication difficulty, or
sometimes both. There may be pragmatic
impairments, language disturbances, and
effects on prosody or fluency. More global
effects also occur. There is a high rate of
epilepsy in children with autism. It is said
thatup
tohalf of
all children with epilepsyhave some learning difficulties. A figure of
up to 50 per cent of boys and 15 per cent of
girls has been suggested( 10). Sometimes the
original cause of the epilepsy causes learn
ing disability too, but it is also possible for
uncontrolled epilepsy itself to cause brain
damage and hence learning difficulties.
UnderachievementAlthough most children with epilepsy are
of normal intelligence, underachievement
at school is common. Children make less
academic progress than expected for their
IQ and age(1l)(12). There is an increased
risk of problems with reading comprehen
sion, perhaps more so with spelling and
arithmetic. These difficulties can persist to
secondary school and beyond. The outlook
is best where the epilepsy starts later, there
is only on e seizure type an d a quick
response to a single anti-epileptic drug( 13).
Educational problems are more likely to
arise where seizures persist for severa .1years.
Speed of information processing, memory,
alenness, sustained and focused attention
and motor fluency appear to be particular
ly vul nera ble skills( 14). As the difficul ty
can vary with the type of epilepsy, age of
onset or seizure frequency, the therapist
will find it helpful to know what type of
epilepsy the child has. Several criteria areused to classify epilepsy:
• seizure type - partial, generalised (arising
in both hemispheres) or unclassified
• aetiology - idiopathic (spontaneously
arising) versus symptomatic (associated
with known or unknown brain damage of
varying degrees)
• anatomical localisation (eg. frontal, tem
poral). Seizure types are further subdivided. In
idiopathic generalised epilepsy, there
seems to be an association with visual
memory and visuomotor deficits. Four
main subtypes of learning difficulties have
been suggesled(2):
• memory deficits, associated with tempo
ral lobe dvsfunction
• a [ \ e n t i o ~ deficits, associated with gener
alised tonic-clonic seizures (formerly
known as 'grand mal')
• slow information-processing, associated
with multiple medication, and
• difficult.ies in verbal reasoning an d con
cept formation. Many of these difficulties can create com
munication problems for the child. They
can also affect assessment results and
response to therapy.
Behaviour debateThis low performance at school can lead to
poor self-esteem and impaired social inter
actions, compounded sometimes by low
expectations from parents or teach
ers( 15)( 1). Parents frequently report that
the epilepsy has affected their child's
schooling, feelings about themselves and
plans for the future( 16). There may also be
an effect from missing periods of schooling. About half of all children with epilep
sy and normal intellectual ability have
some degree of behaviour disturbance,
more than their own siblings, age and abil
ity peers, or children with other chronic
diseases( 17). Anti-epileptic drugs can have
(reversible) adverse effects on behaviour.
This association between poor school per
formance an d behaviour problems has
caused some debate, with each being felt
by some authors to cause the other.
Then there are more specific effects on
communication. Some epilepsy-related
communication difficulties are transitory
and related to the seizure itself. In both
generalised tonic-clonic an d complex par
tial seizures, consciousness is impaired
and temporary associated language distur
bances may occur. These may involve a
'prodrome', a variable period leading up to
a seizure when there may be changes in
behaviour, especially irritability(18).
There may be bizarre language or perhaps
swearing. Sometimes this is parents' only
clue that a seizure is 'brewing'. The child
may become dysphasic as a type of 'aura'
just before a seizure. During a seizure there
may be vocalisations, gestural automa
tisms or other behaviours that may look
purposive. Afterwards, a child may be
mildly dysanhric or dysphasic. This can be
distressing. David, aged 14, told me: "I
want to tell people not to crowd round me,
but I can't say it. "
Advocacy mlePerformance can be affected for hours or
even days after such seizures. There may be
after-effects on attention from general ised
tonic-clonic seizures for up to 30 days( 14).
Nocturnal seizures are believed to have a
detrimental effect on language functions,
memory and alertness the next day, per
haps through disturbed sleep patterns. The
therapist has a role as advocate for the
child, supporting the parents in alerting
staff to what to expect.
Tonic (stiff) or atonic seizures (drop
attacks) carry an obvious risk of injury as
the child can crash to the floor. Some of
ou r children wear helmets to protect heads
an d faces. Sometimes front teeth are bro
ken, or occasionally there may be worse
damage such as a broken jaw or lacerated
tongue. .Acute effects on speech or eating
an d drinking skills from such injuries, an dsubsequently from any surgery or onho
dontic work needed, can require short
term speech an d language therapy.
Cumulative effectGeneralised seizures of a far less obvious
kind are absences (formerly known as
'petit mal'). Lasting typically 5 - 10 sec
onds, with little to see other than perhaps
eyelid flutter, they can easily be missed
altogether or mistaken for daydreaming or
noncompliance. Each on e interrupts con
sciousness only briefly but the cumulative
effect of frequent absences can be very dis
ruptive. Absence seizures are commoner inteenagers, and in girls rather than boys. In
the uncommon childhood absence epilep
sy (which affects less than 1 in 1,000 chil
dren under 16) there can be up to thou
sands in a day, undetected without special
monitoring.
The resuLt can be loss of concentration,
reduced comprehension of long or com
plex language, difficulty holding the thread
of a conversation, or other memory prob
lems. The child misses social as well as ver
bal cues and may appear "out of it". At the
extreme, a child may have a period of non
convulsive status, that is with no recovery
between absence seizures. Here the childmay appear depressed, withdrawn or unre
sponsive. Even a child with few clinical
absences may have reduced attention con
trol between seizures. Some are aware that
they miss things, while others are simply
bewildered. Their ow n speech can lose
coherence, with frequent jumps of topic or
filler-phrases in an attempt to stay in con
trol. This type of epilepsy usually responds
well to medication and tends to resolve in
the teenage years. However, treatment which
successfully reduces seizures may not always
eliminate the difficulty in atten tion co ntrol.
Focus effectWith partial seizures, where discharges are
concentrated in on e area, the location of
................. .continued over ...
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EPILEPSY
the focus of discharges will have an effect.
Dominant temporal lobe epilepsy is often
associated in adults with impairment of
verbal memory, especially affecting long
term consolidation and retrieval( 19). In
children with temporal lobe epilepsy,
impairments are less consistently evident.
They also may show memory impair
ments, which can be related to hemispher
ic specialisation(20) although are not con
sistently so(21). Children with left-sidedfocus may show poorer performance on
reading comprehension( 11) or phonologi
cal and syntactic lexical tasks(22).
Children with a focal seizure disorder can
develop effective language, perhaps due to
the mediation of the normal hemisphere,
although development may be
delayed(23). In benign partial epilepsy with
centrotemporal discharges, verbal functions
generally seem less affe aed, although there
may be subtle impairments in auditory per
ception and short-term memory(24).
Children with right-sided focus may per
form less well on tasks requiring attention
control and visuospatial processing(2S).There can be effects on prosody, for example
slowed speech rate. Adults with right-sided
focus have been found to use a smaller fre-
quency range(26) and this may occur in
children as well. Intonation in our children
is certainly often reported as monotonous.
j i l l EEG pattern known as CSWS (continu
ous spikes and waves during slow sleep) is
associated with severe and complex neuro
logical impairment, mainly in language and
behaviour. It can occur in more than one
epilepsy syndrome(27) .
Frontal lobe epilepsy may lead to an
inability to concentrate or a 'dreamy' qual
ity(28 ). Frontal lobe seizures can include
complex gestural automatisms, vocalisa
tions or facial movements. Phonemic and
semantic verbal fluency can be reduced. In
my experience, word-finding problems
and a tendency to perseverate can hamper
communication in these children.
T a n ~ r t o r y cognitiveImpaIrTnentA child does not need to have visible seizures
at all for effects on communication to occur.
Some people with frequent 'subclinical' dis
charges, showing up on EEG but not
observable as seizures, appear to experience
transitory cognitive impairment (TCI). Thiscan affect attention, immediate memory
and speed of reaction. Children can show
reduced verbal learning when they have
subclinical discharges during test
ing(29)(14), with clear implications for
the reliability of formal assessment. The
effects may show up between discharges as
well(30). Landau-Kleffner syndrome may
be an example of subclinical discharges
disrupting language function, but it also
occurs more widely. Although these are
no t observable seizures, anti-epileptic
medication such as lamotrigine can be very
effective in reducing the discharges, with
associated improvement in function(31).Mood, alertness, concentration, and school
performance can improve(32) and with
them , communication.
If a child has a past history of seizures,
there is some chance of lasting effects on
communication. Status epilepticus (pro
longed or serial seizures without recovery
in between) in young children may be fol
lowed by specific deficits - for example
memory problems, following damage to
the hippocampus, or losing early words, at
least for a time(33). However, long-term
adverse effects may be decreasing(34) .
Children without epilepsy, but with a his
tory of neonatal seizures, may show specif
ic learning difficulties such as in spelling
and arithmetic possibly arising from the
same subtle neuro-developmental vulnera
bility which led to the early seizures(3S).
II. r;1edicationet1ects .
Anti-epileptic drugs can, as we have seen,
improve cognitive function through their
action in reducing seizures or abnormal
discharges. However, they can themselves
sometimes have side effects which impaa
on communication, or on general cogni
tive skills. Of the older drugs, high levels of
phenytoin can cause cerebellar ataxia and
dysarthria It can also lead to gum hypertro
phy, while over long periods there can be
motor slowing and impairment in higher
intellectual functions. There may be specif
ic effects of some newer drugs also. Word
finding problems have been noticed after
topiramate(36) although this is temporary
and has not yet been studied in children.
HypersalivationIncreased salivation can be a side effect of
certain drugs such as clonazepam and
related benzodiazepines, which can also
lead to hypotonia, affecting oral co-ordina
tion and thus the ability to deal effectively
with the saliva(37). Hypersalivation can
also occur with some other drugs, particu
larly when first prescribed , or can occur as
a result of uncontrolled seizure activity.
Drooling is a problem which tends to be
resistant to therapy but can improve
noticeably with medication changes.
All established anti-epileptic drugs can
have unwanted neurological effects, suchas on memory, concentration, mental or
motor speed. Evidence about effects on
cognitive function in children is conflict
ing(21). Side effects may no t necessarily
occur in children, or may be mild and part
ly offset by the benefits of a reduction in
seizures(38), bu t worry about them may
tempt parents to discontinue use. If they
do occur they can be particularly disruptive
for the child 's development as, even
though they appear reversible when the
drug is stopped , they can limit learning
during the important years.
Most anti-epileptic drugs can cause drowsi
ness, including carbamazepine(39), sodium valproate and phenytoin(40), as well
as many of the newer drugs such as
gabapentin, lamotrigine, topiramate, viga
batrin( 41) . The child with epilepsy may
already tend to sleep more in the day, fol
lowing night disturbances or tonic-clonic
seizures. Carbamazepine can have effects
on rnemory(42), perhaps secondary to
more general cognitive effects.
Concentration problems can occur for
example with phenytoin or topiramate,
mood changes occasionally with vigaba
trin, slowed thinking with barbiturates
such as phenobarbitone, used in treatment
of acute episodes, or the similar primi
done. Paradoxically, barbiturates can also
produce hyperexcitability in young chil
dren and tend to be avoided for long-term
therapy. Tremor may be associated with
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EPILEPSY
sodium valproate, diplopia with carba
mazepine, motor speed may be affected by
phenytoin while response delays can be
associated with higher levels of medica
tion. Adolescence may lead to erratic com
pliance with a medication regime, withresultant risk of seizures and associated
problems reappearing(l) .
III. AssessmentWhat are the implications of epilepsy r. r
assessm ent?
I. BaselinesFrequently repeatable baselines may be
needed along with formal tests. As well as
in therapy planning, our observations of achild's performance can be helpful in eval
uating the results of medication changes, if
we can locate and inform the prescribing
doctor. Co urses of steroids can sometimes
produce dramatic improvements in speech
and language, at least during treat
ment(43). There can be substantial
improvements in language and communi
cation when frequent seizures or dis
charges are brought under better controL
indicating that skills are not necessa rily
lost but suppressed . When I first met
Justin, at 12, he spent much of his day
asleep in a corner of the classroom. He
could notrem
ember
whoI was, select pictures on request or tell me what he was
doing. Three years later, after starting on
lamotrig ine, his cheery voice greeted me all
over campus, "Hi, Linda' Are you seeing
me today?"
For a few children with highly resistant
seizures, neurosurgery may be an option,
and the local therapist can help the hospi
tal team with pre- and post-surgical assess
ments to chart progress. Depending on the
site of surgery, there can be some chance of
specific deficits afterwards, but the
improvements in imaging techniques in
recen t years give much better localisation
of function, so that the operation can be
tailored to minimise this risk. The risk is
further reduced in young children by some
degree of plasticity and / or behavioural
compensation. Language is usually
thought to have lateraIised by the age of six
years, an d earlier damage may affect cere
bral dominance(21). After temporal lobe
resection, likely to affect verbal learning
and memory in adults, children tend to
show unchanged or improved learning
(19), although deficits can also occur(44).
There can be temporary naming problems.
Children can show substantial improve
ments in cognitive function , behaviour
and communication after neurosurgery,
whether thi s is caused by a reduction inseizures or by reduced need for anti-epilep
tic medication. Improvements tend to be
greater in those who become seizure-free.
2. InterpretationFormal assessments may not show up what
the therapist is expecting. Close observa
tion may indicate lapses of awareness dur
ing testing. Any deficits apparent may be
transient, directly related to a seizure.Temporary 'peri-ictal' disturbances may
need management strategies, but should
not be confused in assessment with any
long-term residual language problems .
Test results may reflect problems other
than speech an d language disorders.
Children \ ith epi lepsy may score poorly
on as menlS need ing a tt en tion controL
uch as the TR OG , o r those we ighted
towa rds memory skills. such the CELF-R,
or tho e mak ing I isuo- perceptual
demands, such as BI' Develop men tal
assessments will also not be design ed to
pick up aphasic type disorders. Decidi ng
whether naming errors are semantic p raphasias or immature vocabulary is an exam
ple of the questions that may arise. Hearing
should be checked, as many of the effects of
subtle seizures mimic hearing impairment ,
but a (eal loss may also be present.
3VariabilityThe response to assessment is like ly to be
variable. Variability is one of th e key fea
tur es of epilepsy, although with newer
drugs there may be more stability(12). It
causes much confusion for parents, teach
ers and therapists. One day a child can
hold a reasonable conversation, the next
he misunderstands questions, barely
replies, shows word-finding problems,
slurred speech or perhaps dysfluency.
Repeated assessment results fluctuate, or
suggest loss of skills. It is easy to blamebehavioural problems, or to feel that other
people's accounts of him are unrealistic.
With th e perspective of a fluctuating
epilepsy these inconsistencies become
more comprehensible. The picture can
vary from minute to minute, or with the
time of day, or over longer periods.
Choosing the best time of day to assess,
taking into account last drug dose, seizure
pattern and alertness can make all the dif
ference. A close relationship with the carer
or perhaps classroom assistant is a real
help here. The speech and language thera
p ist has an important role in assessing
function at both 'good' and 'bad' times,
an d providing strategies for managing
communication in the bad times.
Slowness of thought is another dlaracteristic
to watch for, whether caused by the epilepsy
or its medication. It can look like a lack of
social skills, if the child answers a question
too late, when the conversation has already
moved on. Stephen, 16, can answer eventu
ally, if allowed to do so in his own time.
Interrupt his train of thought, however, with
a well-meant prompt, and he will have to
start processing all over again. Timed assess
ments put the dlild at a disadvantage....... ..... .... . .........continued over ...
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EPILEPSY
IVTherapyEpilepsy has implications for therapy as
well as assessment. Flexibility and team
working are the keys, to target intervention
to fit the child's needs and ability to benefit.
Ideally, this means constantly reviewing
alternative models of therapy and keeping
in touch with other agencies. The speech
and language therapist can provide impor
tant emotional support for the child and the
family by acknowledging that the commu
nication difficulties are real. Compensatory
strategies to try are those providing some
kind of anchor. For example, with absence
seizures, as auditory processing appears
most vulnerable, static visual cues in the
form of photographs, pictorial guides or
written instructions can help a child re-ori
ent to the task in hand. Rebus symbols help
by supplementing the meaning of text. An
awareness of alternative and augmentative
communication methods is helpful.
Simply waftingChildren can respond better to paired or
small group work than in a large class.
Reducing distracting background noise
where possible helps. Spoken instructions
can be reduced in length an d information
content, overlearning can be built in
through frequent repetition across a range
of contexts, an d understanding can be
checked frequently. It is important to work
through the child's individual areas of
strength. Therapy is often best if practical
and functionally based, that is, delivered in
context rather than through withdrawal, as
children may have difficulties in generalis
ing. Extra information-processing time
should be allowed. It can be a real chal
lenge to encourage others to simply wait
for delayed responses, or provide nonver
bal cues, when both adults an d peers are
anxious to help by explaining even more.
Strategies and teamworkSocial skills intervention can be appropri
ate, as the child 's often over-protected envi
ronment , missed schooling an d perceived
Unda Edwards Is
senior speech
and language
therapist at St
Piers in Llngfleld,
Surrey, aresidential centre
(or children with
epilepsy and
other special
needs.
difference from his peers limits his oppor
tunities and so his confidence. Add to this
lapses of awareness, limited attention an d
perhaps visual perceptual problems, an d
children can prove poor at picking up sub
tle nonverbal social cues. Slowed response
times are a further hindrance. Even with
out memory problems or limited language
skills, the child can be considerably disad
vantaged in the fast-moving whirl of play
ground chat. Coping strategies can be
taught with some success, at least to staff
but also to a receptive child. Paediatric
occupational therapists also work with
social skills, so it is worth investigatingwhether there is any input. Joint working is
a luxury well worth taking up if ever avail
able, as ou r complementary approaches
can provide a really rounded therapy.
Where a child has epilepsy, there is an extra
incentive to set therapy tasks at the right
level, as either boredom or stress can
increase the frequency of seizures.
Clinicians ask whether using computers
brings on seizures. This is unlikely, both
because the rate of screen flicker is too fast,
and because only two to five per cent of
people with epilepsy are photosensi
tive( 40). It is twice as common in girls and
often presents around puberty. For a pho
tosensitive child, television flicker may be
more 'risky' than the computer, especiaJly if
the child is too close to the screen. It is
worth noting that patterns such as stripes or
checks can trigger seizures as well as flicker,
so a computer task or even the screensaver
may be relevant. Remember dothes too
my navy an d white narrow-striped shirt has
had to be relegated to weekend wear.
Epilepsy can affect commun ,cation an d
the delivery of speech an d language thera
py for children in many ways. fo r me, it is
a fascinating challenge to try to follow the
path through the epilepsy maze, and an
endJessly rewarding opportunity to offer
some, often hugely appreciated, help.
Suggested reading
Cull, C. an d Goldstein, L.H. (1997) (eds.)
Th e Clinical Psychologist's Handbook of
Epilepsy: Assessment and Management.
London: Routledge.
Lees, J. and Neville, B. (November 1996) Fit
for Neurosurgery? Bulletin Royal College of
Speech & Language Therapi sts (RCSLT).
Lees, J. an d Neville, B. (June 1998)
Landau-Kleffner Syndrome. Bulletin RCSLT.
Lees, J. (1993) Children with Acquired
Aphasias. London: Whurr Publishers.
Lees, J. and Urwin, S. (1997) Children with
Language Disorders. London: Whun
Publishers.
Parkinson, G. (July 1995) Complex epilep
sy and language disability. Bulletin RCSLT.
Other references
A full list of references (indicated by num
bers in brackets) is available to subscribers from the editor, tel. 01569 740348 or as a
file attachment to an e-mail (avrilni
coll@sol.co.uk).
Contacts
British Epilepsy Association (BEA) Tel:
0113 243 9393
National Society for Epilepsy (NSE) Tel:
01494601300
St Piers, Lingfield, Surrey Tel: 01342
832243
Resources
'Epilepsy at School' (1995) NSE Leaflet
'Drug Treatmentof Epilepsy' (1998) NSE leaflet
'Epilepsy and Children' (1995) BEA leaflet
for parents
'Epilepsy an d Education' (1998) BEA
leaflet for teachers
Test for Reception of Grammar (TROG)
(Bishop 1992) is available from TROG
Research Fund, Dept of Psychology,
University of Manchester tel. 0161 2752557
British Picture Vocabulary Scales (BPVS)
(Dunn, Dunn ,Whetton and Pintillie 1982 ,
2nd ed, Dunn, Dunn, Whelton an d Burley
1997) is available from NFER-NeJson, tel.
01753 827249
CELF-R (Wiig, 1988) is available from The
Psychological Corporation, tel. 0181 3085750. •
Questions AnswersWhy do all speech and Given its prevalence, an understanding of the effects
language th erapists need of epilepsy and its drug treatment on functionalto know about epilepsy?1 1 M ~ . " ' M ! I ! ! I 1 I ! . 1 communication skills and assessment performance is
needed.
How will the presence of Depending on the bias of the assessment, results mayMIIliliR4 ~ 1 M 1 ! I i 1 i l l l l ~ . i ~ ~ ~ i l l ~ N , - I , , ' f 4 f i i ' t t l reflect attention control, memory or visuo-perceptualpilepsy influence the choice
of standardised assessment? problems rather than speech and language disorders.
What makes speech and language therapy effective? 'with other disciplines gets the best response. .
M• • i U ! ~ . . .n Flexibility according to individual need and team working
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NASALITY
Nasality:
what,WhX and when to refer on Therapy for children with nasality problems is usually provided in a
co mmunity clinic. The generalist therapist needs clear criteria to identify
when special ist input is required while the specialist therapist benefits
from her colleague's know ledge of the 'whole' child. Here, Sarah Mooreand Anne Harding suggest how generalists and specialists can
collaborate effectively.
Management of speech disor
ders involving nasality can be
a daunting prospect for gen
eralist speech an d language
therapists. However, their
role as part of a wider team of professionals
is crucial (figure 1). Stengelhofen (1989)
observed that the majority of babies born
with a cleft develop normal communication
whilst 40 per cent require intervention from
a speech and language therapist. The com
munity clinician is in a position to view the
'whole' child and is able to relay pertinent
information to a cleft team regarding issues
such as educational ability, social factorsaffecting therapy and the child's ability to
cope with invasive assessments.
In addition, since not all speech disorders
involving nasality are a consequence of a
cleft palate, a number of children in com
munity clinics present with resonance and
airflow disturbances without any previous
specialist assessment. This includes children
with nasal fricatives replacing fricatives and
affricates, or children with unclear and
"muffled" speech and enlarged tonsils.
Sharpening skillsSpeech assessment requires transcription of
unusual speech patterns. Current defini
tions of speech characteristics associa ted
with velopharyngeal function can be found
in Harding and Grunwell (1996) , Sell et al
(1999), and Wyatt et al (1996). Therapists
often feel unable to make judgements of
resonance an d nasa l emission an d ill
equipped to transcribe compensatory artic
ulations in cleft palate speech, but there are
many ways to sharpen your skills:
1) liaise closely with the relevant specialist
speech and language therapist
2) experiment with your own velopharyn
geal sphincter
3) arrange a workshop with colleagues to
watch the GOS.SP.ASS. video (see resources)4) invite a specialist speech and language
therapist to carry ou t a transcription work
shop
5) use the International Phonetic Alphabet
(lPA) chart (1993) and extensions to the
IPA (Duckworth et aL 1990). See Harding
and Grunwell (1998) and Grunwell and
. Harding (1996) for an accurate transcrip
tion of nasal fricatives .
Speech assessment by a community clini
cian may be requested by a cleft team fol
lowing surgery or may be in response to a
referral from the community. A full speech
assessment and a cleft palate protocol
should be interpreted in relation to oral
struoure and function . For example, lack of
pressure consonants would suggest that the
velopharyngeal sphinoer is unable to closefully. This might be due to a short soft palate,
a large nasopharynx or an immobile palate.
"Muffled" speech might be caused by
enlarged tonsils and adenoids. Glottals and
nasal fricatives may be developed as a result
of effort to establish intra oral pressure.
If the specialist speech an d language thera
pist forwards copies of a recent assessment,
the community therapist could base thera
py on this data . Cleft speech, orofacial an d
general developmental speech and lan
guage assessments should all be carried
out by the generalist and / or the specialist
clinician. An equipment checklist for cleft
specific assessments is in figure 2.
Cleft speech assessment1. Commercially available assessments:
• PACS toys (especially for younger chil
dren, 1;6-6;0)
• South Tyneside Assessment of
Phonology (STAP)
• revised GOS.SP.ASS. '98
2. Resonance
There is a distinction between resonance and
nasal emission. Resonance relates to voice
and can be rated listening to vowels and
approximants /w I j /. Nasal emission relates
to nasal airflow and can be rated listening to
voiceless pressure consonants / p t k s f sh /.To judge resonance, listen to numbers or sen
tences with no nasal consonants (2,3,4, 5,6),
and eliminate voiced pressure consonants as
well ego"Hurry Harry, you 're late."
3. Hyponasality
Judge hyponasality on counting, particu
larly the "nasal-loaded" numbers, (seven
teen, eighteen, nineteen, twenty).
4. Nasal emission
Inaudible nasal emission can be detected
by holding a small mirror under the nose
during production of sustained fricatives
/sss fff/ an d voiceless plosives. The special
ist speech and language therapist may have
access to nasal airflow instrumentation for
confirmation of the perceptual impression.
_---------------------, 5. InstrumentationFigure I Team of professionals ............... (p lastic) surgeon
or thodontist
Videofluoroscopy and
nasendoscopy can be per
formed in the specialist cen
tre.
G. Voice quali ty
Voice quality needs to be
noted . Patients with
velopharyngeal dysfunction
have a higher incidence of
voice disorders and an y
_
dysphonia may result in a misleading reso
nance judgement.
7. Health
In addition to speech characteristics information about hearing, eating. sleeping.
mood an d general health may rE':'v<.'31signs
................ .....continued wer .. .
SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 1999 9
Figure 2 Equipment checklist
• assessment protocol
• tape recorder
• spatula• pe n torch
• small mirror
• IPA chart.
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__
NASALITY
Figure 3 Diagram of oronasal structure for oral examination
Figure 4 "Cleft Palate" speech summary
Sam 0 ,- 9ame / Ref. Age
i 2 i ,.. __ .,GlottaJa1.Jcuf(J{ion[Q] No rmal ad ult targets
D Cleft-type real isations
!:::::i Non -Eng lISh compensatory sounds
Comments:
-+ continued from previous page.... .............. .
of fluctuating hearing loss, nasal obstruc
tion or allergic rhinitis . This informati o n,
when considered by the specialist team,
may influence managemen t decisions.
8. Other factors
Idea lly, the community clinici an and th e
cl eft specialist discuss whether and when
th e child is ready for direct intervention or
whether a different approach is required,
for example, input thera py for very young
children. Attention levels, language ski lls
and family dynamics need to be taken
into account.
Orofacial examinationUseful checklists for an orofacial examina
tion are in Working with Cleft Palate and
GOS.SPASS. (see figure 3 for a summary).
Be sensitive to the child's feelings relating
to an oral examination. Look in a puppe t
< or the parent 's mouth before asking the
child to open their mouth.
Speech a nd language therapists are fre
quently the first profeSSionals to suspect a
submucous cleft palate. The features are a
bifid uvula, palpable notch between the
hard and soft pala te, and / or an opaque
line medially in the hard palate. In addi
tion to oral structure and function, anysyndromic features should be noted. A
small mo uth , flat affec t, slanting eyes, long
tapered fingers, and shon stature may indi
cate velocardiofacial syndrome (Sell and
Nyak, 1998). The therapist's
concerns should be shared with
the consultant or GP.
Categorisation oferrorsPre-speech assessments can be
plotted on a phonetic diagram
(figure 4). This provides evi
dence of the range of conso
nants available, with an indica
tion of the use of the speech
m e c h a n i s m .
Conso nant reali
sations are cateD a t e ! ' 9 , 97 gorised as cleft
type or developHypemasalttymen t a I
HyponasalitySpecialist spee ch
Nasalemission
assessment willNasal turbu len ce have ca tegorisedFistula consonant pro-
Mouth breathing duction erro rs
Hearing loss within four
Dysphonia Yes/@ descriptive cate
gories: anteriorOral structure
cleft type characAnterior fistulaterist ics (CTCs) ,
-] posteri o r CTCs,
non oral and pas------------------i:r sive. These are
defined an dSpecialin speechllanguage therapist described by
Harding an d
Grunwell (1998). Having categorisedCTCs in relation to oral structure they
should be distinguished from develop
mental speech patterns. As an example,
backing alveolars to velars is a CTC rather
than a normal developmental process. The
term 'developmental ' includes both
delayed ma turation and phonological dis
orders. In addition, speech a nalysis might
reveal other speech and language distur
bances such as a vowel disorder, word
order or word finding difficulties which
may be masked by cleft-related un intelli
gibility.
Therapy v surgeryRecent research (Harding and Grunwell,
1998) reveals active and passive processes
in cleft palate speech. This means when
children cannot achieve intra-oral pressure
at th e time of speech acquisition , they
either find alternatives (active processes)
or make do with what comes naturally
(passive processes ). It is currently thought
that active processes may respo nd to thera
py and are unli ke ly to be affected by
surgery. In contrast, passive processes may
no t respond to therapy until surgery has
facilitated structural change. Indeed, surgery
alone may eliminate some passive processes.
If a child has nasal fricatives replacing f, s,sh and ch but normal plosive production,
the therapist can establish whether air is
actively forced into the nose during con
sonant production by gently holding the
child's nose during production of sus
tained /fff/ and /sss/. If the consonant pro
du ction is impeded, an active nasal frica
tive is diagnosed. This is a learnt phenom
enon which requires therapy. If the noseholding facilitates an oral realisation, this
is a passive process and will possibly
require surgical intervention .
PhonologyPhonologica I analyses are necessary as the
aniculation disorders associated with cleft
palate usually involve phonological conse
quences (Harding and Grunwell, 1996), for
example, if /p / is realised as Ihl, other
voiceless plosive targets are likely to share
the same realisa tion . When /p , t, k/ -+lhl
there is a loss of contrast and" pea, tea and
key " would a ll be perceived as Ihi].
Analysis is vital for diagnosis of the problem and for subsequent planning of ther
a py. It is vita l that community clinicians
receive information about the reasons
behind recommendations for "therapy
rather than surgery". Therapists sho uld feel
abl e to contact centre clinicians for infor
ma tion and advice at any point in the ther
apy process.
The case examples 1 - 3 on page 11
describe children managed in a specialist
centre but whose therapy has been deliv
ered in a community clinic.
As a result of the Clinical Standards
Advisory Group (CSAG) repon (1998) ,
cleft palate care is expected to be cen
tralised in major centres, reducing the
number of tea ms from 57 to between 8
and 15 nationwid e. Whilst it is hoped that
specialist speech and language therapists
in these teams will consolidate communi
cation links with local therapists, it seems
likely that the maj o rity of therapy will con
tinue to be provid ed locally by com muni
ty clinicians.
We hope that, in the future, stronger links
will be forged between the specialist and
the community clinician . Harding and
Tate (1998) recently reponed on a pilot
scheme whereby liaison clinics allow close
collaboration between the th era pists on
neutral ground. This enables realis tic man
agem ent plans to be devised and fosters
mutual profess ional respect. A mod el of
service such as this helps to meet the rec
om mendations of the CSAG repon as well
as a llowing professional develo pment for
the therapists involved. Ultimately, it is the
patients who should benefit from such
approaches.
Sara h Moore and Dr Anne Harding are speech
and language therapists with North Herts NHS
Trust at Lister Hospital, Coreys Mill Lane,
Stevenage, Herts SG1 4AB , tel. 01438314333.
Resou rces
Cleft Lip and Palate Association (CLArA) leaflets from Gareth Davies, 134
Buckingham Palace Road, London SWI W
9SA, tel. OJ71 824 8110 , fax 0171 824 8109.
GOS.SPASS. vid eo details from Speech &
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NASALrrY
Case example I (see also figure 4)
Details:Sa m (9 months), repaired bilateral cleft lip and palate.
Action:
Language Therapy Dept, Great Ormond
Street Hospi:al, tel. 0171 4059200 ext 5043.
Micronose details from Medical Physics,
Pinderfields Hospital , Wakefield, tel.
01924 201688.
PACS toys from NFER-Nelson, tel. 01753
85896l.
Working with Cleft Palate (ed . J.
Stengelhofen, 1990) an d Cleft Palate
Sourcebook (L. Albery and J. Russell , 1994)
available from Winslow, tel. 0800243755.
STAP avaiJable from STASS Publications,
tel. 01661822316 .
References
Clinical Standards Advisory Group Report,
1998. HMSO
Duckworth,M., Allen, G. , Hardcastle, W.
and Ball, j\\ . (1990) Extensions to the
International Phonetic Alphabet for the
transcription of atypical speech. Clinical Linguistics and Phonetics 4, 373-283.
Grunwell, P. and Harding, A. (1996) A
note on describing typ es of nasality. Clinical
Linguistics and Phonetics 10 (2) 157-16l.
Harding, A. , and Grunwell , P (1996)
Characteristics of Cleft Pal a te Speech .
European journal of DisoTdeTs of
Communication 31, 331-357.
Harding, A. and Grunwell, P. (1998) Active
versus passive cleft-type speech characteris
tics. International journal of Language &
Communication DisoTders 33 (3), 329-352.
Harding, A. and Tate, H. (1998) Cleft
palate across the specialist divide. RCSLT
Bulletin,September.
Sell, D., Harding, A. and Grunwell, P.
(1999) GOS.SP.ASS. '98: An assessment for
speech disorders associated with cleft
palate an d / or velopharyngeal dysfunction
(revised) . International Journal of
Language & Communication Disorders 34
(1) , 17-33.
Stengelhofen, J. (ed.) (1989) Cleft Palate
the Nature and Remediation of
Communication Problems. Churchill
Livingstone.
Wyatt, R., Sell, D., Russell, J., Harding, A. ,
Harland, K and Alber)" E. (1996) Cleft
palate speech dissected: a review of current
knowledge an d analysis. British journal of
Plastic SUTgery 49,143-149. •
QuestionsWhat can generalist therapists
a) Observe and, through play, elicit babble - plot phonemes on phonetic diagram or GOS.SP.ASS.
b) Introduce sound play - a bubble popping 'p', a leaky balloon 'ff' Key concern: Looking for evidence of any pressure consonants in vocalisations and babble, indicating velopharyngeal closure post operatively. Key aim: Input modelling new patterns for Sam to compare and store to eventually produce a new motor programme. Advice to parents: a) Ensure that they understand normal speech development and possible effects of cleft. Back this information up in writing. b) Give an idea of the sounds Sam might begin to produce post-operatively, ego should get bilabials but not sounds on the end of words as yet, and f, s, sh, ch will not be present. c) Reassure parents that it will take time (months) before full function is developed. d) Encourage parents to "pattern-back" Sam's utterances, particularly new sounds, so that output is reinforced. e) Babble play with "turn-taking" f) Model front consonants - encourage Sam to look and listen; no need to teach, just model.
Case example 2
Details:
Michael (5 years), non-cleft child with an active nasal fricative replacing [s,z,sh,ch,;] and dysphoniaDiagnosis:Phoneme specific nasality, therefore only therapy reqUired, not surgery. (For this diagnOSiS, try holding the nose during production of [s, z, sh, ch, i).lf this stops production of the sound the child is producing an active nasal fricative resulting from mislearning. If the sound changes to a more normal production ego m / ~ [ b l this needs investigation and possibly surgery.) Action:
• Elicited's' through repetitive'r'• Micronose used for visual feedback (or the therapist could draw two faces with an enlarged noseon one and a small nose on the other. The therapist makes sounds "through the nose" or "throughthe mouth" and the child points .)Outcome:The phonological disorder resolved qUickly once the child was made aware of it. The dysphonia wasinvestigated by ENT and showed vocal nodules.These may be linked to misuse of the vocal tract butMichael is also a"shouter". As he was not motivated to change by therapy, he was discharged.
Case example 3
Details: Christopher (3;2 years), repaired soft palate, single words, small vocabulary, no pressure consonants ('passive pattern'), would not cooperate with articulatory exploration in therapy. Key issues: Possible velopharyngeal insufficiency or mislearning. This complex situation requires a differential diagnosis by a specialist speech and language therapiSt. Therapy:• Input modelling of whispered sounds for non speech targets (see Harding and Grunwell 1998). Aim was to facilitate new articulatory motor programmes which could establish potential for velopharyngeal closure. • Experimentation with effect of nose-holding to give oral airflow. Outcome: No evidence of oral pressure, therefore videofluoroscopy carried out and palatal surgery, but changes in phonetiC repertoire and language development were slow due to co-existing dyspraxia and language disorder.This shows the importance of liaison with a specialist to establish which features of speech
are directly cleft related and which might be co-occurring with a speech and language disorder.
~ A n s w e r sTherapists can attend workshops, liaise with and learn
do to sharpen their phonetic• ' I , j . M ' f ~ from specialist colleagues and use the newtranscription skills?
Why is differential diagnosisnecessary?
How is a decision regardinctsurgery reached?
GOS.SP.ASS. training video.
When nasality is involved, i t is easy to make assumptionsand to overlook co-occurring speech and language disorders.
Specialist speech assessment followed byvelopharyngeal investigations are essential beforesurgery is undertaken.
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DYSPHAGIA
In Figure I Care plans, stages I - 4
Swallowing inslrudions Name: Date: Stage 1 • Nothing 10 eat or drink
Ongoing assessment by speech and language therapist
• Administration of medicines through feedingline or IV infusion
Signature:
Swallowing instrudions Name: Date: Stage 2 thick smooth consistency only Fluids: normal
thickenednone
Posture: patient sitting upright in bed or chairlevel of supervision: requires supervision dur-ing meal times Y 1 Nl 1Requires nurse ta complete menuAdministration of medicines: through feedingtube, IV infusion or crushed in food (ie. Sometablets may be crushed)Verbal instrudions:Signature:
Swallowing instrudions Name: Date: Stage 3 soft food onlyFluids: normal
thickenednone
Posture: patient sitting upright in bed or chairlevel of supervision:
• requi'es ~ cloring M tires Y 1N 1• by nurse only Y [ 1Nl 1• FlO! tl assist a t i e r t ~ menu seIedion Y 1N 1Administration of medicines:
soluble Y 1N [ 1syrup Y{ 1 N[ 1tablets Y[ 1 N[ 1crushed Y[ 1 N[ 1capsules Y [ 1 N [ )
Verbal instrudions:Signature:
Swallowing instructionsNome:Date:Stage 4 varied consistenciesAny consistency still to be avoided:Fluids: yesPosture: patient sitting upright in bed or chairlevel of supervision:• requires ~ <lmg meal tires Y ) N )• FlO! tl assist paieriwifJ menu seIedioo Y ) N ) Verbal instrudions: Signature:
ysp agIa. ..:.. \t<' \ 1/ 1.;.-
r - - - - - . Continuity of patient care and thet'\ ~ } > - provision of food of appropriate
I, 111\"
consistencies are perennial challenges in
dysphagia management. Clinical effectiveness
depends on the extent to which a tean1 approachis embraced and implemented. Penny Gravill reports on one
hospital's experience over an eighteen month period.
Aworking group was instigated
by the Nurse Consultant on
th e Neurosciences Unit
(NU) , Aberdeen Royal
Infirmary to:
1. produce a local protocol
for management of dysphagia in the neu
rologically impaired patient in accordance
with the Scottish Intercollegiate Guidelines
Network recommendations (SIGN, 1997)2. promote safe management of the dys
phagic patient
3. educate nurses in dysphagia.
The group comprised a speech and lan
guage therapist , senior staff nurse, dietit ian
and diet cook. A physiotherapist and occu
pational therapist became "occasional "
members, attending meetings when issues
directly involved them.
Classification agreedOne area of conflict identified was the dif
ferent terminology used to describe the
same food consistency. This not only
occurred between th e difierent professional groups but also between members of the
same profession. We therefore agreed on a
classification:
• Stage 1 - nil orally
• Stage 2 - thick smooth consistency
• Stage 3 - soft consistenoies
• Stage 4 - varied consistencies.
Following assessment and subsequent
reassessment by the speech an d language
therapist, a patient's needs were to be met
by on e of these stages. An 'alert sign' spec
ifying the stage was put by the patient 's bed
and the care plan into the patient's Kardex
(figure 1) . To request a stage 2 menu , the
patient 'smenu
card had 'Stage 2'wrinen or
stuck on . To order a stage 3 diet, the soft
option was selected (indicated by [s] on
the menu card).
Four months after introducing this system,
a questionnaire was sent ou t to all nurses
on the NU to gain their feedback on the
system and any effect on the management
of dysphagic patients. A total of 49 ques
tionnaires was sent out. Included in this
were 11 to permanent night staff, only on e
of whom completed the questionnaire.
Of the questionnaires sent out, 23 were
returned.
ResultsPercentage of retumed questionnaires - 47%
Familiarity with trial - 52%
Management of dysphagia
- easier - 57%
no change - 22%
- more complicated - 4%
- no comment - 17%.
Comments are in figure 2. As a result of
this feedback four changes were made:
1) Introduction ofa Stage 2 menu card
The original system of writing or sticking
'Stage 2' on the standard menu card was
no t working consistently.It had been a long term problem for nurs
ing staff and speech and language thera
pists alike that a "soft smooth I pureed Iliquidised" diet - or 'Stage 2' as it was now
known - was frequently no t of an appro
priate consistency. This may have been
partly because there was only on e diet
cook with experience and, if she were off,
the seconded person did no t have the
knowledge to do the job to her standard.
The dietitian suggested offering training to
three other members of the catering staff
to ensure cover is available in both hospi
tal kitchens. This is still to be pursued.
In the meantime, a 'Stage 2'menu
card wasintroduced (figure 3) . This is a different
colour to the standard menu cards and
allows easy identification of the special
requirements .
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2) Introduction of liquids to Stage 2
The original Stage 2 care plan did not allow
for liquids to be taken unless they were
thickened to the appropriate consistency as
this would be the usual recommendation.
The change allows for 'normal' liquids, assome patient groups with an unimpaired
pharyngeal phase of swallowing - for exam
ple, a facial palsy following excision of an
acoustic neuroma - could manage normal
liquids but require a Stage 2 diet due to
impaired oral preparation.
3) A 48 Hour 'Total Intake Chart" at Stage 2
All patients recommended for a Stage 2
diet following the speech and language
therapist's assessment should be put onto a
Total Intake Chart' to allow the dietitian
and nursing staff to be more aware of nutri
tional status. This group of patients could
easily be malnourished du e to their dietary
restrictions.
4) Colour coding of 'alert signs'
To make the system clearer, the 'alert signs'
by the patient 's bed were colour coded:
Stage 1 pink/red
Stage 2 orange
Stage 3 green
Stage 4 white
An A4 laminated sheet with a definition of
each stage was placed in each bay within
the ward to allow for easy reference . The
Stage 2 menu card was made the same
colour as the Stage 2 alert sign for easy
identification for menu completion.
ModificationsTo gain more feedback regarding this system, it was introduced onto the hospital's
Acute Stroke Unit (ASU) although two
modifications were made to accommodate
their different working arrangements:
1) Colour coding
On the ASU the different therapy services
are colour coded, therefore all alert signs
and Kardex care plans were made on e
colour to fit in with this system rather than
different colours as on the NU.
2) Menu card stickers
Prior to the introduction of the Stage 2
menu card, the ASU used 'Stage 2' and
'Stage 3' stickers to alert the kitchen to con
sistency requirements. These have becomeredundant, though 'Stage 3' is still written
on the menu cards as a back up to the
selection of the 'soft' option from the stan
dard menu.
The ASU staff were asked to complete the
same questionnaire as the NU staff to pro
vidS' feedback as to the usefulness of the
system. The sample size for this unit is
markedly smaller than for the NU and, as
the total number of permanent nursing
staff is smaller, the results appear rather
more favourable . The ASU also had the
benefit of a 'tried and tested' scheme being
introduced, as opposed to on e which was
modified whilstin
use. The totalnumber
of questionnaires sent ou t was 28, with 15
returned . The comments provided by the
nursing staff are in figure 4 ..
DYSPHAGIA
Figure 2 Feedback from Neurosciences Unit nursing staff
"Good ideo. Encoul'C!9es standard throughout hospital with clear guidelines. Could have beenimplemented more effectively with leaching sessions for 011 stoff prior ta use. Would be usefulta haveguidelines printed on sheet."
"Maybe having the different stage diet sheets that go above the bed in different colours". " Stage 2 diet comes up 100 liquidised." " Stage 2 can sometimes manage soft option." " liquidised food is nat appetising in any way. Far 100 big portions, often frothy." " I was unaware of the trial, however, the swallowing ossessment sheets in Kardex help nurses ta know how ta deal with 0 patient's dietary needs."
" Documentation clear and helpfuf." " Stage 3 and 4 often mistaken; common belief that Stage 3 is nannal diet." " Very helpful as Iwork part time therefore at a glance Ican tell whet stage the patient is on." " I hink we have a good rapport with the speech and language theropists on Ward 40 regarding
continuity of patient care. They always make it clear ta the nursing stoff what they have found on assessment and what the patient is able ta take."
" As a member of permanent night stoffc{p /T 2 nights /week), we sometimes miss news of what's happening on the ward unless it's posted ta us personally, like the questionnaire."
Figure 3 Stage 2 Menu Card
Aberdeen Royallnfinn<l)' Aberdeen Royallnfinnary Aberdeen Royal Infirmary
Ward No. Room No. Ward No. Room No. Ward No. Room No.Name: Name: Nome:
Stage 2~ StaMa2Brea st
Are you vegetarian? Y[ I
Lvnch High Teo
Are you vegetarian? YI I Are you vegetarian? YI IN[ I N[ I NI I
[ I Pureed HP Soup I I Pureed HP Soupwith pololo I I Pureed Porridge
I I Weetobix
with poIoIo
I I Pureed Main Course [ I Pureed Main Course[ I Ready Brek
[ I Pureed Potata I I Pureed Potata
I I Yoghurt [ I Pureed Vegetable [ J Pureed Vegetable thick and creamy
[ J Fruit Juice
[ I Milk Pudding [ I HP Milk Pudding[ I Pureed Fruit [ I Pureed Fruit
I I Yoghurt [ I Yoghurt [ I Enterothick and creamy thick and creamy
I I Entera I I Entera
Figure 4 Feedback from Acute Stroke Unit staff
" The pink sheets make it clear for anyone ta read." " Good ideo ta have different stages. Makes it easier for all stoff and new stoff." " Clearer instructions as ta what each stage is for new stoff." " On Stage 3 diet, sometimes the patient does not get a meal, nor a yoghurt." " ... na clloice ta the patient ... items added on are not put up from the kitchen." " Puddings should automatically corne up for Stage 21lut they never do. The trial certainly saves time." " Why is it that you prefer trained stoff ta feed some patients when the auxiliary nurses have the
practical experience."" Could the nursing stoff be shown 1) the 3 stages of swallowing; 2) the complications of dysphagia and
3) types of equipment used, ego ~ i a CUt"" Definitelv improved with the type of fOod se patients con eat ... problems with kitchen putting up
correct fOod."U Excellent idea."" Originally menus nat ticked as recommended for Stage 3 and then nothing arrives. Overall a great
help for nursing stoff knowing correct consistency - huge improvement."" ... the diets are left for the diet cook to fill in that means that sometimes patients have puddings missed
out if the diet cook is off."
Results Stluctured assessment1) Percentage of returned questionnaires With the feedback from the two Units and
53% modifications made, the working group
2) Familiarity with trial 100% drew up a protocol (Appendix L page \ 5).
3) Management of dysphagia To conform to the recommendations ma
- easier - 100% in the SIGN Cuidelines (1997) we th en- no change - 0% worked on the intIoduction of an as
more complicated - 0% ment for screening dysphagic patien ts.
- no comment - 0% .... .wntinued over -+
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Figure 5DONSS SCREENING ASSESSMENT
Patient must be AWAXI and reasonably AI.IIn'. They must be in an UPRIGIn' position for assessment.The following procedure should be administered 3 TlMES:-
1 Give patient a teaspoon of cold water.2. Walth for swallow.3. Observe the following risk signs: NO SWAllOW
IMMEDIATE OR DELAYED COUGHWE T VOICE ON SAYING "AH"
BREATHLESSNESS AFTER SWAllOWINGIf YES to any of these If NO to all of these1) Nil orally 1) Continue with hoK a glass of cold wafer,2) Refer to SLT one sip at a time
2) Observe for risk signs
Adapted from Guys & Sf Thomas Swallow Tesf
If YES
Refer to SLT
If NOProceed caAioWt with scIt choicefrom menu with normal liquidsObserve for risk signs
If YES refer to SLT
Figure 6 Feedback on DONSS introduction
a) Neurosciences staff
" Appearsto be
apositive
andworthwhile
move."" Have not had the chance to screen a patient yet but feel it is a good idea for experienced nurses to beaHowed to screen patients."
" Positive definitely. It seems very worthwhile, especially at a weekend."" Very helpful."b) ASU staff"The more screenings you perform the more confident you become at doing the procedure."" Sometimes the nursing staff are really busy and Ifeel at times it is quite time consuming."" Although it appears appropriate for nursing staff to carry out this procedure, Ido consider the
screening to be yet another task for nurses to add to their busy schedule."
Figure 7 Strengths and weaknesses of dysphagia protocol
Strengths1) Clear unambiguous terminology.2) Clear instructions and procedures for all to follow.3 lime saving for speech and I o ~ therapist and rursing staff in documentation.4) An increase in the awareness of dysphagia.
5) Steady progress indicator.6) Greater awareness of the patient's nutritional status.7) Nursing staff able to feel mare c o n ~ d e n t re patients put onto oral intake as screening procedure helps
identifY potential problems.8) Amore structured approach to the assessment and management of the dysphagic patient.Weaknesses1) Apatient can remain on the Stage 1 level for a long period of time if early referral is made and poor
progress is mocle.2) The speech and Ionguage therapist works regular"office hours" therefore progress can be hailed by
unavailability for assessment.3) Stage 2 consistencies continue to cause problems.
Although an audit had previously estab-
lished that 100 per cent of neurology and
93 per cent of neurosurgical patients
referred to speech and language therapy
from the NU for management of dysphagia
were appropriate, a more structuredapproach giving useful baseline informa-
tion could only be of benefit.
Following a review of the literature and
documented assessments, The Guys and St
Thomas ' Swallow Screening Assessment
was felt to be the most suitable and per-
mission was sought to use and modify this
work. It was adapted to include our
labelling system and tenninology and pro-
duced in the form of a flow chart for easy
use (figure 5).
Nurse trainingWe decided to introduce the Department
of Neurosciences Swallowing Screening(DONSS) simultaneously to both the NU
and the ASU. Nursing staff were asked to
attend on e of four 45 minute training ses-
sions scheduled to introduce the assess-
ment. Th e session was run by either of the
speech and language therapists responsible
for the Units or the 'Dysphagia Nurse' on
the working group. The nurses to be
trained were Grade E or above from the
NU, but included some Grade D nurses
with a minimum of one year's experience
from the ASU, as their staffing arrange-
ments required this.
The training session involved background to
the project and the reasoning behind theDONSS. Practical 'hands on' experience was
included to ensure confidence. A time for dis-
cussion encouraged the exchange of observa-
tions and raising of queries or concerns.
These training sessions remain ongoing and
are arranged as the need arises. The speech
and language therapist on the ASU carries out
ones for the nursing staff there and the
Dysphagia Nurse on the NU provides its staff
with ongoing training and support.
Spring 99 sPeechmag:
reprinted articles:• Assistants· who are they and what do they do? (Anna van der Gdag and Phmp Davies, February 1993)
• Intentional communication of adults and children with ep;Jepsy (Gm Parkinson and Denise Volpato, May 1993)
.. • Challenging to communicate (Jois Stam.t;eld and Sally Cheseldine, May/June 1994)
All from Human Communication, the previous title of Speech & Language Therapy in Practice, courtesy o( Hexagon Publishing
student section
Top Tips on formal assessments:
New or old; say in a sentence or two why a particular assessment is invaluable and for whom. It would be helpful if you could also say where it is available from_
The Winter 98 speechmag asked for Top Tips for Circle Time. The book Turn Your School Around by Jenny Mosley was recommended. It ispublished by Chris Lloyd Sales and Marketing Services (1993), ISBN 1855031744, price £19.95. The same author has a more recent (1996)publication, Quality Circle Time in the Primary Classroom, ISBN 1855032295, price £19.95.
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On e month after the introduction of the
DONSS, the nursing staff who received the
training were given a further questionnaire.
ResultsNeurosciences unit / Acute stroke unit
(figures in brackets)
1. Returned questionnaires 58% (83%)
2. Nurses who had used assessment
43% (100%)
3. Nurses who had carried ou t assessment
alone 43% (60%)
4. Nurses who had carried out joint
assessments 66% (60%)
4a.lf joint assessments carried ou t
agreement in findings is achieved·
always 100% (100%)
sometimes 0% (0%)
never 0% (0%)
The most obvious contrast is the apparent
ly more favourable result from the ASU. It
should be noted that the difference in sam
ple sizes is significant, being 12 and 6
respectively. In the NU, medical and nurs
ing staff can screen any patient they feel
may have a dysphagia bu t this is by no
means a routine procedure administered to
all patients. On the ASU, part of the
admissions procedure is to screen a patient
for dysphagia.
A greater return rate with a higher percent
age of nurses having carried out the
DONSS assessment may have been
achieved if more time between the intro
duo ion of the assessment and the ques
tionnaire being sent ou t had been given.Some staff had no t had the opportunity to
carry ou t the procedure due to the patients
not requiring it, annual leave, shift patterns
and so on.
Each nurse who returned the questionnaire
felt the training was at least adequate and
the way the theoretical questions were
answered showed a consistently good level
of understanding of the rationale behind
the assessment.
The contrast in 'comments' made by the
two Units is interesting (figure 6). The
general feeling from the Nt! i posil i · .
with an improvement in pa ti ent care.
However on the ASU there i more of afe el ing of this being an additional duty fo r
Questions
management system be31IIII..,introduced quickly?
What will make a newsystem more effective?
Why does a nameddysphagia nurse improvedysphagia services?
_M• • • I
Stage 3 - Soft o p ~ from menu
Pureed vegeloblesMashed potatoes
Stage 4 - Soft o p ~ from menu
Pureed vegetables
Mashed potatoes
nurses which was originally with medical
staff Perhaps this panly reflects the faci
that this system has come from another
unit and is not an ASU development as
such.
The recent development of a named
'Dysphagia Nurse' on the SU may
improve perceptions. The 'U's DysphagiaNurse encourages and reminds staff that
the project is mutidisciplinary. The nurse
has a very active role to play alongside the
speech an d language therapist and is no t
dictated to bv he r_The success of systems
such as our may be highly dependent
upon th ,k il l of th is individual who can
liaise wit h lh o ther professionals and pro
ide ad\'ice an d suppon to less experienced
memb rs of e nursing staff
The 0 era ll response to the dysphagia man
agement projeo is encouraging (figure 7)
and it will be rolled ou t next to the ENT
a nd Oral-Maxillofacial wards. They have
slightly different needs as the patients' dysphagia is not of a neurological nature.
DYSPHAGIA
Appendix I - Excerpt from dysphagia management protocol
Four main types of patients referred
1. Stroke patient with poor or no swallowing reAex or chewing.
2. Neurological d isorders which affect swallowing.
3. Poor swallowing as a consequence of ageing4. Oesophageol.strictures which affect swallowing.
Dietetic Referral
D i e ~ ~ a n should be notified at onset of treatment if ony of the following criteria are mel.
1. P a ~ e n t is already on a therapeutic diet ego Diabetic or Coeliac.
2. Patient is obviouSly underweight - ie. BMlless than 19.
3. P a ~ e n t is declored unsafe 10 swallow any food or drink ond enteral feeding is indicated as support.
Stages of Consistency
Stage 2 - Smooth pureed high protein soups and puddings, yoghurt.
Pureed savouries blended with Thick and Easy.
Discussions are also underway regarding
the medical wards. Having been tried ou t
in the various surgical and medical con
texts within the acute hospital setting, the
suitability of this system can be more accu
rately judged for other settings, such as
home or schooL
A review of the procedures and protocolwill be carried ou t at regular intervals to
ensure the remit of the projeo continues.
Implicit in this is more effective manage
ment of the dysphagic patient
Mrs Penny Gravill is a specialist speech and
language therapist with Aberdeen Royal
Hospitals NHS Trust.
References
SIGN Guidelines (1997) are on the
Internet at http:((pc47 .cee.hw.acuk(s ign(
home.htm
Smith and Lockard (1995) The Guys an d St
Thomas' Swallow Screening Assessment. StThomas' Hospital, London. •
Can a new dysphaftia111111 Time is needed to plan, pilot, review and modify a new
Answers
system before i t can be implemented fully.
All team members - including kitchen staff - should be
involved in the process from the star t and anyadministration required should f i t in with existing systems.
A skilled d y s p h a ~ i a nurse facilitates multidisciplinaryworking, profeSSional development and continUity of care.
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REVIEWS
Hearing impairment atthe forefrontPractical Audiology for
Speech.language TherapistsJanet Doyle
Whurr
ISBN I 86156 059 I [19.50
Whilst my own experience is limit
ed, I think it wo uld be fair to say that
most therapists use little of their
aud iology training In day to day cl in
ical case loads This book has brought
ho me to me just how important It is
for hearing im pairment to be at the
forefront of every speech and lan
guage therapist's mind. Not only
does the therapist need to be able
to identify cl ients, both adults and
children, for whom an audiology
assessment may be beneficial, but
also to have an understanding of
hear ing aid funct ion and relevant
troubleshooting skill s. The sections
on screening tests and hear ing aid
provision, usage and problems may
thenefone be the most useful.
Practical Audiology will be a useful
revision aid foI- any practising thera-
pist who feels their knowledge of
audiology issomewha t rusty and for
newly qualified therapists and stu
dents, the book being "practically
oriented".Eugenie Booth is a student in the
Department of Speech, University of
Newcastle.
A fundamental resourcelearning about voice. Vocal hygiene
activities for children.A Resource
Manual (includes audio tape)
Michael I Moran and Elizabeth Eyna Jones
Singular
ISBN 1-56593-942-5 [3350
This manua l is a fundamental resource for any
speech and language therapy department. The
programme itself is easy to follow and may be
adapted to both individual or group therapy
contexts Its use encompasses more than ch il-
dren and it may be appropriate ly used wrth
adolescents. The illustrations are delightful andappeal to many age leve ls. In particular Its depic-
tion of what are frequently elusive vocal para
meters is excellent, for example prtch: tuba ver
sus nute, bear's roar versus bird's chirping.
This book provides both a rationale for a vocal
hygiene programme and a var iety of sugges
tions for actiVities to ach ieve its clearly defined
aims and objectives. The programme spans six
stages and wrth in each stage goa ls are speCi fied
and procedures suggested.
Tru ly a resource!
Fiona Mongan s a commun ity based speech and
language therapist in Co. Laois, Ireland
Easy to digestGenetics, Syndromes and
Communication Disorders
Robert Shprin tzenSingular
ISBN 1-56593-620-5 [36.00
This book may not immediately
sound like light bedtime reading,
but the author makes the topic
easy to understand and digest.
Rather than an everyday clinical
guide, this is an informative and
useful neference book.
The text serves a varied audi
ence. The first three chapters
wo uld be helpful and accessible
to students, and speech and lan
guage therapists wanting to
revisrt the field of genetics.
The later chapters are more
climcalr/ usefu l and include a
series of suggested questions
which may help speech and lan
guage therap ists refine the diag
nostic process and get the most
out of taking a case history.
Therapists working with chil
dren wrth a syndrome or in
child development centres will
want to turn to the appendices
which list around 350 known
syndromes which have related
communication disorders.Elaine Christie is a speech and
language therapist with the British
Stammering Association.
Useful chapter on cochlear implants A starting pointAudiology in Education Approaches to the Treatment of Aphasia
Ed NancyHelm-Estabrooks & Audrey L. Ho llandd Wendy McCracken and Siobhan Laoide
Whurr Singular
ISBN I 86156 017 6 [3500 ISBN 1-56593-841-0 [34.00
Atthough wr itten primarily for teachers of he deaf. selective This is the result of a mini-confenence where well-known aphasia
clinicians discussed approaches to the treatment of aphasia throughhapters provide some useful information.
The first section provides information about the diffenent the presentation of single case studies.
This book provides a weatth of ideas for aphasia treatment and isudiological assessments in use. It includes discussion of the
implications of a conductive or sensori-neural hearing loss informed by theoretical models. It will be a starting point for stu
on language acquisition, different syndromes associated wrth dents and newly qualified clinicians in providing a model for a spe
deafness and the needs of a muttiply-handicapped deaf child. cific approach to a specific area of language breakdown. More expe
The second section contains a very detailed description of rienced aphasia therapists may have liked amore in-depth study with
hearing aid technology, more nelevant to an audiological sci mone emphasis on current literature and neferences, although for
those clinicians who are interested in writing up their own cases, thentist. A very useful chapter by Sue Lewis on Cochlear
Implants is far easier to digest. It includes a description of models provided here could prove a welcome starting point.
Each case presentation is followed up with a discussion and clinicianshe ethical issues, rehabilitation and recent resea rch on out-
comes which proves to be both informative and thought are not afraid to state whene they may have chosen an alternative
treatment option or where a tneatment may not have been as sucrovoking.
The final section discusses the day to day management of cessful as was hoped.
hearing aids, selection of classroom amplification and the need The final chapter puts the treatments wrthin the context of managed
for optimum listening environments and includes a detailed care and makes salient suggestions as to how clinicians may need to
desc ription of the Audrtory Rhythmic Training programme. change their approaches to fit in with a changing heatth care system.Aileen McKay is Speech and Language Therapy Adviser in Elsje Prins is a speCialist speech and language therapist with Harrogate
Hearing Impairment for Grampian Healthcare NHS Tru st. Health Care NHS Trust.
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GROUPS
~hiPMiilil le
Through drama we
learn how to act inlife, how to be in
different situations
(Starratt, 1990).
Myra Kersnercontinues her
exploration of the
use of drama inspeech and
language therapy
groups to improve
clients' language
development,
social interactionand pragmatic
skills.
Part 1 in the
Winter 98 issueaddressed
Beginnings and
Endings. Part IIdemonstrates the
versati ty,flexibility and
creativity of the
main body of the
work, the Middle.
Myra Kersner
creativetherapy-Leamlngthrouglldrama
ne of the major advan
tages of using creative
drama when working
with children with com
munication problems is
its versatility. [n speech
and language work it
may be not only in relation to gener
allanguage development and enhancement,
but it also may be useful when concentrating
on work with a more specific focus, forexample: sequencing; sound work; auditory
awareness and discrimination, or when
developing social skills. In addition to
improving language skills, McClintock
(1984) suggests that, through drama work
children often benefit "in the areas of imagi
nation, communication and in their social
and emotional development". Another
advantage of using drama with communica
tion-impaired children is its flexibility; for
most dramatic techniques, individual activi
ties, games and exercises may be adapted
specifically to meet individual children's
needs according to their age and their lin
guistic abilities (see Kersner, 1997).
Beyond wordsCreative drama enables children to enjoy a
wide range of different experiences (Peter,
1995) . As the importance of such work
lies 'in the experience itself (see Part I), the
drama process provides ways of learning
how to use that experience effectively
(Courtney, 1981). Drama allows children
to express themselves as they experiment
and 'play', though not necessarily through
lan guage, for the language of drama
extends beyond words. Essentially, howev
er, drama is a shared process which devel
ops through a flow of interaction an d rec
iprocal response (McGregor et aL 1977).
Thus, whether they are communicating
verbally or non verbally the children learn
how to be with, an d relate to others, and
through simple dramatic techniques they
have the opportunity to reinforce and gen
eralise their speech and language work in a
variety of naturalistic settings.
Developing creative dramaAims and objectives
The main body of drama work is devel
oped in the Middle section of the session
and it is within this section that exercises
may be geared towards the specific aimsan d objectives devised for each child, as
well as towards the group aims. However,
each exercise and activity in creative drama
may fulfil a variety of aims (as shown in
example 1) and, conversely, each aim and
objective may be approached in a variety
of different ways (as shown in e.xample 2) .
Example 1: Mirroring
Working in pairs, the children are asked
to face their partner. Child A is asked to
initiate' a hand dance ', to create a series
of movements using only the hands.
Child B is requi red to mirror those move
ments, to follow them and copy them
exactly. The roles may be reversed. Time
is then given for the two to discuss the
experience from each of the perspectives.
Some of the objectives which may be
achieved by this exercise include: the devel
opment of confidence in the leading child;
providing opportunities for spontaneous
creativity in the Ieading child; the develop
ment of visual observation ski.ls in the fol
lowing child; the development of trust and
co-operative working between the pair; the
development of self-discipline, concentra
tion and attention skills for both children.
and conversational skills. In addition, irre
spective of any of the specific aims, there
will be incidental learning about social
behaviour, as this inevitably results from
working in pairs, or small and larg group
...cominued at't'T ~
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GROUPS
However, if for instance the improvement
of social behaviour and the acquisition of
social skills are the specific focus of the
work, there are many different ways in
which this may be approached throughdrama. Example 2 shows this in relation to
working towards the objective of develop
ing group co-operation.
Example 2: Group co-operalion
• The group may be asked to form them
selves into a line according to their
respective height.
• Children with limited verbal skills may
be asked to build something together
from materials provided .
• Children with verbal skills may be
asked to agree on a topic for discussion,
or devise an outline for a brief improvi
sation relating to a specific social situa
tion.
• Children of any age and abilities may
be asked to work together to create an
inhabited space planet, either by drawing,
using materials provided, or using their
initiative to find appropriate materials.
Extending dramatic techniques
As the Midd Ie section is usually the longest
part of any drama session, on e of the pri
mary aims of the therapist will be to l<eep
th e children engaged and interested to
maintain - and possibly improve - their
attention an d concentration. In most
instances this may require a frequent
change of activity. However the nature of
these changes and the type of activities
chosen will differ according to the needs
of the children.
Targeting specific skills
It may be necessary for example, for the
dramatic techniques to be directed towards
the acquisition of specific skills required
for speech and language development. In
such instances there may be no obvious
theme or link between the individual activ
ities and exercises as each may be targeting
a different aspect of speech and / or language.
This is illustrated in examples 3 and 4.
Example 3: Auditory awareness, audito
ry discrimination an d sound making
A sound, or a word, is aSSigned to each
child. The group are then asked to listen
carefully to a story as it is narrated by the
therapist and to insert the relevant sound
or word into the story appropriately. This
activity may begin by using the sounds
made by noise makers or musical instru
ments; it may progress to the children
making their own vocalisation or ver
balisation according to their individual
abilities. The level of difficulty ma y be
increased if the sounds given to each of
the children in the group have minimal
phonemic contrasts or if pairs of chil
dren are assigned minimal pairs of
words. Written words could also be used .
Example 4: Sequencing
• Activities for work on sequencing may
include a simple well known listing and
memory game such as 'I went to the zoo
and 1 saw .. : played verbally or using
objects or pictures where each child
repeats the previous animals or objecls
seen, adding an additional on e of their
own.• A more complex activity targeting a
similar objective could involve a familiar
story which is broken down into individ
ual scenes. These may be practised and
developed separately establishing the
sequence of the action within each scene.
The scenes may then be chosen at ran
do m to be briefly enacted or presented in
tableau to the remainder of the group .
Finally, the group, or on e child acting as
'director' - must re-assemble the scenes
in order.
• At a more difficult level, two sub
groups could develop scenes from two
different stories. Eachgroup could then
'show' the individual scenes ou t of
sequence, asking the members of the
other group to re-order them.
Practice and rehearsalThe Middle section may also be used to
build on dramatic techniques which may
be required for a larger piece of work.
These may extend from the warm-up exer
cises used in the beginning of the session
(see Pa n I in Winter 98). If, for example,
the ultimate-goal is a social skills exercise
in which the group will enact a role play,
the exercise will be of greater value to the
participants if they are able to develop theirskills and techniques for example, in rela
tion to improvisation, character develop
ment and taking on a role. These tech
niques may be developed using activities
such as those described in examples 5, 6
and 7. Practice and rehearsal may also help
the children to desensitise to performing in
front of each other, so that they are not
inhibited by the nature of the task itself,
and thus will be able to use the exercise
more effectively.
Example 5: Expressing feelings
• There are several ways in which these
skills-may be developed. A simple ·initialexercise may be 'passing the facial
expression'. On e child is asked to express
a feeling using only facial expression.
The next child is asked to imitate this
expression, then the next, until each
child has imitated the initial expression.
Alternatively, ensuing children may be
asked to change on e feature of the
expression each time it is passed on.
• The children could be asked to show
their feelings through movement, walk
ing and moving as if they were angry,
excited, or afraid.
• They could be given an emotive topic
and asked to express their feelings aboutit, in pairs, communicating only by
sounds, or animal noises, or using a sin
gle word such as 'rhubarb'.
Developing the work
Using creative drama, children are able not
only to rehearse specific skills and techniques,
but also to create situations within which
these skills may be practised meaningfully.
For as Starratt (1990) says, through drama
we learn how to act in life, how to be in dif
ferent situations. We learn how to react and
respond, how to expect others to respond
and how to control different situations. We
learn the conventions and mores of our
own society and begin to understand about
the different roles which people need to
play. Thus, creative drama encourages the
children to be themselves while at the same
time providing opportunities for lhem to
take on the role of 'another'. This enables
them to see the world from different perspec
tives and helps them gain insight not only
into their ovm actions but also into the effecLS
of those actions on others (Kersner, 1989).
On e of the most popular examples which
demonstrates how drama may be used
most effectively in this way is in the devel
opment of social and interactional skills.
Many of these skills begin to develop inci
dentally as a result of the activities under
taken within the drama sessions. For exam
ple, from the moment the group forms lhe
children begin to acquire the basic skills of
negotiation an d compromise, learning
how to function co-operatively within a
group, how to share and take turns, how to
work with a partner or in a small sub
group. However, for those with adequate
verbal skills it may also be possible to
develop more advanced social skills
through creative drama, an d to focus
specifically on such skills development, for
example using a social skills improvisation
as illustrated in example 8. In such an exer
cise it is possible to involve the wholegroup in different aspects of the improvi
sation according to their abilities, the aims
for the group and the individual children,
and the time available.
Example 6: Developing character
• Following on from the warm-up exercise
for characterisation described in Pan /, each
group member is asked to think of a
famous person, or a person they know well,
and to think about how that person walks,
talks, and uses gestures. By imitating these
and by incorporating any specific manner
isms, they then try to be' that person,• Older children may be able to invent an
individual character, crealing a life histo
ry and developing their movements an d
actions accordingly.
Example 7: Improvisation
• Group members could begin to impro
vise individually by finding a movement
sequence involving their whole body to
represent the sea, a jelly on a plate, a pair
of scissors, or an electric light bulb.
• They could then be given a speCified
place such as a doctor's waiting room , or
a park and, in pairs, using their previous
ly developed characters they couldimprovise together a short interactive
scene, either verbally or using move
ments and gestures only.
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GROUPS
Example 8: Social skills improvisation
o Once the decision has been made
about the type of scene to be enacted,
such as eating in a restaurant, making a
complaint about poor quality goods pre
viously purchased or asking for an exten
sion for a piece of work at school, the
group may be involved in setting the
scene. This may be done physically using
props, or merely imaginatively.o Unless the whole group is taking part
in the action, they must then decide who
are to be the initial players and who the
audience.
o The roles to be played must be clearly
defined and some time may be spent on
characterisa'tion and role development as
discussed above, although the audience
may also become involved.
o It may be important to rehearse some
basic improvisation - see example 7.
o While the 'scene' is being enacted, it
may be helpful for the therapist to
'direct', possibly stopping the action at
critical points for discussion. Once again,the audience may become actively
involved, suggesting different approaches
to the problems so that the actors may
experiment with alternative solutions.
o The actors and audience may replace
each other as appropriate so that all the
group have an opportunity to be audi
ence and players.
When the group reflects and discusses the
enactment at the en d of the session it is
important that the exercise is not 'judged'
according to the acting abilities of the play
ers . Such an improvisation can only be
evaluated in terms of the manner and styleof the social interactions, and on the
potential effectiveness of th e solutions and
approaches to each of the problems.
The condusion of the
middlelust as it is important for the whole sessionand series of sessions to have a specified end
ing, so it is critical that at the end of the main
body of work the children have an opportu-
nity to derole, (see exercise 9). They need to
be 'centred', refocused back into their own
role so that they are able to put behind them
any of the characters they may have played
and any strong feelings which they have
expressed as that character. They must be
able to act once again as themselves within
the context of their normal lives. In addition,
wherever possible, the group should derole
the room, dismantling the acting space cre
ated for the session and reruming the furni
ture to its original position.
Exercise 9: Deroling
o All those who have taken on a role
must have the opportunity to shake off
the costume and the character they have
embraced. They may do this by saying: 'I
am no longer (name of the character) I
am (name of child)'.
o They may wish to add a sentence either
referring to something they are wearing,
something they are going to do next out
side of the session, or something they
like to do at home.
o They could be asked to name three
ways in which they are different from the
character they have portrayed .
If this section is then concluded by an
Ending as discussed in Part I, the drama
session may be considered to be complete.
References
Courtney, R. (1981) Drama Assessment. In
Schattner, G. and Courtney, R. Drama in
Therapy Vol I. New York: Drama Book
Specialists.
Kersner, M. (1989) Drama in therapy is
more than acting. Speech Therapy in
Practice 5 (5).
Kersner, M. (1997) The use of drama in
working with children with learning dis
abilities. In Fawcus, Ivl. (Ed) Children with
Learning Difficulties London: Whurr
Publishers.
McClintock A.B. (1984) Drama for
Mentally Handicapped Children. London:
Souvenir Press.
McGregor, L., Tate, M. and Robinson, K.
(1977) Learning Through Drama. Oxford:
Heinemann Educational.
Peter, M. (1995) Making Drama Special.
London: David Fulton Publishers.
Starratt, R.J. (1990) The Drama of
Schooling The Schooling of Drama.
London: The Falmer Press.
A'lyra Kersner is a Senior LeCLUrer in the
Department of Human Communication
Science, University College London.
Address fOT deUliis of drama courses and corre
spondence: Myra Kersner DHCS, UCL,
Chandler House, 2, Wak efield St, London
WCl N 1PC Tel: 01 71 504 4217e-mail M.Kersner@UCL.ac .uk •
Questions AnswersI . I f l ~ M i ~ i t 4 ! i M i l ~ i M ~ By its nature, drama is a shared process which gives us
undertaken in a group?Why should drama be• insight into our own and others' communication.
How should drama The value of drama lies in the way it facilitates socialexercises be evaluated?. M I ' t ~ interaction and problem-solving, not in 'acting' ability.
What does d e r o l i n ~l l M M ~ J Structured activities for individuals and theirmean'? surroundings enable group members to throw off roles
and associated feelings.
NEWS ..NEWS ...NEWS ...NEWS...NEWS...NEWS ...NEWS
Stammering developmentsThe British Stammering Association IS to 'lake the vital message of
eafly intervention to the parents of the 188000 UK under fives who
stammer.
Following the flllal report of the successful primary healthcare work
ers project, due out in June 1999, the new three year campaign aims
to have stammering seen largely as a preventable childhood illness.
The BSA has already introduced a National Telephone He lpline and
is hoping to secure funding to provide employm ent su pport services to
people who stammer. In 1999 its schools liaison officer will pro
mote in-service training courses on stammering throughout the UKfollowing a successful pilot period.
BSA Telephone Helpline (sUlffed by a qualified counsellor), JOam-4pm Mon
day to Fliday, tel. 0845 6032001.
Changes for Paget GormanWith Mr R. Newey, Development Officer of the Paget Gorman
Society retiring at the end of March 1999, the charity has new
arrangements for publications and information .
Paget Gorman Signed Speech publications are now only available
from STASS , 44 North Road , Ponteland , Northumberland i\E20
9UR, tel. 01661 822316, fax 01661 860440. Prices on applicati o n.
General information enquiries should be addressed to PC S, 2
Oowlands Bungalows, Dowlands Lane, Smallfield, Surre, RH6
9S0, tel. 01342 842308, e-mail PruP@compuserve.com. with theInternet site remaining at http://www.pgss.org
Bob Newey will be available on a personal basis to run cour . C mad
him at 3 Gipsy Lane, Headington, Oxford 0X3 7PT, tel. 01 865 76190
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OJ
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8V )
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'"J:;t::
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PARTNERSHfP
From
StartThe end of the (bad)
beginning? In spite of previous efforts to :"Ilpmve how
parents are told about their childs disability. there
has been IrttJe actual change.Anne Leonard
explains how the charity Scope and its partners
are working to make a difference by ensuring a
consistent appmach based on best practice,
ight From The Start (RFTS) is
now a national project to
improve the way parents find
out about their child's dis
ability, following four years
of hard work on the pa rt of
Scope and its many partners.
It arose from several sources. Innumerable
research findings (1) showed widespread
parental dissatisfaction with the process as
it is generally experienced. Aw areness of
the research was coupled with Scope's
direct day to day knowledge, through the
Cerebral Palsy Helpline and field workers'
reports, of the disastrous way parents are
affected by their experience at the time of
diagnosis and disclosure.
Further, a Scope study of parents' views of
the assessment and statementing proces s
for special educational needs (A Hard Actto Follow, 1993) dramatically highlighted
the pre-existing evidence. Many of the par
ents contacted spoke or wrote sponta-
neously about the pain and distress of the
process of learning about their child's dis
ability. The research did not ask qu estions
about this issue, but the qualitative study
allowed parents to flag up their own con
cerns. Their unhappy experience at the
time of diagnosis and disclosure was what
emerged. This direct and unedited quota
tio n summarises responses:
"I (ound my biggest upsetment was the way in
wh ich I was told that my daugh te r was handi-
capp ed, wh ich I think mos t pa rents would agree.I be lieve doctors should explain cor rec tly and then
answe r all questions hones tly. I am very lucky to
have lived nea r a schoo l (or speCia l needs and
they explained everything to me at a time I (elt
very alone. My only Wsh was that I had bee n to ld
earlier in her li(e, as the docto r always made an
excuse whenever I asked ques tions and never
expla ined what was wrong with her apa rt (rom
te lling me she had bram damage which was left
to my imagina tion."
Scope consequently published a compila
tion and analysis of the unsolicited evi
dence about parents' experience of diagno
sis and disclosure in the report 'Right From
The Start'. Its launch in June 1994 also saw
the start of the campaign to attempt to
remedy the situation.
We were well aware of the enormous ener
gy and skill that had already been directed
at this problem (2). It was also clear that
progress had been disappointing.
Accumulated experience
The first task was therefore to draw together as many as possible of the individuals
and organis a tions who had previously
done work on this issue, or for whom it
was relevant. This included parents and
disabled adults. In this way, we intended
to learn from earlier initiatives and bring
together all the interested parties to make a
concerted effo rt to find new ways to deal
with the problems. The RFTS project is
thus a genuine consortium basing its
efforts on learning from accumulated
experience.
Our original professional partners, the
Roy al Colleges of Paediatrics and Child
Health; of Nursing and of Midwives, andthe National Portage Association have
been augmented by the Royal College of
General Practitioners, the Health Visitors
Association and the English National
Board . The voluntary secto r partners
Contact a Family, Hemi-help, Mencap,
Royal National Institute for the Blind,
Downs Syndrome Associa tion and the
National Portage Association continue towork with us on all our activities. Above
all, parents and disabled people are active
ly involved at all levels - on the Working
Gro up, in training activity, in conferences
making the project a true partnership of
professionals, voluntary groups and users
of services, just as the Warnock Report, the
1989 Children Act and the 1993 Education
Act envisaged .
The RFTS Working Group is comprised of
expert and experienced representatives
from all the sources listed. Its first task was
to attempt to understand why earlier suc
cess had been so limited and sporadic. The
reasons which emerged form the basis ofour approach to th e key task of the RFTS
strategy and include:
• isolation of people or groups working on
the issue
• discontinuity
• dependen ce on single 'champions ' or
single groups
• th e complex nature of the problems of
diagnosis and disclosure, such as: the dif
fering stages of a child 's life when disabili
ty might become evident; the large number
of professionals who might be involved;
the variation in circumstances an d
responses of families themselves.
Finally, and probably mo st significantly, itwas agreed that there had been insufficient
concern with the underl ying problem of
values - the widespread negative attitudes
to disability which undermine relations
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tor members are mobilised to
combat the isolation of previous activities.
Discontinuity is being replaced by persis-
tent and consistent activity made possible
by our wide and powerful membership in
both the professional and the voluntary
sedor. The collective efforts of the group
have replaced those of single energetic
individuals who inevitably burn out' or
move on. Above all, there is a consensus in
the working group around the values iden-
tified as crucial to progress on this issue.
between parents and profes-
sionals as th.ey go through the
process of acknowledging a
child's disability.
Persistent andconsistentThe RFTS consortium has
responded to these
intractable difficulties using
the collective strengths of the
Working Group. The well
established national an d local
networks of the voluntary sec-
Social modelThe key message of the RFfS project is the
need to value disabled children as children
first an d foremost. to move away from the
'medical' approach to a child's disability,
and to take on the positive messages of the
'social' model of disability. Allied to this is
the recognition that the foundation for
real partnership is good communication
based on mutual respect. The majority of
parents of disabled children do not think
that this has been achieved.
Progress on improving the way
parents of disabled children
are told about their child's
impairment will bring benefits
not only to those parents and
their disabled children, bu t to
all users of services wh o
depend on the flexibility an d
communication skills of
providers of services. The
RFfS project can make a con-
tribution to the much Jarger
project of creating sensitive,
imaginative an d responsive
services for everyone.
Greater sensitivityProfessionals themselves need support an d
training to bring about the difficult
changes needed for parents an d children to
benefit from greater sensitivity at the time
a child's disability is recognised. This is
why the project is so concerned to influ-
ence professional training and has put so
much energy into devising and offering an
appropriate training model. The working
group realises that parents' experience and
. .... .......... .. ..continued on page 23 .. .
RESOURCE UPDATE. _.RESOURCE UPDATE. . .RESOURCE UPDATE. . .
Change ofpublisherAphasia - A Social Approach
by Lesley Jordan and WendyKaiser is now published byStanley Thomes, price£15.50 + £2. 75 p+p. Itreviews aphasia services inBritain and considers theimplications Of differentmodels Of disabilityfo raphasia services. It providesa ramework fo r developingprofessional practice.Tel. 01242 228888.
AutismA reference point on autismand guide to further resourcesfo r parents, teachers, CPs andother health professionalshas contributions f romleading practitioners. (TheAutistic Spectrum - aHal]dbook 1999, £6 + p&p.)A booklet aims to give practicaladvice and tips on how todeal with common behaviourproblems in young childrenwith autism. (It can get better- a guidefo r parents andcarers, £5 + p&p.)80th from the NationalAutistic Society,tel. 0171 903 3595,e-mailPublications@nas.org.uk
Reading and writing skillsThe therapy programme Reading Again using audio tapes andbooklets to aid the recovery of everyday reading skills following a
stroke or head injury is most suited to those with moderate language impairment. It includes work on shopping lists, postcards andappointment letters. A sample package is available.Author and speech and language therapist Sue Lakin has also produced a resource file Letter-by-Letter Dyslexia which includes a casediscussion, information gathering activities, activity ideas and adviceand photocopiable worksheets. Profits are donated to Action forDysphasic Adults. Details and prices from Sue Lakin, tel. 01159254593.
learningdisabilitiesA practical guide illustrated bycase studies explains techniquesfor communicating with peoplewhose behaviour is challenging
or displays autistic features.Person to Person by PhoebeCaldwell with Pene Stevens is
£79.95 +pap rom PavilionPublishing, tel. 01273623222.
EthnicminoritiesA book from Age Concern aimsto improve service provision toethnic minority elders. Theparticular needs of Black, Asian,Chinese and Vietnamese andJewish, Polish and Turkishcommunities are considered,Caring fo r Ethnic Minority Elders: aguide by Yasmin Alibhai-Brown,£74.99 from Age Concern, tel,
01Bl 765 7203/B.
Carers - strokeStroke: a carer's guide aims to explainthe range of services and supportavailable while pointing readers toother sources of reliable informationand help, It particularly concentrateson the most vulnerable times such as
onset and adjusting to life at home,From the Stroke Association, tel.0171 5660300, fl . For bulk
orders, tel. 0171 5660313,
Child languageA charity has worked with EastKent speech and language therapists to produce a series of 12booklets for parents and carers.Titles include Making sense of
language, Helping your child toconcentrate, Learning position
words, Learning the's' soundand Putting two words together.From AFASIC, tel. 0171 236 6487,£1-£2 each or £12 .50 fo rfull set.
Carers - childrenParents Of a child with adisability or special need are
being offered practicalpointers on the kind of
advice, information andemotional support that theycan access. A directory Oforganisations at the end of
the guide leads carers tofurther help and advice suitedto their individual needs.There are approximately onemillion parent carers in theUK. Financial and housingproblems are common.Caring for your child is freeto carers from CarersNational Association, tel.
0171 490 8824 or Contact aFamily, tel. 0171 383 3555
Different strokesEach year over 10 000 peoplein the UK under the retirementage have a stroke. A charity,Different Strokes, formed bya group Of younger strokesurvivors aims to provide aninformation pack beforedischarge from hospital, acounselling service andadvice and information oneducation, work and benefits.Different Strokes, tel. 0171
2496645,http://www.strokes.demon.co.uk
SPEECH & LANGUAGE THERAPY IN PRACTICE SPRINC 1999 21
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PARTNERSHIP
Figure I Excerpts from RFTS Template of Good Practice
I . Valuing the child
Th e ch ild is central to th e situation . In the case o f diagnosis during the early months. it is va lua ble fo r th e baby to be present
when being discussed, and responded to in a w ay that reflects that the child is valued. fo r example by using the child's name.
In some circumstances either parents or professiona ls ma y not feel that it is appropriate. advisable or practicable fo r the baby
or child to be present; it is then all th e more impol-tant that language and the manner o f commun icating should reflect
respect fo r th e child. Discussions about the child should have a positive focus. Predictions about the child's future should be avoided - no on e can claim to know what any chlld's capabi lities will prove to be.
2. Respecting parents Professionals should demonstrate respect, understanding and war mth in their manner towards parents.
Honesty on th e part o f professionals in sharing information with parents, and acknowledging th e limitations o f professional
knowledge. is essential if respect fo r parents is to be conveyed effectively. An y uncertainty should be shared.
Plain understandable language accessi ble to th e parents should be used in giving explanations that w ill build up parents' con
fidence to handle th e situat ion. They need ample opportunity to ask questions and explore the situation, a process which
should also allow professionals to check whether parents have fully undel-stood what they have been told.
3. Initial concerns
If it is the parents w ho are concerned about their child. their concerns should be treated seriously and responded to quickly
and honestly. Available information should be shared and its limitations acknowl edged ..4. H ow to tel l Fam ily circumstances var y enormously.
Decisions as to how parents are told about a child 's disabi lity are best made on th e basis of the team 's knowledge of each
individual family.
Th e varying cultural needs o f families with different ethic backgrounds need to be care fu lly and sensitively taken into account
and accommodated.
a. Who should be there?
Parents report that they wo uld prefer no t to be alone when told . T he y generally say they would prefer to be told together.
However. this cannot be taken fo r granted. Fo r example. a child may live with only on e parent. Fo r th is or m any other re asons the parent being told may need the support o f a fnend or relative. rather than the other parent.Arrangements should take these possib ilities Into account.
There w ill be occasions when sharing the concern with only one unaccompanied parent cannot be avoided. In these ci rcumstances it is particularly important that professional support should include en suring that arrangements are made that
take into account th e pa rent's needs for support and practical help immediately follow ing the discussion (eg. how will the
parent ge t home /) . When on ly on e parent has been told separately, arrangements need to be made for one of the professional team to tell the
other parent as qUickly as possible, with th e agreement o f th e parent who already knows.
b. Which staff should be involved
Parents' vulnerability and right to pr ivacy should be respected by ke eping th e number o f people involve d at th e t ime of being
told to a minimum .. Th e family' s general practitioner should be informed o f th e situation immediately, and provided with the notes of the disclosure meeting and w hatever other infol-mation is necessary. c. Tuning in to the parents
Respecting parents' reactions to th e news Once again, parents' neactions var y enormously and cannot be predicted.
Professional s shou ld respect pal-ents' individua l reactions and attempt to be aware of them and respond to them appropr iately and supportively.
Some parents w ill need immediate support from a team membel- as they may be in a state o f shock and do no t want to
be left alone.
Others ma y wa nt to be left alone fo r a w hile, and will need to be given space. The opportunity to meet one o f th e profes
sional team again before going home is known to be valuable in these circumstances.
Follow-up contact (preferably with the same team member) should always be made immediate ly on the parents' return
home w ith early contact w ith community teams planned and guaranteed.
d. The need fo r privacy
Most parents say that pr ivacy is Important to them at the t ime o f learning about their child's disability...
e. Written information
Parents should be given notes immediate ly after the meeting to clarify what wa s said fo r future reference. These should be
available in th e language appropriate to th e parents...
A telephone number should be given so that parents can ask further questions as necessary. 5. Practical help and information
Parents' Information needs wi ll vary... Pamphlets should be made available. both about the child's conditio n and about practical help...
Contact with another parents (o r parents' group) should be offered and made available when the parents indicate they
would like such contact.
The needs of parents who se fir st language is not English must be taken into account throughout all these processes.
Legislation states that parents should be pu t in touch with relevan t voluntary organisation s. Parents value the help they have
received in this way, bu t many repor-t that this information was not given to them or only found by chance . Collaboration
between professionals and vo luntary organisations should ensure that parents benefit fully from th e help available through
the vo luntary sector:
Figure 2 - Summary of activity
Since it began in 1994, th e RFTS Working Group has created;
• a Template o f good practice to support professionals in getting to grips with the problems
• a training resource pack
• a CD-ROM and video
• national networks toSUPPOl
-t loca l initiatives and share experience• training and dissemination activities across th e whole country
• an 'audit document' to help professionals review progress
• severa l conferences.
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HIP
Referenceserspectives are most powerfully
(1) examples:onveyed by parents themselves.
• Survey of Disability in Britain,imilarly, the positive value and
Report 6 (1989) OPCS.ontribution of disabled people is
• Determinants of Parentalemonstrated as well as communi
Satisfaction with Disclosure ofated by disabled people themDisability, Sloper, P. and Turner,S.elves working with professionals
in Developmental Medicine andn these issues. In view of this, RFTS
Child Neurology, (1994) 35, 815ecruits and supports parents and
825.isabled people to work as trainers
(2) examples:n these issues. 'Pilots' of this train
• Cunningham, e.e. and Davis, H.ng model have proved very success
(1985) Early Parent Counselling.ul. There is a 'rolling programme'
• JUPp,S. (1992) Making the Rightf professional training in some
areas and we are planning training
and induction programmes for disabled
people and parents of disabled children to
ensure a supply of 'trained trainers' to
carry on the work.
In addition to training needs, Health
Authorities and Trusts usually do not haveexplicit policies and procedures on this
issue. The RFTS campaign urges that all the
organisations that may have an input at the
time of diagnosis and disclosure should
work with staff and parents to devise and
adopt clear polices and procedures of
which everyone is made well aware.
Imagination and inrtiativeAs a framework for devising such mea
sures, the RFTS team wrote a Templare of
Good Practice, highlighting the main
underlying issues that have to be consid
ered and taken into account in policies
and proced ures. (See figure 1 on page 22
for excerpts.) It is a guiding framework, not
a strict reci pe; the RFTS project accords
professionals the same respect and autono
my that should be offered to parents.
Imagination and initiat ive are called for
and we do not want to iron out these rare
and invaluable qualities by being over-pre
scriptive. 'Ownership' has to be local.
The latest addition to the resource pack is
the audit document. The group produced
this to help staff to review progress in
achieving the RFTS objectives.
The whole of the complex project - its prin
ciples, networks research base, strategies,
databases - are drawn together in an inter
active CD-ROM, which includes a RFTS summary and presentation section which is
also available on video. Both the video and
the CD-ROM are training tools adap table for
use interactively according to the specific
needs of the wide range of people involved.
These resources are also capable of being
edited and re-issued as the project develops.
A highly successful conference in London in
June 1997 brought together over 200 parents
and professionals from all parts of Britain to
celebrate three years' progress and to plan
future strategy. Further local conferences and
training events have 'spun-off from the orig
inal conference in Birmingham, Manchester,
Northampton, Somerset and Durham, with
others due in 1999. As with the rest of RFTS
activities, all of these conferences are organ
ised in partnership with the voluntary and
professional bodies that make up the RFTS
consort.ium.
A summary of the work to date of the RFTS
project is in figure 2. The project addresses
the structural and organisational factorsthat have inhibited the development of
good practice at the time when parents first
learn about their child's disability. It also
confronts the attitudes an d values that
make life more difficult than it need be for
disabled children (and adults) and their
families. We are confident that there has
already been some success in reaching a
wide range of the people wh o can 'make a
difference'. We are even more confident
that there is still plenty of work to be done
and a long way to go before we get it com
pletely RIGHT FROM THE START.
Anne Leonard is Research Officer for Scope, 6
Market Road, London N7 9PW, tel. 0171 6197100, http://www.scope.org. uk/
Start. Opened Eye Publications,
Hyde, Cheshire.
• Breaking The News (1992) North-West
Training an d Development Team.
• Shared Concern (1987) SOPHIE and the
King's Fund.
Resources
The RFTS CD-ROM is f30. The video pre
sentation part of this is available for £20
on video tape and the Report, Template
an d Audit document are available as a
Resource Pack for £ 10, cheques payable to
Scope (RFTS). Contact Scope's Library an d
Information Unit, 6 Market Road, London
N7 9PW, tel. 0171 6197100 for more infor
mation.
Conferences
• Late March 1999, Bradford details
from Scope's Wakefield office 01924
366711.
• Wednesday 5 May, Eiland Road
Stadium , Leeds - details tel Rena Martin,
Family Fund Trust, 01904 550007.
• Wednesday 26 May, Durham County
Cricket Club Ground, Chester-Ie-Street
details tel Debbie Mackie, Mencap, 0191
4870444.
Acknowledgements
The Family Fund Trust generously under
took the administration of two of the
northern conferences. Th e Joseph
Rowntree Foundation also magnanimous
ly contributed bursaries to fund parents'attendance. •
\ Answers~ ~ i l i i ~ . I I i ~ M I ~ ' ~ \ \ - " ' i I i i i - Working collectively, networking, ensuring~ • • ~ i i N M t ; J continuity and valuing all concerned is~ vital.
. ~ . l t l i l i f i . ( i l I t 1 M ~ Good communication based on mutualM ~ M . M . M ~ I f i I M . ~ respect is the foundation for partnership.
w . I t ~ ~ . l i f i f i i M M i l M ~ N M N i t a The good practice at the time of disclosureM i " " ~ • •n••W i ~ also applies to the provision of s e n s i · ~ i v e ,imaginative and responsive services.
SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 1999 23
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HEARING IMPAIRMENT
Calderon , R. and Low, S. (1998) Early social-emotiona l, language,and acad
emic deve lopme nt in children with hearing loss. Families with and withoutfath ers. Am Ann Dea( 143 (3) 225-34.As a group, children with signi(tcant hearing loss are at greater risk than other
L.
(1)
FU IITHER R E A D ~
' f u r t he r r e ad i ng . . .This regular feature aims to provide information about articles in other journals whichmay be of interest to readers.The Editor has selected these summaries from a Speech & Language Database compiled byBiomedical Research Indexing. Every article in over thirty journals is abstracted for this database, supplemented by a monthly scan of Medline to pick out relevant articles from others .To subscribe to the Index to Recent literature on Speech & Language contactChristopher Norris, Downe, Baldersby, Thirsk, North Yorkshire Y07 4PP. te l. 01765
640283, fax 01765 640556 .
Annual rates areDisks (forWindows 3.I,can run on Windows 95): Institution £90 Individual £48Printed version: Institution £60 Individual £36.
Cheques are payable to Biomedical Research Indexing.
children (or outco mes (or below their poten tJOl, despite the institu tion o( various
educational approaches at increasingly ear/,er ages Resea rch suggests some
bene(tts o(early intervenuon (or dea( children and their {amilies . However, there
remains a paucity o( re search in to how (am ly variables may affect child out
comes. The present study investigated the effect o( paternal presence or
absence on the social-emotional, language, and academic outcomes o( 22 dea(and hard o{ hearing children ages 43-83 months. The children hod graduated
anywhere (rom 9 to 47 months earher (rom on early interventio n program {or
dea( and hard o{ hearing children 3 years o{ age or younger Results indicated
that children whose (other is present have slgm(tcantly better academic and lan
guage outcomes than those without a (othe r presenL Possible explana tions (or
the {tndings are discussed, as well as imp /icotions o{ these (tndings (or services
offered by ea rly intervention programs .
BRAIN INJURY
McHenr y, M. (1998) The ability to effect intended stress fo lowing traumatic bra in inlury. Brain Inj 12 (6) 495-503.
This study was designed to explore the production o( word stress (ollowlng trau
matic brain inj ury (fBI). Ten subjects wi th TBI and ten ma tched normal controls
produced a sentence with stress elicited on different words. The difference
betVleen stressed and unstressed productions o{ the some word was colcula ted{or In tensity, (u ndamental (re quency and duration Subject's intensity range, (un
damental (requency range and vital copacity were also obtained Na ive listen
ers judged which word was stressed within each sente nce. Individuals with TBI
were signi(tcantly less accurate conveying intended stress compared with normal
controls. IndiViduals with TBI produced significantly less difference in durauon
between stressed and unstressed words. There was no correlation {or either
grou p between percentage change In intensity. {undamenta l (requency, or dura
Uon and the related phys iological range. Durauonal cont rol requires subtle phys
iological adjustments that individuals Wth TB I may be unable to accom plish .
Furthe r, compensatory strategies may place excessive cognitive demands on the
spea ker. Thus, he producuon o( stress contrasts me1'j not be amenab le to ther
apeutic intervention. Rother, listeners may be required to rely on context to in(er
intended stress.
SEVERE APHASIA
Cunningham, R(1998) Cou nse llin g so meo ne with severe aph as ia: an exp lo
rative case study Disabl/ Rehabil 20 (9) 346-54.
PURPOSE: To exp lore a counselling approach (or a clienl HN, with a severe
aphaSia. /v1ETHOD The principles o( Personal Construct Therapy were used
Therapy (s ix sessions) was started and finished by HN producing a repertory
grid Sessions were pauent-/ed but the In(ormation (rom the repertory gnds was
used to help (aCi litate the process. Each session was Video taped RESULTS:
AnalySISo( thera py sessions revealed HN was (o llowng a pattern, i( erratic. He
used good conversational strategies to control the less structured sessions .The
thera pist was dominant when the repertory grids were produced Statisucal
analysis o{ the repertory grids was mainly nonsign ificant but there was a shift
{or the (Inal gnd to a greater variety o( and more posluve responses. General
Im provement in comprehenSion Via s also noted CONCLUS ION: A counselling'
approach with someone With severe aphaSia IS poss ib le. Using a repertory gridwas a use{ul tool (or understanding HN better It seemed to initiate HN to diS
cuss things o(Importance. The changes seen in him could have been due to on
Im provem ent in confidence as a commvnicator. This stud/ has implications (or
how we can enable people with limited language to adop t to their situations.
24 SPEECH & LA NC UAGETH ERA PY IN PRACT ICE SPRIN G 19 99
VOICENixon , C.W, Morri s, L.j., McCavitt, AR, McKinley, R.L ., Anderson, TR,
McDaniel, MP. and Yeager, D.G, (1998) Female voice com munications in high
Ie els of airc raft cockpit no ises- Part I: spectra, levels, and microp hones.
AVia Space Enwon Med 69 (7) 675-81HYPOTHESIS. Female produced speech,although more intellig!l)/e than mole speech in
some noise specrro. may be more vulnerable to degradation by high levels o{some mil
ltary aircraft cod<pit noises. The acoustK:: teotures o( (emale speech are higher In fre-
~ e n c y , icM'er n p o w e and appear me re suscepoble than mole speech to m a s k i ~ by
some o( these military fiOlSeS Ctm-en military voice communic(l(jon systems
'vere optimised (or the mo!e voice and ITl0' no adequately accommodate the (emale~ e in these high level nOises METHODSThis oppbed swdy i()<l€stigateci e intelligi
bility' o( (emale and mole speech produced in menoise Spec!m of f()(J r rruhrary O l r a acockpits at I€vels ranging {Tom 95 dB o I15 dBThe expetJmefltal subjects used sum-dard flight helmets and headsets, noise-cancelling microphones, and military r o u ~voice communications systems during the measurements .RESULTS: The ! I ~ I i of
[emale speech wos lower than that o( mole speech (or all experimental conditions,
however. d/ferences were small and insignificant except at the highest levels o( the
cockpit roises.lntelligibility fOr both genders varied with a i r c r a ~ noise spectrum and leve .
Speech In elllglbllil!/ o( both genders was acceptable dvring normal crUise noises o(all
(our aircra{1, but Impravements are required in the higher levels o( noise created during
a i r c r a ~ maximum operating conditions . CONCLUSIONS The intelligibility o( (emale
speech was un accepwbie at the highest measvred noise level or I 15 dB and may con
stitute a problem fOr other mif tary !Motors. The inte/iiglbility degradation due to the
nOise con be neutraised by use o(on available, I proved noise-cancellmg microphone,
by the application o( current oaNe noise reduction technology to the personal com
munlc(l(jon eqUlpm en4 and by the development o( a voice commvnico tions system to
accommodate the speech prodtKed by both (emale and mole avia tors.
LANGUAGE DEVELOPMENTUkra ine tz, TA ( 1998) Stickwriting stories: a qUick and easy narrat ive repre
senta ti on st rategy Lang Speech Hear Serv Schools 29 (4) 197-206.Narrative is on important target o( language intervenuon. However. orol narro
IJves are difficult to remember. reVle v,: and revise because 0 their length and
complexity, Writing is an option, b r So{!en ;NS' ating (or both student and clm
ICian,Th is arode Introduces a notatIOnal system co iled pictography can be
usefUl (or remporanly preseniJI1g ,1f)( (o nte'lL Children represent the characters,
settings, and sequences of ocoons wrth simple, chronologicaly or episodIcally
or an,sed stick·flgUre drmvmg;.As a qUick and easy representa tionalstrategy, pic
tography i- o.ppf'lcn e to both indlvid 01 language IntervenlJon and Indusive
dassroom serungs, This arode describes bene(lts observed in narraUve Interven
(IO, doong (aCilltation o( a time sequence, Increased length and qualiy. and ag ~ a t (ocus on narratJve content rather than on the mechaniCS o( Writing
DYSPHAGIAPochaczevsky, R. (1998) The chewable barium tablet slow tracki ng of oral
and pharynge al swa llow ing dys funct ion.) Clin Gastroenterol26 (4) 32/ -1Dysphagia can be due to oralor pharyngealdys(ur;ction as well as to oesophageal
causes. Oral and pharyngeal disturbances, howe'fer, are more common in okkr
people becavse o( their attendant risks o( laryngeal, trachea l, and pulmonary aspl
mUo n.To guide any dietary prescrip tions it is Important 10 es tablish whether the
patient con best tolerate liqUids, (oods, solid chewable boluses, all, or none o(
these. It therefore becomes important to supplement liquid barium swallOWing
studies with and chewable boluses mixed with banum. Here I deSCribe the
novel in troduction o(chewable barium tablets in conjunction 'Mth routine swallow
Ing studies . Chewabie barium tablets, i( used proper/y, are sa(e, supp ly needed
information, and can shorten the evaluation o( oral and pharyngeal dysfunctionstudies. Becavse o( the granular appearance o( the tablets, aspirati'on due to this
solid chewable bolus can be distinguished trom liqUid aspiration. Moreover. i( the
barium tablets are S\¥ollowed whole, they can help delineate oesophageal stIic
tures i( the oral and pharyngeal phases o( swallOWing are normal.
L. (1),
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Howlwork ·
assislaKate Richards is the speech & language therapy
service manager for North Warwickshire NHS
Trust, based at Brooklands in Birmingham, tel :
0121 3294943.
Lorraine Kelly-Atherton is a speech and language
therapist in Cardiff.
Irys Lindsay is a speech and language
therapist with Yorkhill NHS Trust in Glasgow.
H OW l...
There are over 500speech and languagetherapy assistants in theUK. The work they carryout, the training andassessment they undergoand the relationship theyhave with speech andlanguage therapists WIll
vary across services anddient groups. Theopportunities andchallenges posed bymultidisciplinaryteamsare also present forspeech and languagetherapists working withassistants. Here, threetherapists suggest howthe conbibution of
assistants can bemaximised. Training andassessment thecomponents ofagoodworking partnership andthe kinds oftasks and
responsibilities assistantscan take on are eotNdered
SPEECH & lANGUAGE TIiERAPY I PRAcnC PRiNG 1999 25
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HOWl . ..
u n d e r s t a n ~assistants
advocate
K a r e ~ r d s ~ ~ w ~ ~ ! T d v ~ m e f u rassistants p'repares them qUICklyand effectively for h e ~ chaDenges of
the wO rKpla<."e.Training for speech and language therapists'
is available in many guises. The
essential on-the-job development many of us
remains at the core of any training pro
gramme for assistants and should continue to be so. T he skills and
knowledge acquired in this way can now be recognised by formal
assessment under the Scottish/National Vocational Qualification
(S/NVQ) (Level 3) Programme. There are, in addition, any num
ber of structured courses which can contribute to the underpinning
knowledge required by the S/NVQ (Level 3) assessment standards
and also contribute to individual and departmental needs.
The BTEC programme offered at Brooklands is one such structured
format. It is unusual however in its extent and depth. The BTEC is
a course of study and is offered on a day-release basis over 40 days
but also promotes the shared, lifelong learning approach byencouraging students to undertake 'Home Based L e a r n i n g ~The course is at Level 4 and, having been developed, tutored and
administered from the outset by speech and language therapists,
provides not only a comprehensive knowledge base but also the
majority of the underpinning knowledge required by the speech
and language therapy units in the new S/NVQ III award. Ou r
intention is that, from day one of the course, students can take
away information and skills which immediately translate i nto prac
tical application in the workplace.
Learning quicklyOne of the key questions I am asked is "how can I train myassis
tant in all the areas of speech and language therapy - I need her to
understand quicklyl " There isn 't an easy answer here as we all
learn so differently, but the BTEC is as near to answering the practical issues as we could achieve as a group of therapists. We too
needed newly appointed assistants to learn new skills quickly. The
lectures cover all areas of speech and language therapy work and all
client groups ranging from large incidence language disorder
groups to small incidence forensic services. All contributors to the
course are speech and language therapists or associated specialists
such as teachers and psychologists. They are briefed to adopt a facil
itative approach to teaching and to point out the relevance of their
subject to all client groups so, for example, students learn about the
systems of the body such as the Circulatory system, but it is presented
alongside the disorders arising from difficulty with the circulation
system, such as cerebrovascular accident. This whole context
approach means that students never lose sight of the client and that
the compartmentalising of human communication disorders into
that which is relevant only to certain age groups, is challenged; for
example, students learning about language development are asked
to consider why this is relevant to adults with a learning disability.
Confident communicatorsAssessment on the course is ongoing and looks at group interac
tion as much as formal assignments. Again the emphasis is on how
we learn and develop as communicators as much as how we devel
op as therapists and assistants. The dreaded word 'assignments'
does still engender a kind of terror, however past students have
remarked "Why was I worried" or "It really helped me to focus on
communication" - isn't hindsight wonderful? The process of
preparing the assignment and presenting it is also practical and not
that fearsome. Students are given skills which will enable them to
confidently report back or present client needs in a number of sit
uations in the work place. The final part of the course enables
them to extend presentation skills to include group situations such
as career conventions / parents' evenings. It is therefore the total
approach to communication and to the joint role of therapist and
her assistant which has proved to be so successful for the students.
The course allows us to start off together as therapist and assistant
and to progress to problem solving and then to joint planning. The
Whole issue of communication difficulties and how to help through
both direa methods and alternative service delivery models is also
addressed. I have found the course to be a learning exercise for
myselfand the other tutors - we always want more time and so do the
students. This, I hope, is a positive sign and plans are afoot to create
'the next level' of structured learning to enable assistants to move on.
Distance no objectAs busy practitioners we are always grateful for assistant colleagues
who can 'hit the ground running' - is there ever time for any other
option? The Brooklands BTEC recognises this and its whole struc
ture is aimed at maximising every learning opportunity, from creating a portfolio to preparing assignments, but the one difficulty is
location. Many people contact us interested in the course but can
not access it due to distance. It is however now possible for other
speech and language therapy departments to offer this course. The
route we have established means centres can register their students
through us at Brooklands, so don 't let distance put you off.
There are five units which constitute the course:
• anatomy and physiology
• social development
• behavioural science
• communication
• workplace systems and practice.
These units are integrated throughout the lectures into learning
objectives. This means that students cannot complete one unit, get
accreditation and leave. The whole course must be completed. It is an entry requirement that assistants must be working within a
speech and language therapy department or very closely with the
department. Students from local education authorities or social
services are only accepted with the agreement of the local speech
and language therapy services manager, and only if they have regu
lar contact with a supervising therapist.
Evaluation is through
• ongoing course input and contribution
• three formal assignments
• portfolio development - home based 'tasks'
• attendance.
Each student must have a speech and language therapist supervisor
who attends for three meetings per year or stays in touch by tele
phone. Feedback sheets are completed by speech and language
therapy supervisors as well as students.
Sense of ownerShipThe course offers a thorough 'backcloth' to communication diffi
culties and the role of the speech and language therapist and
speech and language therapists' assistant. The standards and
importance of our professional body, the Royal College of Speech
& Language Therapists, are stressed throughout. Improved mutual
understanding across agencies is always a result of the course as
participants come from a number of backgrounds. Students not
only gain study skills and confidence but also a sense of ownership;
it is up to them to keep in contact with their supervisor and up to
them to maximise their learning. This in itself helps in the work
place where the therapist is not present all the time.
Our experience has shown that structured learning, iflinked strong-
Iy to the workplace, can provide speech and language therapists'
assistants with the knowledge and skills they require to meet exacting speech an d language therapy standards. This complements our
role as clinicians and widens the opportunities for our clients
• BTEC awarding body has IIOW combined with London Examinations and is known as Edexcel Foundation - the awards themselves are unchanged.
26 SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 1999
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H \ I
Speech an d language therapists
impart advice to a variety of pro
fessional groups and ' their' assis
tants. However, the relatively
recent awareness an d acceptance
of the need to train our own
assistants has led us to focus on developing
good working practice. There are some key elemen ts of wo rk-
ing together which, if made explicit, can enha nce the wo rki ng rela
tionship to the benefit of therapist, assistan t and c.lient.
Personal experience gained from working with a varierv of carers
and professional grou ps is invaluable and the work of Carl Rogers,
Bernstein an d Geo rge Kelly is useful in providi ng methods to
understand th e perspective of staff for whom we are responsible.
Approach to supervisionSpeech and language therap ists do not have as long a histoty of super
vision as do professionals such as social workers (Thompson 1996).
The supervision of an assistant who does not hold a speech and lan
guage therapy qualification requires a different approach than , for
example, the sup ervision of a speech and language therapy student or
newly qualified therap ist (Kimbarrow 1997). It is significa nt that the
assistant may not have the same theoretical knowledge, nor the
means to gain that knowledge. However my assistant, Samantha
Lomax, has an NN EB qualification and has worked in state nurseries.
She was at a school for PMLD children for a year before being
appointed as a speech and language therapy assistant there with me
as her supervisor. The service is jointly funded by Cardiff NHS Trust
and Cardiff County Council Education Department; Sam is an
emp loyee of education and I remain with the health service.
Sam 's knowledge of chi ld development proved invaluable as ashared baseline. She has ten sessions and I have two. We do not
have day-to-day contact so need to be clear about the parameters
of supervision. Planned sessions promote co llaboration and can
include a teacher or other staff member. They provide a source of
co nfidence, training and reassurance regarding issues related to
clients in particular and to the school in general and include:
• discussion of specific cases / disorders
• planning objectives
• sourcing materials
• reviewing actions taken to date
• sharing concerns.
Negotiation and planning It is important that we are clear about the use of time management
as this can prevent mistakes and misinterpretations on the part of
colleagues. We are fortunate that the head teadler has been sup
portive and willing to discuss issues related to improving the service.
Specific procedures are necessary and advisable and might include:
1. an agreed fo cus for the service, in our case the lower school. This
takes into account Sam's experience and tacitly acknowledges the
greater potential fo r change in the you nger group. Through focus
ing on a timetabled caseload, Sam has achieved an excellent rap
po h as a basis for individual programmes, an d would advocate this
as a positive way to ensure job satisfaction.
2. regular discussion with class teachers (speech and language ther
apist and assistant speech and language therapist , or speech and
language therapist alone) seeking their views on prioritisation and
suitability of children for one to one work; listening to their obser
vations about the children and fostering a two-way exchange of
views and information .
3. the provision of written short term objectives. In our case thattends to be three or four objectives which might include pre-verbal,
skills, turn-taking, choice or early vocabulary. Targets are retained
for a term and modified or changed if little progress is made. Some
targets are taken from the curriculum, from individual ed ucation
plans or devised by the speech and language therapist.
4. A multipurpose record form has been devised which captures
data such as baseline or emerging skill on entry, attendance, areas
targeted for treat ment and a section for the assistant to write com
ments after each treatment session . This is copied for Annual
Reviews and the child's file and updated termly.
5. our timetable is on the wall of each dassroom we are involved with
and updated termly. Supervisory sessions are noted on the timetable.
Positive, genuine and reassuring In a busy school of children with challenging behaviours and com
plex comm u nication disorders, feeling of helplessness could pre
vail. Person al qualities such as
• a positive attitude
• a genuine interes t in the client group
• a sense of humour
• good communication skills
• a reassuring, war m approach
• enthusiasm, interest, motiva tion, initiative, adaptability, flexibility
together with an ability to modify language at an appropriate level
an d a confidential and professional attitude to colleagues are all
highly desirable.
The speech and language therapist's awareness of the particular
learning style and cognitive attitude of her co-worker is also impor
tant (Furnham , 1992). Periods of active hands-on experience are
facilitated via client contact, and reflective observation aided by joint
sessions. The discussions help to conceptualise the next stage which
is recorded in note form before being transferred to the reco rd form.
Need for training and supportA degree of maturity and fairness is essential on our part as is an abil
ity to work cooperatively, which requires self confidence and seOJrity
about our own skills. An awareness of certain issues, in our case those
surrounding assess ment, feeding and alternative and augmentative
communication, is essential to ensure that professional assistants do
not get drawn into areas which require post-graduate training.
Sam contributes comments an d observations on her caseload
while referring any other queries to me. Future development might
include additional sessions to satisty the ever present need for the
consultative role of the speech an d language therapist. Assistants
should be aware of selvice development issues but need not be too
deeply involved. Training is an issue which can be partially
addressed by in-house education courses, in our case on chal.leng
ing behaviour and health and safety. Sam has also attended a Royal
College of Speech & Language Therapists ' SIG in Autism study day.
Although a small group of assistants in our district are e mployed by
health and have different pay an d conditions to Sam's, they could
be a source of support for her in the future . We should be aware
that assistants are a minority group wh o are vulnerable and require
protection and empowerment. We need to support their need for
access to a variety of equipment and recogn ise their achievement.
A long association , as clinician and ma nager, with the specialism of
learning disability affirms my belief that we need new an d inn ova
tive approaches to overco me inherent diffi cu lties with recru itment
and retenti on of staff. The lure of working with an assistant
brought me back in 1997 to the school where I sta rted my career
many years ago. Comparing then and now, th e outcome has been
positive and beneficial to myself and the children on the caseload.
References
Thompson, N. (1996) A Guide to Effective Practice in the Human Services. McMillan.
Furnham, A. (1992) Personality at Work. Routledgt'.
Kimbarrow M. (Fall , 1997) ASHA pAI-44 .
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HOWl . .
andIrvs I)r:ldsav's department ~ ~ wot1<iru!'with assistants for several years.Sne lists h ~ kindS of respombilitiesand tasrcs they take on
COMMUNI I Y CHILO HULl H SeRVICES
The main emphasis of ou r assistants' work has always been the sup
port of therapeutic practice in any setting, in any model of delivery,
with individual speech and language therapists or within shared
discipline group activities.
Yorkhill NHS Trust in Glasgow is a discreet Paediatric Trust. Assistants
in speech and language therapy have been employed since before Trust
status and their roles have evolved and developed over these years.
Developing expertiseAssistants have been given training by ou r own speech and lan
guage therapists, learning about general expectations an d require
ments within the department and also about particular speCialist
areas and how the assistants can best support the clinicians . This
has been done through varied programmes of in-service, presented
in the Trust's training centre, including presentations from col
leagues outwith speech and language therapy.
Much of the assistants' knowledge is, howeve r, acqui red by on-site
lea rning. They develop expertise in adapting to each situation as it
arises and eventually to anticipating the requirements of the clinician
by way of accommodation set-up, materials needed and the level
of privacy required for some interviews.
Home visitsFor the many clients wh o requite domici.\iary visits an assistant's
presence can be extremely beneficial. The assistant can spend time
with th e child while the therapist concentrates on parent / carer
discussion or, while the therapist offers an activity to the child, the
assistant can observe therapist / child interaaion an d can comment
at a Iater case discussion.
Whether in school, nursery, clinic or home an assistant can be most
helpful during assessment. S/ he becomes familiar with the formal
test presentation and can help with placing the toys, presenting thequestions or transcribing responses. During informal assessment,
the assistant learns the aims being targeted an d can produce requi
site pointers to assess particular skills.
Recording interactionThe assistants become skilful in the use of camcorders. They work
unobtrusively to record child / parent / therapist interaction. These
records are so valuable to the therapist for later analysis and dis
cussion an d they can be used for discussion with the parents too.
Much use of this skill has been made throughout the Hanen
Programme. The assistants can carry out all the video recording
required at the various stages an d the parents get to know them and
are pleased to welcome them into their homes.
Supporting groupwork
Speech an d language therapy in Yorkhill Trust now puts greater
emphasis on group work than ever before. The assistants' input has
become an important part of this work. They themselves build an
awareness of how they can best help in the groups, as well as carrying
out aaivities - games, worksheets, stories -as requested by the clinician.
The assistants are able to guide and support the children to respond
at the level of comprehension being targeted. They can encourage
the children to wait and listen, to wait for the ir turn and to maximise
their attempts at achieving the aims of the session. Clinicians and
assistants build a bond and an understanding which promote joint
working to the benefit of the clients an d their families.
In addition to eight assistants, Yorkhill Trust employs two bilingual
co-workers. Their work is similar to that of assistants but it is also
expanded to cover knowledge and use of the language and culture
of many bilingual families. These co-workers link with the assis
tants at meetings every two months. At these meetings they discuss
matters particularly pertinent to their jobs. The head of service often
attends so that she can hear at first hand how the ass istants and co
workers feel their work is fitting in to the whole department's aims
and objectives. All assistants and co-workers are having the oppor-
tunity to gain Scottish Vocational Qualifications (SVQ). All are also
members of the MSF Union and have their own representative at
Trust-wide union meetings.
The assistants' current job description is on e planned an d discussed
by the assistants themselves, supported by a senior clinician. Th e
Key Re sult Areas put all the emphaSis on the job being on e of sup
port to the clinicians' therapeutic interventions.
Integral roleNew recruits hear from an assistant already on the staff about the
expectations of the work. People in this job find it varied an d challenging bu t never boring. Retention of staff can be difficult because
the financial rewards are not high. However, on e assistant left to
train as a nurse an d two others have gone to study speech an d lan
guage th erapy. The role of the assistants is still evolv ing but they are
now integral to the staff complement in speech and language
therapy as they expand their range of skills to continue to support
clinicians' input to their client group.
ResourcesInformation on the Hanen Programme from Anne McDade. Hanen UK /
Ireland Co-ordinator, tel. 0141 9465433, e-mail uk_ireland@hanen .org
Details of MSF from Membership Services, MSF Centre. 33·37 Moreland
Street, London EClY 8SS. •
Background• 1980s - assistants begin to be employed more frequently by speech andlanguage therapy departments. Training and assessment is informal.Gradually more formal structures emerge, for example from 1he
A s s o c i a ~ o n of Speech & language Therapy Managers.• 1996 - a Royal College of Speech & language 1herapists' survey findsassistants make up nearly 10 per cent of the speech and languagetherapy workforce (RCSLT B u l l e ~ n ) .
• 1997 - formal N/SVQ assessment awards for assistants introduced.Assessors must be speech and language therapists and must assess theassistants consistenHy over ~ m e . BTEC training is developed atBrooklands and elsewhere.
• 1997 - the Royal College of Speech & language Therapists sets up anAssistant Network. Benefits include a quarterly newsletter and directory
of network members. For further information, contact Jenny Pigram on01716136415.
Practical points1. the focus of an assistanYs work should be onsupporting therapeutic p r a ~ c e
2. assistants can provide invaluable help with homevisits, assessment, videaing and group work
3. the best training is on-the· job, supplemented bystructured, p r a c ~ c a l courses of study
4. assistants should be encouraged to develop ascommunicators
5. planned time together to exchange viewspromotes collaboration and confidence
6. an agreed focus and caseload gives job satisfaction
7.a supervising therapist needs to be mature,confident and secure
8. planned contact with other assistants issupportive.
Speech and language therapy assistants - subscribe 10 Speech &Language Therapy in Practice for only £15! Tel 01569 740348.
28 SP EECH & IANGUACETHERAPY IN PRACTICE SPR INC 1999
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IMPORTANT NOTICE Subscribers should contact the publisher if they have not received their magazine(s) within two weeks of the publication date.
Tel: 01569 740348
EVENTS ASLTIP 'Clinical ExceJlelll;e' Day, Saturday 6 March 1999
Speakers include Tessa DuffY of Symboland Sheila Ryan ofThe Learning Journal.
This event at Robinson College. Cambridge,is free to ASLTlP members, £45 to non-
members and includes lunch .The Association of Speech & LanguageTherapists in Independent Practice wouldwelcome prospective independent therapiStsat this eventDetails from Gail,ASLTIP Office
Manager, tel. 01630 655858, or theAssociation's web site,http://www.aidaweb.co.uk /asltip/
Estill Voice Training Systems
Courses in Voice C r a ~ (Anatomy &
Physiology, Level One and Level Two) with Jo
Estill will be held at the Uverpool Institutefor Performing Arts from 6- I I April 1999.Future courses planned include Voice Skills
for Speech Therapists and Safe Belting.Details from : Felicity Blair, EVTS UKAdministrator. 0 181 463 0543.
I CAN training centre
Courses in Summer 1999 include ADIHD,autism, cued articulation, IndividualEducation Plans, developing thinking skills,developmental cognitive neuropsychology.
dyspraxia, effective staff development,Hanen and speech and language targets.Booklet I details from The CourseAdministrator, tel. 01932 820470.
International Scientific Centenary Conference
Organised by the Stroke Association, thisevent from 13- I4April 1999 is aimed atall involved with research or stroke careand includes a presentation from
Profession Pam Enderby.Details: Stroke Association, tel. 01715660300.
British Aphasiology Society
The BAS Conference will be in Londonfrom 13 -15 September, 1999. (Detailsfrom Hetty Lynn , tel. 0171 477 8288.)
A study day on the evaluation of therapywill be held in Harrogate on 15 April1999. (Details from MargaretRobinson, tel. 0 1423 553604 .)
Contributions to~ e e c h &LanguageTherapy in Practice:
Contoa Ihe Editor (or more InfofTT'GtJonand Ior tD dlSQJSS your plansPlease note:• orrides must be or rroctJcal use 10
clinlC/ans• use case examples IJnd list use(ulresources• lengrh is genemlfy around 2500 words•
supPlycopy
011 disI<
,rpoSSIble• keep statistIcal mformanon andreferences 0 a mlntmum
• photographs Clnd illustrations WII/
be returned
£40 authorities (sin Ie subscription)
£15 students I assistants I unflaid
:, or more - £18 each
Special offer for personal subscribers Introduce a colleague* to Speech & Language Therapy inPractice and you both get an extra issue - free!The new subscriber fills up theIr details on the form and pu u your nom e in the 'recommended by'space. Once their payment has been received, they will ge t 5 copies for the price of 4 In their firstyear's subScription, and you will be notified thot your subscription period has been moved on bythree months.
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.ds Centre e should.cation AI hat e'leryon I am
communi ource t rfe sa'ler.\ . . local res much a I to Sarar\ere IS a and is 'Iery nd ideas the
esS to h ughts a ho haSha'le aC
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2. Care an d Responsibility
Training Breakaway Techniques
There are times when my 'breakaway'
training is invaluable. and there have
been times when being able to hold a
pe rson safely has been necessary.
However the greatest value is knowing
tha t, if the going gets tough, I w ill be
able to deal with the situation. This
makes me more relaxed when work
ing with an individual who is known tohave aggressive outbursts.This in rum
has a positive effect on the cl ient.
which usually results in less outbursts.
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orlessj'USt 'd oreOUtSI e the door: Ik 'the hills helps me to . ' a 109
get It all intperspective and re-char e 0
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With the cl ' worlents and h I
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materials whit chains (no wondervibrating balls. and et a reputation!).that "m startlOg to g u h it. and
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_,II, ;_ f t Points
much of my work is involved in skill tranS"
and training others - creating an awareness
the presenting challenging behaviour
associated with a communication difficulty.
P i ' I I I S 8 I ~ t i l l l ! concepts in an interesting and fun
is difficult. so the activities presented In
- . · _ ~ . f t file' makes my life so much easier.
leave the training sessions saying that they
enjoyed themselves - my only hope Is thatalso learn something!
Points Sue Thurman, Kath Stewart,Jane
MvToDResources
Gwenan Roberts is PrincipalSpeech & Language Therapist fo r
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