DISCUSSION PAPER

Speech Therapy And General Practice InHong Kong

S F Stokes,* PhDE Yiu, PhD

Department of Speech and Hearing SciencesThe University of Hong Kong

Summary

Speech therapy services in Hong Kong have changed dramatically in the past two decades. Further development is

urgently required in three main areas; norms of speech and language development in Cantonese, descriptions of disordered

communication in adults and children, and the development of screening and diagnostic speech and language instruments.

General Practitioners and speech therapists can work in concert to develop a database on normal and disordered speech

and language skills of the Hong Kong population, to increase the likelihood of identification of disability and referral to

an appropriate agency, and to develop assessment tools. (HK Pract 1997; 19:374-379)

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Speech therapy services firststarted in Hong Kong in the mid-sixties as a subspecialty of the ear,nose and throat speciality. However,it was not unt i l the early eighties thatthe g o v e r n m e n t recognised theimportance of speech therapy andbegan a scheme of training therapistsoverseas. Since then, the education ofspeech therapists and speech therapyservices have changed rapidly. Localtraining of Cantonese-speaking speechtherapists was first established at theUniversi ty of Hong Kong in 1988.

The mode of service delivery haschanged dramatically in the last 10years, not only in Hong Kong, butworld-wide. Whereas therapists onceworked only with individual patientsin clinical settings, they now alsowork with individuals and groups inschools and n u r s i n g homes , incollaboration with other professionalssuch as nurses and teachers. Modelsof service delivery have broadened toa w i d e r range of r ec ip i en t s andvenues. Speech therapy services usedto be based on an 'expert model' but

are beginning to evolve to either an' o r g a n i s a t i o n a l m o d e l ' or a'collaborative model.'(Figure 1).

The 'organisat ional model ' isuseful in helping an institution, like anursing home, to provide moreo p p o r t u n i t i e s for p a t i e n t s tocommunicate. The ' co l labora t ivemodel" r equ i r e s a l o n g - t e r mcommitment from team members toengage in problem i d e n t i f i c a t i o n ,p l a n n i n g , i m p l e m e n t a t i o n a n devaluation of programmes.

Address for correspondence : Dr S F Stokes, Department of Speech and Hearing Sciences, The University of Hong Kong, 5 F, Prince Philip DenialHospital, Hong Kong.

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DISCUSSION PAPER

Figure 1: Models of service delivery in speech therapy

(Expert model)

Doctor -»- SpeechTherapist

-*• Patient

(Organisational model)

Speech Therapist »• Nursing Home *

Nurses, Administrators,Doctors, Paramedicals

(Collaborative model)

Speech Therapist •*« ^- Teachers

Communicationneeds of patients

Pupils

The following examples illustratehow a speech therapist can work onan organisational or a collaborativemodel. A speech therapist

1) works wi th teachers toincorporate specific speech andlanguage goals into the classroomcurricula;

2) provides information on childlanguage development to groupsof parents;

3) trains child care workers onintervention techniques forchildren with special needs;

4) consults with nurses onfacilitation of communication inspeech/language impaired adults;

5) trains family members onfacilitation of communication instroke patients.

In short, speech therapy serviceshave become community-based.

However, doctor's referral remains themost common source of referral tospeech therapy.

Agencies and referralpractices

In Hong Kong, most speechtherapy services are provided by fivemain agencies:

1. Special Schools and SpecialEducation Division, supervisedby the Education Department.Children are usually referred tothe school by medical socialworkers, or via Child AssessmentCentres.

2. Special Education ServicesCentres (such as Heep HongSociety and the SpasticAssociation), supervised bythe Social Welfare Department.Children are referred by ChildAssessment Centres.

3. Chi ld Assessment Centres ares u p e r v i s e d b y t h e H e a l t hDepartment. Children are seeno n l y by a doc to r ' s r e f e r r a l(usually a general practitioner).The Child Assessment Centre hasa close l i n k with the Maternaland Child Health Centres, whichconduct regular developmentalscreenings, also supervised bythe Health Department.

4. Hospital Authority inpat ient andoutpatient services which acceptonly a doctor's referral.

5. Private Agencies

Therefore, a pa t i en t wi thsuspected speech problems seen by amedical general pract i t ioner can bereferred to the Chi ld AssessmentC e n t r e s , H o s p i t a l A u t h o r i t yOutpatient Clinics or private speechtherapy clinics.

In p a e d i a t r i c speech the rapyclinics in Hong Kong, chi ldren withspeech and language problems usuallyhave concomitant disorders such asau t i sm, mental r e t a rda t ion , cleftpalate, cerebral palsy, congeni ta lsyndromes or hearing impai rment .Although a pure language disorderexists without a concomitant disabil i ty(specific language impairment) , thisdisorder is often neglected in HongKong. At present, this may be due tothe lack of identification criteria andmethods. General practitioners canplay a major role in the identificationof developmental speech/languagedisab i l i t i es . Apart from obviousconditions for referral to a speechtherapist, such as the d i s a b i l i t i e smentioned above, there are indicatorsof developmental d isabi l i ty whichrequire referral to a speech therapist(Table 1).

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Speech Therapy and General Practice in Hong Kong

DISCUSSION PAPER

The symptoms listed in Table 1can indicate a developmental speech/language disability in the absence ofother disability. These children maysimply be delayed and outgrow theirslow start, or they may have apervasive disorder which will resultin poor social development andimpaired academic achievement. Inshort, "developmental disabilitiesaffecting language are extremelyse r ious . . . " 1 A complete speech/language assessment is required todetermine the degree of impairmentand type of problem.

In adult speech therapy clinics,voice problems and neurologica lcommunication disorders are the mostcommonly seen cases. The majorityof these cases are referred to speechtherapy clinics by specialists such asear, nose and throat surgeons,neurologists or physicians. Patientswith speech disorders caused by,for example, hearing impairment,dysfluency or articulation disorders(e.g. unc lea r speech or imprecisearticulation) generally see a generalprac t i t ioner first. The generalpractit ioner plays an important rolein the identification and referralprocess . Table 2 l i s ts thecharacteristics of some of the commonspeech and language disorders inadults.

Therapy

F o l l o w i n g a s s e s s m e n t , atherapeutic programme is devisedwhich usually operates similarly toFigure 2. The programme will varyaccording to the service deliverym o d e l , b u t s h o u l d i n c l u d e t h ecomponents shown in Figure 2.

Table 1: Indicators of developmental speech and language disability

Age Symptom

Under 1 year Does not respond to nameDoes not babble/jargon

12 to 18 months Does not say about 12 single words

18 to 24 months Does not increase vocabulary to about 50 wordsDoes not follow simple instructions

24 to 30 months Does not combine words (2-3 word phrases)Does not understand 'what', 'where' questions

30 to 36 months Does not use simple sentencesDoes not understand 'who' questions

36 to 48 months Does not use long sentences, ' and', ' but' , ' then'Does not understand 'why', 'when' questions

Above 48 months Cannot tell a simple story

Table 2: Characteristics of some common adult speech andlanguage disability

Characteristics Action required

Dysphonia Harsh or husky voice Refer to ENT surgeonsbefore seeing a speechtherapist

Articulationdisorders Imprecise or unclear speech

lisp Refer to speech therapists

Dysarthria/Aphasia Inability to communicate

(speaking or understanding)after a stroke or head injury Refer to speech therapists

Fluencydisorder Stuttering, blocking Refer to speech therapists

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Hong Kong Practitioner 19 (7) July 1997

DISCUSSION PAPER

Figure 2: Components of speech therapy

Assessment -*

observation

case history

standardised tests

informal assessment

consult significant others

Requires treatment

set direct treatment goals

set indirect treatment goals

measure success/failure of treatment

review goal achievement

Discharge Re-assess

State-of-the-art in HongKong

Identif ication of d isabi l i ty isdependent on the establishment of anormative database, description of thecharacteristics of disability, and validand re l iab le assessment tools. InHong Kong there is an urgent need fora database of normal speech andlanguage development. We havesome information of phonologicaldevelopment which shows that mostchildren acquire tones and vowels bythe age of two, and that 75% ofchildren have acquired all speechsounds by the age of 3.6 years.2

However the aspiration contrast is not

Requires review

fully established until after the age offive.3-4 We know very little about thedevelopment of semantics and syntax,despite studies of classifiers,5'6 aspectmarkers,7 question formation8 andlocative markers.9 We know thatchildren begin to use noun phraseconstituents (e.g. classifiers) and verbphrase cons t i tuen ts (e.g. aspectmarkers) before two years of age andthat early development of questionwords seems to be dependent on verbtypes8 and the pos i t ion ing of thequestion word in a sentence (e.g.' bingo' at the beginning of a sentenceis learned before ' bingo' at the end ofa sentence).10 A new database ofdevelopmental Cantonese is acomputerised collection of language

samples he ld at Carnegie M e l l o nUniversity, which can be accessedby the Web." This database isbeginning to characterise languagedevelopment. Whilst research teamsand i n d i v i d u a l s have con t r ibu tedvaluable information to our knowledgeof this area12 there is s t i l l much to bedone.

A second field of invest igat ionwhich requires urgent attention is thenature of speech/language d i sab i l i t y inCantonese-speaking ch i ld ren andaphasic i n d i v i d u a l s . A g a i n , somepub l i ca t i ons a re a v a i l a b l e 1 3 - 2 1 bu twork is in its infancy. The t h i r d area,the development of standardised tests,h a s p r o g r e s s e d m o r e q u i c k l y .Therapists now have access to testsof receptive vocabulary," receptivelanguage,23 speech accuracy,24 andaphasia tests.25

The role of the generalpractitioner

G e n e r a l p r a c t i t i o n e r s c a ncontribute greatly to the identificationand c h a r a c t e r i s a t i o n of speech/language d i sab i l i ty in Hong Kong.Patients with speech and languaged i f f i c u l t i e s w i l l r a r e l y k n o w o fspeech therapy services, and wi l lconsult t h e i r doctors in the f i r s tinstance. Therefore, it is importantfor general practitioners to i d e n t i f ypatients who require speech therapyservices. It wou ld be h e l p f u l toreinforce communica t ion betweengeneral p r ac t i t i one r s and speechtherapists. This can be achieved byestablishing a dialogue between theCollege of General Practitioners andthe Hong Kong Associat ion of

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Speech Therapy and General Practice in Hong Kong

DISCUSSION PAPER

Key messages

1. Speech therapy models of service delivery have evolved to include community-based services.

2. Speech therapy services in Hong Kong are provided by five main agencies.

3. General Practitioners can play a major role in the identification of Specific Language Impairment in children,(which at present is largely unrecognized in Hong Kong) and in the referral of adults with voice problems andneurogenic communication disorders.

4. In Hong Kong there is an urgent need for a database of normal speech and language development.

5. Collaboration between General Practitioners and speech/language therapists will facilitate the study of speech/language disorders in Hong Kong.

Speech Therapists, or the Universi tyof Hong Kong. Such a d ia loguecould include discussion of types ofcases seen in general practice, referralcriteria and follow-up. Optimally, theestablishment of research collaborationwould contribute to our database onspeech/language disabil i ty in HongKong. •

References

1. K l e i n HB, Moses N. InterventionPlanning for Children withCommunication Disorders: A Guide forClinical Practicum and ProfessionalPractice. Eng lewood Cl i f f s , NJ:Pren t i ce H a l l , 1994;p.258.

2. So LKH, Dodd BJ. The acquisit ion ofp h o n o l o g y by Can tonese - speak ingch i ld ren . Journal of Child Language.1 9 9 5 ; 2 2 : 4 7 3 - 4 9 6 .

3. Stokes SF, Ciocca V. PhonologicalRepresentation and ArticulatoryConstraints: Evidence from theAcquisition of the Cantonese AspirationContrast. ( submit ted) .

4. Clumeck H, Barton D, Macken M, eta l . The a s p i r a t i o n c o n t r a s t inCantonese w o r d - i n i t i a l stops: Datafrom ch i ld ren and adul ts . Journal ofChinese Linguistics. 1981:9:210-225.

5. Stokes SF, So L K H . Classifier use byn o r m a l a n d l a n g u a g e - d i s o r d e rC a n t o n e s e - s p e a k i n g c h i l d r e n . Asia-Pacific Journal of Speech, Hearingand Language. (in press): to appear 13.Dec, 1997.

6. Mak D. The Acquisition of Classifiersin Cantonese. Doc to ra l Disser ta t ion,U n i v e r s i t y of Read ing . 1991. 14.

7. Leung SCS. The Development of AspectMarkers in Cantonese-SpeakingChildren between the Ages of 21Months and 45 Months. P h . D .d i s s e r t a t i o n , U n i v e r s i t y of Hawai i a t 15.Manoa, USA, 1996.

8. Cheung ASY, Lee THT. Cantonese-speak ing ch i ld ren ' s comprehens ion ofw h - q u e s t i o n s . I n E . C l a r k ( e d . ) .Proceedings of the 25th Annual Child 16.Language Research Forum, S tanford:Center for the Study of Language andI n f o r m a t i o n . 1993 ;pp .106 -117 .

9. Cheung SL. The acquisi t ion of locativec o n s t r u c t i o n s in Can tonese c h i l d r e n , 17 .Papers and Reports in Child LanguageDevelopment, 1990:30:20-27.

10. C h e u n g ASY. The Acquisition ofInterrogatives by Cantonese-speakingChildren, paper presented at the 1992L i n g u i s t i c S o c i e t y o f Hong Kong 18 .Annua l Research Forum, CUHK, 1992.

11. Lee THT, Wong CH, Leung S, et al.The Development of GrammaticalCompetence in Cantonese-speakingChildren. Report of a project funded 19.b y H o n g K o n g R e s e a r c h G r a n tCommit tee CUHK 2/91. 1996.

1 2 . L e e T H T T h e o r e t i c a l i s s u e s i nl a n g u a g e d e v e l o p m e n t and C h i n e s e

c h i l d language. In H u a n g C-T. I . Li Y-HA, edi tors . New Horizons in ChineseLinguistics. D o r d r e c h t , K l u w e rAcademic P u b l i s h e r s , 1996:293-356.So LKH, Dodd BJ. P h o n o l o g i c a l l yd i s o r d e r e d C a n t o n e s e - s p e a k i n g c h i l -d r e n . Clinical Linguistics andPhonetics. 1994;8:235-255.Stokes SF, W h i t e h i l l TL Speech errorpatterns in Cantonese s p e a k i n g ch i ld renw i t h c le f t p a l a t e . European Journalof Disorders of Communication. 1996;3 1 : 4 5 - 6 4 .Stokes SF, W h i t e h i l l TL. Yuen KCP,et al. EPG t r e a t m e n t of s i b i l a n t s int w o Can tonese - speak ing c h i l d r e n w i t hcleft palate. Clinical Linguistics andPhonetics. 1996;10:265-280.Whi t eh i l l TL, Stokes SF, Man Y.Elec t ropa la tography t r e a t m e n t w i t h anadu l t w i t h late r epa i r of c lef t palate.The Cleft Palate - C r a n i o f a c i a lJournal. 1996:33:160-168.W h i t e h i l l TL, Stokes SF. H a r d c a s t l eWJ, et al. E l e c t r o p a l a t o - g r a p h i c andpe rcep tua l a n a l y s i s of the speech ofCantonese-speaking c h i l d r e n wi th cleftpalate. European Journal of Disordersof Communication. 1995:30:193-202.Yiu EM-L, W o r r a l l LE. P a t t e r n ofg r a m m a t i c a l d i s r u p t i o n i n C a n t o n e s eaphasic subjects. Asia Pacific Journalof Speech, Language and Hearing.1 9 9 6 : 1 : 1 0 5 - 1 2 6 .Y i u EM-L, W o r r a l l L E . S e n t e n c ep r o d u c t i o n a b i l i t y o f a b i l i n g u a lC a n t o n e s e / E n g l i s h a g r a m m a t i cspeaker. Aphasiology. 1996: 10:505-522 .

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20. Yiu EM-L, Worra l l LE. Agrammat icP r o d u c t i o n : A c r o s s l i n g u i s t i ccomparison of English and Cantonese. 22.A p h a s i o l o g y . 1996; 10: 623-648.

21. Yiu EM-L, Worral l L. L imi ta t ionsof m o d e l s of s en tence p r o d u c t i o n :Ev idence from Cantonese data of 23.n o r m a l and aphasic speakers In DoddBJ, Campbe l l R, Worrall L, editors.

Evaluating Theories of Language.L o n d o n , W h u r r . 1996.Lee K, Lee L, C h e u n g P. HongKong Cantonese Receptive VocabularyTest. Hong K o n g Child A s s e s s m e n tCent re , 1996.C h e u n g P. Comprehension ofGrammatical Structures. U n p u b l i s h e dBSc d i s s e r t a t i o n . D e p a r t m e n t of

S p e e c h a n d H e a r i n g S c i e n c e s .U n i v e r s i t y o f H o n g K o n g , 1994 .

24. So LKH. Cantonese Test of SegmentalPhonology. H o n g K o n g . B r a d f o r dPress, 1994

2 5 . Y i u EM-L. L i n g u i s t i c a s s e s s m e n t o fC h i n e s e - s p e a k i n g a p h a s i c s : D e v e l o p -m e n t o f a C a n t o n e s e a p h a s i a b a t t e r y .Journal of N e u r o l i n g u i s t i c s . 1 9 9 2 . 7 :3 7 4 - 4 2 4 .

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