Speech & Language Therapy in Practice, Summer 2000

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SUMMER 2000

TrainingA client-centred approach

Intensive TherapyChanging trends

InclusionA model of good practice

Differential diagnosisAvoiding inappropriatetreatment

In My ExperiencePersonality traits

My Top ResourcesBilingual children

Reader Offers Win special needs

software Win aphasia

software

ISSN 1368-2105

C O P I N G W I T H C H A N G E

http://www.speechmag.com

How I managetransitionsservice children,special needs,adult neurology


2/32

http://www.speechmag.com

Reprinted articles

Clinical Focus on Dysfluency: Should alladults be treated? (Armin Kuhr, 1 (1), November1991)**

Clinical Focus on Education: Should teachers havemore training in language development? (Annocke, 1 (4), August 1992)**

Using the Alexander Technique in Voice Therapy(Carol Harris and Sheila Pehrson, 2 (3), May 1993)**

All from Speech Therapy in Practice* / Human

ommunication** , courtesy of Hexagon Publishing.

a report on the 8th Annual Meeting of the Dysphagia Research Society, USA

from Lisa Hurst and Paula LeslieIt can be quite an aggressive forum at which to present but world

experts are in attendance and available for discussion. This is thecutting edge of research and such a concentration of focused ideacan be very motivating.

Quality of light - Kim Talbot shares her experience of working atArohanui Special School in New ZealandOccasionally, I forget that challenges are good and a challengefrom a colleague - and particularly a parent - can throw me off

guard.

Short articles / conference reports / comments for the speechmag

site are welcome.

The Summer 2000 speechmag website includes:

Speech & LanguageTherapy in Practice

Also on the site - contents of back issues and news about the next one, links to other sites ofpractical value and information about writing for the magazine. Pay us a visit soon!

For more information please call 020 7424 4456 or visit our website at www.tpc-international.com

UK

UK norms Improved scoring

Now in full colour UK norms

NEW UK editions now available

CELF

Clinical Evaluation of Language Fundamentals

THIRD EDITION

UK

3

Full colour stimulus materials Upgrade kit available

Extended age range Quick start for current CELF-RUK users


3/32SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2000 1

14 InclusionWe make no distinction between the role played by

the specialist language teacher and the specialist

speech and language therapist. Both professionalswork collaboratively in the special school setting, so it

was an obvious step to work together on the

implementation of the new model.

Sarah Gill and Julia Ridley share a model of good

practice for partial integration of children with

speech and language impairment into a mainstream

secondary.

18 In my experienceAfter talking with a parent, professionals are often

aware that a child is quite tense or anxious. The

danger is that we register this fact as if it were simply

another of their traits - and fail to acknowledge that

the tension or anxiety is very often responsible for

the traits.

Patricia Sims believes the time has come for a

change in direction for childrens speech and

language therapy.

20 DiagnosisEarly and precise diagnosis is of major importance in

the management of Paradoxical Vocal Cord

Movement. It allows for rapid intervention,

maximising potential benefits and minimising surgical

and medical treatment for asthmatic symptoms, thus

reducing risks and side effects (Goldman, 1997).

Yifat Raz and Paul Carding find a path through the

maze of this poorly understood condition.

24 Further ReadingHearing impairment, dysarthria, dysfluency,

dysphagia,

bilingualism.

30 My TopResourcesA small grant from

our Trust and assorted

shopping trips later,

we have the first trialversion of

photographic object

and action pictures

featuring activities and

dress which reflects

the local community.

Carol Stow and Sean

Pert work with

bilingual children.

SUMMER 2000(publication date 29th May)

ISSN 1368-2105

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

Production:Fiona ReidFiona Reid DesignStraitbraes FarmSt. CyrusMontrose

Printing:Manor Group LtdUnit 7, Edison RoadHighfield Industrial EstateHampden ParkEastbourneEast Sussex BN23 6PT

Editor:Avril Nicoll RegMRCSLT

Subscriptions and advertising:Tel / fax 01561 377415

Avril Nicoll 2000Contents 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.

2 News / Comment

4 TrainingThe objectives of our training wereTo enable staff to:

carry out an assessment of their clients

communication skills

identify their clients communication strengths and

needs

formulate a booklet describing how their client

communicates

create a more positive communication environment

develop an individual plan for improving their

clients communication.

Tracey Moore and Amanda Irwin describe how

their client-centred approach to staff training is

leading to long-term improvements in

communication in a day care environment for adultswith learning disabilities.

7 Reader OffersWin Laureate software and Personalised Advice

Booklets for Aphasia (PABA).

8IntensivetherapyTherapy has been

directed

increasingly at the

whole person, with

encouragement to

change thinking as

a starting point for

altering not only

speech but

patterns of

communicating.

Latterly,

visualisation,

neuro-Iinguistic

programming (NLP) and hypnotherapy have

been used to expand thinking and control

mind and body as part of speechmanagement.

Rosie Sage reports on the Apple House

Courses which have been helping stammerers

for over 32 years.

12 ReviewsDeafness, cancer, phonology, voice, adult

neurology, education, AAC.

ContentsSummer 2000

Cover

picture by

Caroline

Hutcheson.

See page

25, How I

manage

transitions.

Photo

posed by

model.

www.speechmag.com

IN FUTURE ISSUES

APHASIA MORE ETHICS STAMMERING VOICE EARLY FEEDING PSYCHIATRY

FRAGILE X PROGRESSIVE NEUROLOGICAL DISORDERS

How I managetransitionsProbably the most fundamental

factor in facilitating a successful

transition between services is

active communication between

services and clients.Three contributions coming from

armed service children (Dawn

Synnuck), special needs (Fiona

Johnstone and Gillian Welsher)

and adult neurological (Anne

Whateley) perspectives consider

how we can smooth the path of

change.

25 COVER STORY

Please note our new address!


4/32

Experts believe an invisible hearing aid implanted into

the mastoid is set to replace conventional hearing aids

altogether.

The Totally Integrated Cochlear Amplifier (TICA) is cou-

pled directly to the middle ear bones, avoiding the need

for a loudspeaker. Even its batteries are implanted, mak-

ing it completely invisible and suitable for water activi-

ties without any special precautions. The TICA andVibrant Soundbridge, a semi-

implantable hearing device for

the middle ear in use for just

over a year, will be among

developments reviewed at the

3rd International Symposium

on Electronic Implants in

Otology and Conventional

Hearing Aids in Birmingham

from 31 May - 2 June, 2000.

www.otology2000.com

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 20002

news

A charity dedicated to improving access to technology

for disabled adults and children has opened its first cen-

tre in Scotland.

AbilityNet staff assess peoples needs at home, school or

in the workplace and provide adapted computer equip-

ment, training, technical support and awareness educa-

tion for carers, professionals and employers. A free

national helpline has had an increase in use of more

than 30 per cent in the past year.

The organisation now has offices in Warwick, West

Byfleet, Malvern, Liverpool, Reading, York and

Edinburgh. It works in association with partners from

public, private and voluntary sectors.

Freephone 0800 269545, www.abilitynet.co.uk

I CAN gofor itA challenging

programme of

fundraising events for

the year 2000 is

planned by the

national educational

charity for children

with speech and

language difficulties.

I CAN go for it is

seeking volunteers to

scale Mount Etna in

September and toundertake a nine day

jungle trek in Guyana

in November. At any

time of the year, the

charity is looking for

people to make a

10 000 foot sky diver or

solo parachute jump.

A registration fee of

250 is payable for the

overseas events and a

minimum amount of

sponsorship must be

raised.

For an information

pack, tel. Hannah

Bence or Kate Gannon

on 0870 010 40 66.

communication. Recommendations

include the assessment and pro-

vision of appropriate alternative

or augmentative communication

aids, and there is a list of what to

consider when preparing local

guidelines. Evidence based practice is

given priority, and tables of evi-

dence include the natural history

and management of dysphagia.

The Stroke Association welcomed

the guidelines, believing theyprovide a detailed framework

which will make it easier for hos-

pitals to introduce organised

stroke care leading to a massive

reduction in the levels of death

and disability from stroke.

See full text at:

www.rcplondon.ac.uk/ceeu_stro

ke_home.htm or order a copy of

National Clinical Guidelines for

Stroke (22 inc UK p+p) on 0207

935 1174 ext. 254.

For The Stroke Association, tel.

020 7566 0317.

New national clinical guide-

lines for the treatment of

people with stroke emphasise

the importance of client-cen-

tred, seamless care with specialist

management and an agreed

terminology.

The guidelines have been devel-

oped by an Intercollegiate

Working Party following a damn-

ing report on stroke care from the

Royal College of Physicians in 1999.Claire Gatehouse, chief speech and

language therapist at Northwick

Park Hospital, represented the

Royal College of Speech &

Language Therapists on the panel.

The guidelines make it clear that

Untrained clinicians may misdi-

agnose the cause of abnormal

communication. Accurate diag-

nosis is essential to guide and

inform the team and the family.

A speech and language therapist

is the most competent person to

assess a patient with abnormal

Accessfor all

SpeakabilityAction for Dysphasic Adults has been renamed

Speakability.

At a House of Commons reception to mark the

change, the charity called for greater access to

speech and language therapists, recognition that

loss of language can be severely disabling and access to appropriate support for lan-

guage disabled people. A quarter of a million people in the UK have aphasia.

Speakability, tel. 020 7261 9572, helpline 080 8808 9572.

Carol Bird of Walsall, WestMidlands, the first person inthe UK to have the VibrantSoundbridge implant.

Invisible aid

Evidence basedstroke care

HRH The Princess Royal opening

AbilityNet Scotland.

A qualityservice

A speech and language therapy service in Belfast is the

first to be accredited by the Royal College of Speech &

Language Therapists.

The new Signed-up to Quality scheme involved the

speech and language therapy department of the Royal

Hospitals Trust being assessed across 73 administrative andclinical standards. The department was commended in a

number of areas including clinical care, technology for

treatment of patients, audit and conference presentations

and publications.

Service manager Christine Hayden says, The scheme was

timely in that it provided the department with a framework

for a total service evaluation which met the Trusts Clinical

Governance agenda. The peer review aspect was important,

in particular the standards relating to clinical care. The

award adds to the Charter Mark and Royal Recognition

awards received by the department within the last year.

Partnership for ScopeThe national disability organisation whose focus is people with cerebral

palsy has benefited from a campaign at this years Education Show.

The British Educational Suppliers Association (BESA) used various meth-

ods to encourage educational suppliers to support Scopes work in edu-

cation. Scope runs seven special schools for children whose educa-

tional needs cannot at present be met by mainstream education. It

also operates a School for Parents network which helps parents in

preparing preschool children for mainstream and special school.

BESA supports Scopes campaign for equality in education for disabled

children.

The Education Show ran from 23-25 March at the NEC Birmingham.

Scope, tel. 0171 619 7200.

Parkinsons campaignA campaign aims to increase the num-

ber of Parkinsons Disease Nurse

Specialists in the UK.

The Parkinsons Disease Society is con-

cerned that only 64 such staff are

employed in the UK and believes 240 are

required if there is to be a nationwide

and equitable service. The nurses providea link for people with Parkinsons and

other health and social care profes-

sionals. They can give information on

drugs, monitor therapies, provide

education and training and offer

essential emotional support.

The PDS now has a freephone

Helpline staffed by nurses with a spe-

cialist knowledge. It is open from

9.30am-5.30pm.

PDS, tel. 020 7931 8080, Helpline 0800

800 0303.



news & comment

Moving onClients are often moved on in the sense of having their therapist or

placement changed - but do we help them move on mentally? The three

contributors to How I manage transitions point out how difficult change is

for everyone, and how much more so for people with communication

difficulties who dont have the strategies to make sense of it.

A key message ofJulia Ridleyand Sarah Gills article is that support must be

given before, during and after a real life event for it to be effective. We shouldtherefore plan therapy to include adequate preparation of the client, specialist

assistance during the event and time afterwards to catch up, reflect on and

reinforce what has been experienced. As they have realised, it is not only the

client but staff who are able to move on professionally as a result. In a different

setting, Tracey Moore andAmanda Irwin have also found a way of helping

carers take responsibility for developing their clients access to communication.

Reading the reprinted articles on thespeechmag website

(http://www.speechmag.com), we see how the profession is moving on by

building on what has gone before. Carol Stowand Sean Perts top resources

draw heavily on their enthusiasm for computers. Given the increase in

information available via the web and software for therapy, the profession

has to continue moves in this direction.

Constant change can be threatening, but less so if it is evolution rather than

revolution. In her report on the fluency courses at the Apple House, Rosie

Sage comments that the treatment, while not being controversial, is curious

because of its longevity. Therapists there built on their earlier understanding

of stammering and fluency control techniques, over time incorporating the

importance of communication with an audience and ways of tackling the real

life implications of a stammer.

Patricia Sims has moved on from traditional speech and language therapy

approaches to looking at anxiety and tension as an underlying cause of

various childhood disorders. The interplay between the physical and the

psychological is also explored by Yifat Razand Paul Carding. The authors

stress the importance of the multidisciplinary team working effectively to

avoid clients going round in circles and receiving inappropriate symptomatic

treatment.

The new multidisciplinary stroke guidelines from the Royal College of

Physicians also attempt to address this (see news, page 2). They were

developed in response to qualitative research with the people who know

how clinically effective we are being - the clients and their families. By

facing up to rather than ignoring unpalatable facts about the service we

offer, clients, families and professionals have the opportunity to move on

in every sense.

...comment...

Afasic AbstractThe charity representing children and young adults

with communication impairments is bringing infor-

mation about new developments in research and

practice to professionals and parents.

Three year funding for the twice yearly Afasic

Abstract, edited by Professors Julie Dockrell and

Geoff Lindsay, has come from the Department of

Health. Each broadsheet will be distributed to

schools, speech and language therapy services, GPsurgeries and educational psychology and specialist

teacher services and can also be accessed on the web.

Afasics other plans for this year include expanding

the Helpline service, training additional volunteers,

appointing development workers across parts of the

UK not currently covered and developing Afasics

website and corporate image.

Afasic, tel. 020 7841 8900, Helpline 08453 55 55 77,

www.afasic.org.uk

Avril Nicoll,

Editor

33 Kinnear Square

Laurencekirk

AB30 1UL

tel/ansa/fax 01561

377415

e-mail

[email protected]

Software for phonologyA research project aims to develop and evaluate

software for children with phonological difficulties.

Subjects recruited to the Hear IT - Sound ITproject

based in Bristol will be aged between four and eight

years, attend mainstream schools and have receptive

language within normal limits. In the final phase of

the study, the children will be randomly allocated to

one of two groups - those receiving standard therapyand those receiving standard plus computer therapy.

Details: Yvonne Wren, research speech and language

therapist, e-mail [email protected]

Autism actionAutism Awareness Week from 15th May aims to raise

the profile of autism and Asperger syndrome amongthe general public.

Led by the National Autistic Society, the title of this

years campaign is Action for Autism.

Details: NAS, tel. 0171 833 2299.

Office for WalesThe Parkinsons Disease Society has opened its first

Welsh office in Pontypridd.

There are an estimated 6000 people with Parkinsons

in Wales where the society has 15 branches. In addi-

tion to improving the speed and level of support for

families and carers, the office will allow the society to

respond to the local cultural and political landscape.

PDS Wales Office, tel. 01443 404916.

Child careThe strategic body representing everyone working

with children up to eight years is promoting involve-

ment of men, people from ethnic minorities andpeople with disabilities.

The Early Years National Training Organisation is

undertaking a case study survey to show how chil-

dren can benefit by being cared for by these groups.

Overall, the bodys aim is to raise the standard of

care and education of young children by identifying

training needs and facilitating provision for high

quality training for the Early Years sector.

Early Years NTO, tel. 01727 738300, e-mail

[email protected]


6/32

training


s speech and language therapists

working with adults with learn-

ing disabilities, we are frequently

faced with a surge of referrals

from a Social Education Centre.

Even after setting up several

communication groups, many clients remain who

need individual communication action plans. In

the past we have spent many hours assessing

these clients and meeting with a large number of

staff on a one to one basis, discussing similar

issues, only to find the action plans discarded

inexplicably a few months later. We were desper-

ate to find an alternative way of working with

this particular client group and service providers.

As a department, we see training significant

others as a priority. We also recognise that the

success of our interventions depends on the

staff/carers we work through, and we needed to

take into consideration the large number of

referrals we receive, our limited resources and the

demands already made on staff within the Social

Education Centre environment. Other speech and

A

Making animpactThe success of therapy often depends on the staff

or carers we work through, and training significant others

therefore has to be a speech and language therapy priority.

The frustration comes when what is taught does not

translate into a long-term change in practice. Tracey Moore

andAmanda Irwin describe how they have addressed this

with a client-centred approach in a Social Education Centre.

Read this if you want to ensure communication

action plans aremaintained

motivate carersinterest in

communication change staff

behaviour to improvea clientscommunication

language therapists working in day care environ-

ments may be interested in our project, particu-

larly in the light of the limited number of pub-

lished assessment and training packages in this

field.

OwnershipOur aim in developing the package (table 1) was

to:

1. increase staff follow-up of individual communi-

cation action plans by

involving staff throughout the process of

assessment and programme planning to

develop ownership of the action plan

ensuring action plans are realistic and achievable

by giving staff responsibility for developing them

raising staff awareness of communication

difficulties and their consequences to help them

understand the need for intervention

2. help staff identify changes within the environ-

ment which would benefit all clients.

The importance of creating a positive communi-

cation environment for people with learning dis-

Tracey Moore and Amanda Irwin



training

abilities is widely recognised. Our professional

standards state: Building an environment that is

conducive to good communication is particularly

significant to this client group. It

must be recognised that developing

improved physical surroundings,

personal circumstances and appro-

priate communication used by car-

ers will significantly benefit the

clients communicative success.

(Royal College Of Speech and

Language Therapists, 1996, p.134.)

The importance of increasing the

knowledge and skills of significant

others is frequently identified with-

in the literature. Cullen (1988) stat-

ed ...in order to change the com-

munication skills of the clients, it

may be essential to first change the behaviour of

staff.

The package was presented to the Social

Education Centre manager clearly stating the

aims of the approach and the commitment

apist being off sick for a long period during the

course, an extra session was held to reorientate

staff. Staff put forward many suggestions for

improvements within their day to day practice to

enhance the communication of their chosen client

and other service users. These were written up in

the form of action plans (see examples in table 2).

The course was evaluated qualitatively through

notes kept by the speech and language therapist

following each session, feedback forms complet-

ed by staff on the final session and an interview

with staff six months after the course to review

the progress of the action they had identified dur-

ing the course.

SupportMany issues were highlighted as the course pro-

gressed, for example:

Staff needed more support in developing their

action plans than we anticipated.

Some staff appeared anxious about being asked

to complete assessments and a

communication action plan. We felt this was

required from staff, and the managers agree-

ment was obtained. Van der Gaag and Dormandy

(1993) state the success of any training initiative

depends upon securing

and maintaining the sup-

port of the management

(p.143). Staff members

were nominated by the

manager to represent

each of the clients

referred for input.

Nine staff attended the

course - three practice

supervisors, four day cen-

tre officers and two care

assistants. Each selected

one client to work with

throughout the training

period. We recommended that staff chose a

client with whom they worked on a regular basis.

When designing the course we planned to hold

six sessions - five one hour sessions and one three

and a half hour session. However, due to the ther-

We were desperate to

find an alternative way of

working with this

particular client group

and service providers.

Table 1 - Training Package

5 x 1 hour workshops at weekly or fortnightly intervals.1 x 3 hour 30 minute workshop (session no. 4).

Interactive sessions involving discussion of key topics and stafffeedback of assignments completed between sessions.

Each staff member to select a client with a communication difficultyto work with throughout the course.

To enable staff to: carry out an assessment of their clients communication skills identify their clients communication strengths and needs formulate a booklet describing how their client communicates create a more positive communication environment develop an individual plan for improving their clients

communication.

1. Assessing communication: what we need to consider when assessing communication methods of communication assessment2.The importance of consistent interpretation of

communication behaviours and the development of a

communication booklet to encourage this3.Categorising a clients communication with regard to strengths

and needs4.Observation of staff-client interaction - identification of

good partner skills5.Choices: comparing the number, quality and types of choices we make

with those made by people with learning disabilities increasing the number of choices available within the Social

Education Centre environment6.Using objects, pictures, symbols and signs (Makaton) to create a

positive communication environment7.Formulating a communication action plan to meet an

individual clients needs.

Course participants to present completed communication actionplan to significant others.Therapist to offer support should they wish to implement a similarprogramme in their environment.

Table 2 - Examples of action identified by staff

1. to develop guidelines regarding the use of key phrases,

Makaton signs and objects of reference with their

chosen client

2. to use objects to help the client anticipate what isgoing to happen next, for example:

giving the client a cup to let him know it is time for

coffee

assisting client with her apron to let her know dinner is

being prepared

3. to enable the client to use objects to initiate, for

example a tape to request that music is put on

4. to obtain pictures of activities so the client can be

shown what is going to happen next

5. to develop a communication book to encourage

initiation of / engagement in interaction and provide a

means of requesting an activity if s/he is unable to

express it verbally

6. to identify / document Makaton signs client already

knows

7. to inform other members of staff of the Makaton signs

to use with the client

8. to introduce new Makaton signs (list of signs

identified)

9. to include client in a Makaton group

10. to organise Makaton training for staff

11. to reinforce an appropriate greeting such as shaking

hands

12. to assist client to choose own snack / drink at the

snack stop.

Sessions

Teaching Style

Objectives

Topics

Involvement OfSignificantOthers


8/32

Yvonne Collins, course participant

possibly due to the terminology used rather

than the task itself.

There was a poor response to the letter to

significant others inviting them to attend a

meeting to discuss the communication action

plan. Only one out of nine responded, although

the therapist was also aware of one other carer

who made direct contact with

the staff member concerned.

On the final session, staff were

asked to list the advantages and

disadvantages of the course

(tables 3 and 4).

Seven of the nine course partici-

pants were interviewed six months

after completion of the course.

(Six of the nine staff were still

working at the Social Education

Centre, one had moved to another

Social Education Centre, one had retired and one

was on maternity leave.) The action plans had

been passed on by two out of three of the mem-

bers of staff who were no longer at the Social

Education Centre. Staff were continuing to work

on action plans for eight of the nine clients stud-

ied during the course.

The interviewees were asked if their day to day

training


Table 3 - Most frequently identified advantages

1. having the opportunity to discuss clients communication skills / needs with others (five

staff)

2. being involved (three staff)

3. an increased awareness of the need to consider how we communicate with

client (two staff).

Table 5 - Improvements in working practice

I use more objects of reference and Makaton.

Weve set up a Makaton group and are reinforcing the use of

Makaton in everyday practice.

If I cant communicate one way, I try something

else - for example, demonstrating using objects,

making use of touch, Makaton.

Were more aware of the need to provide choices

for dinner.

Im more aware of the non-verbal behaviour of

clients.

It has sharpened my practice and brought to my

attention different methods of communication.

Table 4 - Most frequently identified disadvantages

1. insufficient time to

complete assignments (four staff)

carry out recommendations made on the course (three staff)

2. time-scale (due to therapist being off-sick) (three staff).

practice had changed since attending the course.

One member of staff reported that she had less

contact with special care clients now due to man-

agerial responsibilities, but she felt she was possi-

bly more aware of how other staff are interact-

ing. One member of staff didnt feel her practice

had altered as Im always aware of the need to

improve communication. Five

members of staff identified ways in

which their working practice had

improved (examples in table 5).

The training package we devel-

oped was very successful. Positive

feedback on the course was

obtained from staff and many

excellent ideas were put forward

for improving the communication

skills of clients and creating a posi-

tive communication environment

within the Social Education Centre. In eight out of

nine cases communication action plans were being

continued six months after the course, according

to staff reports, and an increase in staff knowl-

edge was noted by the speech and language ther-

apist following the course. Additionally, positive

working relationships developed through the

implementation of the programme.

Modifications to the course in the future will

include:

1.Reconsideration of the terminology used to

describe the course - that is, the use of words

such as assessment.

2.A formal agreement with managers prior to the

course to ensure:

Staff will be given time to complete

assignments.

Staff will be supported in carrying out their

action plans following the course.

Staff selected will be working with their client

for the foreseeable future.

3.Modifications to the course content to meet the

needs of Special Care clients.

4.Reconsideration of how significant others could

be involved in the project to provide a

consistent approach for the clients.

5.Meetings with staff during and following the

course to provide further support and guidance.

It may also be useful to consider using video

recordings during the course particularly when

discussing how staff can support clients commu-

nication. This will raise issues of an ethical nature

and will therefore need careful consideration.

Although the course appeared to be very suc-

cessful, the evaluation methods used were limited.

Staff needed more

support in

developing their

action plans than

we anticipated.

Chris Barnbrook,

course participant

Lyndon Rogers and Ruth Powell, , course participants

Barbara Maltby, course participant


9/32

To provide more conclusive evidence further mea-

sures would need to be obtained, for example:

measures of staff behaviour before and after

the course, such as mean length of utterance, or

frequency of use of augmentative methods of

communication changes in client communicative behaviour, for

example an increase in initiations.

MouldedSince the initial project, the training package has

been repeated in several daycare placements with

similar success. The project has also been imple-

mented in resi-

dential homes.

Although many

positive comments

were obtained

from staff, the

therapist felt that

the project was

less successful in

these environ-

ments and staff

appeared to have

more difficulty

taking responsibil-

ity for devising

action plans. This

perhaps supports

Van der gaag and

Dormandys 1993

statement that It

is important that

training is mould-ed as closely as

possible to the individual care staff and the con-

texts in which they work.

Our evaluations suggest this method of working

is an effective approach for use within the Social

Education Centre and other day care environ-

ments. It has resulted in increased staff awareness

and knowledge and this has had a direct impact on

both the clients studied within the training pro-

gramme and other clients with whom staff work.

Tracey Moore and Amanda Irwin are specialist

speech and language therapists, Adult Learning

Disabilities, for Dudley Priority Health NHS Trust

(Thanks to Prof. Margaret Bamford for support

and advice).

ReferencesCullen, C. (1998) A review of staff training: the

emperors old clothes. Irish Journal Of Psychology

9, p309-323 cited in Chatterton, S. (1999)

Communication Skills workshops in learning dis-

ability nursing. British Journal Of Nursing 8 (2).

Royal College Of Speech and Language Therapists

(1996) Communicating Quality 2. RCSLT.

van der Gaag, A. and Dormandy, D. (1993)

Communication and Adults with Learning

Disabilities. New Map of an Old Country. Whurr

Publishers.

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2000 7

training

eflectionsDo I ensure

managers of care

taff are fullybehind training

nitiatives?

Do I encourage

taff to take

esponsibility for

developing their

own ideas?

Do I amend the

raining I offer

according to the

ecipients needs?

PABA is a new software package incorporating the latest theoretical

and practical approaches to aphasia. It contains advice on the specific

nature of the language impairment and helpful strategies which can

be selected for each client according to their needs. Personal infor-

mation such as family, friends, interests and work can be printed from

information provided by the family on the carers questionnaire.

Gender sensitive text and graphics are selected automatically.

Once the therapist has decided on content, the booklets can be

generated by an assistant or secretary in under 10 minutes. The

result is a cost-effective, professional looking booklet tailored

to each individual client.

Speech & Language Therapy in Practice has a copy of PABA to give away FREE to a lucky sub-

scriber courtesy of its developers, the speech and language therapy department and medical illustra-

tion services at Glasgow Royal Infirmary.

To enter, simply send your name and subscriber number / address marked PABA to Avril Nicoll,

33 Kinnear Square, Laurencekirk AB30 1UL, tel. 01561 377415, e-mail [email protected]

by 14th July, 2000. The winner will be drawn randomly from all valid entries.

PABA will run on most modern PC and Macintosh computers. Demo versions of the software can

be downloaded from http://www.medill.co.uk. It normally retails for 240 + VAT.

PABA is available from Medical Illustration Services, Royal Infirmary, Glasgow, G31 2ER, tel. 0141 211 4692.

Laureate software, developed in the USA by Dr Mary Sweig Wilson to complement her Linguistic

Hierarchy, is now available in the UK. Speech & Language Therapy in Practice has a single user

copy of First Words I, First Words II and First Verbs to give away FREE to a lucky reader, courtesy

of Rompa, the UK distributor.

These computer programmes are recommended for children and adults with special needs who

need to master essential early vocabulary, for example, those with language learning disabilities,developmental disabilities, physical impairments, visual impairments, hearing impairments and

autism. They provide highly-structured tutorial training of 100 early developing nouns and 40

verbs. There are six levels of direct instruction and a variety of features allowing you to customise

lessons. Record keeping is automatic.

To enter, simply send your name and subscriber number / address marked Laureate to Avril

Nicoll, 33 Kinnear Square, Laurencekirk AB30 1UL, tel. 01561 377415, e-mail avrilnicoll@speech-

mag.com by 14th July, 2000. The winner will be drawn randomly from all valid entries.

Laureate Learning software will run on most modern PCs, for example, anything from a 486 with

Windows 95. Recommended levels are Windows 98, Pentium processor and 16MB RAM. The pro-

grammes normally retail at 199 each or 389 for all three. A FREE demonstration CD ROM and

further information is available from Rompa, tel. UK local rate 0845 3000 899 (01246 505 151

from outside UK) or http://www.laureatelearning.co.uk

1. Entrants must subscribe personally or as one of a department to Speech & Language Therapy inPractice, and only one entry per subscriber number is allowed.

2. Entries must be received by the editor on or before 14th July, 2000.3. The winner will be randomly selected from all valid entries.4. The winner will be notified by 21st July, 2000.5. The winner will have access at work to suitable computer hardware.6. The winner will be required to review the prize for Speech & Language Therapy in Practice by a

date agreed with the editor.

1. Entrants must subscribe personally or as one of a department to Speech & Language Therapy inPractice, and only one entry per subscriber number is allowed.

2. Entries must be received by the editor on or before 14th July, 2000.3. The winner will be randomly selected from all valid entries.4. The winner will be notified by 21st July, 2000.5. The winner will have access at work to suitable computer hardware.6. The winner will be required to review the prize for Speech & Language Therapy in Practice by a date

agreed with the editor.

Win

Win Laureate software

Congratulations to Neil Thompson who won theBoardmaker software courtesy of Mayer-Johnson in the Winter 99 issue of Speech &Language Therapy in Practice. Neil will review the software in a future issue.

The winner of the five audio taped translations of Does Your Young Child Stammer?courtesy of the British Stammering Association in the same issue was Ann Adams.

Personalised Advice Bookletsfor Aphasia (PABA)

Previous winners...

..READ

ER

O

FFER

S..READ

ER

O

FF

ERS..READ

ER

OF

FERS..READ

ER

O

FFERS..

COMPETITIONRULES:

COMPETITIONR

ULES:


10/32

intensive therapy


tammering has intrigued man for cen-

turies. Laotze mentioned this interrup-

tion of speech rhythm in a poem 500

years BC. The Bible (1611) proclaims the

blessings of the glorious kingdom, The

tongues of stammerers shall speak

plainly. Contentious treatments have included

whistles beneath the tongue, leeches on the lips,

leather chest straps and elk oil.

Dysfluency has resulted in many management

philosophies such as self-help, psychotherapy,

behaviour modification, speech education, mindcontrol, medication and surgery. Six common

treatments were ranked by Andrews et al (1980)

in order of effectiveness: prolonged speech, gen-

tle onset, rhythm, airflow, attitude therapies and

systematic desensitisation. The conclusion was

that techniques can be beneficial and compare

favourably to others in health sciences.

Most therapy programmes now contain ele-

ments of teaching the person who stammers to

modify dysfluency as well as reducing fear and

avoidance behaviour. Therapists work to change

attitudes and build self confidence and communication

skills in a range of informal and formal activities.

However, efficacy studies are victims of account-

ability, looking only at outcomes of specific

processes and procedures as evidenced in calcula-

tions of percent dysfluency. Although used as a

progress measure, it encourages teaching to the

test, ignoring complexities of internal and external

changes taking place in and after treatment.

Studies generally lack client views and the ques-

tion of whether treatment works is limited to

measurement of dysfluency in clinical rather than

normal situations.

Offering hopeThree factors regarding dysfluency are mentioned

in the literature.

1.Predisposing ones are hereditary. Researchers

Read this if youare interested in: how therapy

trends arechanging

getting clientsviews

relating theoryto practice

S

Reachingthe partsothers dont

(Andrews & Harris, 1964; Bloodstein, 1987;

Peters and Guitar, 1991; Webster, 1996) indicate

50-70 per cent of people who stammer show a

genetic pattern.

2.Precipitating factors include upsets, illnesses or

losses that activate existing biological weaknesses.

3.Perpetuating ones, such as insecurity, stress and

unsuitable demands facilitate development of

stammering behaviour.

Presently, little can be done about predisposing

and precipitating factors. Perpetuating factors,

however, offer hope. Cooperative approachesbetween parents and professionals now exist, so

lessening chances of dysfluency becoming estab-

lished in infancy. Therapy has taken a broader

approach, concentrating less on speech and more

on a relationship with an audience. This has led to a

communicative focus with opportunities to develop

a wider range of skills and change mental attitudes.

In addition, brain scan techniques are pinpoint-

ing neural activity and show how the electrical cir-

cuitry is altered so biochemical movements are

understood. Webster (1996) describes this in rela-

tion to fluency and non-fluency behaviour. Present

work, under Professor LeDoux at the Center for

Neural Science, New York University, holds

promise. Certain connections between nerve cells

within the amygdala, at the brain base, become

strengthened when someone learns to fear. The

rate at which nervous signals flow through the

brains fear centre is raised, so increasing intensity

of emotion. This confirms the importance of con-

trol methods in managing dysfluent speech.

The treatment reported here is curious because

of its longevity. Gerda Wilson managed adult flu-

ency problems at the Apple House from 1966 -

1998. Part-time input from Sylvia Davey, a noted

voice specialist, was available from 1976. Research

took place in 1997-1998 to evaluate a unique

treatment experience before retirement of both

therapists as follows:

photocourtesyoftheBritishStammeringAssociation,t

el02089831003

Dysfluency is as much a social problem as a personal one. For therapy to succeed, it

must help clients interact effectively in spite of any continued dysfluency. According

to participants, courses at The Apple House in Oxford over the past 32 years have

addressed this successfully. How? Rosie Sage reports.



intensive therapy

A) Audit of course activities as a record of theory

and practice.

B) Four client case studies to present real life

issues of individuals and families.

C) Questionnaire to 25 per cent of past clients to

elicit information on course satisfaction.D) Communication profile and follow-up of

participants on a 1997 course.

E) Course rating.

A) AuditFluency courses began at Warneford Hospital, site

of Oxford University Institute of Psychiatry, as

research by Dr Seymour Spencer, Consultant

Psychiatrist, and Catherine Renfrew, Chief Speech

Therapist, in 1964. Psychotherapy and drug treat-

ment for people who stammered was unsatisfac-

tory and a method targeting speech fluency was

more appropriate. The aim was to replicate work

of Andrews and Harris (1964) using syllable-timed

speech, giving each word-part equal emphasis.

The method proved positive for dysfluent speak-

ers. Ten-day intensive courses were set up and 800

plus adult clients have been treated.

Over time, other methods of shaping talk have

been introduced. Therapy has been directed

increasingly at the whole person, with encour-

agement to change thinking as a starting point

for altering not only speech but patterns of com-

municating. Latterly, visualisation, neuro-

Iinguistic programming (NLP) and hypnotherapy

have been used to expand thinking and control

mind and body as part of speech management.

Each course is tailored to meet the specific needs

of each client group of eight people, from aframework of five core principles:

1. Speech EducationParticipants are introduced to speech control

methods: slowed speech below normal rate; pro-

longed speech by lengthening long vowels; sylla-

ble-timed speech from altering timing patterns;

slow onset, soft contact speech by gliding softly

onto words and airflow techniques releasing

breath then word. A technique other than pro-

longed speech (more unnatural than the other

methods) is chosen as the start for normal talk.

Speech emphasis is reinforced when participants

describe their stammer:

tongue and jaw shoot forward, lips pout in a

sucking action, words muddle, panic sets in,

tongue feels too big, lack of breath, muscles tense

everywhere, words catch in the throat, powerless,

idiotic sensations, sounds forced out, mouth dries,

choking feelings.

Descriptions suggest speaking occurs with the

tongue forming the anterior wall of the throat.

The larynx drops to allow for this as in the infant

sucking pattern. In adult speech, the tongue and

Iarynx drop back and down as the styloglossus

muscle strengthens to suspend the tongue back-

wards and upwards for greater mobility in talk-

ing. Voice work strengthens this muscle so the

tongue is in a better position and dysfluency more

easily controlled. Beasley (1876) suggested dysflu-

ent speakers: Learn the art of speaking. This will

induce self-respect, calmness and confidence.

Although improper use of articulators as the

cause of dysfluency is not implied, its involvement

is suggested. Work on voice dynamics and therhythm of an utterance is part of the process of

learning to communicate effectively.

2. Communication OpportunitiesAvoidance behaviour has cumulative effects with

speaking skills underdeveloped for a range of situa-

tions. Participants are prepared in role plays to try

speaking activities such as enquiring about train

times. They alter performance from

group/video/audio feedback before tackling real talk

outside the Apple House. Prose, poetry, play readings

as well as talks, discussions and question and answer

sessions facilitate effective communication.

3. Group Support and InfluenceThe forming, storming, norming, conforming and

performing processes of group interaction help

participants come to terms with difficulties and

find ways of dealing with these based on others

experiences. The therapist pro-

vides activities, monitors per-

formance, encourages and

reproves it if necessary and,

although their presence may

prevent the emergence of a

leader, there is continual

opportunity for individuals to

use initiative. The Apple House

does not have the feel of a

taught course and participants

describe a family atmosphere

in surroundings which demon-

strate value, care and consid-

eration for everybody. The set-

ting helps relaxation and enjoyment of the

course. The Stammer Trust works to provide

resources which have included renovating and

equipping the Apple House.

4. Attitude and Behaviour Changethrough TherapyParticipants think of themselves as stammerers

and this construct is reinforced by families, friends

and work colleagues. A person who is dysfluent

does not produce a normal response in communi-

cation exchanges so cannot experience positive

feedback. They may describe a holiday incident,

producing a hesitant, incoherent account result-

ing in their listener looking away embarrassed, or

anticipating and supplying words not uttered

freely. When faced with a repeat they anticipate

the struggle and expect to perform badly. So, a

person with dysfluent speech may avoid certain

sounds, words, phrases, topics and unpleasant

experiences such as using a telephone. Allowing

others to speak for them, circumlocution or com-

plete silences are strategies employed.

To deal with learnt responses and negative feel-

ings, the client is helped to think differently

before changing behaviour. Using relaxation,

visualisation, neuro-linguistic programming and

hypnotherapy, they free unhappy experiences

stored unconsciously and develop positive selfconcept and control. When relaxed, the mind can

create, with visualisation enabling a person to

face angry and miserable feelings, leading

through this process to less threatening forms.

The experience allows the brain to develop

whole notions (Bell, 1991) as well as critical and

creative thinking to understand the totality of the

problems and different ways in which they can be

solved. Participants vouch that to thinkbetter is

to feelbetter,speakbetter and be better.

5. Maintenance ActivitiesNine intensive, consecutive days begin changes

but these must continue if fluent speaking is to beattained. Monthly follow-ups offer further prac-

tice and support for as long as is needed.

Supervision is vital, as research suggests 50 per

cent of people undergoing treatment will relapse

after a year (Garvin-Cullen, 1990). The Stammer

Trust provides links through a newsletter

and social events, establishing networks

for those who want them.

Therefore, the aim is to help the person

present themselves confidently and clear-

ly to others. Attention to speech alone is

useless. The new fluency is an aid to a bet-

ter life - but how? It is not just going out

and speaking competently but under-

standing how the fluency and good feel-

ings it generates can help towards a new

way of communicating and living whilst

maintaining and improving this. The

client needs help in rearranging their life

and communicating more effectively.

But who can best judge the quality and effective-

ness of a particular treatment and by what criteria

- objective external evaluators or subjective inter-

nal participators? There is growing consensus that

clients are the most informed, fair judges of their

experiences and this study design reflects this view.

B) Case studiesFour cases were chosen at random from AppleHouse records to present individual views of the

courses. Two subjects attended in the 1960s and

the others during the 1990s. Three were male and

one female to reflect the reported gender ratio

for dysfluency. Participants were asked the same

six questions over a two hour period, including

How do you think about your stammer? and

How has the course helped you to communicate

more successfully?

Answers suggest that, in spite of initial lack of

success in reducing the stammer and continual

negative experiences, it is possible to progress per-

sonally and achieve good jobs. Dysfluency may

prohibit a career dependent on constant speaking.

efficacy studies are

victims of

accountability,

looking only at

outcomes of

specificprocesses

and procedures


12/32

intensive therapy


Helen wanted to be a television presenter but

ended up a dress designer and Paul wished to lec-

ture but decided the Civil Service was a better

option. Most people adjust aims because of cir-

cumstances and the interviewees show ability to

do this successfully.The course reduced suffering. Robert suggests

he is now cured although sometimes dysfluent.

Misery has gone and the stammer is no longer a

dominant issue. He suggests people feel that flu-

ent speech leads to instant happiness but this is

rarely the case. Many problems are bound up in a

stammer and must be tackled for a successful out-

come. John mentioned that the Apple House

course got to the parts that others didnt and

all four subjects suggested this was the reason it

had worked for them. They felt the Apple House

offered a total approach in contrast to previous

treatments that mainly targeted fluent speech

with less emphasis on personal and social issues.

C) QuestionnaireA four section questionnaire was sent to 200 (25

per cent of) past participants. Six were sent to a

random sample of the 25 clients on average each

year (192). Seven were sent to the first and last four

years to make up the sample of 200. A 79 per cent

return rate, with an even response across years,

was achieved. There was a variability of responses

within and across years with a tendency for satis-

faction to increase a year post-treatment, so this

could be a useful point to evaluate. Age is not a sig-

nificant factor in predicting successful outcomes.

Section 1 presented 20 communication skills

(selected after an exercise on the January 1997

course) for a binary rating: happy / unhappy, to

provide a general impression. Table I records sat-

isfaction with communication skills, ranging from

34-90 per cent, with an average rating of 65 per

cent evenly spaced across age groups. In the first

10 rankings, 80 per cent refer to non-verbal and20 per cent to verbal skills whereas in the bottom

half the reverse is the case. Formal communica-

tion brings most trouble but this is probably the

case for everybody. Section 2 required comments

on how the course has helped (most significant in

table 2). There are roughly four positive com-

ments to each negative one. Section 3 requested

views on how the course has not helped (most sig-

nificant in table 2a). Section 4 used an interval

scale I - 10 to rate the course.

D) Profile and follow upOne aim was to find a method to measure change

but the project timing only allowed 12 clients to

be monitored. A profile, comprised of 40 state-

ments representing a range of positive and nega-

tive views about how a subject felt about them-

selves and their communication, was used and

rated true or false. Test-retest reliability was at a

0.9 level. Five out of a possible twelve subjects

completed a pre/post course and six month fol-

low-up profile.

They present very different profiles, with initial-

ly subjects A and E showing almost exact oppo-

sites in negative / positive views. Over the group,

the six month period demonstrated an increase in

positive views and a decrease in negative ones.

The time of greatest change was during the

course, but there was a steady increase in positive

attitude at the six month stage. Cases A, B and D

were experiencing difficult circumstances at this

time which undermined their performance. Their

profiles confirm this when compared with C and

E. Since data suggests a year post-treatment that

respondents feel happier about communicationskills, information indicates attitude changes

before behaviour.

E) Course RatingTable 3 reports course rating and frequency values.

An 81 per cent level of satisfaction, with 89 per

cent of replies clustering in the 7-10 band, suggests

high success when compared with other health

service treatments which deem a 65 per cent rat-

ing as excellent. The crucial outcome for partici-

pants is increased self-confidence (66 per cent).

The fact that 42 per cent of respondents are still

unhappy about fluency is less important. As Robert

(a case study) reminds us: The first and most

important thing to do for someone who stammers

is to cure the unhappiness and instil confidence.

Three per cent reported no improvement in fluen-

cy although feeling better about coping with life.

Answer in interplayWhy is the Apple House course successful? The

answer may lie in the interplay between the neu-

rology and psychology of stammering. Webster

(I996) suggests high right brain activation in those

who stammer (reverse of normal state) is linked

with fear. This overflows to the left hemisphere

and interferes with the supplementary motor area

organising speech movements. Fox (1996), whose

imaging techniques showed intense activity in the

Table 1 - Satisfaction with communication skills

The Communication Skill No. responses No. positive % positive

1. Listening attentively 146 131 89.72. Chatting informally with people you know 147 131 89.13. Reading easily with quick understanding 146 124 84.94. Using a wide vocabulary 146 123 84.25. Understanding large amounts of spoken information easily 147 121 82.36. Writing in logical order and to the point 148 118 79.77. Spelling accurately 148 115 77.78. Using gestures to support words 146 108 74.0

9. Using facial expression to support words 146 92 64.410. Using voice with variety and interest 146 92 63.011. Making eye contact with listeners 147 92 62.612. Pronouncing speech sounds easily 147 90 61.213. Expressing spoken ideas clearly and in order 146 87 59.614. Giving spoken instructions and explanations 148 87 58.815. Using the telephone confidently 147 75 51.016. Speaking at a proper rate with pauses 147 69 46.917. Chatting informally with people you do not know 147 66 44.918. Discussing ideas in formal setting (eg. a meeting) 148 66 44.619. Speaking with a fluent rhythm 147 62 42.220. Talking formally as in giving a speech 148 50 33.8

Table 2a - How the course has not helped

Summary of answers No. of Percentageresponses

23 16%

15 10%

12 8%

12 8%

Table 3 Course rating

Rating Value Frequencyranging from 0 (dissatisfied)to 10 (very satisfied)

0 11 12 03 44 25 46 67 228 449 4210 30Total 156

Table 2 - How the course has helped

Summary of answers No. of responses Percentage

Self confidence 98 66%Learning techniques and how to adapt them 44 30%

Understanding the problem 32 22%Greater self awareness 32 22%Aware of aspects of talk and communication 32 22%Support of group 30 20%Awareness of the importance of slowing down 22 15%Reduction of anxiety 20 14%Acceptance of the stammer 15 10%Introduced to a range of communication activities 14 10%

Specific situationsdealing withstrangers and formalsettings

Still need helpwith formalcommunication skills

Non-specificsituations stillcause trouble

Still experiencerelapses

The late Sylvia Da


13/32

It is vital to confront

questions of social

expectation if there are

to be competent

communicative

exchanges.

The Stammer Trust Report of Fluency Courses at

the Apple House, Oxford (1966-1998) (ISBN 0

9534807 0 4) price 5 plus 2 postage & packing is

available from Ruth Thomson, The Farm House,

Blakesley, Towcester, Northampton NN12 8RB.

Cheques made out to the Stammer Trust.

ReferencesAndrews, G. and Harris, M. (1964) The Syndrome

of Stuttering. London: Heinemann.

Andrews, G., Guitar, B. and Howie, P. (1980) Meta-

analysis of the effects of stuttering treatment.

Journal of Speech and Hearing Disorders 287-307.

Beasley, B. (1876) The Beasley System. London:

W.J. Ketley.

Bell, N. (1991) Visualizing and Verbalizing. Paso

Robles CA 93446: Academy of Reading Publications.

Pub. by Winslow

Press in the UK.

Bloodstein, O.

(1987) A Handbookon Stuttering.

Chicago: National

Easter Seal Society.

Fox, P. (1996) A PET

study of the neural

systems of stutter-

ing. Nature 382,

p.382.

Garvin-Cullen, A.J.

(1990) The relation-

ship between locus

of control and the

effectiveness of

post remediation

activities on the

maintenance of flu-

ency following

short-term inten-

sive behavioural

therapy for stutter-

ing. PhD Thesis.

Health Science,

New York University.

Peters, T.J. and Guitar, B. (1991) Stuttering: An

integrated Approach to its Nature and Treatment.

Baltimore: MD: Williams and Wilkins.

Webster, W. (1996) Some keys to understanding

stuttering and its management. Speaking Out17 (3)

London: The British Stammering Association.


intensive therapy

Reflections

Do I appreciatethe importance o

the historical

context of therap

I am offering?

Do I take accou

of the social

implications of

communication

difficulties in

treatment planning Do I provide

long-term suppo

to ensure gains o

therapy are

maintained?

right brain of those who stammer, reinforces this

view. Such an explanation suggests it is possible to

control speech function successfully in two ways:

1.Reducing right brain activities by overcoming

fear and anxiety which in turn means less

interference with the left brain supplementary area.

2.Counteracting left hemisphere inefficient

control of speech motor movements by slowing

and simplifying utterances to bring them within

the systems capability.

Apple House courses operate on these principles.

Therapists help a person believe they can speak

fluently and reduce fear by showing them how

they can achieve this by altering the way they

think and speak. This is followed by opportunities

to develop communication skills and practise con-

trol techniques. Underpinning this is the under-

standing of each persons leaning style, affecting

how messages and methods are constructed.

Although a theory of right brain interference

with left brain speech action suggests controlmanagement, the speech pattern that results is

different to the norm. In a contrived situation a

person may not feel the stress of communicating

in a new way and at a slower rate. In real life,

with pressure to conform to the speaking format

of others, the use of control techniques generates

stress that may send right brain activity soaring.

This is a problem for some, who are dragged back

into old stammering routines by social pressure.

Dysfluency is as much a social problem as a per-

sonal one. It is vital to confront questions of social

expectation if there are to be competent commu-

nicative exchanges. Successful therapy helps

clients become effective interactants with others

in spite of stammering responses that occur in con-

versation. Those who have long experience of the

Apple House courses mention how therapy has

broadened to consider social communication in

more detail. Questionnaires confirm multi-level

involvement in speech and communication acts.

One respondent elaborates: When I reflect on my

stammer I view it as a disturbance of thinking as

well as speaking performance. My thoughts seem

as tangled as my tongue. Non-verbal difficulties

are also apparent with 37 per cent reporting prob-

lems with eye contact, 36 per cent feeling they do

not use appropriate facial expressions to support

meaning and 37 per cent suggesting inadequate

use of voice to speak expressively.

Crucial aspectHowever, when a person becomes fluent they

assume a new persona. Changes occur which must

be possible to identify. Why is it that people who

stammer are, in general, fluent for 75 per cent of

the time? Looking at periods of fluency may be asuseful as examining dysfluent phases. More in-

depth study of a number of cases, investigating

personal and interpersonal issues, could precipitate

new directions in management and provide clearer

understanding of fluency and non-fluency pat-

terns. Relapse is a crucial aspect. There needs to be

comparison of clients who make excellent progress

with those whose gains are not as satisfactory.

Research and experience suggest biological and

psychological differences in those who stammer

but ways of identifying and classifying these need

more detailed attention. The Apple House uses a

wide range of techniques to manage personal and

social problems, but it should be possible to isolate

core elements in behaviour and target them in dif-ferent ways. For example, is one stress reducer

(neuro-linguistic programming or hypnotherapy)

more effective than another for clients showing

particular profiles? Are some components more

suited to self-organised learning than others?

Breathing techniques seem more difficult to

acquire than slow speaking. Would video/audio

tapes and written guides provide useful aids?

There is much in the daily grind that bears you

down and bowls you over but, for most, Apple

House therapy is a pivotal experience. Comments

from the questionnaires include: There was a

light at last at the end of a tunnel; I can talk at

conferences and am 99 per cent fluent; It gaveme dignity and a knowledge of what to do; I

was taught to believe in me; I did not see it as

a fluency course - it was a way of improving my

life; It brought calm and peace. Helen (a case

study) says My stammer gave me the feeling of

having one leg. I was like someone in a wheel-

chair, fairly handicapped. Now I can speak with-

out stammering it is as if Ive grown another leg

and can go out wearing short skirts.

The challenge for us now is to use this knowl-

edge and target help more precisely.

Rosemary J. Sage is based at the University of

Leicester.

Gerda Wilson (centre)

p Therapy - photo courtesy of the British Stammering Association


14/32

reviews


A lucid account

Speech/Language Therapists and Teachers WorkingTogether (A Systems Approach to Collaboration)

Edited by Elspeth McCartney

Whurr

ISBN 1 86156 124 5 19.50

Elspeth McCartney has edited a most user-friendly

book. She sets her work in the context of the leg-

islation and working practices that teachers and

therapists have had to take into account. It not

only mentions things I have found myself, but

gives many practical solutions.

I have no hesitation in recommending it to

teachers and therapists at all levels of experience.

It is a lucid account of working methods, sympa-

thetically set against the recent history of both

professions, helping promote an understanding oftheir likely perspectives. To the experienced, the

pitfalls of collaboration are highlighted, and solu-

tions offered that have been researched in various

educational settings. To the inexperienced, pre-

emptive wisdom is available. It is very readable

with all terms defined and practical, with the

sound knowledge base of experienced therapists

and special needs teachers.

Caroline Windham is a specialist speech and lan-

guage therapist working in a Language

Development Centre within a First School in

Norfolk and collaborating daily with teachers.

REVIEWS. . . . . . . . . . . . . .r e v i e w s

Hearing Attitudes in Rehabilitation

Questionnaires (HARQ)

Dr Richard Hallam

The Psychological Corporation

72.50

The HARQ is intended for use in Audiological

Rehabilitation Clinics. This questionnaire for

adults with acquired hearing loss attempts to

measure attitudes towards, and beliefs about,

hearing loss and its consequences.

The purpose in constructing a questionnaire that

assesses attitudes is derived from an assumption

that this form of self report is most likely to be

useful in the prediction of a range of behaviours -

such as avoidance of social situations - and there-

fore will give a prediction of possible outcomes to

rehabilitation.

The questionnaire covers both cognitive and

affective elements. Questions have been framed

bearing in mind that self perceptions are request-

ed, and not self reports, on the amount of disabil-

ity, handicap or emotional distress caused by the

hearing loss. It has not been designed to measure

a persons coping strategies for hearing loss, but is

designed to give a prediction of outcomes follow-

ing rehabilitation, and a measurement of attitude

changes through time.

When I first saw it, I was intrigued. Here was a

questionnaire which could predict who wouldbenefit from rehabilitation - amazing! However,

the more I looked at it, and the more I tried it out

on a few patients, I came to realise it is of little use

to speech and language therapists. There is noth-

ing complicated about it, and the manual is easy

to read, but the conclusions should be well known

to professionals working in the field of acquired

hearing loss - that, following diagnosis of hearing

loss, people who receive counselling along with

their hearing aids will become better hearing aid

users. Experienced therapists working with adults

with acquired hearing loss will be able to predict

the outcome to rehabilitation through careful

case history taking, and by asking questions simi-

lar to those in the HARQ. However, for therapists

who are new to the field of acquired hearing loss,

this could be useful as a guide to the kind of ques-

tions to ask.

This questionnaire is designed primarily for audi-

ologists to help them decide who will be good hear-

ing aid users. In the current climate of outcome

measures and efficacy of treatment - and given the

cost of hearing aids - it could be useful for the audi-

ologists to have another tool to add to their assess-

ment battery. There might then be fewer hearing

aids kept in kitchen drawers and handbags.

Susan Howden is a senior specialist speech and

language therapist with Tayside University

Hospitals NHS Trust.

Of little use to speech andlanguage therapists

Interesting andcomprehensive

DEAFNESS

CANCER

Communication Disorders in Childhood

CancerBruce Murdoch

Whurr

ISBN 1 86156 1156 25.00

This offers an excellent review of current research

into speech and language disorders associated

with posterior fossa tumours and acute lym-

phoblastic leukaemia, including the effects of

surgery and central nervous system prophylaxis.

There is a range of interesting case studies and a

comprehensive battery of published assessments

is recommended - including a number of physio-

logical assessments - which may not always be

readily available in a therapy clinic. There are

detailed references at the end of each chapter

and a clear index. This book would be a valuable

addition to both paediatric acute and community

speech and language therapy departments and

especially to students and clinicians who are

becoming familiar with this caseload or who are

looking for research projects. It is packed with

accessible data and is good value for money.

Angela Hawthorne is a speech and language

therapist in paediatric neurology at Newcastle

upon Tyne General Hospital.

Ideal for busy cliniciansPHONOLOGY

Phonological Awareness Screening Pack /Phonological Awareness Activities Handbook

Alice Peters and Lynne Kemp

From Kathleen Sharkey, tel. 01382 462857.

10.00 each or 15.00 for both, cheques to

Dundee City Council

The real plus point about these eminently practical

booklets is the cost. At 15.00 they are good value

for money with lots of photocopiable worksheets

ideal for busy clinicians to use as handouts.

Essentially designed for preschool children and

early primary readers, they could be used with

older children at a lower developmental level.

The first booklet provides a range of informal

assessment tasks of phonological awareness, the

second corresponding intervention activities.The booklets assume purchasers have a clear

understanding of phonological awareness and can

make their own judgements about developmental

progression and why some areas have not been

included. There is a very brief theoretical intro-

duction but the focus is essentially practical.

Black and white pictures are provided for the

screening assessment but the purchaser needs to

cut up and laminate. In the second booklet, the

equipment and materials needed are listed but

not provided. Many good ideas are presented

which are applicable to the primary school child.

Both booklets are easy to read and well presented. They

would be a positive addition to the resource library oftherapists working in schools, clinics and nurseries and

are particularly valuable to those new to this area.

Angela Hurd is a senior lecturer at the University

of Central England and a practising clinician.

Useful timesaver

Total Phonology

Lisa Abba, Sara Ayub & Vicki Selwyn-Barnett

Winslow

ISBN 0 86388 204 8 44.50

A lot of work has gone into devising this assessment

and intervention programme. The assessment section

is neat, covering production, auditory discrimination

and a quick screen of phonological awareness

which I found helpful with older children. The

drawings are clear and the programmes useful -

for some children as they stand, and lending them-

selves to adaptation for others. The section on par-

ent workshops would be a useful framework for

the less experienced clinician.

This would be a relevant additional resource for

therapists covering busy schools or clinics where a

clearly explained and well presented off the shelf

package would be a useful timesaver.

Margaret Rooney is a community speech and lan-

guage therapist, Amber Valley, with Southern

Derbyshire Community NHS Trust.

PHONOLOGY

EDUCATION


15/32

Well worth having

The Sentence Processing Resource

Pack

Jane Marshall, Maria Black, Sally

Byng, Shula Chiat, Tim Pring

Winslow

ISBN 0-86388-207-2 54

As most current psycholinguistic assess-

ments are aimed at single word level, this

pack is a very useful addition for thera-

pists working in aphasia.

It consists of two assessments - The

Reversible Sentence Comprehension Test

and The Event Perception Test - and a

handbook. The tests are easy and quick

to administer and the handbook written

in an easy-to-read format. It discusses

both production and comprehension of

sentences and the final chapter neatly

follows on by covering therapy for sen-

tence processing skills.

The three volumes are held in a neat,

portable container which is light to carry.

At 54, definitely value for money and

well worth having.

Lynda McLean is a speech and language

therapist for Fife Rehabilitation Service

within Fife Primary Care NHS Trust.


reviews

Look no further

Manual of Voice Treatment

(Pediatrics Through Geriatrics)

Second EditionMoya L. Andrews

Singular

ISBN 1 56593 998 0 42

For the student or less experienced clini-cian this manual provides comprehen-

sive and accessible information about the

nature of voice disorder, intervention

selection strategies and treatment

approaches across the age range. The

application of theory to practice is well

illustrated with case studies.

This second edition admirably reflects

recent progress in voice research in its up-

to-date clinically relevant references.

Useful appendices include assessment

forms, therapy materials and treatment

outcome scales. However there is an

inevitable bias, with no reference to cer-tain voice facilitation techniques prac-

tised in Europe.

If your department needs a central

resource about voice, look no further

than this volume in the Clinical

Competence Series. However, experi-

enced and specialist clinicians are unlike-

ly to find topics covered in adequate

detail.

Linda Heggie is a specialist speech and

language therapist (Voice) with Sandwell

HealthCare NHS Trust.

Technical and complex

Augmentative and Alternative

Communication: New Directions in Research

and Practice

Filip Loncke, John Clibbens, Helen

Arvidson, Lyle Lloyd

Whurr

ISBN 1 86156 143 1 50

This book came out of developments in education,

clinical psychology, speech synthesis, sociology,

engineering, psycholinguistics and speech-lan-

guage patholody. In many parts it is difficult to

read due to its highly technical language and com-

plex concepts. I felt this book was written primari-

ly for researchers and for presentations at confer-

ences. It is expensive to buy at 50.00. The contri-

butions came from all over the world but the main

emphasis was American. Unfortunately, I did not

find that it related to any of my clinical work.

Ann Gosman is a speech and language therapist

with Orkney Health Board.

Advice for an increasingchallenge

Supporting Young People With Language

Impairments in Secondary Mainstream

Schools - A Practical Guide

Anita Marks and colleagues

(Cheques payable to) Worthing Priority

Care NHS TrustISBN 1 902131 004 16 inc. p+p

Available from Speech & Language

Therapy Service, Trust HQ, Arundel Rd,

Worthing BN13 3EP.

This pack, designed for speech and language

therapists and special educational needs coordi-

nators (SENCOs), consists of a series of photocopi-

able information sheets and proformas. Of these,

the strategies with a functional focus (chapter 3)

have the most universal and practical application,

particularly Quick problem solving ideas for the

classroom. Other useful sheets focus on memory

strategies, self help and lists of vocabulary.

This resource presents much needed advice toaddress an increasing challenge. Based on the prac-

tice and philosophy used in Worthing, it would be

useful as a starting point for addressing specific

local needs. I am not certain it would be suitable for

SENCOs as many of the activities need a speech and

language therapist for effective implementation.

It would benefit from being more attractive and

user friendly, with tighter editing, plain English

and positive rather than negative wording to

describe students and their needs. It puts emphasis

on educating school staff in speech and language

therapy terminology, assessments and activities. A

more functional, strategies-based emphasis would

have allowed for better use of limited teacher time

and led to more realistic expectations of students

with communication difficulties.

Elaine Hirst works for Nottingham Community

Health NHS Trust with children with specific lan-

guage impairment who attend mainstream schools.

...RESOURCES...RESOURCES...

SpellmagicSelf-sticking letters pro-

vide an alternative way of

helping children learn

about letters and sounds.

Spellmagic letters are sup-plied with a holding board

and a pupils spelling

board.

Samples and details from: Adhere Industrial Tapes,

tel. 01206 210999, www.spellmagic.co.uk

Softwarefor dyspraxiaDyspraxia drills on CD ROM developed in Australia

are now available in the UK.

A set of two CD ROMS provides multimedia cues for

531 consonant/vowel and consonant/vowel/conso-

nant words covering 19 consonant sounds in initial

position. There is also a print option for 20 colour

photographs of consonant articulatory position.

Designed for adults with dyspraxia, it may also be

suitable for children.

Dyspraxia Drills on Disc, 90 + 5 delivery + VAT for

single copies from Gordon Russel l, Propeller

Multimedia Ltd, tel. 0131 446 0820,

http://www.propeller.net/react

AAC

EDUCATIONVOICE

ADULT NEUROLOGY CataloguesTwo Winslow catalogues for 2000 cover Health &

Rehabilitation and Education & Special Needs.

Free from Lynn Smith, tel. 01869 244644, e-mail

[email protected]

Expressing viewsA package from the University of Stirling allows

people with motor neurone disease to express

their views about quality of life issues using pictor-

ial symbols, even if they have no speech or limited

hand control.

Have I got views for you! 25, tel. 01786 467645

Speech & Language Therapy in Practice, Summer 2000

Documents

Transcript of Speech & Language Therapy in Practice, Summer 2000