Speech & Language Therapy in Practice, Spring 2002

7/28/2019 Speech & Language Therapy in Practice, Spring 2002

1/32

Collaborationworks!Early Years Centresunder scrutiny

EthicsDilemmasand decisions

Changingpractice

A journey

withpre-terminfants

Welcome MatsTraining themultidisciplinary way

In my experienceA tongue-in-cheek view ofresearch

How I managedeafness in childrenand young people

My top resourcesUndergraduate education

InclusionSwitching on toShakespeare

E N T H U S I A S M I S I N F E C T I O U S !

ISSN 136

SPRING

http://wwwspeechmagcom


2/32

WinALPHASMARTDo you see clients who have difficulty

with structuring and organising theirwork? Who struggle to express their ideaseasily? Or perhaps who have trouble with

vocabulary, spelling or handwriting?Help is at hand for a lucky reader, as Speech& Language Therapy in Practice has a

copy of the AlphaSmart 3000 computer-companion pre-loaded with the Co:Writer SmartApplet (shortlisted forthe BETT 2002 Special Educational Needs award) to give away in a FREE

draw, courtesy of AlphaSmart.To enter, simply e-mail your name and address marked Speech &Language Therapy in Practice - AlphaSmart offer to

[email protected]. The closing date for receipt of entries is25th April and the winner will be notified by 30th April.The AlphaSmart 3000 computer-companion enables people to type,

edit and electronically store text (for example, for assignments, e-mailsor notes), while at the same time developing keyboard skills, withouthaving to be at a computer. Text and information can then be easily

transferred to a PC or Mac or straight to a printer. It is being used inschools for all age ranges and ability groups and for children with spe-cial needs, but would also be suitable for adult clients who have access

to a computer.

The AlphaSmart has been designed to run SmartApplets, mini applicationsthat extend its functionality to aid literacy and learning. The Co:Writer

SmartApplet was developed by Don Johnston to help people focus on thecontent of their writing. Co:Writer word prediction technology allowsthem to construct sentences which are grammatically correct using topic-

specific words.The AlphaSmart 3000 (www.alphasmart.co.uk) is available for around190 per unit from a variety of sources including TAG Learning

(www.taglearning.com). An AlphaSmart pre-loaded with Co:Writer canbe purchased for around 230 from Don Johnston and copies of Co:Writercan be purchased individually for 89 (www.donjohnston.com/uk).

Spring 02 speechmag

New IndexIn need of inspiration? Doing aliterature review? Or justwanting to find that fantasticarticle you read recently?Searching Speech & Language

Therapy in Practicejust goteasier, with an index to backcopies now available on the

speechmagwebsite!

Reprinted articles to complementthe Spring 2002 issue of Speech& Language Therapy in Practice:

Mother and child - building thebonds beyond speech. (Nov/Dec1994, 4 (1))**Sue Sims used a BT Bursary award to conducta ground breaking study of mother-childinteraction in preverbal infants. Her pilotinvestigation looks at the effects of recurrentupper respiratory tract infection on the vitalearly stages of communication development.

Talking Mats: Speech and languageresearch in practice. (Autumn 1998)***Even experienced communication aid userscan struggle to express complex views.Joan Murphy describes the impact a lowtech tool developed to address this hashad on the lives of people with severecommunication difficulties.

Whose needs come first? (Summer1999)***The variable use of objects of referencewith children and adults with severe andprofound learning disabilities raises manyquestions. Advisory teacher Keith Parkchallenges us to address issues ofindividualisation, theory and practice,multidisciplinary collaboration andworking with parents.

Also on the site - contents of back issues

and news about the next one, links to othersites of practical value and information aboutwriting for the magazine. Pay us a visit soonand try out our search facility and index.

Remember - youcan also subscribeor renew online viaa secure server!From Speech Therapy in Practice*/HumanCommunication**, courtesy of Hexagon

Publishing, or from Speech & LanguageTherapy in Practice***

w

ww

.speechm

ag.c

om

READER OFFERSREADEROFFERREADEROFFERREADERO

FFER

Win SPEAKING & LISTENINGTHROUGH NARRATIVENarrative intervention is taking speech and language therapy by storm.Heres your chance to come on board, with copies of Speaking & ListeningThrough Narrative available in a FREE draw to two lucky readers of Speech

& Language Therapy in Practice, courtesy of Black Sheep Press.To enter, send your name and address on a post-card or sealed envelope to, Speech & Language

Therapy in Practice - SLTN offer, Alan Henson,Black Sheep Press, 67 Middleton, Cowling,Keighley, W. Yorks BD22 0DQ by 25th April. The

winners will be notified by 30th April.This pack presents a flexible approach to develop-ing speaking and listening skills through narrative

with small groups of children aged from around4-6 years. Sample session plans guide therapistsand teachers in raising childrens awareness of

the individual components of a simple story,retelling, then generating their own storyideas. During the pilot study in Stockport,

author Becky Shanks recorded significantimprovements in children on formal languageassessments and in attention, listening and

confidence in the classroom.Speaking & Listening Through Narrative is available for 40 + 3 p&pfrom Black Sheep Press, tel. 01535 631 346,

or online at www.blacksheep-epress.com.

The winners of the Black Sheep Press prize draw in the Autumn 2001 issuewere: Concepts in Pictures - Clair Brookes, Helen Glover and South TynesideHealth Care NHS. Time to Sing CD - People in Communities Family Project, M.

Tydfil and Deirdre Oxx.Congratulations also to Speechmarks Working with Dysphagia winners fromthe Winter 2001 issue: Linda Collier, Julia Loughlan, Sarah Harris, PetreaWoolard and Deborah Marshall.


3/32

Inside coverSpring 02 speechmagReader offersWin AlphaSmart 3000 with Co:Writer

SmartApplet. Win Speaking &Listening Through Narrative. See

also p.20 to win a Talking Mats

and Learning Disability Package.

2 News/Comment

7 ReviewsAutism, voice, language, linguistics,

phonology assessment, mutism.

8 The earlyintervention gap - can

we fix it? (Yes, I CAN!)

...parents reported the adaptiveand social behaviours of the I CAN

Centre children to have

significantly improved (expressive,

compliant and pro-social

behaviour).

Following evaluation of I CANs

pioneering Early Years Centres,

Alex Hall argues it is now time for

us to put our money where our

mouth is - and shift resources out

of the clinic.

11 Further readingAAC, Fragile X, stammering,

dysphagia, stroke, voice.

12 Making the case for changeFrom the evidence collected - and from our own

experience of working with young children with

feeding related problems - we can see the potential

for altering our practice.

Elspeth Mair and Anne Scott scour the literature for

evidence on best practice with pre-term infants and

argue for our earlier involvement in the

multidisciplinary team.

16 Preliminary findings of aninformal longitudinal study into the

research / practice interface: notingthe influence of extra trees in thewood rather than throwing thebaby out with the bath-waterI never again want to wake from a nightmare

saying, Please dont make eye-contact with Jim - hes

in the control group for Intensive Interaction.

Cath Irvine is passionate about her work with adults

with learning disabilties. Here, she takes a tongue-in-

cheek look at the challenges of evaluating its

effectiveness.

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2002 1

18 Let your mats do the talkingMany participants did not initially like the thought of

using the video...Despite this expressed dislike, it was

clear that the use of the video was a crucial part of the

learning process.

Therapy tools are only as

successful as the practitioner

who uses them so Joan Murphy

and Lois Cameron have

developed a winning format

for multidisciplinary training

in the use of Talking Mats.

21 Resources /

Feedback on Intothe Mouths ofBabes article

22 From dilemmafacing to decisionmakingShould medical ethics be

incorporated into undergraduate

and postgraduate speech and

language therapy training?

Are we fully equipped to deal

with many of these challenges

at the level of basic dysphagia

training? Are we involved

enough in close working with

doctors and nurses in making these difficult decisions?

Fiona Graham and Alison Davison find that training inmedical ethics as applied to dysphagia management

has improved their team working, note keeping,

confidence and objectivity.

25 How I manage deafness inchildren and young people...good multidisciplinary relationships provide the key

as the speech and language therapy service would be

struggling were it to go it alone.

The value of speech and language therapy for deaf

children is now widely recognised, but the debate

about how we can best organise and deliver our

service continues. Liz Fairweather, Liz Kraft and Susan

Howden offer their views.

Back cover

My Top ResourcesSuccess in learning to be a good clinician results from

commitment of a university, in partnership with clinical

supervisors, to the development of students as active

participants, with responsiblity for their own learning.

Aileen Patterson finds the best resources in

undergraduate education are often human.

SPRING 2002(publication date 25th February)

ISSN 1368-2105

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

Production:Fiona Reid

Fiona Reid DesignStraitbraes FarmSt. CyrusMontrose

Website design and maintenance:Nick BowlesWebcraft UK Ltdwww.webcraft.co.uk

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

Editor:

Avril Nicoll RegMRCSLT

Subscriptions and advertising:Tel / fax 01561 377415

Avril Nicoll 2002Contents of Speech & LanguageTherapy in Practice reflect the viewsof the individual authors and notnecessarily the views of the publisher.Publication of advertisements is notan endorsement of the advertiseror product or service offered.

Any contributions may also appearon the magazines internet site.

ContentsSPRING 2002

Cover picture by Paul Reid.See p.4.Thanks to Billy Walker and speechand language therapists and staff at

Kingspark School, Dundee.

www.speechmag.com

IN FUTURE ISSUESLITERACY ATTENTION VOICE CASELOAD MANAGEMENT

EDUCATION AAC

4 Switching on to

Shakespeare: A

Midsummer Nights DreamA large glittery blanket (the wall

through which Pyramus and Thisbe

have been talking) is held up by one or

two people so that everyone can see it.

It is gradually lowered over someone as

the adieus are called out, and then

thrown over someone as everyone

suddenly shouts Byeeee!

Keith Park turns bard as pupils with

severe and profound learningdisabilities participate in a series of

poetry workshops at Shakespeares

Globe Theatre.

COVER STORY


4/32

Television personality Lorraine Kelly presents the inaugural Women Who Mean Business

award from the Dundee and Angus network Women Ahead to Speech & Language Therapy

in Practice editor Avril Nicoll. The aim of the award was to celebrate the achievements of

ordinary women who juggle commitments to family and friends, work and the community.

Avril commented that, luckily, a tidy house was not part of the judging criteria. The 1000

prize money is being used to purchase a digital camera and dictaphone for Speech &

Language Therapy in Practice, and should also provide an opportunity for Avril to travel in

the UK to report on innovative practice. www.womenahead.co.uk

news

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 20022

Developmentsfor deaf peopleThe Royal College of Speech & Language Therapists has con-

tributed to the development of a dedicated website set up in

response to the piloting in England of Universal Neonatal

Hearing Screening.

The aim of the screening is to test all newborn babies for deafness

within the first few days of life to lower the average age of iden-

tification of deafness from twenty months to three months and

allow families to take positive action to support the development

of language and communication much earlier. The website,

launched by the Royal National Institute for the Deaf, is a new

training and information resource for professionals who work

with deaf babies to help them support families and be aware of

best practice in areas such as language and communication.

www.deafnessatbirth.org.uk

Meanwhile, RNID has welcomed the governments announce-

ment that it plans to modernise audiology services in England to

give more people access to digital hearing aids on the NHS.

However, the charity points out that two thirds of all people inEngland will still not have access to digital aids because of where

they live.

RNID, tel. 020 7296 8000, www.rnid.org.uk

Autism.The problem is

understandingAn advertising campaign has kickedoff the 40th anniversary of the UKs

leading autism charity.

The National Autistic Society hopes the

simple strapline, Autism. The problem is

understanding, together with back-up

autism information resources provided

by telephone or the Internet will

increase public awareness of the com-

plex needs and experiences of people

with autism. With the money raised

through its 40th anniversary campaign,

the Society intends to expand theAutism Helpline operation, train more

practitioners in the use of the EarlyBird

programme, increase participation in

the NAS Autism Accreditation

Programme, expand adult services and

schools capacity, and develop its advoca-

cy, volunteer and employment work.

NAS Supporters Line, tel. 08702 33 40

40; Autism Helpline, tel. 0870 600 85 85,

www.autism.co.uk / www.nas.co.uk.

The UK charity dedicated to supporting research into hearing

problems believes the watchful waiting policy on glue ear has

gone too far.

Defeating Deafness is calling for earlier referral to ear, nose and

throat specialists of those most likely to benefit from surgery, cit-

ing recent research that suggests children with glue ear are at

risk of behavioural and educational problems lasting well into

their teens*. Its five-point checklist urges early referral of chil-

dren with persisting hearing loss especially if they

1. show related behaviour and communication problems

2. are prone to repeated ear infections

3. are exposed to smoking at home

4. attend - or have siblings attending - school, playgroup or nursery

5. have a family history of ear infections and glue ear.

Professor Mark Haggard, Director of the Medical Research

Councils Institute of Hearing Research and Chief Adviser to

Defeating Deafness believes the correct intervention for estab-

lished glue ear is surgery, particularly for children over the age of

three-and-a-half. He says, This concept of watchful waiting to

stop children being routed too directly into surgery was a neces-

sary step in its time, but the policy has now gone too far. There

are no firm guidelines about when to stop watching and do

something. The charity has produced a new edition of its parent

information leaflets in light of this.

www.defeatingdeafness.org, freephone 0808 808 2222.

*The paper Behaviour and developmental effects of otitis media

with effusion into the teens from Arch Dis Child (2001; 85) is

available on the website.

Watchfulwaiting - but

for how long?

PicturebyWalterNielson,

tel.01592655303,

forCaledoniamagazin

e.


5/32SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2002 3

news & comment

Enthusiasm isinfectious!Pop Idols Gareth Gates is clearly relishing his new role. A seventeen year old with

what the judges describe as the complete package and a voice of the moment,

Gareth responded well to voice coaching and feedback and consistently turned in

expressive, confident performances in spite of - and no doubt partly because of -

his experience of a severe stammer. Gareths barely contained enthusiasm forbeing in front of an audience, attending movie premieres, photo shoots, meet-

ing other stars and going to recording studios is infectious and he is a great

role model for young people with communication difficulties.

We dont know whether, given his stammer, Gareth would have found his

way to pop stardom by a more conventional route. Inclusion often requires us

to think differently - as Keith Park(p4) did when taking students with severe

and profound learning disabilities to the Globe Theatre to participate in A

Midsummer Nights Dream, the sights, sounds, smells and people of a real

theatre generating more enthusiasm among professionals and clients than

dry clinic or school imitations.

Pop Idol judges talked about the elusive X factor - difficult to describe, but

you know it when you see it. The specialists writing for How I manage deafness

in children and young people (p25) for example remind us that, howeverskilled you become at your craft, enthusiasm remains a basic aspect.

Cath Irvine (p16) almost has us believing that she despairs of staff who

become so enthusiastic about their work that they mess up her research

designs - however her own enthusiasm for the value of research in practice

shines through.Joan Murphyand Lois Cameron (p18) also mix research with

clinical practice. Recognising that therapy tools are only as good as the person

who uses them, they planned multidisciplinary training to enable the users to

generate their own enthusiasm and therefore improve their learning. This

approach also underlies Aileen Pattersons top resources (back page) for

undergraduate students. A literature review, visits to other areas and attendance

at a conference stimulated the enthusiasm ofAnne Scottand Elspeth Mair(p12)

for improving services to pre-term infants. Fiona Graham andAlison Davison

(p22) attended a multidisciplinary conference on an ethics approach to

dysphagia management, and enthusiasm for this now permeates all their work.

Alex Halls excitement about I CANs pioneering Early Years nurseries (p8) is

palpable, but enthusiasm alone is not enough. The initial research findings on

outcome and cost effectiveness, however, suggest that we can now drive

forward a different style of service delivery to young children with persistent

communication difficulties.

As members of a profession facing constant change and recruitment / retention

difficulties, and with ever-increasing demands on our time and skills, we have

to hang on to our enthusiasm - and make sure it is catching.

...comment...Avril Nicoll

Editor

Kinnear Square

Laurencekirk

AB UL

tel/ansa/fax

email

avrilnicoll@speechmagcom

Putting pupils firstAn Order of Parliament next year will give Local

Education Authorities in England greater freedom

to form partnerships which put pupils first.

Schools Minister Stephen Timms believes creative

partnerships with other Local Education

Authorities and external providers such as private

companies, voluntary bodies and non-profit-mak-

ing organisations will bring benefits in the deliveryof Special Educational Needs assessment and early

years development work.

Software awardsThe software shortlisted for the BETT 2002 Special

Educational Needs category was:

Learnhow Publications - IEP Writer 2

Crick Software - Find Out and Write About Series

(winner)

SEMERC - Assessability

Don Johnston Special Needs - Co:Writer

SmartApplet

CALSC Communication & Learning Skills Centre -Mastering Memory

Stroke donationsThe Stroke Association can now take donations

online. The organisation funds around 2 million

of research each year to look for successful thera-

pies and find ways to prevent strokes.

www.stroke.org.uk

Calling aphasia

cliniciansThe British Aphasiology Society is encouragingclinicians to present a paper at its therapy sym-

posia in September.

In particular, it believes practising clinicians may

have discovered effective ways of encouraging

generalisation, working in the community and

using volunteers and technology. To assist thera-

pists who have not presented papers before, the

Society is allocating them a mentor.

Further details from Rosemary Cunningham, tel.

01332 254679, e-mail [email protected].

Seamless careThe growing emphasis on the need for seamless

care for patients is behind the development of

the new Institute of Health Sciences at City

University.

The language and communication science depart-

ment will join with nursing and midwifery, radiog-

raphy, optometry and the health management

group to form the Institute, which will have close

links with other health and counselling groups.

Health-related activities account for a third of all

academic activity at City University. The Institute is

looking for opportunities for students from differ-

ent health professions to work, train and research

together to produce strong disciplines who also

understand the contributions made by others.


6/32

Switching on to

Shakespeare:A Midsummer Nights Dream

cover story


hy should young people with

severe and profound learning

disabilities want to experience

the story line, the atmosphere

and the language of

Shakespeares A Midsummer Nights Dream in

performance on stage at Shakespeares Globe

Theatre? Vygostsky (1978, p.88) observed,

Human learning presupposes a specific social

nature and a process by which children grow into

the intellectual life of those around them.

Life experiences and opportunities for people

with the highest support needs are often very

restricted, and so Vygotsky presents us with an

interesting challenge: if we do share a social

nature, and the intellectual life of a shared cul-

tural heritage, how might we include people with

multiple disabilities? Our poetry workshops are

an exploration of this question.Shakespeare seemed an obvious starting point:

his monumental and enduring influence on

English language and culture has been described

by Bernard Levin (1983, 167-168) in one long and

enthusiastic sentence:

If you cannot understand my argument, and

declare Its Greek to me, you are quoting

Shakespeare; if you claim to be more sinned

against than sinning, you are quoting

Shakespeare; if you recall your salad days, you are

quoting Shakespeare; if you act more in sorrow

than in anger, if your wish is father to the thought,

if your property has vanished into thin air, you are

quoting Shakespeare; if you have ever refused to

budge an inch or suffered from green-eyed jeal-

ousy, if you have played fast and loose, if you have

been tongue-tied, a tower of strength, hoodwinked

or in a pickle, if you have knitted your brows, made

a virtue of necessity, insisted on fair play, slept not

one wink, stood on ceremony, danced attendance

(on your lord and master), laughed yourself into

stitches, had short shrift, cold comfort or too

much of a good thing, if you have seen better

days or lived in a fools paradise - why, be that as

it may, the more fool you, for it is a foregone con-

clusion that you are (as good luck would have it)

quoting Shakespeare; if you think it is early days

and clear out bag and baggage, if you think it is

high time and that is the long and short of it, if

W

see

www.

peechm

ag.

com

insidefro

nt

cover

you believe that the game is up

and that truth will out even if it

involves your own flesh and

blood, if you lie low till the

crack of doom because you sus-

pect foul play, if you have your

teeth set on edge (at one fell

swoop) without rhyme or rea-

son, then - to give the devil his

due - if the truth were known

(for surely you have a tongue in your head), you

are quoting Shakespeare; even if you bid me good

riddance and send me packing, if you wish I was

dead as a doornail, if you think I am an eyesore, a

laughing stock, the devil incarnate, a stony-heart-

ed villain, bloody-minded or a blinking idiot, then

- by Jove! O Lord! Tut, tut! for goodness sake!

what the dickens! but me no buts - it is all one to

me, for you are quoting Shakespeare.Our second aim was for participants to develop

language and communication skills within the frame-

work of the poetry workshops. Examples include:

1. Awareness

demonstrating any kind of awareness of the

sights and sounds of the activities

2. Anticipation

for example, demonstrating an anticipation of the

loud donkey noises that end two of the activities

3. Turn-taking

participating, in any way, in the turn-taking call

and response structure of the activities

4. Showing self

the participant demonstrates a this is me behaviour

to gain someone elses attention by, for example,

smiling, laughing, eye contact, and vocalizing

5. Showing objects

this is a look at this, attention-sharing behaviour

6. Giving objects

in contrast to the showing objects behaviour

7. Seeking physical proximity

moving, or turning, towards another person to

indicate intention or desire to communicate

8. Gaze alternation

looking from an object to someone else - or

vice versa - as a means of sharing attention

9. Joint attention

two or more people are intentionally looking

at the same thing (or person) at the same time

10.Declarative pointing

pointing to an object, while look-

ing at the communication partner

before, during or after the point,

to indicate look at that.

Participants who do not have

speech may also use VOCAs (Voice

Output Communication Aids).

Anecdotal evidence suggests that,

while many Alternative and

Augmentative Communication (AAC) users may

often be provided with switches to respond to

questions, they do not always have the opportu-

nities to initiate an interaction so, in particular, we

wanted to give participants who are switch users

the opportunity to initiate each of the exchanges. It

seems a priority that, when an aim is to encourage

the use of a switch and its social functions, we

should also provide opportunities for users to initi-ate and then to practise a new skill. Therefore the

lines that start each activity are context-setting,

and then become time-independent, so they can be

repeated as often as possible throughout the activ-

ity. This allows switch users to contribute through-

out the exchanges. It follows that it is also useful to

provide them with a pre-recorded message that is

the final line of an exchange, or of a song or story.

Initiated by a switch userEach of the six activities from A Midsummer

Nights Dream (see figure 1) contain extracts of

original text that is performed in call and response

(one or more persons calling out the words, and

the others then repeating those words or respond-

ing by any movement or sound). Each of the work-

shop activities can be initiated by a switch user say-

ing the first line, as indicated in italics in figure 1.

Each first line is also time-independent and can be

used repeatedly throughout each activity. For

example, Titanias snoring initiates the first

exchange and, when repeated, can contribute to

the comic effect of the activity. The final line of

each activity, also indicated in italics in figure 1, is

called out by everyone together. Participants with

sensory impairments may also use a drum or tam-

bour, and the resonance of the wooden stage. In

the classroom a resonance board can be used.

We have been very fortunate in having access to the

if you agree withShakespeare when he says

Question your desires never anything can be

amiss When simplenessand duty tender it

How happy some oer

other some can be!

Read this

Keith Park turns bard as two groups of pupils with severe and profound learning disabilities participate in aseries of poetry workshops at Shakespeares Globe Theatre. Get your communication aids, parachute, glitteryblanket and drum ready, and prepare to join in the fun...



cover story

6. Let the audience look to their eyes

So says Bottom, convinced that their play Pyramus andThisbe will move the audience to tears. TheMidsummer Nights Dream is full of references to eyesand the imagery of vision. Helena says Love looks notwith the eyes but with the mind and that Demetrius isdoting on Hermias eyes - an indication that this mightnot be true love. All the mistakes follow from magicpotions to the eyes. This is a brief selection of poeticimages about eyes and vision from the play. Linesfive and six are spoken by Hermia as the two coupleswake up in the woods the next morning, dazed andconfused. The final two lines are Oberons, as hereleases Titania from the magic spell of her love for

the donkey-headed Bottom.SssshhhhUpon thy eyes I throwAll the power this charm doth oweI see these things with parted eye,When every thing seems double.I will her charmed eye releaseAnd all things shall be peaceSssshhhh

Activity:These lines are spoken quietly, initiated by the switchusers Sssshhhh, while a parachute is gently raisedand lowered over all participants. As the final longSssshhhh is spoken the parachute is released andcovers everyone, and is followed by as long a silenceas possible. This is a calm and quiet activity to endthe workshop.

5. Pyramus and Thisbe

This is the silliest stuff that ever I heard. Sosays one of the characters (V, i) about the playPyramus and Thisbe presented by Bottom andhis friends to the nobles at court. It ends withPyramus, believing Thisbe to be dead, stabbinghimself (lines 1-4); Thisbe then appears, seesPyramus dead, and duly stabs herself (lines 5-7).

OooohhhhO Fates, come, come!Cut thread and thrum;Quail, crush,Conclude and quell!And, farewell, friends;Thus Thisbe ends:AdieuAdieuByeeeeee!!

Activity:A chance for some real over-the-top acting, withthe words being accompanied by grand sweepinggestures. A pre-recorded melodramatic groan -Oooohhhh - on a switch initiates the activity,and can then be repeated throughout, toaccentuate the comedy of the awful acting. Alarge glittery blanket (the wall through whichPyramus and Thisbe have been talking) is heldup by one or two people so that everyone cansee it. It is gradually lowered over someone asthe adieus are called out, and then thrown oversomeone as everyone suddenly shouts Byeeee!

Figure 1 - Workshop activities from A Midsummer Nights Dream

1. Oberon

Storyline:Oberon, the king of the fairies, is having anargument with his queen Titania (II, ii). He decides to teachher a lesson, and puts a magic herb on her eyes as she sleeps.She will fall in love with whatever she sees when waking up -Bottom, with the head of a donkey (III, i). Titania is snoring.....

Zzzzzzzzzzzzzz..........

What thou seest when thou dost wake,Do it for thy true-love take;When thou wakest, it is thy dear:Wake when some vile thing is near.Eee - Eee - Eee - Eee orr!!!I pray thee, gentle mortal, sing againEee orr!! Eee orr!! Eee orr!!

Activity:One person (or two or three) is in the middle of the circle asTitania. The lines are spoken in call and response; after theexchange is initiated by Titania with the snoring sound recordedon the switch, everyone makes a very loud donkey noise.The first Eee orr is done rather like a sneeze (Eee Eee EeeEee-Orr! like Aah Aah Aah Choo!) to provide an exaggeratedanticipation. The donkey sounds can then be repeated twicemore - and even louder - in reply to Titanias words on wakingup. This activity is also done using a parachute: participants

gently wave the parachute over the sleeping head(s) ofTitania; the parachute is then dropped by everyone (as theEee-Eee-Eee is spoken) except one or two people who quicklypull back the material to reveal the waking Titania as everyonecalls out Eee-orrr! (Our parachute is dark blue with brightyellow stars - the sky of the Midsummer Night.)

2. Hermia to Helena

Storyline:Helena and Hermia are lost in the woodsand are very cross with each other (III, ii). Inthe play, Helena is often played by someonetall, and Hermia by someone short, hencethe painted maypole and dwarf insults inthe next two extracts.

You puppet, you!Painted maypole!How low am I?Not yet so lowBut that my nailsCan reach intoThine eyes!

Aaarrgghh!

Activity:This activity is initiated by Helenas wordsYou puppet you! pre-recorded on theswitch. Hermias lines are spoken withsimulated anger, starting quietly and gettinglouder each line, until the Aaarrgghh isscreamed out with everyone stamping theirfeet and waving their arms in a simulatedtemper tantrum. If Helenas words are

repeated by the switch user throughoutthe exchange, it contributes to the effectof two people having a noisy argumentOne or more participants can be in themiddle of the circle as Helena, to provide afocal point for Hermias invective.

3. Helena and Lysander,to Hermia

Storyline:Helena and Lysander take theirturn at insulting Hermia (III, ii).

Oooohhhh!When shes angryShe is keen and shrewd

Though she be but littleShe is fierceGet you gone you dwarfYou minimusYou beadYou acornOooohhhh

Activity:The Oooohhhh! on the switchstarts this exchange, which wedo in a pantomime dame style(think Julian Clary) to provide acontrast to the previous activity.It finishes with everyoneputting their hands on theirhips and calling out a veryexaggerated Oooohhhh!

Participants can also suggestanother character whose stylecan be imitated - ClintEastwood (make my day) orPatsy or Edina from AbsolutelyFabulous.

4. Bottom

Storyline:After his Midsummer Nights Dream,Bottom wakes up and announces: Iwill get Peter Quince to write a balladof this dream: it shall be calledBottoms Dream, because it hath nobottom (IV, i). But he just cannotget the words right.

Eee orrI have had a dreamMethought I was -Methought I had -The eye of manHath not heardThe ear of manHath not seenWhat my dream wasMan is but an assEee orrr!!

Activity:The Eee orrr that dominates thisexchange is heavily ironic: an Eeeeorrr that means something like stu -pid. Anyone who has ever seen JohnCleese and others playingthe verygormless Mr and Mrs Gumby (knottedhandkerchief on head, rolling eyes,trousers rolled up, arms held out likepenguin flippers, and calling outDhhrrr!) may have a role model.

Mark Rylance, Artistic Director of the Globe Theatre,meeting the group of pupils from Charlton School whoare doing A Midsummer Nights Dream on stage.

pisode 2: Hermia to Helena:Thine eyes!

Aaaarrrggghhh!!!How low am I?Not yet so lowBut that my nailsCan reach into


8/32

cover story


Encounter: being present, being provided with

sensations.

Nicole attended each of the workshops. Shewas placed in the centre of the semi-circle of

the participants, and was supported by amember of staff sitting next to her. Nicole layon the stage floor; participants stamped on

the stage floor during the words of theexchange so that she could feel the vibrations.

Awareness: noticing that something is going on.

When the gong was used during the workshops

(episodes 1 and 6), Nicole would often turntowards it. She also often looked at and

reached for the parachute (episode 6) as it waslowered over her as well as the glittery blanket(episode 5).

Attention and response: showing surprise,enjoyment, dissatisfaction.

Nicole smiled when she was helped to use thedrum to set the tempo of the call and response.On several occasions she answered the sound

and resonance of the gong by calling out in aloud and low call (confirmed by her family whowatched the video of the workshop).

Engagement: directed attention, intentionallooking, listening, showing interest, recognition.

On many occasions, Nicole looked at the white

glittery blanket as it was lowered over her aspart of one of the activities (episode 5). Shealso directed her attention towards the gong

and the parachute on many occasions.

Participation: supported participation, sharing,

turn-taking.

With the support of a member of staff, Nicolefully participated in the turn-taking of the call

and response method of storytelling by beat-ing the drum. This enabled her to help initiateeach activity.

REV

stage of the Globe Theatre, and also the participation

of three actors from the Globe, whose enthusiasm

and commitment helped to make the workshops

very special. On several occasions we were also able

to use the musical instruments that were used in the

Globe Theatres summer production of Cymbeline.

To evaluate the workshops we are using a frame-

work for achievement based on the work of Brown

(1996) and Grove (1998). This is the evaluation form

for Nicole, who is 12 years old and has high support

needs including a dual sensory impairment:

I will roar, that I will do any mans

heart good to hear me; I will roar,

that I will make the duke say, Let

him roar again, let him roar again.

... I will roar you as gently as any

sucking dove; I will roar you as

twere any nightingale.

Dark night, that from the eye his

function takes,

The ear more quick of

apprehension makes;

Wherein it doth impair the seeingsense,

It pays the hearing double

recompense.

So we grew together,

Like to a double cherry, seeming

parted,

But yet an union in partition;

Two lovely berries moulded on

one stem;

So, with two seeming bodies, but

one heart.

Reflections

LINGUISTICSNARROW INPERSPECTIVEHUMAN COMMUNICATION: ALINGUISTIC APPROACHGraham WilliamsonSpeechmarkISBN 0 86388 236 6 25.95The intended target audience for this text

includes professionals, teachers, carers and stu-

dents. It addresses human communication

from a linguistic perspective, including lan-

guage acquisition, language use, semantics,

grammar, phonetics and phonology.

Although most aspects of communication

were covered, the content tended to be

quite narrow in perspective, giving little con-

sideration to areas such as bilingualism, signlanguage and written language.

This book would be difficult for non-special-

ist readers to get into, as some sections tend-

ed to be technical in terms of written style

and terminology. Some quite good chapters

would be a suitable resource for profession-

als giving presentations, but for students this

would be better suited as a supplementary

text.

Betty Martin is a speech and language therapy

student at UCE, Birmingham.

LANGUAGEGENERALLY FUNKYTIME TO SING! (CD)The Centre for Creative PlayBlack Sheep Press (UK Distributor)12.00This CD has 26 traditional songs mostly, but

not all, familiar. The words are helpfully

enclosed.

Although sung at a slower pace than usual,

other features - the use of Sesame Street style

funny accents, occasionally quite uncomfort-

able phrasings, extra verses and potentially

confusing word changes (Head, Tummy, Knees

& Toes) - makes a few songs difficult and some-times irritating to listen to. However there is a

nice mix of adult and childrens voices on cer-

tain tracks.

The music is generally funky and interesting,

but some of the introductions and refrains

are long and potentially boring for those

with short attention spans.

When it worked I enjoyed singing along with

ohhh the okey cokey at the top of my lungs.

Unfortunately it didnt happen often enough

for me to recommend this as a must have.

A very good idea, but still needs some work.

Marion Hall is a speech and language thera-

pist working in Newcastle upon Tyne for the

community paediatric service.

Readers of our version of A Midsummer Nights

Dream may be interested to know that the

workshop materials have also been used in school

classrooms as well as onstage at the Globe

Theatre. Apart from the appropriate communica-

tion aids, the workshops only need a parachute, a

glittery blanket, a drum, and staff enthusiasm, to

be done anywhere.

Keith Park is an Advisory Teacher for Sense in

Greenwich and Lewisham, tel. 0771-502-6354,email: [email protected].

ReferencesBrown, E. (1996) RE For All. London: David

Fulton Publishers.

Grove, N. (1998) Literature For All. London:

David Fulton Publishers.

Levin, B. (1983) Enthusiasms. London: Curtis

Brown Ltd.

Vygotsky, L. (1978) Mind in Society: Cambridge:

Harvard University Press.

Nicole



reviews

EWS. . . . . . . . . . . . . . . . . . . . . . .r e v i e w s

AUTISM

DONT BORROW IT, BUY IT!AUTISM WITH SEVERE LEARNING DIFFICULTIESDr Rita JordanSouvenir Press ISBN 0 298 63599 9 9.99This excellent, straightforward guide to an extremely complex

area will be an asset to therapists working in the field.It refers largely to work with children and young people, but

there is a good chapter on transition to adult life and a chap-

ter on helping adults with autism to lead a productive life.

There is a useful section on sources of help.

Dr Jordan wears her considerable learning lightly and express-

es herself well in an eminently readable and practical book.

Dont borrow it, buy it!

Jane Neil-McLachlan is the Adult Autism Co-ordinator with

Lothian Primary Care NHS Trust.

LANGUAGEVERY CLEAR AND

EXCELLENT VALUEDEVELOPING LANGUAGE (AMETACOGNITIVE APPROACH TOTEACHING GRAMMAR ANDMEANING)Wendy RinaldiNFER-NelsonManual 1: from before first wordsto word combinations (10 monthsto 21/2 years)Manual 2: grammatical elements,sentence level and beyond (21/2 to 7years)75 + VAT each / 137+VAT for

both manualsThis programme is for children who have

delayed or disordered language, with

emphasis on the development of seman-

tics and grammar and some early prag-

matic skills. It can be implemented by

speech and language therapists and their

assistants (supervision or training may be

needed) and teachers, and is aimed at a

group size of five to six children.

There is much emphasis on listening,

watching, thinking and understanding

and in building up processing skills

toward the ultimate goal of consolidated

sentence construction. The skills learnedare intended to be cumulative.

To provide some answers to perennial time

constraint problems, both books contain:

copiable session planning and record

sheets

pictures to support individual lessons

preparation notes re-equipment

abundant, well thought out exercises to

demonstrate how the different elements

in language work, their meanings, and

graded steps to develop language

processing, comprehension and use.

The focus on a metacognitive approach

throughout the levels also appealed

greatly.

The programme has potential for groups

with preschool children who have not yet

learned to use language, through to

those with tail end grammar delays. It

will also appeal to teaching staff from

the writing point of view.

Very clear, and excellent value.

Kareen Cairns and Claire Blandford, senior

speech and language therapists (language

disorder) work for Lanarkshire Healthcare

Trust providing outreach support from a

Primary Mainstream language unit Base

and clinical / Mainstream Peripatetic sup-

port respectively.

VOICE

CD PARTICULARLY USEFULTHE ACCENT METHOD (A RATIONAL VOICE

THERAPY IN THEORY & PRACTICE)Kirsten Thyme-Frokjaer & Borge Frokjaer-JensenSpeechmark ISBN 0 86388 272 2 25.95The book covers four areas: history and principles; anatomy,

physiology and acoustics of phonation; teaching the method;

and acoustic and physiological measurements. The section on

teaching, although short, is extremely practical and describes

fully the dynamic approach of the method. However, I would

have liked to see some sample case presentations and felt the

writing style was rather wordy.

It represents good value for money but should not be consid-

ered to be a substitute for the intensive training courses run

by the authors.

Lynn Busby is a specialist speech and language therapist

(voice) within the Ulster Hospitals and Community Trust.

ASSESSMENT

VERSATILE, STRAIGHTFORWARDAND ATTRACTIVEPHONOLOGICAL SCREENINGASSESSMENTNeil Stevens and Deborah IslesSpeechmark ISBN: 0 86388 273 036.00Ages: Child to AdultThis test is versatile, straightforward and attractive.

The vocabulary is appropriate from Nursery age

upwards. The pictures are clear and, being

coloured photographs, not babyish. The 32 indi-

vidual picture format means a variety of presenta-

tions can be used, and there are helpful sugges-

tions catering for differing levels of cooperation

and attention...and avoiding tedium for the thera-

pist. The photocopiable score sheets are compact

but have adequate space, plus a useful section on

phonological processes with age norms. The items

are listed alphabetically - a sensible follow-through

to presenting the pictures in differing orders. Most

initial and final consonants are covered and practi-

cally all vowels and diphthongs.

Good value.

Fran Neale is a specialist speech and language

therapist in phonology and dyspraxia in

Norwich.

VOICEQUICK REFERENCE EASYGREENE AND MATHIESONS THE VOICEAND ITS DISORDERS (6TH EDITION)Lesley MathiesonWhurr ISBN 1 86156 196 2 29.50The long awaited 6th edition of this classic

British voice textbook will not disappoint.

Massively extended and updated it is almost

double the length of the 5th edition, but man-

ages to cover all aspects of voice clearly and

without overwhelming the reader.

A clear outline of normal voice leads on to an

excellent and very comprehensive section on

voice pathology. The presentation and classifica-

tion of voice disorders is especially well

described. The voice therapy section begins with

a clear and thoughtful overview from initial con-sultation to outcome and discharge.

Principles and techniques are clearly described.

Throughout, boxed in tables and summaries

make quick reference easy. My student and I

were able to look up both straightforward and

unusual voice disorders and decide on appropri-

ate treatment approaches. The typeface is clear

and the book is well indexed.

It is excellent value for money and should be on

every voice therapists bookshelf.

Christine Mills is a speech and language thera-

pist working for Lincolnshire Healthcare Trust at

Pilgrim Hospital, Boston.

MUTISMLOTS OF PRACTICAL EXAMPLES AND IDEASSELECTIVE MUTISM RESOURCE MANUALMaggie Johnson & Alison WintgensSpeechmark ISBN 0 86388 280 3 37.50Although a rare condition, some practical advice on the man-

agement of children with selective mutism is essential and this

manual fulfils that need while being excellent value for money.

The theoretical section is easy to read and therefore useful to

parents and professionals. We found the Frequently Asked

Questions useful in the early stages of identification and gave

the parent information sheet later on. The assessment is thor-

ough with photocopiable parent and child interviews and there

is guidance on facilitation of other standardised assessments if

gaining the childs cooperation is difficult. The section on

reaching a diagnosis, which includes contra-indications, is par-

ticularly useful.

Most of the manual is concerned with management of thechild, both day to day advice and a systematic treatment pro-

gramme. It includes lots of practical examples and ideas but

will be a big time commitment for those involved.

Nevertheless, an excellent resource.

Carole Davies is clinical leader for speech and language ther-

apy services at Solihull Primary Care Trust.


10/32

collaboration


CAN, the national educational charity for children with speech and language difficulties, started work-

ing with NHS Trusts and local education authorities over a decade ago to put some of the experience and

expertise gained in its special schools into action for the benefit of younger children. At this time the

development of I CAN speech and language nurseries was largely initiated in response to anecdotal evi-

dence from teachers and speech and language therapists in the field. Experienced professionals were

saying that they could identify children with persistent speech and language difficulties, who were likely to

require some type of special educational provision as a result, at nursery age (usually three to four years), but

were unable to provide appropriate provision until statutory school age, the few existing speech and language

nurseries in existence at this time providing notable exceptions. Consequently, speech and language therapists

reported, these children were often long-term members of clinic caseloads, and only started to make signifi-

I

if you want models for early

intervention

could work morecollaboratively

think intensive jointprovision would be tooexpensive

Read this The early

interventiongap -can we fix it?(Yes, I CAN!)

In Alex Halls

experience, most

therapists assume that

specialist educational

placements for

preschool children

with persistent speech

and language

difficulties would have

good outcomes butbe too expensive to

provide. Evaluation of

I CANs pioneering

Early Years Centres

indicates otherwise,

and Alex argues it isnow time for us to

put our money where

our mouth is - and

shift resources out

of the clinic.

Picture from an I CAN Early Years Centre



collaboration

cant progress once placed in language unit provi-

sion at four or five years old. Concern was also

expressed about the likelihood of these children

developing secondary difficulties with behaviour,

literacy and social skills, which might have been

prevented with appropriate early intervention.

Building on this work, I CAN launched an ambi-

tious Early Years Development Programme in

1999 with three major parts:1.The development of 20 Early Years Centres for

the provision of integrated education and

speech and language therapy throughout the

United Kingdom. (By April 2002, 13 will have

been opened or approved.)

2.The rigorous evaluation of I CAN Centres in

comparison to other early years provision for

children with speech and language difficulties.

3.The development of an Accreditation Scheme,

which would identify key features of high quality

effective service provision and set the standard

for this specialist area. This will be launched at

I CANs National Conference, 4th March 2002.

Highly significant contributionA recently completed study, undertaken by James

Law (City University) and Julie Dockrell (Institute

of Education) on behalf of I CAN (part funded by

the Department of Health and the John Ellerman

foundation) makes a highly significant contribu-

tion to the evaluation component of this pro-

gramme, and is supported and reinforced by

ongoing evaluations carried out by practitioners

at other I CAN Early Years Centres. The objectives

of the study were to:

a) provide a description of I CAN Early Years

Centre provision contrasted with national

preschool educational provision

b) analyse changes in the language and social

skills of children attending I CAN Centres in

comparison to a group of children receiving

local speech and language therapy and

preschool education

c) provide an initial economic evaluation of the

services received by children attending I CAN

Centres and the comparison group.

Subjects came from two I CAN Early Years

Centres (figure 1); local NHS trusts wereapproached to recruit comparison group children.

The children were assessed

and parents were interviewed

immediately prior to the

intervention, immediately

after the intervention, and six

months after initial assess-

ment. Language, cognition

and social development mea-

sures were collected for a

total of 90 children with pri-

mary language difficulties, 58

of whom came from the I CAN

Centres. The mean age of the

children (in both groups) was

3;4 years. The economic evaluation was carried

out by comparing the costs of the I CAN Centres

with those of NHS speech and language services

and preschool education as determined from

national data.

The evaluation study showed that children who

attended the I CAN Centres made greater

improvements, relative to the comparison group,

in the following areas:

productive vocabulary

language comprehension scores as measured by

the verbal subtests of the British Abilities Scales

(Elliot et al, 1996)

adaptive and social behaviour

Positive changes were also noticed by parents

and teachers, relative to the comparison group:

parents reported the adaptive and social behaviours

of the I CAN Centre children to have significantly

improved (expressive, compliant and pro-social

behaviour) parents reported a decline in disruptive behaviour

for children who attended the I CAN Centres

teachers indicated that there had been a significant

improvement in the childrens compliance and

pro-social behaviour.

I CAN Early Years Centres, including the two which

participated in the research, share a model with fea-

tures that were not seen in the services received by

children in the comparison group. It is not a pre-

scriptive model; indeed, it is operationalised differ-

ently in all the Centres to accommodate local fac-

tors. Variation is often a result of policies such as

school entry age, complementary services - for

example, how much support the children will

receive when and if they return to a local main-

stream setting - and geography, where long travelling

distances may mean attendance is for fewer sessions.

The model and associated good practice are being

disseminated, by I CAN, through a training cascade

and accompanying materials during 2002, as well as

through the I CAN Accreditation scheme.

The model has the following features, which

could usefully be replicated in other services:

1. The integrated delivery of speech and language

therapy and preschool education, achieved

through collaborative work of teachers and

therapists who together plan, deliver and monitor

programmes. Of particular significance is the

joint preparation of Individual Education Plansand matching of activities into Early Learning

Goals.

2. Parental involvement (frequent

communication, child specific

advice, parent workshops).

3. Participation in a mainstream nursery

environment (the I CAN provision is

either part of a mainstream class or

attended concurrently with a

mainstream placement supported by

the I CAN staff).

4. Outreach activities to support the

children in any concurrent placement

and through the transition into

subsequent educational provision.

5. The Law & Dockrell research found the I CAN

Centres to excel in all dimensions of the Early

Childhood Rating Scales (Harms et al, 1998)

apart from space and furnishings. The one I CAN

Centre which scored poorly in this area has

since been relocated. Specifically, they noted:

good use of language, reasoning and interaction

skills, for example staff child interactions

individual learning needs described for the

children were of a particularly high standard

emphasised social/pragmatic tasks such as

greeting and departing

excellent use of books and pictures to facilitate

the language skills of the children.

Positive changes

were also

noticed by parents

and teachers,

relative to the

comparison group

Figure 1 - Different models of provision

I CAN Centre A

children enter between the ages of 2;8-3;3 years ten week programme for up to sixteen children per intake (eight morning, eight afternoon) programme carried out within mainstream nursery setting, with children spread through

the nursery groups replaces attendance at playgroup or, for a few children, other nursery staffing: speech and language therapist, SEN nursery teacher, nursery nurse (all full-time),

nursery nurse outreach worker (four days per week), educational psychologist (three sessions

per intake, one to attend admissions panel and two for advice and support to staff and parents) the therapist, teacher and nursery nurses work as a team to support children within the

nursery classrooms and carry out the individual programmes. Any one of them can carryout the group activities.

I CAN Centre B

children enter between the ages of 3;3-4;6 years six week intensive intervention programme for up to sixteen children per intake (eight

morning, eight afternoon) intervention in a segregated area away from the mainstream nursery, in addition to the

placement each child has at a mainstream nursery direct contact is four days per week with one day used for outreach, administration,

planning and training team works with childs concurrent mainstream placement staffing: speech and language therapist, SEN nursery teacher, SEN special support assistant

(all full-time), educational psychologist (one day per week) the staff work as a team and interchange in the carrying out of the big group activities, as

well as other functions there are three staff for up to eight children for the majority of group activities

Both Centres provide high levels of outreach to subsequent mainstream nursery / school placements.


12/32

collaboration


PrioritisingWhere a model of service delivery showing these

features is available, the Law & Dockrell research

provides clues to assist in appropriately selecting

and prioritising children for placement:

Children with the most severe

language comprehension difficul-

ties at initial assessment whoattended I CAN Centres made the

greatest gains in this area, rela-

tive to the comparison group, and

are therefore ideal candidates.

Both at baseline and at six

month follow-up there was no

significant difference between

the Centre and comparison chil-

dren in intelligibility. Using the

Goldman-Fristoe Test of

Articulation (1986), both groups

had similar improvements in the

number of items they attempted

to name and the number of

sounds produced correctly. This suggests childrenwhose primary difficulty is with phonology should

not be given priority for these two I CAN Early

Years Centres.

Whilst the long-term financial benefits of effective

provision (reduced need for specialist support and

education, reduction of secondary difficulties and

parental and child well-being) may be difficult to

evaluate, the direct costs of delivering the model

of service provision described and the comparative

costs of a clinic based speech and language service

coupled with a mainstream preschool education

are easier to measure. The Law & Dockrell

research has provided a useful first step for studies

in this area, although the wide differences in levelsof speech and language therapy provided in clinic

based services and issues around costs to parents

in accessing services require further investigation.

SurprisingWhen I talk to therapists, there is a general presump-

tion that this type of intensive provision - where a

therapist, teacher and assistant / nursery nurse are

allocated to a relatively small number of children

- will be expensive relative to provision of therapy

in a clinic setting. The true picture is therefore

perhaps surprising.

The costs over one year for comparison children

receiving separate NHS speech and language ther-

apy and preschool education provision (obtained

from national data) were analysed and compared

to those receiving the integrated I CAN service.

The provision to the comparison group was more

expensive than the provision to the I CAN service

group for one I CAN Centre, whilst the other I CAN

Centre was moderately more expensive. Given

the long-term benefits of the I CAN provi-

sion, and their likely cost implications, I CAN

Early Years Centres offer a relatively costefficient service, therefore redeployment of

staff from a clinic setting to an integrated

early years setting should be considered by

speech and language therapy managers.

It may be that the greatest obstacle to

the development of integrated education

and therapeutic provision for children in

the early years is the organisation and man-

agement of the two services, split as they

are between the NHS and education

authorities. The new flexibilities for com-

missioning, funding, and managing services

permitted through the 1999 Health Act for

England and Wales provide an opportunity to begrasped for the benefit of children. In the mean-

time, based on these findings, my advice to thera-

pists working with preschool children with persis-

tent speech and language difficulties is to work col-

laboratively with teachers in early years settings to:

Assess, so that:

both have access to a fuller picture of the childs

strengths and needs.

Plan, so that:

the child has one integrated plan which furthers

both their language development and access to

the curriculum

priorities are agreed rather than conflicting.

Intervene, so that:

the therapist understands the demands of the

1. Grasp the opportunity provided by new funding flexibilities and I CANs

training and Accreditation Scheme to set up integrated early years services.

2. Respond creatively to local policies, provision and geography.

3. Prioritise children with severe language comprehension difficulties for

collaborative work with nursery or playgroup staff.

4. Assess, plan, intervene and monitor collaboratively.

5. Ensure parents receive consistent information and are involved at all stages.

Five steps to better practice

Children withthe most severe

language

comprehension

difficulties...

made the

greatest gains

in this area

curriculum and preschool environment, and the

teacher understands what are appropriate

strategies, language demands and expectations

intervention is consistent

different skills and knowledge are exploited

the time a child is exposed to appropriately targeted

work is maximised

intervention occurs in a naturalistic setting

opportunities for reinforcement and generalisationare increased.

Monitor, so that

change or additional information is rapidly

known by all

intervention can rapidly reflect changes.

Taken as a whole, this collaboration ensures that

parents and other professionals can receive con-

sistent information.

Alex Hall is I CANs Director of Services

Development. Further information on I CANs Early

Years Centres, the new Accreditation Scheme, the

training cascade and the Law & Dockrell research

from I CAN, 4 Dyers Buildings, Holborn, LondonEC1N 2QP, tel. 0870 010 40 66, www.ican.org.uk.

ReferencesElliot, C.D., Smith, P. & McCollock, K. (1996) British

Ability Scales (BAS II). Slough: NFER-Nelson.

Goldman, R. & Fristoe, M. (1986) Goldman Fristoe

Test of Articulation. Circle Pines USA: American

Guidance Service Inc.

Harms, T., Clifford, R.M. & Cryer, D. (1998) Early

Childhood Environmental Rating Scales: Revised

edition. New York: Teachers College Press.

Resources For information on the1999 Health Act, see

www.doh.gov.uk/jointunit/index.htm.

CORRECTION

Figure 1 in Ruth Paradices

article Putting partnership

into practice (Winter 2001)

should have appeared as

shown here. Apologies for

any confusion caused.



further reading

STROKEWhelan, K. (2001) Inadequate fluid intakes in dysphagic acute stroke.

Clin Nutr20 (5) 423-8.

The fluid intakes of 24 patients with dysphagic acute stroke were stud-

ied prospectively to evaluate the effect of disability, the ward speciality

and the type of fluid given on oral intake. Patients were randomly

assigned to receive powder-thickened fluids or ready prepared pre-thickened fluids and parenteral, enteral and oral fluid intakes, urine

output, clinical sequelae and the frequency of requests for biochemical

measures of hydration were recorded for a maximum of fourteen days.

Mean thickened fluid intake was 455 ml/d (SEM+/-70) resulting in the

use of an extra 742 ml/d (+/-132) of supplementary fluids. The resulting

total intake was inadequate due to insufficient volumes being given for

too short a period. Patients not on specialist stroke units who received

pre-thickened fluids drank almost 100% more than those on powder-

thickened fluids (P=0.04). The results demonstrate that fluid intakes in

dysphagic acute stroke are insufficient to achieve hydration require-

ments. Hospital staff must ensure adequate fluid intakes in patients at

risk of dehydration, through both an adequate prescription and provi-

sion of supplementary fluids.

FURTHERREADING

This regular featureaims to provide

information about

articles in otherjournals whichmay be of interest

to readersThe Editor has

selected thesesummaries from aSpeech & Language

Database compiledby Biomedical

Research IndexingEvery article in

over thirty journalsis abstracted for

this databasesupplemented by a

monthly scan ofMedline to pick outrelevant articles

from others

To subscribe to theIndex to Recent

Literature on

Speech &Language contactChristopher Norris

Downe BaldersbyThirsk NorthYorkshire YO PP

tel fax

Annual rates are

CDs (for Windows):

Institution Individual

Printed version:Institution

Individual

Cheques are

payable toBiomedical

Research Indexing

g

g

g

g

AACBondy, A. & Frost, L. (2001) The Picture

Exchange Communication System [review].

Behav Modif25 (5) 725-44.

The Picture Exchange Communication System

(PECS) is an alternative/augmentative communi-

cation system that was developed to teach func-

tional communication to children with limited

speech. The approach is unique in that it teach-

es children to initiate communicative interac-tions within a social framework. This article

describes the advantages to implementing PECS

over traditional approaches. The PECS training

protocol is described wherein children are

taught to exchange a single picture for a

desired item and eventually to construct pic-

ture-based sentences and use a variety of attrib-

utes in their requests. The relationship of

PECSs implementation to the development of

speech in previously nonvocal students is

reviewed. (26 References)

DYSPHAGIASmith, M.E., Berke, G.S., Gray, S.D., Dove, H. & Harnsberger, R. (2001)Clicking in the throat: cinematic fiction or surgical fact? Arch

Otolaryngol Head Neck Surg 127 (9) 1129-31.

The complaint of a clicking in the throat when swallowing is uncommon

but very discomforting and painful for those who experience it. It is

such an unusual complaint that symptoms may be dismissed as psy-

chogenic because a cause for the problem may not be readily apparent.

We present a series of 11 cases in which all patients had an audible click-

ing or popping noise in the throat associated with neck and throat pain

when swallowing or turning the neck. The most helpful diagnostic pro-

cedure was careful examination and palpation of the neck while the

patient swallowed to localize the side and source of the clicking.

Laryngeal computed tomographic (CT) scans helped in some cases to

demonstrate thyroid-cartilage and/or vertebral body asymmetry. Each

case was treated with surgery of the neck and larynx to trim the portion

of the thyroid cartilage causing the clicking. In most cases the superiorcornu of the thyroid cartilage projected posteriorly and medially.

Surgery was successful in all cases to eliminate the symptoms. Though

an uncommon complaint, our experience suggests that the clicking

throat is a surgically treatable problem.

FRAGILE XRoberts, J.E., Mirrett, P. & Burchinal, M. (2001)

Receptive and expressive communication

development of young males with fragile X

syndrome.Am J Ment Retard106 (3) 216-30.

We prospectively examined the developmental

trajectories of receptive and expressive commu-

nication skills of 39 young males, 20 to 86

months of age, with fragile X syndrome. Eightshowed features characteristic of autism.

Children were tested one to three times using a

standardized language test. They showed

marked delays in language development, but

substantial individual variability. Participants

acquired expressive language skills more slowly

than receptive language over time, gaining

receptive language at about half the rate

expected for typically developing children and

expressive language at one third the rate. Both

cognitive skills and autistic characteristics of the

young males with fragile X syndrome related to

receptive and expressive communication devel-

opment, but neither predicted the discrepan-cies between expressive and receptive language

acquisition over time.

STAMMERINGSnyder, G.J. (2001) Exploratory research in the measurement and modi-

fication of attitudes toward stuttering.J Fluency Disord26 (2) 149-58,

quiz 159-60.

This study measured changes in graduate speech-language pathology

clinicians attitudes after they had viewed either a factual video demon-

strating the fluency-evoking effects of altered auditory feedback (AAF)

or an emotional documentary showing the negative social conse-

quences of stuttering on a young girl. Twenty one subjects completedsurveys before and after viewing the emotional documentary, and

another group of 34 subjects completed surveys before and after seeing

a brief video on the amelioration of stuttering by AAF at both normal

and fast speaking rates. The post test results showed that both docu-

mentaries produced few changes in perceptions of stuttering, and the

changes that were produced were subtle. The results can not be consid-

ered as successful in modifying graduate clinicians perceptions of stut-

tering to better resemble the population described by prior psychologi-

cal and stuttering research. Past, present and future methodologies

attempting to change negative stereotypes of stuttering are discussed.

VOICEComins, J. (2001) Do you need to be trained tospeak? SingerApr-May, 25-6.

This article discusses the importance of the

speaking voice on- and off-stage, particularly in

singers who experience problems with talking

due to inefficient use of the laryngeal muscles

when speaking. When singers try to talk in the

same way that they sing, they use too much thy-

roid tilt, affecting voice quality. The comments

and advice of voice specialists, singing and

drama teachers and speech and language ther-

apists are recorded, together with tips for a

more efficient speaking voice.


14/32

early intervention


ver the last five years, the number

of referrals to speech and language

therapists in Ayrshire and Arran of

very young children presenting

with eating/drinking related diffi-

culties but with no specific medical diagnosis has

increased. However, working in the field of special

needs, it has come to our attention that, despite our

medical and nursing colleagues recognising the

appropriateness of referral of these children to ourservice, our involvement is often delayed. The intro-

duction of normal eating/drinking developmental

processes is therefore delayed and, in many cases,

increases already immature patterns of speech

development. In addition, late referral often pro-

longs the necessity of our involvement which adds

to the financial and resource burden of the service.

A Partnership in Developmental Care confer-

ence focused our thoughts and led us to review the

literature regarding developmental care and inves-

tigate how and to what extent the principles of this

model of care are incorporated into Neonatal

Intensive Care Units. It prompted us to consider

extending our current pathways of care to incorpo-

rate earlier intervention for our pre-Nursery clientgroup, many of whom were pre-term infants. (For

the purposes of this article, pre-term infants are

defined as those born before 30 weeks gestation

but not less than 24 weeks, weighing less than 1250

gms and mechanically ventilated within three

hours of delivery and for more than 24 hours in the

first 48 hours of life (Als et al, 1994.))

During the 60s and 70s much of the caregiving in

Neonatal Intensive Care Units focused on providing

care in a stimulation enriched environment in an

attempt to ameliorate developmental delays and

facilitate achievement of specific developmentalmilestones. Much research and reporting followed,

documenting the effects of such environments

including frequent handling and overstimulation

(Long et al, 1980; Gagnon 1989). As premature

infants do not have the neurodevelopment to

cope, they respond negatively to frequent han-

dling, displaying increased episodes of hypoxemia

(Long et al, 1980). Excessive noise causes increased

blood pressure, apnoea and bradycardia (Gagnon,

1989). In the last 10-15 years nursing practices

have altered in response to this evidence.

Values basedPioneering work by Hiedeles Als (Als et al, 1994)

focused on investigating the effectiveness of indi-vidualised developmental care in reducing med-

ical and neurodevelopmental sequelae for the

Making the

case for change

if referrals to your service

are being delayed introducing change is

slow and difficult

you aim for evidencebased practice

Read this

O

1. LightingThe pre-term infant isborn from a darkenedwomb into an environmentwhere the light iscontinuous, high leveland fluorescent.Infants can spendmonths exposed tothese conditions.Researchers have

hypothesised thatcontinuous light canresult in endocrinechanges, variations inbiological rhythms and

sleep deprivation(Jorgensen, 1993) and

studies have foundreduced incidence ofretinopathy when lightingwithin the incubator isreduced. In view ofthese factors, units nowreduce general lighting,cover incubators and

shield babies eyesduring procedures.

2. NoiseBritish SafetyStandards of 60decibels inside anincubator havebeen shown to befrequentlyexceeded inneonatal intensivecare units (Jack,

2000). Excessive

noise can damagedelicate auditory

structures andcause adverse

physiological andbehaviouralreactions, includinghypoxia andincreased intra-cranial pressure, so

staff are madeaware of theimportance ofreducing noiselevels within their

sphere of practice(Jack, 2000).

3. Care GivingStaff areencouraged to

provide carewhich makesuse of andenhancesinfants

specificstrengths anddiminishes

theirvulnerabilities,(Als et al,1994) and torecognise

stressbehavioursand regulatorybehaviours ofthe pre-terminfant.

4. Positioning of Pre-termInfant

Appropriate positioning isparamount in facilitatingneurobehavioural developmentand preventing posturaldeformities and delay inmotor development. Acontained mid-line flexed

supported position (Jack,2000) allows hand to mouth

activity, self soothing and selfregulatory behaviour as couldbe achieved in utero.Containment is an importantfactor in developing the pre-term infants feeling of

security and calmingbehaviours (Fleisher et al,1995) resulting in increasedweight gain and the pre-terminfant requiring lessmedication. Short et al(1996) showed that this

positioning technique canenhance neuromusculardevelopment of the very lowbirth weight infant.

5. HandlingAn importantfactor is sleep.Frequent handdisturbs sleep aleads to less wgain and decre

state regulatio(Jorgensen, 199Emphasis is plaon minimal

handling,promotingrestfulness,containmentduring and afte

stressfulprocedures,structuring sleeand feeding in

synchronisationwith the infant

sleep and wakecycles, individuacluster care andgiving attentiotimings (Jorgens1993; Als et al, 1

very low birth weight infant. This encourages

assessment of the individual infants ability to

cope with excessive stimulation and provides the

caregiver with information to modify each

infants environment and treatment strategies

(Jorgensen, 1993). Hence, Developmental

Supportive Care is not a product, or technologi-

cally based; rather, it is values based (Jack, 2000).

Developmental Supportive Care

is individualised, not consistently applied is derived from behavioural rather than scientific

reasoning

is complex not simple in its application

requires the involvement of multidisciplinary

teams including speech and language therapists

and physiotherapists.

Outcomes may not be readily identifiable but sig-

nificant positive outcomes of individualised devel-

opmental supportive care (Jorgensen 1993) have

been detailed as -

fewer days on the ventilator

earlier feeding success

reduction in the number of complications

shorter hospital stay

improved neurodevelopmental outcomes duringthe first 18 months of life.

Als et al (1994) investigated in some detail

Figure 1 - main characteristics of developmental supportive care

Anne Scott

Elspeth Mair



early intervention

whether there were improvements in medical and

neurodevelopmental outcomes when pre-term

infants were either cared for in a traditional man-

ner or the care followed developmental support-

ive care pathways. The pre-term infants were

assessed at two weeks and again at

nine months after expected date of

confinement. Prior to discharge the

developmental supportive care pre-

term infants demonstrated a signifi-cant improvement in the positive

outcomes detailed above. At two

weeks after the expected date of

confinement, the developmental

supportive care pre-term infants dis-

played improved symmetry of orien-

tation and motor performances,

modulation of tone, movement and

posture and a significantly lower

number of abnormal reflexes. At

nine months after the expected date

of confinement, significantly higher scores were

achieved on the Bayley Scales of Infant

Development and Mental Developmental Index

(Bayley, 1969) for the developmental supportivecare pre-term infants. The largest differences

were found in the control of gross and fine motor

Other professionals often recognise the value of speech and language

therapy but dont make referrals as early as we would like. Elspeth Mair

andAnne Scottscour the literature for evidence on best practice with

pre-term infants and use their findings to argue for earlier speech andlanguage therapy involvement in the multidisciplinary team.

7. Parents RoleWhen a babys condition is stable parents are then encouraged totake a more active role in their babys care. Principles ofdevelopmental supportive care are explained to them and parentstaught how to hold and comfort their baby, using swaddling andcontainment during care giving (Jack, 2000).Parent participation may also include Kangaroo Care. This is the

placing of infants, usually wearing nothing, on the parents chestunder the parents clothing. Kangaroo Care has been shown (Gale& VandenBerg, 1998) to have very positive outcomes for both thebabies and parents. Babies have shown more stable heart rates,

respiration rates, oxygen saturation, less apnoea, better stateregulation and greater conservation of calories. Parents havereported increased confidence and self-esteem. Kangaroo Care isoften cited as an advantageous practice for infants who will bebreastfed. It affords the infant the sensory interaction of touchand smell within the environment of the breast (Als et al, 1994).Not only can the parent and baby feel each others heart beats butthe baby becomes familiar with the smell of breastmilk. Gale &VandenBerg (1998) also describe the improvements achieved wheninitiating and maintaining breastfeeding - breastfeeding beginsearlier and lactation is prolonged, resulting in higher rates ofbreastfeeding at discharge.The sensory interaction, closeness and intimacy achieved duringKangaroo Care develops feelings of security and trust, aidscommunication between parent and child, and leads to facilitedorganisation of regulatory systems (autonomic, motor, state).

Non-Nutritive Suckingon-nutritive sucking is used within some neonatal intensive care units asart of developmental supportive care with the aim of reducing oralypersensitivity. As these pre-term infants are generally tube fed, they are notfforded the opportunity to suck nutritively. Non-nutritive sucking has beented as an effective practice to reduce stressors, facilitate progress and enablearlier discharge from hospital (Pickler et al, 1996; Field et al, 1982).ottle feeding can be a source of stress to pre-term infants and in recent timeson-nutritive sucking has been introduced as part of the developmentalupportive care within intensive care nurseries. Non-nutritive sucking istroduced five minutes prior to tube feeding in conjunction with appropriate

ositioning to facilitate hand to mouth activity. Jack (2000) reports that amoother transition from tube-feeding to oral feeding occurs when thisractice is in place.small developmental dummy is offered to pre-term infants during tubeeds in order to promote sucking and induce an inactive calm state. Infants

ffered dummies during tube feeds are said to average a greater weight gainer day, require fewer tube feeds, be ready to commence bottle feeding aboutree days earlier and leave hospital around eight days earlier (Field et al,

982).ome controversy remains regarding the use of dummies for infants who willubsequently be breastfed, as it is believed that this may lead to nippleonfusion (Lang, 1995). However, generally, most care professionals hold theew that non-nutritive sucking in pre-term infants contributes to increasedeight gain due to reduced restless activity and pro

Speech & Language Therapy in Practice, Spring 2002

Documents

Transcript of Speech & Language Therapy in Practice, Spring 2002