Speech & Language Therapy in Practice, Autumn 2001

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EducationA question of taste

EthicsStrength in

compromise

PrioritiesDesperatelyseekingconsensus!

Service

developmentAn audit result

CollaborationA multi-agency team

In myexperience

Clinicalliaisongroups

How Imanagedementia

My topresources

The London Connect CentreA W A Y F O R W A R D

ISSN 13

AUTUMN

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eprinted articles to complement theAutumn 2001 issue of Speech &anguage Therapy in Practice

Video - a reflective tool.Autumn 1997)***ontinual self-analysis ensures we allractise what we preach. Keenaummins and Sarah Hulme focus on thetrengths of video playback as a reflectiveool in the therapy process and forngoing professional development.

Whose right? - Whos right?Winter 1999)***ack is a 10 year old boy with cerebralalsy. His parents and his speech and

anguage therapist have very differentpinions on how his therapy should beelivered, as does Jack himself. Can anthical perspective help them come ton agreement? Jois Stansfield andhristine Hobden find out.

Activating Potential forCommunication.Winter 1997)***onfused, disorientated and sociallyeprived elderly people are ofteneglected as client groups. Sonas aPc ispackaged programme designed to

meet their needs. Speech and languagend occupational therapy staff of theictoria Infirmary NHS Trust outline its

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READER OFFERS

Two great reader offersfrom Black Sheep PressFirst up we have two copies of the CD

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We have Music Factory software to giveaway FREE to THREE lucky readerscourtesy of WidgitThis program lets students listen to sounds and build their own music from pre-definedsound clips. A variety of styles provides something for every age group, and simple tocomplex combinations cater for all abilities. Music Factory is available in eight lan-guages and can be accessed using a variety of methods such as a touch screen or switch.To enter, simply send your name and address marked Speech & Language Therapy inPractice - MF offer to Ian Wedgewood, Widgit Software Ltd, 26 Queen St, Cubbington,Leamington Spa, Warwickshire CV32 7NA. The closing date for receipt of entries is 25thOctober 2001, and the first three out of the hat will be notified by 31st October.The recommended running specification is a multimedia PC with CD ROM runningunder Windows 95 or higher or Windows NT4 plus. A single user copy is 34 plus VAT+ p&p from Widgit Software Ltd, tel. 01926 885303.

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3/32SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2001 1

14 PrioritiesMotivation should be a significant factor for any

system of prioritisation, providing all aspects are

taken into account. For those who have learningdifficulties, motivation to communicate is as importantas motivation to change.Joanna Manzs pilot prioritisation system for mainstream

school children who have learning difficulties is based

on the opinions of experts in the field.

18 Service developmentAlthough patients are encouraged to contact the

speech and language therapy department when avalve change is indicated, some attend without anappointment. When patient numbers were smallerthese requests could usually be accommodated but,with increased numbers, this is not always possible.

Janice Deys decision to audit a tracheo-oesophagealvalve changing service has led directly to the

establishment of a specific Valve Clinic.

20 CollaborationThe team works very closely together and all work isdeveloped jointly. When referrals or requests fortraining or parent support are received the teamdecides together on which members will respond. Aswell as simplifying the process for the providers ofnursery education, this approach also enables the teamto develop their own skills and learn from each other.

A multi-agency team tackles the needs of children

with behavioural and language difficulties in nurserysettings. Sarah Hulme and Barbara Sampson report.

24 How Imanage

My main strategyis training. Theunderlying principleis that my input willmake little difference

to the patients careunless I can influencethe behaviour of the

staff and relatives.Julie Baker and

Mary Heritage

work with elderly

people with dementia, while Scilla Reeds clients also have

learning disabilities.

AUTUMN 2001(publication date 27th August)

ISSN 1368-2105

Published by:Avril Nicoll33 Kinnear SquareLaurencekirkAB30 1ULTel/fax 01561 377415e-mail: [email protected]

Production:Fiona Reid

Fiona Reid DesignStraitbraes FarmSt. CyrusMontrose

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Printing:Manor Creative7 & 8, Edison RoadEastbourneEast SussexBN23 6PT

Editor:

Avril Nicoll RegMRCSLT

Subscriptions and advertising:Tel / fax 01561 377415

Avril Nicoll 2001Contents of Speech & LanguageTherapy in Practice reflect the viewsof the individual authors and notnecessarily the views of the publish-er. Publication of advertisements isnot an endorsement of the adver-tiser or product or service offered.

Any contributions may also appearon the magazines internet site.

Inside coverSpring 01 speechmag

Reader offersTwo great reader offers from Black Sheep Press, plus achance to win Winslows The Selective Mutism ResourceManualand Music Factory software courtesy of Widgit.

2 News / Comment

4 EducationOne student who was 21 years old was thought tohave little or no discrimination of tastes and wasknown for eating chillies and onion with no reaction;however, on closer inspection and recording, he wasfound to have distinctly different responses to tastes.For example, he would have an increase in saliva forlemons and his eyes would water on onions.Kim Talbot and Julie Stinchcombe address

communication and eating, drinking and swallowing

difficulties in their students through a taste

programme.

7 Further readingPsychiatry, stroke, stammering, interaction, hypernasality.

8 EthicsThe most positive outcome of the situation was seenas one which would reconcile the mismatch between

Marks expectations and speech and languagetherapy management.Mark has severe dysarthria following a head injury

and is keen to use technology he has seen

promoted in the media. What happens if

therapists dont feel this would help? Helen

McGrane and Jois Stansfield use an ethics

approach.

12In my experience:clinical liaisongroupsOn our agenda each speech and languagetherapist is given time to discuss challenging orcomplex patients... We have all shared in andlearned from these discussions even when the

patient is not directly known to all present.What are the benefits of a clinical liaison

group? Carol Harris and colleagues focus on

head and neck cancer, but the concept is as relevant

to other areas of practice.

ContentsAutumn 2001

Cover picture by Paul Reid.Thanks to models and StracathroHospital.See back cover My Top Resources

www.speechmag.com

IN FUTURE ISSUESADULT LEARNING DISABILITY USING MUSIC PARENTS VIEWS AUTISM

REFLECTIVE DIARIES EARLY FEEDING

Back coverMy TopResourcesIn partnership with families andhealth and social care workers, wehelp people living with aphasia todevelop new skills for communicatingwith confidence, so that they canreconnect with their lives.Find out from Tom Penman and

colleagues how Blobby Men, pebbles

and Hello magazine feature in the

work of the London Connect Centre.

COVER STORY

dementia


4/32

Making a differenceGuidance in promoting speech and language development through

Sure Start programmes is now available.

The framework, by James Law and Frances Harris of City

University, includes many examples of current Sure Start practice.

Although it has been written specifically for the cross-governmen-

tal programme to improve the life chances of young children in dis-

advantaged areas, the information is also relevant to all speech and

language therapists and those involved in planning services.Adult-child interactions, home languages, the home and commu-

nity environment, carers, specialists and outcomes are covered.

Research notes summarise evidence-based practice and resource

notes illustrate good practice. Submissions are being sought for a

revised edition planned for 2003/4.

Sure Start will now, in its fifth year, have 437 sites in England. Extra

support is to be announced for programmes in rural areas and places

with small pockets of deprivation. A major six year evaluation is

underway. An initial snapshot survey suggests the programme is

making a difference for children and families in low income areas.

www.surestart.gov.ukPromoting Speech and Language Development - Guidance for SureStart Programmes from DfES Publications, tel. 0845 602 2260, [email protected], ref. SS/SPEECH.

news

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 20012

The burden of caring for a person with autism at home

places huge stress on carers and their families, often leav-

ing them socially excluded or suffering mental ill health.

According to a report from the National Autistic

Society, having a child with autism spectrum disorder can

leave the whole family excluded from normal life. Major

disruption suffered can include loss of a career, neglected

siblings and broken marriages.

Half of all adults with autism are still living at home,

often with elderly parents caring for them. Many parents

report their fears as to what will happen to them when

they become too old or frail to continue caring for their son

or daughter.

Meanwhile, a book published by the society is a new guide

to living in an intimate relationship with a person who has

Asperger syndrome.

Author Maxine Aston has explored the relationships of

adults with Asperger syndrome as part of her academic

research, as a qualified couples counsellor specialising in this

area and from her own personal experience.

The books emphasis is on positive attitudes and strategies

for successful relationships.

A new law has made it easier for people with aphasia to get the

support of an intermediary when appearing as a witness in court.

Reporting on the implications of the Youth Justice and

Criminal Evidence Act 1999, Speakability explains intermedi-

aries are one of the special measures to help vulnerable wit-

nesses give best evidence in court. The intermediarys function

is to communicate to the witness the question they have to

answer and to communicate to the person asking the ques-

tions what reply the witness has given.

Speakability is working with the Home Office on guidance

which will define how the intermediary role differs from wit-

ness supporters, interpreters or appropriate adults. The

organisation is planning some workshops later in the year for

speech and language therapists who would like to know

more. It suggests they should be comfortable with having a

rather detached, non-partisan relationship with the client, as

it is very important that the intermediary is neutral.

Speakability, tel. 020 7261 9572 (contact Anne Keatley-Clarke).

SpeechcomprehensiontargetedA major grant has secured

research aimed at improv-

ing the speech recognition

of people using cochlear

implants.

The research teams wantto quantify the amount of

information coded by the

cochlear nerve in response

to electrical stimulation

from the implant, and to

find ways to increase the

information transfer to

improve speech comprehen-

sion. Methods will include

computational studies and

perceptual experiments

with cochlear implant users.

It is possible the research

could lead to more peoplebeing implanted, including

some who have residual

hearing and get slight ben-

efit from conventional

hearing aids. Cochlear

implantation increases the

probability that a child with

profound deafness will be

placed in a mainstream

school and reduces the

amount of special support

required. Even modest

improvements in speech

recognition would greatly

improve the quality of lifeof the more than 900 adults

and 800 children in the UK

with a cochlear implant.

The three year project has

been funded by the

Engineering and Physical

Sciences Research Council.

Dr Nigel Stocks, Universityof Warwick,tel. 0247 652 2857, [email protected].

Joined up agendaA working party of people with aphasia have drawn up an Agenda for Change to deliver

the right services based on their own experience of living with the condition.

The twenty five requirements for the government to act on reflect the need for all profes-

sionals to take a more holistic approach to clients with aphasia. A section on best treatment

and therapy calls for more research, support for people with aphasia to contribute to service

development, adoption of good practice from abroad and resources for self-help groups and

information services. It recommends that equal weight should be attributed to the qualitative

experiences of people with aphasia as academic findings when evaluating the benefits of

treatments and services, and that research should include efforts to understand what non-

medical services and support mechanisms are of most benefit to people with aphasia.

Joined Up Talking, Joined Up Working from Speakability, tel. 020 7261 9572.

Whole family excluded

Fit to teach?The increased likelihood of

teachers presenting with

voice problems, and the

value of preventative work,

is acknowledged in the gov-

ernments Healthy Schools

Programme.The Voice Care Network

UK, which has long cam-

paigned for this recognition

reports on the development

of two Department for

Education and Employment

publications, Fitness to

Teach. Both give guidance

on occupational health, at

length for medical

professionals and through a

shorter version for teachers

employers, managers and

tutors. The employers legal

responsibility for health riskmanagement is emphasised,

including the risk of voice

trauma. Referral to speech

and language therapy and /

or an ENT consultant is

recommended should

problems arise, and the

important role of prevention

briefly discussed.

www.dfee.gov.uk/hsht/Voice Care Network UK, tel.01926 864000,www.voicecare.org.uk

Best evidence

Ignored or Ineligible? The reality for adults with autism spectrum disorders and The Other Half of Asperger Syndromeare available from the NAS tel. 020 7833 2299, www.nas.org.uk. Autism Helpline, 10am-4pm, Mon-Fri, 0870 600 85 85.



news & comment

A way forwardLikeJulie Baker(p.25), readers of this magazine frequently need the tenacity

of a terrier to find a way forward when our efforts are beset by problems.

The inroads being made by the profession in the dementia field compared

with 10 years ago is hugely encouraging (p.24-28) but has taken great effort

and perseverance. We are also seeing progress in understanding of how

services need to move forward to meet the needs of people living with

aphasia, with the pioneering work of the team at Connect(back page)playing a significant part.

Over the past few years, a programme of increasing centralisation has

ensured clients get access to the most experienced and expert staff for the

most specialist procedures. This does, however, throw up other challenges for

professionals like Carol Harris and colleagues (p.12) who have to

communicate effectively to provide clients with the best service from start to

finish. The way forward they identified was a clinical liaison group, which

provides them with peer support for the development of professional skills to

take back to the multidisciplinary setting.

Different levels of response are needed for different situations. Although most

children with speech and language difficulties are managed very effectively

through a clinic-based service, Sarah Hulme and Barbara Sampson (p.20)recognised that a multi-agency approach was required to meet the needs of a

small number of children with additional behavioural problems. Recognition

that such service developments are necessary is often the first step forward. A

simple audit enabledJanice Dey(p.18) to put a convincing case for the

establishment of a Valve Clinic, and a simple question - how do you know? -

led Kim Talbot(p.4) into developing a multidisciplinary taste programme

which addressed communication and eating / drinking issues in one go.

Contributors to this magazine put good ideas into practice then tell others. A

clear message fromJoanna Manz(p.14) is that, although there is a lot of

good practice going on with children with special needs in mainstream

schools, the way forward is to get better at sharing it. Then, even in the

absence of hard evidence on which to base our practice, we at least haveuseable guidelines by consensus.

Moving forward by consensus is not necessarily an easy concept for speech and

language therapists to take on board when much of our work has a significant

subjective, personal element. Using an ethics approach, as exemplified by

Helen McGrane andJois Stansfield(p.8), can take some of the heat out of a

situation - even one which seems to present intractable challenges.

Speech & Language Therapy in Practice is popular with its readers because it

is practical and because the contributors, like you, are always looking for a

way forward.

...comment...Avril Nicoll

Editor

Kinnear Square

Laurencekirk

AB UL

tel/ansa/fax

email

avrilnicoll@speechmagcom

Scope for ConductiveEducationThe charity for people with cerebral palsy is con-

tinuing its work to highlight the role of conduc-

tive education in promoting independence.

Scope is hosting the 4th World Congress on

Conductive Education in London where they will

be joined by a number of international experts to

explore how disabled people can gain greaterequality in society through Conductive Education,

a learning system which enables people with neu-

rologically based movement problems to function

more independently. In addition to school and

training developments in relation to the

approach, Scope has developed a national net-

work of centres where preschool children are able

to prepare for mainstream or special primary

school through learning programmes based on

the philosophy of Conductive Education.

Scope, tel.020 7619 7200, www.scope.org.ukCerebral Palsy Helpline, tel. 0808 800 333.

Afasic moveAfasic, the UK charity representing children andyoung adults with communication impairments, is

now at 2nd Floor, 50-52 Great Sutton Street, London

EC1V 0DJ, tel. 020 7490 9410, www.afasic.org.uk

The Afasic Helpline offers help and advice on a

range of issues concerning speech and language

impairments, including therapy, assessment,

Statements and Records of Special Educational

Needs and choosing a school. It is open from

11am-2pm Monday to Friday: 0845 3 55 55 77.

Aids on loanSome of the newer communication aids are now

available for loan in Scotland from the CALL Centre.

The expensive and complex systems which needto be trialled before purchase can be recom-

mended include DynaVox 3100 and MultiLevel

Message Mate 40. These personal communication

aids can be loaned following a CALL assessment

or to school teams providing joint teacher/speech

and language therapy assessment and ongoing

collaborative working.

The Centre has placed a database of access

equipment which can be loaned on the internet.

CALL Centre, tel. 0131 651 6235,http://callcentre.education.ed.ac.uk.

Rebuilding workThe Alzheimers Society is planning to award

grants to former carers in an effort to help them

rebuild their lives.

While the Society is committed to supporting

carers throughout the whole process of caring,

from diagnosis through to bereavement and

beyond, it has not previously been able to go past

helping people who are caring on a day to day

basis. A grant from the Millennium Commission

means that people who have had their lives

altered by caring for someone with dementia will

have the opportunity to develop new or forgot-

ten skills and interests as they make the difficult

transition to a different kind of life.

Alzheimers Society, tel. 020 7306 0606, www.

alzheimers.org.uk.


6/32

education


if you want to improve assessment through

observation clientfocused work integration with other

services

Food for

thoughtA school theme of cultural foods gave Kim

TalbotandJulie Stinchcombe the opportunity

to address communication and eating, drinking

and swallowing difficulties in their students

through a taste programme.

Setting the table...I work in a special school in New Zealand that

caters for students from 5-21 years with a range

of disabilities. Many, particularly those with more

significant needs, have eating and drinking diffi-

culties and dysphagia. Frequently, I would hear

the phrases he likes it or he doesnt like itwhen I was asking about a students food prefer-

ences. How do you know? was often met with

a reason that did not make sense. I began to ques-

tion what it was that led staff to make decisions

and assumptions around mealtimes, and to what

extent communication from the child was getting

through to them, as I suspected a mismatch.

In 1999, as part of the social studies curriculum,

some classes chose a theme around cultural foods.

The occupational therapist and I saw this as an

ideal opportunity to develop a better under-

standing of the students in our care by comparing

what was believed about them with their actual

responses through providing a range of foods andobserving and recording their reactions.

Ugh! Whats that?!Our first aim was to provide a range of taste and

smell experiences. We began with cultural tastes

that fitted the theme work and followed that

with salty, sour, bitter and sweet. Morris & Klein

(1987) assert that strong tastes alert the nervous

system and sour and bitter facilitate more move-

ment. I looked at providing distinct flavours so

that, for example, responses to lemons could be

compared to responses to chocolate spread. It was

not an easy task to find foods that neatly fitted

the categories. The occupational therapist waskeen for the students to actively explore and play

with the foods, as a tactile stimulus, before eating.

A sheet was devised (figure 1) that enabled us to

record all the observations including taste, touch

and associated behaviours. We were already

aware that liked / did not like was not enough.

We carefully observed the students to ensure that

Read thisFigure 1 - Record sheet

FOOD/ EXPOSURE/ TEXTURE RESPONSETASTE AMOUNT

e.g. bread One sl ice moist To include: acceptance, rejection, turned head awvocalisations, crying, smiling, toleration, etc etc.

Possible conclusionsWell/unwell



education

their responses were recorded as accurately as

possible and we wrote as much detail as we could

(example in figure la). We began the recording

process and modelled for the staff the level of

detail needed. This was a time consuming process

but the staff were interested in the results andquickly became skilled at making quality observa-

tions. The observing and recording not only gave

us a detailed overview of the students taste

responses, but also empowered the staff to look

more closely at the students.

Whats for dinner?Our second aim was to develop the students

taste memory, including food preferences. The

literature suggests (Morris & Klein, 1987) that, by

a childs first birthday, many food preferences

have developed and that these change over time.

For the majority of the students, little was known

about their taste memory or preferences, and I

therefore decided part of my investigation need-

ed to focus on recognition and memory of food.

Information was also needed from families to

continue to build a picture of the student. A let-

ter was sent home for each student participating

(figure 2) to ascertain current food preferences

and any allergies. Where necessary, it enabled us

to discuss eating and meals with parents and allay

any fears.

Following the letter, the term (10 weeks in New

Zealand) was broken down as follows:

Week 1: Samoan foods eg. green banana, Taro,

fish.Week 2: Tongan food eg. coconut, pineapple.

Week 3: Maori food, eg. kumara, hangi.

Week 4: European food, eg. potato, mince meat.

Week 5: Indian food, eg. spices, naan, curry.

Week 6: Asian food, eg. sweet and sour, rice, stir fry.

Week 7: salty food, eg. hot chips, crisps, feta cheese.

Week 8: sour foods, eg. lemon, lime, sherbet.

Week 9: bitter foods, eg. peppermint, soya sauce.

Week 10: sweet foods, eg. chocolate spread,

honey, jams, syrup.

The food chosen may have varied within the

classes but followed the culture / taste of thisprogramme which, in turn, fitted in well with the

class curriculum. There was a great deal of flexi-

bility within the food categories depending on

availability and ease of preparation. The foods

were negotiated between the occupational

therapist, class teacher and myself week to week,

and we also rotated the task of purchasing the

food.

The sessions were generally done once weekly

with the therapists. The session plan was straight-

forward, and manageable time-wise. There was

usually one food presented per session and occa-

sionally two. The sessions lasted approximately 15

minutes and were always before either lunch or

mid-morning snack. The students were given a

face massage that was familiar to them as a pre-

cursor to food. (This was designed from the

anatomy of the face and eating and from obser-

vations of other speech and language therapists

rather than following any specific technique.) The

students were allowed to touch the food and

experiment within its texture and shape, the

occupational therapist providing some students

with specially adapted trays or bowls to facilitate

this.

The students then either took the food to their

mouths spontaneously, were verbally encouraged

to do so, or had it placed on or near their lips.

Students were never forced or cajoled into eatingand would often initiate licking their fingers. Staff

also actively tasted the food and experimented

with it themselves, although this often took some

persuading! Once the tasting was over, the stu-

dents ate their own meal. Tube fed students were

also tube fed to prevent distress from the false

promise of lunch.

igure 1a - Case example

OOD/ EXPOSURE/ TEXTURE RESPONSEASTE AMOUNT

neapple 3-4 pieces - Chewed. Appeared to smell. Opened mouth for more. No vocalisations.

wi fruit one whole fruit - Tipped head back. Smiled. Opened mouth for more. Chewed. Vocalised.

Figure 2 - Letter to parents

Date:

Name:

Dear Parent,

We are carrying out a tasting programme in[name of child]s class. [Name of child] willswallow the food if she wants to, however themain aim is to taste it. The programme aims to

provide a range of taste experiences, which candevelop a better understanding of [name ofchild]s tastes. The responses to the tastes willbe recorded and will contribute to a feedingprofile for her. The programme is aimed to befor information gathering and assessment onlyat this stage.

I would be grateful if you could complete thefollowing questionnaire and return it to school.This will give us the background knowledge forthe programme.

1) Does [name of child] have any allergies tofoods or ingredients?

2) What is [name of child]s favourite meal?

3) Any suggestions for foods or flavours?

4) Any concerns, queries or advice?

Would you like information from school to carryout the programme at home?

Thank you for your time. If you have anyquestions please do not hesitate to contact meat Base School. I will keep you updated andinformed over the term and will be happy todiscuss any findings with you.

Kim TalbotSpeech and Language Therapist

The students

were allowed to

touch the food

and experiment

within its

texture and

shape


8/32

education


Say ahhhhhOur next aim, of oral hygiene, was built into the

programme for two main reasons. The first was to

indicate to the student that the tasting session

was beginning and ending. At the beginning of

each session the student was given a face massage

and lukewarm water was used to swab the mouthto alert the students that tasting was to happen.

At the end of the session, students had the same

process with cold water; this alerted them that

the session was over and stimulated their oral cav-

ity before lunch.

The second reason was to encourage and main-

tain good oral hygiene practice within the class.

Many students needed to have their teeth

brushed for them and to have support with clean-

ing the mouth. Students who were tube fed and

only tasted the food also needed to have the oral

cavity cleaned to prevent aspiration of food from

the mouth. This helped to reduce any risk from

our intervention.

Having oral hygiene as part of the programme

was useful as the students needed individual oral

hygiene plans, which were then supported and

established in class.

Mmm, that was good...Any afters?The project had some interesting results. It was

important that we were able to review each stu-

dent individually and analyse

and summarise the findings for

class staff and parents. For some

students the findings confirmed

previous beliefs about them

and their diets; for others itshowed the student to be more

or less capable of discriminating

tastes. One student who was 21

years old was thought to have

little or no discrimination of

tastes and was known for eat-

ing chillies and onion with no

reaction; however, on closer

inspection and recording, he

was found to have distinctly dif-

ferent responses to tastes. For

example, he would have an

increase in saliva for lemons

and his eyes would water on

onions. This gave us a more

comprehensive picture of each

student and their sensory

process for taste.

Work has begun on taste

memories and food preferences, although consid-

erably more data is still needed to have a compre-

hensive picture. More work is needed on examin-

ing changes over time and consistency of respons-

es and I hope that continued focus will promote

this. Overall, though, we have a better under-

standing of our students and what they like or

dont like for lunch.

The programme has been taken on not only by

the staff but also by other speech and language

therapists in the area. They adapted the pro-

gramme and had variations on the results. Since

the initial programme it has been repeated with

new students and revisited with others. This has

enabled us to find comparisons and changes from

last year. The teachers have also taken more of anactive role now they are familiar with the format

and the recording sheets.

A team approach is encouraged at the school,

and my piece in the team puzzle here was to facil-

itate structured and precise observations of the

student as well as being an observer myself.

Asking relevant questions and offering support to

the team members in observing the students

more closely avoided actions and behaviours sim-

ply being accepted without question as part of

the students repertoire. A successful outcome

was the teams ability to further generalise obser-

vations to other situations, so that students were

now seen as communicating all day.

In addition to improved awareness of communi-

cation, I was able to assess the textures of food for

safety, and empower the staff to try foods that

they were unsure of without supervision. A bal-

ance was achieved, with class staff trying new

things without being overly adventurous; this

largely came with education around risky foods

and the students own individual needs.

This programme was tried mainly on teenage

and adult students ini-

tially and then expand-

ed to include primary

age students. It can be

used with students of

any age for fact find-ing, or for developing

and refining your

knowledge of them. It

needs to be run regu-

larly so development

and change can be

monitored, and may be

particularly useful for

gathering information

on a new client, or

when someone has a

growth spurt or is in

the process of a transi-

tion. For the students

we worked with, the

profile proved invalu-

able when they left

school and went to day

centres.

Kim Talbot is a speech and language therapistnow back in the UK at St. Elizabeths school forchildren with epilepsy. She was supported in writ-ing this article by Julie Stinchcombe, occupationaltherapist at Arohanui school, New Zealand.

ReferenceEvans Morris, S. & Dunn Klein, M. (1987) Pre-feed-

ing skills. Therapy Skill Builders, Texas.

Do I enable others to

observe, record and

respond to a clientscommunication in

everyday situations?

Do I recognise that

people need to be

familiar and confidentwith procedures

before they can use

and generalise them?

Do I spot opportunities

to integrate my goals

with those of otherprofessionals?

Reflections

Kim Talbot

A successful

outcome was the

teams ability to

further generalise

observations to

other situations, so

that students were

now seen as

communicating

all day.



further reading

HYPERNASALITYHabermann, W., Kiesler, K., Dornbusch, H.J., Friedrich, G. (2000)

Hypernasalitya rare initial symptom of a cerebellar astrocytoma. Int J

Pediatr Otorhinolaryngol55 (3) 207-10.

Nasality is a disorder due to nasal resonance, which may be induced by a variety

of etiologies. Transitional hypernasality is frequently seen in children after ade-

noidectomy. The alleged post-surgical hypernasality in the case presented was

shown to be related to the late detection of an astrocytoma of the cerebellum

and the brain stem in a 6-year-old boy. This case was characterized by increased

hypernasality which failed speech therapy. A developing one-sided vocal fold

palsy in combination with an ipsilateral soft-palate palsy indicated further

investigation. Computerized tomography (CT) and magnetic resonance imaging

(MRI) revealed a brain stem-tumor with a maximum size of 6 cm involving parts

of the cerebellum. These findings demonstrated the need for a strict follow-up,

even after adenoidectomy, in the presence of hypernasality for identifying con-

current etiologies as well as cases suitable for speech therapy.

FURTHERREADING

This regular feature

aims to provideinformation aboutarticles in other

journals which may

be of interest to

readers The Editor

has selected thesesummaries from a

Speech & Language

Database compiled

by Biomedical

Research IndexingEvery article in

over thirty journalsis abstracted for

this database

supplemented by amonthly 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 YO PP

tel fax

Annual rates are

CDs (for Windows

):

Institution Individual

Printed version:

Institution

Individual Cheques are

payable to

Biomedical

Research Indexing

PSYCHIATRYBeitchman, J.H., Wilson, B., Johnson, C.J.,

Atkinson, L., Young, A., Adlaf, E., Escobar,

M., Douglas, L. (2001) Fourteen-year fol-

low-up of speech/language-impaired and

control children: psychiatric outcome.J Am

Acad Child Adolesc Psychiatry40 (1) 75-82.OBJECTIVE: To examine the association

between early childhood speech and language

disorders and young adult psychiatric disorders.

METHOD: In a longitudinal community study

conducted in the Ottawa-Carleton region of

Ontario, Canada, interviewers administered

structured psychiatric interviews to age 19 par-

ticipants who were originally identified as

speech-impaired only, language-impaired, or

nonimpaired at age 5. The first stage of the

study took place in 1982 when participants

were 5 years old, and the latest stage of the

study took place between 1995 and 1997 when

participants had a mean age of 19 years. This

report examines the association between early

childhood speech/language status and young

adult psychiatric outcome. RESULTS: Children

with early language impairment had significantly

higher rates of anxiety disorder in young adult-

hood compared with nonimpaired children. The

majority of participants with anxiety disorders

had a diagnosis of social phobia. Trends were

found toward associations between language

impairment and overall and antisocial personality

disorder rates. Males from the language-

impaired group had significantly higher rates of

antisocial personality disorder compared with

males from the control group. Age of onset and

comorbidity did not differ by speech/languagestatus. The majority of participants with a disorderhad

more than one. CONCLUSIONS: Results support

the association between early childhood speech

and language functioning and young adult psy-

chiatric disorder over a 14-year period. This

association underscores the importance of

effective and early interventions.

STROKEvon Koch, L., Holmqvist, L.W., Wottrich, A.W., Tham, K., de Pedro-Cuesta,J. (2000) Rehabilitation at home after stroke: a descriptive study of an

individualized intervention. Clin Rehabil14 (6) 574-83.

OBJECTIVE: To describe the content of a programme involving early hospital dis-

charge and continued rehabilitation at home after stroke. DESIGN: Quantitative

and qualitative descriptive study of an intervention within the context of a ran-

domised controlled trial. SETTING: Huddinge University Hospital, Stockholm,

Sweden. SUBJECTS: Forty-one patients, moderately impaired after stroke, rehabil-

itated by a team of six occupational, physical, and speech and language therapists.

RESULTS: The average duration of the programme was 14 weeks, the mean

number of home visits 12, and the median total time consumption 23 hours and

20 minutes, of which face-to-face contact with the patient constituted 54%. The

rehabilitation process was pursued by the patient and the therapist in partnership.

Supported by the team the therapists incorporated a wider domain of activities

than usual and left a considerable amount of the training to self-directed activities.

The most common foci of the visits were speech and communication, ADL activities

and ambulation. When planning the intervention the therapists paid attention

to discrepancies between the desires and abilities of the patient on the one

hand and environmental demands on the other - discrepancies detected

through observation of the patient in the home environment. CONCLUSIONS:

The home environment offers therapists working in a team opportunities to

adopt a behaviour that enables patients with moderate neurological impairments

after stroke to resume responsibility and influence over their rehabilitation

process, resulting in an individualized rehabilitation programme that varies in

duration, content and frequency of home visits.

STAMMERINGGinsberg, A.P. (2000) Shame, self-con-

sciousness, and locus of control in people

who stutter.J Genet Psychol161 (4) 389-99.

Stuttering is a multidimensional disorder,

including psychological as well as physiologicalelements. This investigation of the value of 3

psychological constructs (shame, self-conscious-

ness, and locus of control) in the prediction of 3

self-reported behavioral dimensions of stutter-

ing (struggle, avoidance, and expectancy)

revealed shame and self-consciousness to be

significant psychological predictors of the

selected dimensions of stuttering, whereas

locus of control was found not to be. Certain

demographic elements, including affiliations

with others who stutter, were also determined

to be predictive of the stuttering dimensions.

The present findings and their implications for

theory, research, and practice are discussed.

INTERACTIONPennington, L., McConachie, H. (2001) Predicting patterns of interaction

between children with cerebral palsy and their mothers. Dev Med Child

Neurol43 (2) 83-90.

Children with cerebral palsy (CP) have often been described as passive communi-

cators. Their familiar conversation partners tend to direct and control interaction.

Such conversation patterns may have various precursors: childrens motor impair-ment, their intelligibility difficulties, and/or their level of cognitive development.

To test the comparative influence of these factors, measures of motor function,

speech, communication, cognitive and language skills were applied in 40 chil-

dren (18 males, 22 females) with CP who were aged from 2 years 8 months to

10 years. These variables were correlated with measures relating to interaction

patterns to investigate whether individual features predicted communication

style. In this group, poor speech intelligibility was the main predictor of restric-

tive communication patterns, such as fewer child-initiated conversation

exchanges, more simple child communicative acts such as yes/no answers and

acknowledgements of the other partners messages. Results support the provision

of therapy to increase childrens intelligibility, whether spoken or augmented, such

as the introduction of communication aids and training programmes for parents.


10/32

ethics


Strength incompromise

Mark (26) has severe dysarthria following a head injury. He accepts AAC as a short-term measure,

but is keen to use technology he has seen promoted in the media to improve his oral skills.

What happens if speech and language therapists dont feel this would help? Helen McGrane and

Jois Stansfieldseek a way forward using an ethics approach.

thics in practice is rarely easy. Speech

and language therapists make decisions

daily regarding who is to be offered

therapy (prioritisation), and the most

suitable intervention for clients. The

Royal College of Speech and Language Therapists

provides a code of ethics to guide decision-making(RCSLT, 1996), acknowledging that ethical principles

must be applied in considering the various cir-

cumstances of each individual case. This code of

ethics encompasses the generally acknowledged

principles of ethics which are considered to be the

foundational points in health care (Beauchamp,

1994). These principles are

1. beneficence (do good)

2. non-maleficence (do no harm)

3. respect for autonomy

4. justice.

Seedhouses ethical grid (figure 1) was devel-

oped to facilitate decision making with explicit

reference to aspects of moral reasoning in health

care (Seedhouse & Lovett, 1992). This framework

enables one to justify decisions and actions in

moral terms. The grid consists of detachable

boxes in a framework of four different coloured

layers representing:

the principles behind health work (Blue)

the duties one believes one has (Red)

the general nature of the outcome to be

achieved (Green)

the pertinent practical features (Black).

Acknowledging that each circumstance is differ-

ent, consideration of every box is not essential;

however, it is important that the situation in ques-

tion is considered in the light of each coloured

layer (Seedhouse & Lovett, 1992).

EHere, we consider the issues involved in the case

of Mark, a 26 year old man with a head injury asa result of a road traffic accident. The Seedhouse

ethical grid (references italicised in the following

text) was the model used in the decision-making

process on the best intervention for him.

On referral, Mark was three and a half years

post-trauma. It may therefore be assumed that

Mark is near the end of any spontaneous recovery

period and must use his present abilities and

adapt to his impairments to facilitate his commu-

nication skills. Mark is wheelchair bound although

he reports some slow recovery of his lower limbs.

He was observed to have a stable sitting balance

and reasonable head control with slow neck

movement. He doesnt report any auditory or

visual difficulties. He has a high level of compre-

hension and uses complex linguistic structures

with his Lightwriter, with no apparent dysphasia.

Marks full medical notes were not available;

however, certain tentative hypotheses may be

offered concerning his oral abilities. An oro-facial

examination report on his first visit to the clinic

diagnosed severe dysarthria. Mark displayed flac-

cid muscle tone in his neck, head and facial

region. He also displayed right brachiofacial

weakness and apraxia of tongue, lip and left limb

movement, suggesting some higher cortical dys-

function (Lindsay & Bone, 1997).

Mark requires excessive effort to phonate, which

- along with slow, low, monopitched vocalisations

and the lack of volume variation - suggests bilat-

eral pseudobulbar (spastic) dysphonia (Greene &

Mathieson, 1989). His inability to co-ordinate

appropriate closures in the larynx, oral cavity

........... and the out-of-phase quality of breathing

and phonation (Greene & Mathieson, 1989; 252)

also fits with this tentative diagnosis.These observations are clearly subjective and

ideally would have been supported by objective

assessment and confirmation of Marks exact med-

ical status. They do, however, serve to illustrate

the severity of Marks condition which was a fac-

tor considered in the decision-making process

(degree of certainty of evidence on which actionis taken - Black).

Issues which arose before Mark was accepted as

a client in the clinic described below have a bear-

ing on the contract offered to him.

Mark lives with his two parents and four sisters

(two older and two younger). He was a mature

student prior to the accident and now continues

his education with the assistance of a sister who

accompanies him to college to help the recording

of relevant lecture notes.

Mark and his family had some disputes with

their local speech and language therapy service.

The family did not accept the prognosis for Mark

as a total communicator, that is, with some single

vocalisations but mainly an alternative and aug-

mentative communication (AAC) user (wishes ofothers - Black). Mark and his family were adamantthat he could speak (single words) at home but he

was unable to demonstrate this in the clinical

environment (disputed facts - Black). His familyrefused to accept concurring speech and language

therapists diagnoses and sought numerous subse-

if you find evidencebased

practice is not accepted want partnership with

clients face demands following

media stories

Read this

see

www.

speech

mag.

com

inside

front

cover



ethics

quent opinions to find some therapy which would

meet Marks needs as they saw them.

Immediately prior to referral, the only support

Mark was receiving for communication was from

a voluntary organisation and his family. His moth-

er and sister implemented a daily programme of

muscular exercises and ProprioceptiveNeuromuscular Facilitation (PNF) techniques

taught at this organisation. During this time

Marks father saw an article in the

local newspaper claiming new tech-

nology had been developed which

would help cure speech difficulties

(Hendry, 1998) (disputed facts -Black). As a result, he sought out aclinic which was able to provide this

facility - the electropalatograph (EPG).

This instrument is designed to

record the location and timing of

tongue contacts with the hard

palate during continuous speech.

EPG may be useful in the treatment

of dysarthria (Main et al, 1997); how-

ever, when considering EPG as a pos-

sible therapeutic intervention, it is necessary to

ensure that the clients speech problem is essen-

tially one of lingual placement or dynamics. Other

factors such as velopharyngeal incompetence will

affect the overall prognosis for treatment out-

come (Hardcastle et al, 1991). Although Mark had

lingual placement difficulties, he also has difficul-

ty initiating and maintaining volitional phona-

tion, along with velopharyngeal incompetence.

This was noted in the decision-making process

(degree of certainty of evidence on which action

is taken - Black).

Marks suitability for EPG was assessed by the

speech and language therapist at the specialist

clinic. The resulting report stated that, as Mark

had very severe dysarthria, he did not demon-

strate adequate range of movement or tongue

control for EPG to benefit him. The report sug-

gested the most appropriate computer pro-gramme to assist in achieving longer and more

systematic use of voice was SpeechViewer (domost positive good - Red). Markrefused the offer of

SpeechViewer on two occasions,

asserting that he should be

offered EPG (respect autonomy -Blue). After much discussion heagreed to try SpeechViewer with

a view to improving his oral

functioning. It was agreed to

reconsider this after five weeks

of individual intervention, which

would also allow for any under-

performance in the initial assess-

ment (disputed facts - Black).Marks motivation to succeed

was extremely high. He worked hard to improve

the strength and prolongation of his phonation

using SpeechViewer. Tongue and lip exercises were

attempted to improve strength and endurance

(Hibberd & Jinks, 1998) but to no avail. Therapy

also aimed to promote volitional vocalisation and

tongue movement. At home Marks family contin-

ued PNF and oral exercises. Mark also continued to

receive support from the voluntary organisation.

Although there was some improvement in

Marks length of phonation after the therapy

block, he continued to display inconsistency in his

ability to initiate and prolong phonation. The

decision regarding EPG suitability was based on

research evidence and clinical knowledge on real-

istic outcomes for using this technique, otherwise

the ethics of do most positive goodand most ben-eficial outcome (Green) for Mark would have

been disregarded. It was explained to Mark thatEPG was still not considered to be beneficial for

him at this time. Counselling skills were used

offering empathy and advice while acknowledg-

ing Marks feelings of disappointment. The clinic

offered him continuation of speech and language

therapy using SpeechViewer for a mutually

agreed pre-determined period (most beneficialgood - Green). Mark was understandably disap-pointed but agreed to continue with

SpeechViewer, being the only speech and lan-

guage therapy input he could have.

During the intervention period two further

issues arose:-

1.Should Mark be referred for further therapy at

the end of the current contracted therapy block

and, if so, to whom? The clinic he was attending

is a service which only takes clients on a short-

term block basis. Marks previous community clin-

ic was reluctant to maintain him on its books,

partly due to previous disputes, but mainly

because he was considered to be on a plateau and

did not fit their criteria for further intervention.

However, Mark needed to be recorded some-

where in the event of the emergence of suitable

new technology (resources available - Black).2. A meeting between Mark, his speech and lan-

guage therapist and an AAC specialist strongly

advocated the desirability of Mark joining an

AAC group with members of his own age (tell the

when consideringEPG as a possibletherapeuticintervention, it isnecessary to ensurethat the clientsspeech problem isessentially one of

lingual placementor dynamics.

Figure 1 Ethical Grid


12/32

ethics


truth - Redand create autonomy - Blue).This was available for a five week block in

the same clinic and intended focusing on

areas deemed useful for Mark, for exam-

ple, telephone usage as Marks mother

currently takes his calls. At this stageMark declined to attend as he had done

on previous occasions (respect for auton-omy - Blue) (resources available - Black).

ReconciliationThe most positive outcome of the situa-

tion was seen as one which would recon-

cile the mismatch between Marks expec-

tations and speech and language therapy

management. To achieve this reconcilia-

tion, Mark had to be open to advice and

trust, and speech and language therapy

management had to incorporate ethical

considerations explicitly. Figure 2 high-

lights the grid boxes which were used in the deci-

sion-making process and which were thought to

create the highest degree of rectitude given

Marks circumstances.

These influenced the outcome in the following

ways:

1. The levels of practicality (Black Boxes)

The clinic in question had the technological

resources which Mark wished to access. However,

Mark was not deemed a suitable candidate

because his severe neurological impairment didnt

allow him meet the requirements of the EPG.

Mistrust had developed between family members

and speech and language therapy managementbased on disagreement with previous

speech and language therapy diagnoses.

Also as a result of newspaper and journal

articles the family felt that the speech and

language therapy service was holding out

on them. The situation was discussed in

depth with the family and Mark was given

the opportunity to display his oral func-

tioning. This also reflected the level ofduties (Red) speech and language therapymanagement felt towards Mark and his

family. As a result, the levels of trust

between the family with the speech and

language therapy clinic grew, encouraging

a more discursive open relationship,

although this never became fully comfort-

able.

2. The general nature of the outcome to be

achieved (Green Boxes)

The main focus at this level of consequences was

the most beneficial outcome for Mark. Initiallythere was a mismatch between Marks and his

parents perceptions of what this should be (EPG

and speech) and the view of the speech and lan-

guage therapy clinicians (AAC). The dilemma

arose as to whether to offer a management pack-

age which the speech and language therapists

believed could not benefit Mark or to risk Mark

abandoning the clinic situation again. The use of

counselling skills in acknowledging Marks and his

familys emotional responses to speech and lan-

guage therapy recommendations and offering

discursive explanations enabled some resolution.

While the most beneficial outcome for thepatientis acknowledged, the most beneficial out-come for oneself, that is, the individual speechand language therapist, must also be noted. At

times, personal outcomes which were going to be

satisfactory for the speech and language therapist

were in direct opposition to those which were

going to be satisfactory for Mark and his family.

This was particularly the case when Mark was dif-

ficult to place because of differing perceptions ofneed, levels of practicality and pre-

vious confrontations between the

family and the speech and lan-

guage therapy service. It is impera-

tive that speech and language ther-

apists analyse their personal contri-

bution in the light of the justice

principle (Beauchamp, 1994) when

prioritising caseloads, and be aware

of the potential for subjective views

to be a factor - however subtle - in

influencing decision-making.

3. The level of duties (Red

Boxes)

It was felt that the importance of

telling the truth could not be over-emphasised and was felt to complement do most

positive good for Mark. While Mark needed tounderstand facts about his impairments and prog-

nosis, hope could not be taken away from him. It

was reiterated that regaining any speech would

be at best a very long-term process for him. Mark

was advised that AAC would enable him to com-

municate his needs while he worked on his voice,

and the benefits of attending an AAC group were

discussed. This level of duties also involvedonward referral, ensuring Mark didnt just disap-

pear from the system. The speech and language

therapy service manager addressed and

resolved this issue to the satisfaction of

both Mark and the service.

4. The principles behind health work

(Blue Boxes)This is said to be the most important level

in the grid as it indicates the basic inspira-

tion of health care (Seedhouse & Lovett,

1992). One aim of speech and language

therapy management was to enable Mark

to have a heightened control over his

own life (create autonomy). This was feltto best be promoted within the realm of

an AAC age-appropriate group. Group

activities aimed to encourage active par-

ticipation in the communication process

and also focused on telephone skills,

therefore fostering more independence

in Marks life. Balanced against this was

the principle of respecting autonomy especiallywhen Mark refused the use of SpeechViewer on

two occasions and had declined a place within an

AAC group on previous occasions.

Two issues which impacted on Marks expecta-

tions of the speech and language therapy service

remain unresolved:

1. There is a gap within NHS provision for the

chronic needs of young head injured individuals

as their circumstances change over their lifetime.

This gap is somewhat filled by voluntary organisa-

tions; however, this appears to be insufficient for

many clients such as Mark.

2. There is a tendency by the media to overstate

the benefits of new approaches to disability. Thebalance between promoting new technology and

avoiding the suggestion of miracle cures is a diffi-

cult one to achieve.

It was felt that the successful outcome of the

intervention would be demonstrated if Mark

agreed to attend an AAC group and further block

intervention could be agreed, thus reconciling the

mismatch between the clients expectations and

speech and language therapy management.

Happily, this was the final outcome. Further thera-

py was eventually agreed with Mark, encompassing

work with SpeechViewer and AAC techniques. Gillis

(1996) advises that the process of family adjustment

to a family member with Traumatic Brain Injury

resulting in acceptance is an ongoing process. She

states that denial is a coping mechanism which fam-

ilies use to get them through a situation. Clinicians

must work with families to find a balance between

hope and reality (Gillis,1996;297). Using the guid-

ance of Seedhouse & Lovetts (1992) ethical grid the

positive outcome of this case suggests that this

intervention has gone some way in achieving this.

Helen McGrane is a PhD student and JoisStansfield is Head of the Department of Speechand Language Sciences, Queen MargaretUniversity College, Edinburgh. Both are speechand language therapists. Readers are also

referred to a previous ethics article Whose right?

Markneeded tobe recordedsomewherein the eventof theemergenceof suitablenew

technology

Figure 2 Grid boxes used in decision-making process



ethics

- Whos right? by Jois Stansfield and ChristineHobden which appeared in the Winter 99 issue ofSpeech & Language Therapy in Practice.

ReferencesBeauchamp, T. (1994) Four principles approach. InGillon, R. (Ed) Principles of health care ethics. John

Wiley & Sons Ltd.

Gillis, R. (1996) Traumatic brain injury rehabilita-

tion for speech-language pathologists.

Butterworth-Heinemann. USA.

Greene, M. & Mathieson, L. (1989) The voice and its

disorders. 5th edition. Whurr Publishers Ltd. London.

Hardcastle, W., Gibbon, F. & Jones, W. (1991)

Visual display of tongue-palate contact: elec-

tropalatography in the assessment and remedia-

tion of speech disorders. British Journal ofDisorders of Communication 26; 41-74.Hendry, S. (1998) Hi-tech palate makes it good to

talk. In Evening News paper.

Hibberd, J. & Jinks, C. (1998) Muscle specificity:

strength, endurance and functional improvement.

Speech & Language Therapy in Practice Autumn.Lindsay, K. & Bone, I. (1997) Neurology and neu-

rosurgery illustrated. Churchill Livingstone. UK.

Main, A., Kelly, S. & Manley, G. (1997) Teaching

the tongue and looking at listening. Bulletin ofthe Royal College of Speech & LanguageTherapists November, 8-9.RCSLT (1996) Communicating Quality 2. Royal

College of Speech & Language Therapists, London.

Seedhouse, D. & Lovett, L. (1992) Practical medical

ethics. John Wiley & Sons Ltd.

Resources Lightwriter - available from Toby Churchill, tel.

01223 576117, www.toby-churchill.com.

SpeechViewer - UK suppliers include Don

Johnston Special Needs, tel. 01925 241642.

Electropalatography - the Reading EPG 3 system is

suppliedby Millgrant Wells Ltd, tel. 01788 561185.

A new windows version of EPG is available from

Laryngograph Ltd., tel: 0207 387 7793 or from EPG

Enterprises, Research and Innovation Office,

Queen Margaret University College, Edinburgh. Communication aidfundingA new charity, Speakeasier, is providing commu-

nication aids for people with multiple sclerosis

who cannot access other funding.

Steve Brisk, who has had MS for 20 years, was

shocked to discover that while people who are

unable to walk can have a wheelchair on the NHS,

those who lose the ability to talk cannot necessarily

get a communication aid. He persuaded Huw

Evans of financial sector software specialists

Marlborough Stirling to chair the charity, and

fund its first 2500 speech synthesiser.

It is estimated there are around 85,000 people in

the UK with MS. Around five per cent of them

experience acute communication difficulties.

Speakeasier, PO Box 410, Cheltenham GL52 9GH, tel.

01242 674006. (Donations by cheque are welcome.)

Do I work with clients and

families to establish trust and

resolve mismatches of

expectation?

Am I able to continue with aclient where there is a history

of disagreement?

Does our service keep a record

of clients who may benefit

from future developments intechnology?

Reflections

news extra...news extra...news extra..

The Danish instigator of Johansen Sound Therapy iscoming to the UK to train others in the approach.

The four day training with Dr Kjeld Johansen

includes background theory on the effect of sen-

sory deprivation on learning (including dyslexia),

and topics such as auditory sensation and per-

ception, auditory acuity, and auditory laterality.

Participants learn to use audiometry and dichotic

listening as diagnostic tools.

Speech and language therapist Camilla Leslie will

cover the particular application of the technique

to speech and language therapy. She believes

that children with receptive, expressive and written

language disorders can benefit, as can adoles-

cents and adults with language and/or literacy

difficulties. The approach aims to enhance auditoryprocessing skills so that the client becomes able

to benefit more from the support they are

already receiving and requires less input overall.

Johansen Sound Therapy involves a child in lis-

tening to specially-recorded, customised tapes

for 10 minutes per day, for up to 9 months.

9-12 October, 2001, Edinburgh - details fromCamilla Leslie, tel. 0131 337 5427.

Children in Scotland with severe, low-incidence

disorders of speech and language no longer

have to travel to England for residential care.

Donaldsons College in Edinburgh, traditionally

a provider of residential and day placements forchildren who are profoundly deaf, has opened

The Speech and Language Resource, funded by

the Scottish Executive. In the past, many of the

children who are attending would have been

sent to specialist schools in England as there was

no national provision in Scotland specifically tai-

lored to their needs.

Training is high on the agenda, and Donaldsons

has set up a training partnership with Afasic and

I CAN, the two national charities working for

children with speech and language impairments.

The training - typically one day courses - is open

to professionals and parents. Future events

include an Afasic training week from Mon 5 - Fri

9 November 2001 (functional language; selectivemutism; dyspraxia; secondary aged pupils; bilin-

gual issues.) The I CAN courses are: 30 October,

2001 - Intensive interaction; 1 February, 2002 -

multidisciplinary approach with nursery children;

15 March, 2002 - Communication in the classroom;

12 September, 2002 - pragmatic impairment.

Details from Marion Fletcher, Head of Speechand Language Unit, Donaldsons College, tel.0131 337 9911,e-mail: [email protected].

New independent centres for rehabilitation of

people with brain injury plan to work alongside

local and regional NHS services.

Priory Rehabilitation Services now have a five

bedded unit at their Unstead Park neuro-rehabil-

itation complex in Surrey for people with chal-

lenging behaviour following brain injury who

would not be suitably placed on an acute ward.

The newly built Priory Rehabilitation Centre

Peterlee in County Durham specialises in intensive

cognitive rehabilitation after brain injury, and

provides the only dedicated Persistent Vegetative

State service in the North of England.

www.prioryhealthcare.co.uk

In a separate development, The Royal Star andGarter Home for disabled ex-service men and

women is to diversify into mental health care

and expand provision in England beyond London

and the south east. Plans include building a new

40 bed dementia care home in partnership with

another specialist care provider and funding res-

idential and nursing placements.

www.starandgarter.org.

Independent provider

developments

National centre for Scotland

Sound therapy

Training placesneededA college which provides disabled adults with

residential training for work is concerned that

demand for places is outstripping supply.

Fifty four per cent of the students at Queen

Elizabeths Foundation Training College last year

gained employment immediately after their

course which the college compares favourably

with the able bodied rate of 40 per cent. With a

two year waiting list for places, a spokesman

said, The Training College is particularly con-

cerned about the lack of facilities and therefore

the lengthy waiting times as they are aware that

many people lose the impetus to remain inde-

pendent after such a long period of time and

may never embark upon a training course and

consequently never re-enter employment.


14/32

in my experience


he delivery of head and neck cancer ser-

vices over recent years has been restruc-

tured as recommended by Calman & Hine

(1994) and the NHS Cancer Plan (2000),

with surgery, radiotherapy and joint clinics

centralised, and follow-up rehabilitation including

speech and language therapy and nursing care

organised locally. Similar patterns of service deliv-

ery are offered to other patient groups; for exam-

ple, those with cleft palate. Prior to this, acute

work was spread more widely geographically,

being carried out at local district hospitals, andmore therapists, sometimes with less experience,

saw fewer patients all the way through from the

time of diagnosis on a local service basis. The

change has benefited patients, as staff providing

the specialist services have a wealth of experience

and expertise. However, patients are now often

travelling significant distances and across differ-

ent Trusts for their care. Speech and language

therapy services have been challenged to produce

a cohesive and effective service with clear, well

coordinated delivery across these different sites.

In response to this we have found that a ClinicalLiaison Group has been pivotal in us being able to

develop a better speech and language therapy ser-vice. This concept could have applications to other

groups of therapists who share patients, or for

groups of therapists within the same clinical field.

Cohesive serviceThe need to have good communication between

professionals when patients are travelling across

different Trusts and Counties for their care is para-

mount (Edwards, 1997). We were aware that com-

munication was not always as effective as it should

have been because the people involved werent

aware of the different circumstances in different

places, so expectations were sometimes unrealistic.

In establishing the group three years ago, our first

and foremost aim was to ensure a more cohesive

service and to address the communication issues

central to this (figure 1). Clearer care pathways

needed to be developed, such as for equity of

access to surgical voice restoration management.

The clinical liaison group has achieved far more

than these original aims, and now encompasses a

wider remit that includes protocol development

across Trusts, training in a specialised area, peer

group supervision, and offers clinical perspectives

to management strategy development. It has led

to a strong head and neck speech and language

therapy team that is not fragmented by distance.

The core difference between a special interest

group and our clinical liaison group is that our

if you want to coordinate services

across different sites peer support for case

management to build a strong team

Read this

meetings are primarily based on discussion of patients

on our mutual caseload. In contrast, a special interest

group usually has presentations about a clinical topic

to a larger group and might include discussion of

patients not known to anyone else attending.

The clinical liaison group consists of eight speech and

language therapist specialists in head and neck cancer

from five Trusts who meet termly. In the interimthere

are reports and telephone conversations about the

patients, but the gains of meeting in person have

been significant. We have also invited the Head and

Neck Liaison Nurse to join the group as she is oftenable to contribute a valuable overview of the

patients. As the number of health professionals

involved in the team caring for head and neck cancer

patients is large, we could potentially evolve to be a

large multidisciplinary group. However, we aim to

keep it small and with a predominantly speech and

language therapy membership so we can remain

focused on our own profession and our case man-

agement. Were we to increase the numbers or dis-

ciplines of the clinical liaison group, or move the

focus from discussion of individuals, we would lose

the essence of what makes the group work. We

are able to further and develop our own profes-

sional skills to take back to our own multidiscipli-nary setting with confidence, as we have peer sup-

port for what we as individuals are doing.

Reflective practiceWe meet for two and a half hours once a term. On

our agenda each speech and language therapist is

given time to discuss challenging or complex

patients. Problem sharing and reflective practice

approaches are used. Discussions might include

therapy techniques, communication issues that

arose, or problems encountered by the patient

from treatments, disease recurrence or

family/work situations. We have all shared in and

learned from these discussions, even when the

patient is not directly known to all present.

The latter part of the meeting allows time for

related clinical issues and has included:

development of shared protocols such as

Surgical Voice Restoration procedures

compiling a useful contacts directory (numbers

for radiotherapists, dietitians and so on)

feedback from courses and special interest

groups attended

literature reviews

management issues such as staffing changes

within the multidisciplinary team, and implications

for us as speech and language therapists

funding surgical voice restoration equipment

and communication aids

TCentralisation of the

most specialised acute

health services benefits

clients but presents

communication

challenges for all staff.

Carol Harris and

colleagues addressed this

through a clinical liaison

group - and found some

unexpected further

benefits. Although they

focus on head and neck

cancer, the concept is as

relevant to other areas

of speech and language

therapy practice.

Ahead-and-nof th

Rapid Access

andCombined Cllinics

RadiotherapySurgery

Speech and

language therapyOxford

Local speech and

language therapy teams

ClinicalLiaison Group

Oxfordshire Wiltshire

Buckinghamshire Berkshire

Figure 1 Service structure and interfaces around the clinical liaison group


15/32

discussion of other service developments within

the head and neck service.

The interface with service managers is developing

all the time. As specialist clinicans, we contribute

to management issues, and can focus on logistical

management from a clinical, grass roots perspective.

It is useful to have one response from across several

locations which we can then feed back to higher

levels of management such as the Four Counties

Cancer Network.

Communication is now much more effective

because we all have a better understanding of each

speech and language therapy setting and their

constraints and possibilities, so can quickly

troubleshoot and take opportunities as they arise

there has been an opportunity to develop

protocols and pathways that work, which are

firmly based on patient and clinical needs

as a team we know each other beyond a name

at the end of the phone, and have developed a

supportive forum for peer supervision in a

specialist area of work.

Allocating specific time to discuss particular cases

with a peer group is something many therapists

comment would be helpful. This includes thosewith a lot of experience as well as those newer to

an area of work. From our experience, we advo-

cate that formally establishing a clinical liaison

group is time well spent.

ReferencesCalman, K. & Hine, D. (1994) A Policy Framework

for Commissioning Cancer Services. London:

Department of Health.

Department of Health (2000) The NHS Cancer Plan.

Edwards, D. (1997) Face to Face. The Kings Fund.

You can contact The Head and Neck ClinicalLiaison Group c/o Carol Harris, Speech and

Language Therapy, Radcliffe Infirmary,Woodstock Road, Oxford 0X2 6HE.

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2001 13

in my experience

Do I communicate as effectively as

I should with speech and language

therapists in neighbouring areas?

Do I have sufficient peer support to

bolster my contribution to the

multidisciplinary team?

Are our care pathways clear and

firmly based on clients needs?

Reflections

eck

field

A mind odysseyThere is a need for open discussion by both relatives

and hospital staff about policy for resuscitating

patients with severe dementia; more than half of

mothers with postnatal depression have difficulties

interacting with their babies; and drawings of

school-aged children give clues to their mental state.

These issues were among the papers at a confer-

ence to mark the beginning of 2001 - a mind

odyssey, a year-long celebration of the arts, psychi-

atry and the mind organised by the Royal College of

Psychiatrists. Other events included the launch of

four comic books for 4-7 year olds which address

what it is like to be different. They have been

designed to provide a framework for people who

wish to support children to develop their strengths

and confidence, and to help other young people

understand what it is like to be different.

Reading Lights (set of 4 books and activity

poster) costs 12.

The Royal College of Psychiatrists, tel. 020 7235

2351, www.rcpsych.ac.uk

Strategy toraise profileOccupational therapists have been

successful in their aim to raise the

profile of the profession over the

past year.

The annual report of the British

Association of Occupational

Therapists describes how they

have targeted politicians, health

professionals, key decision-makers,

users, carers and the general

public to widen understanding

of how occupational therapists

can improve quality of life and

to ensure the concerns of staff

are heard and acted upon.

Methods include a parliamentary

lobbying strategy, a national

petition drive, developingcontacts with journalists, pro-

moting occupational therapy as

a career, expanding the website,

and producing a Publicity

Activity Book as a resource for

members organising events for

Occupational Therapy Day.

The College has also begun a

series of seminars aimed at

senior practitioners, occupational

therapy leaders and decision

makers with a focus on interme-

diate care.

The seminars involve participants

in addressing key national policy

issues and the opportunities and

challenges they present to the

profession.

BAOT, tel. 020 7357 6480,www.cot.co.uk

Story timeReaders interested in using storytelling /

narrative in their work can contact the

Society for Storytelling for information and

to share ideas.

Started in 1993, the Society has specific

aims to promote, provide information

about and educate the public in the art of

oral storytelling, and produces a magazine,

Storylines. Facts and Fiction is another sto-

rytelling publication. Speech and language

therapist Sue Doncaster, a director of the

Society, is keen to set up a Special Interest

Group.

Society for Storytelling, PO Box 2344,Readin

Speech & Language Therapy in Practice, Autumn 2001

Documents

Transcript of Speech & Language Therapy in Practice, Autumn 2001