ISSN 1368-2105 ISSN (online) 2045-6174 www.speechmag.com Enjoy your SpeecliMMER 1997 meal! Use of th ickener in guage dysphagia Fluency - Promoling Therapy early referral Primary HealtllCare Workers Project

Focus on Your clinical companion Derwen Objective setting in a specialist Trust

Minimal.ly responsive state A team approach to severe brain injury

How I ... Illanage dysartflria Three tllerapists dis uss a case

Naming - more than just right tiv or wrong? Responses to cueing in aphasia

Information for I rod clng WILSTAAR in contributors p om Common queries an wered s ion Is. ISSN (online) 2045-6174 www.speechmag.com

The big breakthrough on a small scale

he new DynaMyte is a lightweight, Tportable device with powerful communication capabilities which introduces a new dimension to augmentative communication by offering greater freedom to the ambulant user. DynaMyte is just half the size of DynaVox 2 and yet it retains all its advanced communication capabilities, and uses the same software. A built-in remote control unit allows the user to access computers and other household appliances, and it The DynaVox 2 augmentative features a system of alarms capable of performing a variety communication aid of preset tasks. A clear, easy to operate touch display has introduced a provides access to the full range of DynaMyte's new era of freedom to people of a/l ages who communication power. Its long life battery and durable, have speech disabilities. rubberised casing guarantees easy to carry communication for people of all ages with speech disabilities. DynaMyte is a natural product extension from the advanced DynaVox 2 communication device which successfully enables many users with mobility impairment to develop a greater sense of self expression and independence. DYNAMIC For full information and demonstration, contact A~ DYNAMIC ABILITIES LTD LIMITED THE COACH HOUSE, 134 PUREWELL CHRISTCHURCH, DORSET BH23 1EU TELEPHONE: 01202481818 ~~ FAX: 01202 476688 ISSN (online) 2045-6174 www.speechmag.com

News / events 2 Cover Story:

Summer 1997 Introduci'1g a (publication date 26th May) preventatIve approach 14 ISSN 1368-2105 Epsom Healthcare Trust has been award­ Published by: ed £70,000 to fund a WILSTAAR Avril Nicoll early intervention project. How did they Lynwood Cottage do it? Sue Oakenfull gives details. High Street Sarah Drumlithie Barton and Stonehaven Sharon AB393YZ McLaughlin How I ... Tel/fax 01569 740348 explore manage e-m ai l avrilnicoll @rsc.co.uk improve­ ments in dysarthria 17 the safety and palatability thickeners Produ ction: offer people with dysphagia, Three therapists set out their manage­ Fiona Reid and the versatility of the ment of a client, Bert. Exploring the Straitbraes Farm product Thick & Easy. client's needs and expecta­ St. Cyrus tions, providing clear informa­ Montrose tion and offering a range of therapy options are impor­ tant. Editor: 6 Avril Nicoll RegMRCSLT Fluencv ­ Reviews 22 Subscription s and advertising: Prom01ing Social skills, voice, drama, Tel / fa x 01569 740348 early dyslexia, ColorCards referral ~~ Cover feature: Elaine Christie explains how the British 24 ~~~~'- ".-/ Stammering Association's Primary .A-"'~_~ Introducing a '::- ~..:::: "" '--- . Healthcare Workers Project is persuad­ preventative approach ­ ing health visitors and GPs that early WILSTAAR early referral is best. ~~J~R~.r ~~;:1 intervention project just right or Focus on Derwen 9 wrong? Derwen is a specialist Trust in West Wales for people suffering Linda Armstrong from mental illness and distress and and Michelle learning disabilities. Objective Brogan argue setting and support workers are vital to that therapy for the speech and language aphasic therapy department. clients with word finding difficulties is improved by closer examination of picture naming errors made spontaneously and in response to cues. The Team Approach 11 ©Speech & Language Therapy in Information for Practice 1997 The team approach to minimally Contents of Speech & Language contributors 27 responsive state Th erapy in Practice reffect the views Recent publicity has highlighted the con­ As with other magazines, Speech & of the individual authors and not troversy surrounding the long- Language Therapy in Practice necessarily the views of the publish­ term management of clients with severe has a specific and consistent style on er. Publication of advertisements is brain injury. Sophie MacKenzie which its readers depend. Common not an endorsement af the adver­ describes her role with one such group queries from potential contributors are tiser or product or service offered. at the Royal Hospital for Neuro-disability. addressed.

SPEECH & LA NG UAGE TH ERAPY IN PRACTICE SUMMER 1997 1 NEWS & COMMENT ISSN (online) 2045-6174 www.speechmag.com

Michael Palin Centre referrals: Time for change New funding policy All full consultations of children referred to Working at the Royal Hospital for Neuro-disability with people the Michael Palin Centre are now being fund­ with severe brain injury, Sophie MacKenzie is at the cutting ed by the Association for Research into edge of speech and language therapy, where careful assess­ Stammering in Childhood. ment over a long period of time is vital in pinpointing a way of Following this specialist and detailed assess­ accessing communication. Even when communication is ment involving the whole family and their established, learning to use the chosen method effectively is a local therapist, funding for further involve­ painstaking process needing hard work and perseverance in ment will continue to come through the exua­ the long-term by clients, staff and carers. In recent times we contractual system between the Camden and have seen a huge improvement in the sophistication of Islington Community Health Services NHS technology available to assist such clients and we can be Trust and local district purchasers. If therapy at confident this will continue in the future. the Michael Palin Centre is felt to be the best Another big change has been the swing in the role of speech option for the child, it will not be offered until and language therapists towards involvement in dysphagia. I funding has been agreed. have unpleasant memories from my first job of daily diets for As referrals for the consultation service come dysphagic clients of mashed potatoes with gravy and congealed from speech and language therapists across thickened drinks. Fortunately, this need no longer be the case as the UK, in many instances the local therapist manufacturers of thickeners such as Thick & Easy have worked is given a detailed action plan with the oppor­ on products to make them safer, more palatable and able to be tunity of continued support and follow up. used more imaginatively. Many therapists find challenges work­ Details: Diana de Grunwald, The Michael Palin ing with kitchen staff who have their own pressures to deal with, Centre for Stammering Children, Finsbury so hopefully the article by Sarah Barton and Sharon McLaughlin Health Centre, Pine Street, London ECI R OfH, will be of assistance in that process. re/: 0171 530 4238 With adults, such as those discussed in Linda Armstrong's article on the effects of cueing in aphasia, we often need sustained Alzheimer's drug gets clearance involvement to bring about change. For children we seem to A new drug for the symptomatic ueatment of be moving more towards finding a 'right' time for intervention. mild to moderate Alzheimer's disease (AD) is Elaine Christie of the British Stammering Association's Primary the first to be licensed in the UK specifically to Healthcare Workers Project quotes research indicating there is ueat AJzheimer's disease. an optimum time to provide intervention, direct or indirect, Whilst providing neither cure nor the ability with children who appear to be stammering. The BSA is giving to stop or slow down the progression of the therapists much needed information resources and opportunities disease itself, ARICEPrM (donepezil to share experiences to try to ensure a more equitable service hydrochloride) may allow a greater concentra­ within and across departments. tion of acetylcholine - associated with memo­ Early and timely intervention is also the message of the ry and learning and in short supply in AD - in WILSTAAR project in Epsom. Many other departments have the brain. Conuolled clinical trials in over 900 requested information about how the funding for this was patients in the USA demonsuated more than achieved; Sue Oakenfull provides the answers. 80 per cent either improved or exhibited no As this magazine changes ownership, I find myself with a unique further deterioration in tests of cognition over opportunity. Time will never change the need for practical, the course of the studies. Patient function, accessible and up-to-date information for speech and language including behaviour and activities of daily liv­ ing, was rated by clinicians as improved in therapists who have much to do and not enough time to do it. approximately two times as many patients on I look forward to continuing and extending Speech & Language the drug in comparison to a placebo after 24 Therapy in Practice's role in weeks of ueatment. It is hoped donepezil meeting this need and extend hydrochloride will also ease the suess the dis­ thanks to Elinor Harbridge of ease causes in carers. Results of UK and Hexagon Publishing for conceiving European uials are expected in the autumn. and publishing this magazine over information on all aspects of Alzheimer's disease is the past twelve years. If you can available from the Alzheimer's Disease Society, find the time to contribute to the Gordon Hou se, 10 Greencoat Place, London magazine in any way (see page SWI P 1PH, tel. 0171 306 0606. information 27), I would be very pleased to sheet 11 describes new treatments. hear from you. Clear speech Avril Nicoll Independent hearing aid audiologist Cubex is Editor offering 'clear speech' uainingsessions for rel­ Lynwood Cottage atives to support their hard of hearing clients. High Street Managing director Adam Shulberg said "Once Drumlithie a client has been fitted with the hearing Stonehaven AB39 3YZ device, we encourage family members to take tel / ansa/ fax 01569 740348 the session. It only takes ten minutes to learn e-mail [email protected] but, with a little practice, can improve the patient's ability to follow a conversation". The It would be appreciated if you could call evenings, Fridays or weekends 'clear speech' technique involves using a slow­ as i am also a pradising therapistfrom Monday to Thursday. er and louder speech pattern with no missing If leaving a message, please leave your home and work numbers. syllables or dropped word endings. Details/leaflets: Danielle Fisher, tel 0171 2470367.

2 SPEECH & lANGUAGE THERAPY IN PRACTICE SUMMER 1997 ISSN (online) 2045-6174 www.speechmag.com NEWS

Equal value decision Pam Enderby has urged cau­ International Dyslexia Conference ti on while welcoming the The role of phonemic awareness in dyslexia Coulandris considered the identification of the DepaI1ment of Health's deci­ was one of the main themes of the British child at risk ofspeech and literacy problems and sio n to equalise her pay with Dyslexia Assodation International Conference the implications for the role of speech and lan- Clinical Psychologist co m­ Over 150 speakers included Vicky loffe who guage therapists and nursery staff. lohn Locke para tors. explored the interaction between reading ability, described a longitudinal study of infants and Professor Enderby said, "I am language development and phonological aware- young children born to dyslexic parents. They particularly pl eased at th e ness in a group of specific language impaired showed general features u h as I advanced recognition th at the work of ch ildren and a matched control group, and the vocal development and expressiVl' language, sig­ speech and language th era­ therapeuti implications. rhe metali ngui ti nificantly lower recall of word and non-word pists is ofequal value, but con­ theme was continued by Liz Dean and lanet strings and less awareness of rhyme. cerned there hasn't been the Ilowell reponing on their study into the chang- A selection of the papers presented at the April political will to address the ing nature of phonological awarenes.<; as a child event in York fonn a new book from Whurr issue of low fem ale pay and develops. Publishers: Dyslexia - Biology, Cognition and poor career structures. Cood 'n1e imponance of working together for early Intenlt'/Iliotl. Editors Charles Hulme and Maggie lip service has been paid with identification and intervention was highlighted_ Snowling point to the dominant view ofdysJex- little difference see n over the Speech and language therapists from me Helen ia as a form of language disorder which runs in las t decade. However, the case Arkell Dyslexia Centre looked at working with families and can be effeaively remediated if does demonstrate that women teachers on teaching oral language kills. identified early. The core cognitive deficit is have access to law and that Andrew ewton, a GP. discussed beIber and t be a phonological one .nd therels there are anomalies in profes­ how should bec.om OlOn: invol Jft 'c component to onol sional structures which are J probably related to gender." The Union backing the cl aim, The Department of Health Teletubbies say hello MSF, hailed the decision as a sa id in a statement, "A fu r­ A new daily BBC-2 series has been "speclfieally designed 10 aid ch ildren 's victory for women staff ther sL'<.teen cases are due to speech developmen t" in a techIlolagical age. throughout the NHS and be heard by the tribunal. It is Th e Teletubbies are four fUll-size cos ttl me characters liIle soft toys, which other industries. National unlikely that the tribunal are linhed 10 technology by the reie1 ision screens in rheir tummies. Co-cre­ Secretary Roger Kline sa id "It is will be able to hear all these aWl's Andrew Oavenpol1 - who studied speech sciences - and Anne Wood a landmark decision and is the cases by the ti me rises on [£sed the first words and phrases children mahe faTthe Teletllbbies' vocab­ biggest single breakthrough 18th Apr il , in which case the ulary. The Teletubbies attempt 10 imitate rhe Nanawr, inserts in the pro­ on equal pay for women fo r conclusion could be expec t­ gramme are repeated and time is left for children to talh bach to th e screen, ma ny years. It wi ll oblige th e ed sometime afte r the tri­ all fa ILures aiming 10 encourage thinrdng and speech skills. NH S to consider carefully the bunal reconvenes in Research for the programme is ongoing through a specially grading of all wo men staff in September. It would be pre­ designed shop in StTarford upon Avon and seven focus aJI professions." mature to speculate on the groups with nursery school children all over the coun­ Legal argu ments continue over implicati o ns until a final try. The lLlrgeL audience is Lwo to fiue year olcls. who should pay Pam Enderby conclusion is reached." A"~"" Anne "Vood says "("Ie should remember that man)' and how much and she The Department plans to little ones spend it great deal of time indoors in believes it will be another two consider each of these lead small spaces for much of each day We ma), deplore years on top of the 11 already cases on its own merits, the conditions in which some children live, so we spent on the case before the thereafter co nsidering 1500 must always remember that television can be a win- wider effect, if any, is felt. furthe r cases. dow 10 other possibilities. "

RES J ~E DATE. ..RESOURC D E Dysphasia Matters A VOICE for the deaf Co:Writer for \l\lindows Concerned at high levels of The Co:Writer intelligent illiteracy and underemploy­ writing assistant software is now available in a ei~~~!iJ~~~~~~~~dical staff teach­ ment among the deaf com­ ing pack for use by speech and language therapists experi­ munity, Morton Warnow Microsoft Windows 95 enced in working with people with dysphasia. has developed a system to compatible version. Consisting of a 20 minute video, lecture notes, workshop ideas, address this. Previously only available overheads and handouts, it can be used flexibly to accommo­ The VOICE program for the Apple Macintosh, date different audiences. involves children round a the software is used in The video gives a simple explanation of dysphasia and illus­ table with a teacher touch conjunction with a word trates its impact on people's lives. Author Celia Woolf of City typing on linked keyboards processing package. After University has prioritised the key information. The pack aims to to communicate with each keying in one or more let­ improve the skills and confidence of hospital doctors, GPs and other. ters, prediction of the required word is provided other professional staff working with dysphasic people and to Details: Morton Warnow, based on word frequency, show the benefits of leaming communication techniques. Educational Technology for SUbject / verb agreement Cost: £100 inc. p&p the Deaf, 19 Main Street, Apt. word relationships and Details: ADA, 7 Royal Street, London SE7 7LL, tel. 0177 267 9572 #703, Danbury, CT 06810 grammatical rules. Speech New from Signalong feedback and built in scanning for single switch Continuing its work on development of sign resources specific to the workplace, a new users helps people with manual for Hotel and Catering occupations will be available soon, containing over 630 reading and physical dis­ signs, about 60 per cent of them new. abilities respectively. Sign and Play , a collection of traditional nursery rhymes in a format designed to Details: Don Johntson Special involve the whole family, is also near completion. Details: tel. 07634879975 Needs tel. 01925247642.

SPE ECI 1& LANCUACE THERAPY IN PRAcnCE SlJII"IMER 1997 3 -- ­ DYSPHAGIA ISSN (online) 2045-6174 www.speechmag.com

Thickener is a vital element in diet modification for people with ~~agia, and . . manufa ers are making efforts to overcome its previous Hmitations. Sarah Barton and Sharon ~~u2hlin exnlore dIe versa ;y • i'ODe S]J 1 . net, Thick & Ea~, wind} aDows

There is a well recognised link between simple addition of a although traditionally dysphagia and malnutrition. This is food thickener. Food pureed diets have an hardly surprising when it is considered thickeners, although unappeal ing and unap­ that many dysphagic patients are served they are a fairly recent petising appearance, a murky diet of pureed food, generally phenomenon, have by using a food thick­ unappetising even to people in good proved to play an ener such as Thief, & health. extremely imponant role Easy, the variety of when used in Iiquids or foods that can be Limitations pureed foods. end- Pureed diets are far from satisfactory in There are a number of many ways. Frequently, they do not thickeners available on the meet nutritional requirements as the market and they can be cate­ addition of fluids in preparation dilutes gorised into two areas - gum patient present­ the nutritional content. Even when the and starch based thickeners. ed with a pureed meals do in theory meet require­ Gum based products can be bowl of ments, their palatability is usually so dispersed easily into liquids, unrecognisable limited that they are rarely consumed in and are used to improve mush should be adequate quantities to provide optimum the safety of both liquids gone. Now foods nutrition. and pureed foods. can be presented The use of separate bowls and plates to However due to the that are colourfuL serve individually pureed meal items, structure of gum based above all rather than an all-in-one slurry, does products they are not to the improve the attractiveness of the meal readily broken down by by adding colour and interest. However, enzymes in the gastro-intestinal there are still problems. tract and this can affect the hydration Stability The safety of pureed foods is a major propenies of the liquid or food. As with anything, change cause for concern. This is because, after It has been recognised over recent years is perceived as difficult; food is pureed, water separates from the that dysphagic patients are at serious risk however, using Thick & Easy couldn't be food pulp and this water may be aspirat­ of dehydration, so it is also important to easier. Depending on the patient ed (Fleming and Weaver, 1987). Further, ensure the food thickener releases the requirements, varioLls consistencies can it has been suggested that long-term use liquid during the digestion process. be achieved in a relatively short space of of pureed food can decrease swallowing Starch based products do release the liq­ time. One of the major advantages of performance due to mechanism disuse uid and can assist in the hydration of the using Thick & Easy is that it can be added (Groher, 1990). patient without the fear of aspiration. to any hot or cold liquid or pureed food As well as the nutritional and safety issues One starch based product available on and it will stal1 to thicken after 30 sec­ of pureed diets, there are also imponant the market which releases up to 98 per onds and remain stable and cohesive psychological, emotional and social ele­ cent of the liquid is Thick & Easy. after 60 seconds. ments which must not be forgotten. This stability can save time during When a patient is presented with a dull, Variety - the spice of life preparation and also ensures the correct unidentifiable liquidised bowl of food Thick & Easy is already used in thou­ consistency is achieved without guess day after day, he is bound to feel unen­ sands of healthcare facilities around the work. Something as simple as fruit juice thusiastic, demoralised and unsatisfied. world. First established in the United can be prepared in large quantities and States, the product successfully thickens be left refrigerated until required. It will Imp,rovements can be liquids and pureed foods and many peo­ remain in a liquid state and will not ma(Je ple who have impaired swallowing now thicken to a solid form. Pureed diets can be improved consider­ enjoy a variety of appealing meals with­ When mixing Thick & Easy into any liq­ ably, not only from a safety aspect, but out the fear of aspiration. uid it is always important that a whisk or also the appearance of the food, with the Everyone likes variety in their diet and, fork is used, as this disperses the thick-

4 SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 1997 ISSN (online) 2045-6174 www.speechmag.com DYSPHAGIA

ener into the liquid and does not form meal when food thickener has been sumption of the regular meals which lumps, even when using hot liquids. used. Once the food has been pureed, reduces waste and reduces the amount Jmagine adding corn starch to a hot often the most time consuming process of supplements required (Figure 1). gravy - you would have to have a sieve at in a pureed diet, food thickener can be Looking at reducing costs is very impor­ hand. However by following the instruc­ added quickly and easily with effective tant, as is improving the quality. of the tions on the back of the Thief, & Easy results. patient's life. By providing a variety of packaging as to the quantities required, interesting and appetising meals, the lumping can be a thing of the past. Scooping person not only can benefit in health The versatility of the thickened liquids is One way of using a food thickener is terms, but also psychologically. [t can be endless. They can be used as a drink, as with pureed vegetables such as carrots extremely frustrating for someone feed­ a sauce OJ; even as a pudding. One par­ and broccoli. Once thickened, they. can ing themselves when the food drops off ticular technique which increases variety be scooped onto a plate, providing a tex­ the utensils; the person loses dignity and in the patient's diet is the soaking solu­ ture which is safe to swallow. Scooping is becomes de-motivated . Thickened tion technique. a fast, effective way. of serving vegetables pureed food is much easier to handle and is less time consuming than ladling and can also reduce the amount of the Cakes and sandwiches ­ the food as was the case years ago. time required for feeding at meal times. the soaking solution By soaking biscuits, crackers or cake for a Moulds Without With few seconds in a solution made up of liq­ Fresenius, the company Thiel< & E.asy* ThIele 41 &By* uid and Thick & Easy, the patient can enjoy which markets and dis­ Daily Supplement Intake 4 (No_ of 200ml packs of ordinary foods without the risk of chok­ tributes Thick & Easy in high energy product eg_ Entera) ing or aspiration. This ingenious method the United Kingdom, Cost of Supplement/Day £5_60 £1.40 softens the food while it retains its shape, also provides a range of (£ I AO/200ml) flavour and appearance. Once soaked, the moulds that can be used Daily Cost ofThickener '1.00 (based on average intake of 60g/day food has to be refrigerated for one to two to re-shape pu reed *£3 _75/225g tin) hours to reach the correct consistency. foods. Using the TOTALS £5.60 £2.40 However, due to the stability, it can be pre­ moulds can be time sav- r------i pared in advance. By using the various liq­ ing, by freezing the *Thick & Easy is approved by the Advisory Committee on Borderline uids such as fruit juices or sugar syrup, pureed foods in the substances (ACBS) and is available on prescription in the community. For further cost savings a Thick & Easy catering pack (IOlb/£63.75) is also available. flavour can be enhanced and the calorific mould and using when value for the patient increased. required. As Thick & Figure 1 Estimates of savings for patient requiring pureed diet alld Sandwiches are usually a thing of the past Eas)1 is freeze-thaw sta­ suppleJllent$, with and u,ithout Thick & Easy for a person on a pureed diet. By soaking ble it can be heated without separation, the bread in the soaking solutjon for a few and the food sti II retains its attractive Food for thought seconds, and spreading a thickened filling appearance. Food thickeners will continue to be such as tuna and cucumber, the patient Over the next few months Fresenius is extremely important in the area of food can now eat what they recognise as a carrying out a number of presentations preparation for pureed diets. By pre­ sandwich and enjoy a variety of fillings. within healthcare facilities, showing the senting meals which are palatable, The soaking solution can also be used For use of the moulds and the versatil ity of attractive and safer for the patient to crisps to add to the plate and improve the Thick & Easy swallow, food thickeners cel1ainly give appearance of the meal served. evetyone food for thought. Cost-effective Sarah Barton is a Nutritionist and Sharon Enjoyment Patients rarely consume a complete tra­ McLaughlin a Home Economist with We all look forward to meal times and di tional pureed mea I. rn fact, large vol­ Fresenius. For fuu]ler information, tel. are often tempted by the appearance of umes are wasted. To counteract the 01928579444. food on a plate before we taste it. The nutritional deficits, many hospitals and References person who has dysphagia is still moti­ residential nursing homes encourage the Fleming, S. and Weaver, A. (1987) Index vated by the appearance and it is use of commercial nutritional supple­ of Dysphagia : A Tool for Identifying ex1remely important the food is well ments such as Fresubin and Entera Deglutition Problems. Dysphagia 1 (4). presented and recognisable. (Fresenius Ltd). These products do have Groher, ,\-I.E. (1990) Managing Nowadays it can be difficult to distin­ a valuable role to play. However, the use Dysphagia in a Chronic Care Setting. guish between a traditional and pureed of Thick & Easy results in increased con- Dysphagia 5.

Questions ~Answers

What are commonMIIgn Safety, nutrition and p,alatability can all be problems with .ititAi4j1alpureed compromised in a pureed diet. diets? Can people on a pureed By using_a soaking solution of liquid with diet eat sandwiches, Tl1ick & Easy, food is softened without any loss of cakes and crisps? taste or appearance and can be eaten with a spoon. How does a versatile Less supplements are required when using a thickener.~ save•• time~ versatile thickener, and stability allows preparation of and money? large quantities in advance.

SPEEC H & LANCUACe TIIERAPY IN PRACTICE SUMMER 1997 5 FLUENCY ISSN (online) 2045-6174 www.speechmag.com

The British Stammering Association

The British Stammering Association would like more dysfluent preschoolers to be referred to speech and language therapy. Through Its three year Primary Healthcare Workers Project, health visitors and GPs in particular are learning the value of early referral. Elaine Christie explains.

grow out of it" - from other healthcare most effective, but for that opportunity professionals and primary educators. to be available to clinicians, we need to get referrals closer to onset than is cur­ "Children just grow out of it, don't Late referrals rently the practice. Only when children they?" Many of the parents reported their are referred to speech and language "I tell parents not to worry about it, or to child had shown signs of dysfluent therapy as soon as there is concern over ignore it." speech from a young age, but a their speech - rather than a wait and see "I don't refer to speech and language therapy referral had been put off because approach - can therapists provide early immediately, the likelihood is that it will have of the 'he'll grow out of it' theory. intervention. passed by the time he goes to schooL" Now at seven, eight. nine years old, the parents of these children were Health promotion "I tell parents to wai t and see how asking BSA where they could get help Therapists have an important role to the stammeri ng develops." and why action had not been taken ear­ play in supporting health care profession­ lier in their child's life. Many of these chil­ als and participating in their informal and Th ese are dren were being referred to speech and formal training (Communicating Quality just some of the comments from health language therapy for the first time at 2, I 996).The Royal College of Sp ee ch & visitors in different parts of the UK when school age, at which point their dysflu­ Language Therapists recognises "the asked their opinion on stammering in ency was more established. extension of this role into appropriate young children.Their former beliefs about . d e health promotion activities". Clinicians making referrals for this client group Sl)1aII WIn OW ~ should ensure that "advice and / or train­ became apparent after they had received ot opportunity ing is available and provided for any indi­ a training session and accompanying Why don t we just 'wait and vidual s, other professionals and voluntary leaflets on stammering. Other health visi­ see' who will remit. and treat those agencies relevant to the individual client tors admitted to being unsure how to children who don't once they are of or care group" (p 180), and that "local identify dysfluent speech and unaware of school age? Much of the current general practitioners are informed of the the importance of early intervention research in the US on early stammering services available for those with fluency with you ng dysfluent children. and studies on the efficacy of early inter­ disorders". vention have demonstrated the benefits Parental concerns of working with preschoolers and their ...Project implementation However; it was not th is lack of aware­ parents (Fosnot. 1992; Fosnot, 1993; ~ The UK-wide phase of the Project ness and knowledge that first persuaded Starkweather et ai, 1990). began in April 1996, following the com­ the British Stammering Association Studies of dysfluent preschool children pletion of a pilot year in two contrasting (BSA) of the need for a project to pro­ have shown therapy is most effective locations - an inner city and suburban / vide up-to-date information and training when begun within 12 months of the rural area - wh ich differed both geo­ for health visitors and GPs.The initiation onset of the dysflu ency (Meyers and graphically and socio-economically. of the Primary Healthcare Workers Woodford, 1992). Yairi and Ambrose During this period, referral data on dys­ Project in April 1995 was a resu lt of the ( 1992) provide evid ence that children fluent ch ildren was collected from these continuous flow of letters and tele­ who stammer for longer than a 12 areas, training was offered to GPs and phone calls from parents throughout month period are not likely to 'outgrow' health visitors and refined , and two the UK expressing their experiences of their stammer. There appears to be a leafl ets for parents and professionals the 'advice' they had received - "don't small w indow of opportunity / sho~gures I and 2) were distributed to worry", "ignore the stammer", "he'll time span when therapy can be ~ these groups.

6 SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 1997 ISSN (online) 2045-6174 www.speechmag.com FLUENCY

For the Project to be impl emented at a national level, a series of one-off region­ al t al ks is being held throughout Britain. This all ows SALTs to learn how they can get involved in running the Project in their Trust and provides an opportunity for them to meet up with the thera­ pistJs in their neighbouring Trusts who are Involved with young stammering children and the Project T he issues dis­ r cussed are listed in fi gure 1 The information co ll ected on dysfiuent refe lTa ls has helped therapists consider several important aspects of their ser­ vice de livery to thiS group (figure 4) . A n example of a study of referral patterns is in figure 5.

SPEEC H & LANCUACE THERAPY IN I'RACIICL SIJM~·Ir:R 1997 7 FLUENCY ISSN (online) 2045-6174 www.speechmag.com

to help them implement the Project In Elaine ChriStie IS a speech and language Changing referral their Trust. SALTs can order quantities of therapist. She is (teldworker (or the British patterns two different leafiets which can be given Stammering Association's Primary there is a very real need for up-to-date to parents, therapy colleagues, other Healthcare Workers Project. information on early stammering and healthcare professionals and primary the children at most risk to be made educators. This national project is funded by the available, both in writing and through The first leafiet is a referral guide for Department of Health, BT arid Smiths training session s, to the main referring professionals which contains informa­ agents of under fives. This is largely tion on children at greatest risk from Charity ~ health visitors and GPs but for other developing a stammer. The other pro­ References NHS Tru sts, ClInical Medical Officers, vides parents with some background Fosnot S. (1992) Flu ency development nursery nurses and teachers, school information on dysfiuency, ways to help in young stutterers: Differential diagnosis nurses and playgroup leaders have a key whilst waiting for an appointment and and treatment. Austin, TX: Pro-ed. role in early identification and referral. who to contact if they are concerned. Fosnot S. (1993) Research design for The feedback from health and educa­ Th ese are available free of charge as are examining treatment efficacy in fiuency tion professionals who have received two different posters. Translations of the disorders. Journal o( Fluency Disorders 18. information and training has been over­ leafiet for parents are being produced. Meyers, S. & Woodford, L. ( 1992) The whelmingly positive. Most importantly it These will be available as aud iotapes Fluency Development System for young has and as written translations in Bengali, children. United Educational Services I) challenged their notion that stam­ Gujarati, PunJabi, Somali and Urdu. Inc., PO Box 1099, Buffalo, NY mering goes away if you ignore it The purpose of the one-off meetings RCSLT ( 1996) Communicating Quality 2) augmented their knowledge of what and opportunities for discussion, and 2. London: RCSLT to listen for and what questions to ask the distribution of resources, is to Starkweather, W., Gottwald, S. & 3) increased their awareness of the enable therapists to save time on what Halfond, M. (1990) Stuttering need to make an early referral would otherwise seem an insurmount­ Prevention. A Clinical Method. 4) broadened their perceptions of able job, even though these health pro­ Englewood Cliffs, NJ: Prentice Hall. speech and language therapists' work motion activities are perceived as Yairi, E. & Ambrose, N. ( 1992b) Onset of with parents and dysfiuent children worthwhile. BSA is endeavouring to Stuttering In preschool children: under five. take out the time-consuming tasks, Selected factors. Journal o( Speech and Qualitatively, changes are becoming all owing SALTs to get this job done Hearing Research 35 . apparent also. GPs and health visitors are more quickly and easily than if they had Yairi, E. ( 1993) Epidemiologic and other providing more accurate information to start the whole planning process considerations in treatment efficacy when referring a dysfiuent child and are themselves. research with preschool age children emphasising to parents the importance Through the Primary Healthcare who stutter. Journal o( Fluency Disorders of attending an initial assessment and not Workers ProJect, the BSA wants to 18. delaying it because the child experiences ensure preschool dysfiuent children in Yairi, E., Ambrose, N., Paden, E. & a fiuent period. GPs are acknowledging the UK are identified and referred ear li ­ Throneburg, R. (1996) Predictive factors the episodic and fiuctuating nature of er than has been previously the practice. of persistence and recovery: pathways early dysfiuency and the need for advi ce By providing speech and language ther­ of childhood stuttering. Journal o( to be given by a professional. e • apists with the tools and support t hey Communication Disorders 29. need to increase awareness and knowl­ Getting involved edge of stammering in young children For this Project to run effectively and be among healthcare professionals, we wi ll Further information on participation in implemented by SALTs, the need for begin to see changes in their referral this national project and copies of the suitable resources was identified, and patterns. This will benefit young dysfiu­ lea~ets for parents and professionals these have been developed over the ent children and their parents, as earlier from Elaine Christie or Norbert Lieckfeldt past two years. All therapists involved referrals provide the opportunity ~Project Administrator) on 0181 983 receive a resource and information pack earlier intervention. )I11III{"" 003 or 0181 981 8818.

Questions Answers

Why is trainin~ of B5A research indicates that, before receivin~ appropriate preschool referral a~ents trainin~ and information, preschool referral agents believe so important? in a wait and see attitude and that most children simply grow out of stammering.

What is the advanta~e of Early referral allows early intervention, direct or indirect, early referral in with therapy provided at the time when it is most efficient dysfluency? and effective, preferably within 12 months of onset.

How can a voluntary The B5A can provide materials, resources and or~anisation such as the information-sharin~ opp'ortunities so speech and lan~uage B5A best sup'port therapists can use tneir time for implementation. practisin~ therapists?

8 SPEECH & LANCUACE THERAPY IN PRACfICE SUM,\,ojER 1997 ISSN (online) 2045-6174 www.speechmag.com FO C US

Since the formation of These objectives are devolved Derwen NHS Trust in 1994, to each community team the speech and language and each member of staff. therapy service has been pro­ Each of the three CTLDs has viding assessment, treatment a Community Clinical and support so the people of Manager to ensure the objec­ West Wales with a learning tives set are achieved'. The d isabiJi ty and their carers are Professional Head of Speech helped to lead as fulfilled a and Language Therapy is also life as possible. a Community Clinical The Derwen NHS Trust (West Manager heading up a team Wales) is a special ist trust consisting of community providing a wide range of nursing, physiotherapy, psy­ home-based, day-time and chology, speech and lan­ in-patient services for those guage therapy and a chal­ suffering from mental illness lenging behaviour service. and distress and learning dis­ To achieve the objectives, abilities. These services each member of staff has a include: ieces Performance Development of and Review (PDR) Strategy • mental health for adults •• • mental health for the psy­ and a Performance chiatry of old age Development Plan (PDP). • rehabilitation for those This is primarily a two way with enduring mental illness e JIgsaw process between the individ­ • psychotherapy ual and his or her manager. • child and family consultation Objective setting and support The CTLD's objectives are • learning disability workers are vital pieces in the jigsaw discussed and the member of • substance misuse. of a specialist Trust in West Wales staff and manager agree indi­ The trust provides services to vidual objectives for the people living in the for people suffering from mental forthcoming year. Tn this Ceredigion, Carmarthen, illness and distress and learning way individual members of Llanelli and Dinefwr areas disabilities. staff know the Trust's aims, and on an in-patient basis to Nigel Miller examines the speech the Learning Disability Pembrokeshire residents. and language therapy role. Service's objectives and the The current team of six profession's objectives (fig. 2). speech and language therapists (SALTs) and five support work­ The objectives on a PDR are key to the success of the speech ers work as part of three Community Teams Learning and language therapy service. They are sufllciently challenging Disabilities (CTLDs) based at Aberystwyth, Carmarthen and to ensure progress, but achievable to avoid frustration through Llanelli. The service is headed by Nigel Miller, the Professional failure. So each SALT has few objectives - a maximum of 10 ­ Head of Speech and Language Therapy who which are: joined the service in 1986 and is part 1. quantiftable (whenever possible they are measurable) • People with a of the Learning Disability Service 2. capable of being tested (the learning disability Senior Management Team. constraints within which The service have a rigbt to nonnal Over half Derwen's SALT ser­ they are to be achieved objective: patterns of life ~itbin the vices are purchased by Dyfed are defined ) • To develop research based ~'? commuDlty. § • People with a learning disability / Powys Health Authority 3. within a definite practice which is sbown to be and the remainder by GP time scale clinically effective '. should have a risht to ~ treated as becomes a speech and language indiililuals. Fundholders. 4. precise (clear, tberapist's individual objeC11ves:­ • People with • learning disability The Learning Disability well-defined). • To assess what practice is research based require additional belp from the Service foUows the principles This is because for speech and lanp. therapists working communities in which tbey live and from professional services if ofthe AJI Wales Strategy (fig.!). the objective: with people a leaming they are to develop their The Learning Disability • Improve the disability through ulonal journals, maximum potential as Service's Senior Management com munica tion literature and Intenlet fadlities by end of 99 individuals. Team provides direction for all skills of people with Ma.r:J 7 I staff through an operational plan. learning disabilities • To recommend to the Head of Speech .:c,!E. Each profession is involved in produc­ may not get you far and Language Tberapy changes in '(so ing the plan so the service is integrated and but clinical practice requJred to ensure " meaningful for each discipline. The plan gives the service's vision: • Provide Hanen rrain- clinical progres~ whicb is shown ,i'i:'" • A range of community orientated services. ing in order to facilitate a to ~ effectiVe by end of ",+'" • A,skilled workforce ofqualified professional staffwith trained family-focused approach to August 1997. ~e'\.' support staff. language intervention by January 'I',t\) • A co-ordinated, client-centred, multidisciplinary approach. 1997 and an evaluation report by March /997 • User-friendly systems which meet the requirements of our will hopefully get you further. purchasers, users and Trust Board. The PDR process consists of regular and frequent infomlal • A high quality, efficient, effective service, which contributes a review discussions and a formal annual review. It is supponed unique expertise to the support of people with learning dis­ by a PDP which identifies training and development nee s for abilities and their carers. the year based on the objectives. For example, in order 10 In addition the plan sets out specific selvice objectives, for achieve example, • To develop research based practice which is shown t b clin­ • To develop research based practice which is shown to be clin­ ically effective ically effective. a speech and language therapist may need to attend appropri ale

SP EECH & LANGUAGE THERAPY IN PRt\GrJCE SUM,\

1. Clinical training and have time allo­ KEY POINTS effectiveness cated to undertake 2. Audiology - providing an re search, so this would • Derwen is a specialist NUS integrated audiologieal serviee to be ide ntified in the dients with a hearing loss PDP Trust providing services to 3. Danen training PDPs deta il those suffering from mental 4. Evaluating ~~~i:n~'::;etraining ca reer and prior­ illness and distress and _ communicatio n skills ity person al 5. Evaluating the dysphagia service d eve lop m en t learning disabilities. G. Developing an interview package for needs and any people with a learning disability seeking formal training "0 employmellt planned. PDPs • A h igh priority is placed on -p 7. Evaluating dlent signing groups may reflect fl ex i­ staff working to objectives in ~ . 8. Evaluating social skills groups ~ 9. Expanding the use of ENABLE ble working, line with the aims of the Trust, \ 10. Evaluating the special care service rotatio n a l posts, '0 ll. Evaluating the dual diagnosis secondments and the learning disability service ;Q/(,J' (people with a learning disability shadowing The PDR and the profession. -0,.. and a mental health objective topics for the ('-:S~ problem)service. D S AI ~-' . D~ erwen . LA service are In rl-y('>f) SALT ' figure 3. • Support workers allow clients ser vICe Further info rmation from : to be seen more regularly and Mr. Nigel Miller, Professional Head of Speech and La nguage Therapy, DenNen NHS Trust (West Wales), free qualified staff to do more 12 Bay View, Capel Ro ad, Llanelli , Carmarthenshire SA 14 8SN specific work.

SUPPORT WORKERS Releasing qualified time qualificatioll NVQ 'Speech and Language Therapy Support' Since the se rvice introduced support workers in 1992, many more clients are receiving regular speech and language when it is available. th erapy and fears of 'des hilling' have been allayed. Fears of 'deskilling' at the initial suggestion of suppon work­ The support workers (not speech and langllage therapy en were quickly dismissed as time was released a/lowillg th e assistants as they are paid on an Admin and Clerical Pay SALTs to concentrate on what the)' are qualified to do: assess­ Scale) have competency based job descriptions taken from mellts, advice, trainillg and investigation of issues such as clinical effectiveness. 11lis did not all happen at once as sup­ level 3 of th e National Vocational QualifiClltiolls (NVQ). port workers require a great deal of twilling and super-vision, Their primary role is to support clients alld carers ill the but they are now Ifital to the leam. deliver), of care II/Ider the supervisioll of a speech IIlld lallguage therapist. Olllies illclude: The evaluation of the support worher role IIfldertahell b" the health IIlItlwrit)' highlighted that "the development of the * assisting clients to communicate by fol/owing illdividual support !(Ior/wr concept irl l.he field of le£l m ing disabilities is therapy prograll/l/les • supportillg the SALTs durillg treatments allli illvestigations a logical eX/ensioll of the mOJle from institutional to COlI/fUU­ Ility care" wul tlrat clie rus {filiI w ren wlthollt e.\·ceptioll sup­ • carryillg out delegated group therap)' sessioll$ ego signing. ported the (ollcept (mil welcolfled the increased iI/put. 11re suppurr workers will be e-.:.-pecred to gail! the Ilew WORKING WITH PARENTS The value of video

One of the POR object i(!es for the rear WlIS to rull aile Illit ial/" paren ts were ~'C' '1 ' reillctant to /)e Lli,ieoed. Howell"'; Hanen Parellt Programme. 71lis fllmil), focused approach to at the elld of lite cour e a/l fell tlillt lll~'}' /r UlI bl'llefited from ItITlgllllge illlerJleutiolf with )'olmg childrell focu ~ es prim(/rily it. Oil the ;IIIPU rWIICe of parelft.~ in till' iuterl'enlion process. I" rile /iI/,ll sessioll t/,e edrJy l'ideowpes were compared co tile In It joilll 1'/UHllre belweell lI,e Oerulell , HS Trust I,ideotapes lIIade tOWards Vie. eml of lire cOllrse. A (JIlS ider­ (I ht>ra/lists /\.1111,,,,111 f)(/tlies !lI1L1 Y"olll,e Miller) and tile II b'e (fiJ[e!'("lct' ill d,ild lIIul pll relll illllmJfL;(/II nlUhi be 'cell UUlleIli Oll/cju'r H Tru.st (tI,el7lpis( He/ell Griffith -) a jt, (Il l flues. PI/relit. were IIOUI ""ti,'el), II/1I.\';/II;5i/l8 1'lIIg"I/ge C(}I/rse wa.~ successfull)' ,.,111 oller all 11 weeil period prior III iellminR opportul/ities. Chrisw",s 19%. l'lIrellls were l Ief)' poSilft-e /lbmll tile IlalU'l' Purellt Prng'/"ill"" 11'. ,PI/remt., of si.t c/,jldn'lI experilmcin II deuw in tillm­1111')' fell tlIe)1 had gll;IIed support fro", at/ieI' pdrelltS mill IIIIIg'IlIse del'elopmeTII altt!mled :it'IOC', ,-'I'l'"il/g l e '~ju/15 IU ga;II I1ftt!lI CU/IImCllh?(/ it 11'115 good TO mlk to ocher people "i" (/,e a bella IIIIderstll ndillg of how cllildrell dwl'iop same bout'~ I1rc JIlIdl .Cl ion int'o(I'etl re-mppirrg aI' t1lillg5 language lllld of tl,e co,wellliolial strategies which urould laelp pn'violl.d" leIJml ",rn - III I/IJ.' ptJrt'IlTS' .m&'l(c.~riO/J - a me(11 I~t promote their "hildrell's languag(' dewlopmellt. tile 10CIli Jilt/I. l)(lrt'tlts (liso rl'ceil'ed fO llr 1I0me l/isits interspersed betwet'tl tl,e Botl! I'u renl.~ alld tlrerapists illvull'ed ;/1 tile Hallen l'dll'IIt eLIf.'nillg sessiolls ur/ljeh invollJ('d videotapillg tile parellts inter­Programme felt il was (' success. '/1,t! parents would strollglr (letitlg with their cllildren. Ollritlg these visits, parellts were recommelld atte/ldillg a programme to other parellL~ of etleouraged to lise tile strah'gies leaTllt in the evening sessions. chilt/rell witl, lallguage difficulties. It is all excellellt TIle parents tllen received feedback on ",e l,ideo interaction. till!rapelltic tool «,l,it-h we will lise further ill the Juture.

10 SPEEC II & I.A"ICUACE I Ht:RAPY IN PRr\C I1CL SLllv\!, ICR 199 7 ISSN (online) 2045-6174 www.speechmag.com T HE TEAM A PPRnAC l 1

A minimally responsive individual may have tile potential to inima I communicate effectively. Sophie MacKenzie describes flow, as a res ,0 estate: speech and language therapist at the Royal ex onn Hospital for Neuro-disability, she works as part of a co m cation team exploring different metllods of accessing potentia communication.

Recent publicity has highlighted the brain injury. They demonstrate the ical disabilities of this client group are controversies surrounding the long­ ability to carry out auditory com­ normally profound, and thus to dis­ term management of clients with mands if these are within their physi­ cover some residual cognitive and lin­ severe brain injury. Giacino and cal capabilities, but auditory compre­ guistic skills and a way of accessing Zasler (1995) discuss the subtle but hension abilities vary from patient to these is of paramount importance fundamental differences between patient. These patients are typically both to the professionals and, of patients presenting as comatose, in anarthric and often aphonic. course, to the relatives. vegetative or persistent vegetative Support for relatives is also a team state, minimally responsive and those affair in that we all need to be partic­ termed 'Iocked in', following injury to The team ularly sensitive to the grief and dev­ the brain and / or brain stem. challenge astation they inevitably go through. The challenge to the speech and However, counselling and structured language therapist working with this support sessions are carried out pri­ Minimally client group is marily by the social worker. We also responsive a) to ascertain the level of residual have regular evening relatives' meet­ This article focuses on the role of the linguistic and communicative func­ ings where a member of the team rehabilitation team with patients in a tioning and normally gives a brief talk about their minimally responsive state - those b) to provide a means of helping role on the unit and then relatives who, following neurotrauma, are no such individuals express themselves and staff are left to mingle and to dis­ longer deemed to be in coma or in to the best of their ability. cuss particular worries or concerns. vegetative state, but who neverthe­ With patients who have such limited It appears from clinical experience less remain very severely physically physical function, this is no easy task. that, despite huge physical limita­ and cognitively impaired. Individuals Management of all aspects of an indi­ tions, some individuals following may present as minimally responsive vidual's functioning is necessarily a severe head injury do still show following a wide range of cerebral team affair with this client group. awareness and some residual linguis­ damage due to traumatic brain Responses are often so limited, subtle tic functioning which, if accessed, can injury (diffuse or focal), hypoxic / and variable that the specific skills of result in a viable communication anoxic episodes, infective, toxic or all disciplines must be brought into method being established (Andrews metabolic disorders, or vascular play in order to maximise these et al 1996). lesions. responses. The team at the Royal Patients defined as minimally respon­ Hospital for Neuro-disability includes: Yes and no sive post-brain injury typically fall • clinical psychologist The speech and language therapist within the Rancho Los Amigos Scales • consultant working with minimally responsive of Cognitive Functioning (1974) levels • dietitian individuals is reliant on two distinct III and IV. They may localise consis­ • medical officer responses to command being estab­ tently to a stimulus, for example, they • music therapist lished before a communicative may track an Object visually or turn • occupational therapists and response can be considered. At the to a sound, and they may show a assistants Royal Hospital for Neuro-disability, limited awareness of self by, for • physiotherapist and assistants this is achieved by the occupational example, responding to the physical • social worker therapists, who determine whether dis~omfort of a catheter. They may • speech and language therapist an individual is able to execute con­ also respond to their own internal • trained nursing staff and health care sistently two movements to com­ confusion, showing agitation and assistants. mand; these may include sometimes incoherent vocalisations. We work together through joint ther­ • two distinct motor responses Individuals who are termed minimally apy sessions and liaison, both in • pressing a single switch with auditory responsive typically present as twice-weekly structured meetings of feedback once and twice tetraplegic, with poor sitting balance the whole team and as necessary • looking at two different objects/pictures ' and head control. They are usually between different disciplines. words (ie. visual discrimination) incontinent of both urine and faeces. Finding a viable method of communi­ • producing two distinct phonemes. They show spontaneous eye opening cation with minimally responsive indi­ These two responses are then linked and the ability to track visually, if viduals is a priority of the interdisci­ to yes and no, so the individual is vision per se is not affected by the plinary team, particularly as the phys­ taught to associate one response

SPEECH & LAN GUAGE THERAPY IN PRACTI CE SUMMER 1997 11 THE T EAM APPROACH ISSN (online) 2045-6174 www.speechmag.com with 'yes' and the other with 'no'. For language therapist can begin to make writing. The PALPA (1992) writing example, an individual might be decisions regarding potential AAC assessments can be adapted for lis­ encouraged to press a switch once to options. tener scanning, although administra­ indicate 'yes' and twice to indicate tion is necessarily time consuming. 'no', or to give one motor response, Patients showing high level written such as !ooking up for 'yes' and Alphabet language ability may be assessed for another, such as a hand movement, stfategies 'high tech' communication systems, if for 'no'. If a minimally responsive patient has this is felt by the team to enhance Once an individual is able to produce shown the ability to recognise letters independence. Such systems include 'yes' and 'no' to command, using and some single words, further the Ke:nx software (Don Johnston whatever modality is felt to be the assessment is carried out to deter­ Special Needs Ltd.) and Lightwriters most reliable, assessment of their mine whether text-based AAC might (Toby Churchill Ltd.), both of which residual linguistic functioning can be viable. Typically, a string of letters can be used by single switch users. begin in earnest. Language assess­ is recited and / or shown in alphabeti­ For those patients who are unable to ment using closed questions does of cal order and patients are asked to use text-based systems, other AAC course have its limitations, but, as signal when they hear or see a given options are explored, such as picture can be seen from the example ques­ letter. If a patient is able to select sin­ charts (using scanning or pointing) or tions in figure 1, the speech and lan­ gle letters in this way, s/he is then simple word charts to express basic guage therapist can use word levels encouraged to identify short needs. These types of low tech AAC as well as some syntactic concepts to sequences of letters, such as C-A-R. If also have their high tech counter­ gauge an approximate idea of an s/he is able to identify sequences of parts, such as the AlphaTalker individual's receptive functioning. letters from a limited selection, the (Liberator Ltd.) and the Macaw (Zygo choice of letters is gradually Industries Inc.), which may be appro­ increased, with the aim of providing priate for some. the entire alphabet, split into manage­ The role of the speech and language able chunks. The most commonly therapist in relation to other members used layout of the alphabet is known as the A-E-I-O-U layout, where the alphabet is split into rows, each begin­ ning with one of the vowels (figure 2). ABeD The rationale behind using this layout is that it is presumed that the patients E F G H have some residual knowledge of alphabetical order, and thus would I J K L M N 4. Is a feather heavier possibly know when the vowels occur than a man? in relation to the other letters. OPQRST V WX Z 5. Is Big Ben the tallest Listener scanner U v building in the world? technique Figure 2: A-E+O·U alphabet layout At the Royal Hospital, this method is Figure 7 - examples oj closed questions to usually employed with the facilitator of the interdisciplinary team when assess aUditory comprehension actually reciting the letters, the so­ endeavouring to establish a meaning­ called 'listener scanner' technique. ful response with this client group is If a patient has a yes / no response This was initially introduced with visu­ represented in figure 3. and / or the ability to access a switch, ally impaired clients but has since Because of the inherent complexity of assessment for a suitable alterna­ proved useful with other minimally this client group, each discipline relies tive/augmentative communication responsive individuals, where pOSi­ heavily on the others to implement system (AAC) which would further tioning of an alphabet chart in the patients' management programmes. increase his or her output can take correct line of vision is problematic, or Thus, the speech and language thera­ place. Again, the entire team will where it is felt that input to both the pist relies on information regarding have accrued information which will visual and auditory channels is benefi­ response to auditory and visual stim­ help in the correct choice of AAC. cial. The listener refers to each row of uli supplied by the occupational thera­ the alphabet by its vowel and the pist in order to begin assessment for Pooling client then indicates the correct row AAC. The interdisciplinary team in has been reached using his / her general relies on the language assess­ information most reliable response. This might be ments carried out by the speech and Information regarding a patient's a head nod, pressing on a buzzer language therapist in order to pitch auditory comprehension skills is switch or vocal ising. The listener then their interaction with the patient at an pooled with information gleaned by scans across the selected row, until appropriate level and so on. other members of the team, most the client indicates that the correct let­ Very profoundly brain-injured individ­ notably the occupational therapist ter has been selected. Depending on uals may present as minimally and the clinical neuropsychologist. For other cognitive abilities, the client responsive either because of their example, is the patient able to recog­ may need constant reminders as to severe physical deficits or because of nise letters, presented either auditorily the letters already selected or his / their severe cognitive defiCits, or both. or visually? Is s/he able to recognise her attention may need redirecting to The speech and language therapist colours or pictures? What are his / her the task. working in this area, however, has to learning ability and memory like? Is If the patient shows some ability to be open to exploring possible com­ s/he able to initiate to any extent? spell using this method, his / her writ­ municative ability which may be pre­ With all this information about the ing skills can begin to be assessed as sent, even in such damaged patient's functioning, the speech and one would for patients using hand­ individuals.

12 SPCCCII & LANCUACETHEI,APY I. 1'RA.CfrCE SUM ,tE R 1997 ISSN (online) 2045-6174 www.speechmag.com THE TEAM APPROAC H

References OT Andrews K. , Consistent response to audHory Murphy L., (non-verbal) stimuli (eg. loud clap) Munday R., Littlewood C. (1996) Misdiagnosis of OT the vegetative Consistent response to command state: a retrospec­ m~tor response, visual discrimination "'...... tive study in a rehabilitation unit. British Medical Journal 313. Giacino J.T., Za sler OT N.D.(1995) Unking consistent response to Outcome after yes and no severe traumatic brain injury: Coma, the vegeta­ tive state, and the SALTand OT minimally respon­ Answering questions using sive state. Journal yes / no response of Head Trauma Rehabilitation 10 (1) Hagen c., Malkmus D. (1974) Rancho Los Amigos Hospital Levels of Cognitive Functioning Kay J., Lesser R., Coltheart M. OT / SALT / PSYCHOLOGIST (1992) Psycho linguistic Information (eg. ~Al...,.nl,",' Assessments of OtIJlttation language skills, acc:..~ Language Processing in Aphasia. Lawrence Erlbaum Associates Ltd ., Hove

Sophie MacKenzie is a specialist speech SALT and language Functional use of AAC therapist at the Introduction of AAC Royal Hospitalfor into daily life Neuro-disability in London

Questions ~Answers What does a minimally Patients who are minimally responsive are no longer responsive state in a coma or vegetative state Dut remain severely mean? physically and cognitively impaired, with problems accessing residual communication skills. How does assessment The establishment of a reliable yes / no response by ••begin?~ occupational therapists allows other disciplines to begin their assessments. What specific The speech and language therapist assesses contributions are residual communication skills and explores ways of made by the speech accessing these effectively, to the benefit of other and language staff and relatives as well as clients. therapiet?

SPEECH & LANGUAGE THERAPY IN PRACTICE SUM,vIER 1997 13 COVER STORY ISSN (online) 2045-6174 www.speechmag.com

WILSTARR (Ward Infant Language Screening Test Acceleration and Remediation) was developed in Manchester by speech & language therapists D~ Sally Ward and Ms Deirdre Service Birkett (fu ll report of the screen in Ward, 1992). WILSTAAR enables infants aged eight to nine months to be screen ed quickly by health visitors as part ofthe routine hearing test Th e screening questionnaire predicts children at risk of lang"uage dif­ Deveopment ficulties and enables a cost effective preventative package t o be delivered in the home to the child and their family over an average period of four months. Epsom Healthcare Trust provides services to a suburban area which includes a wide social spectrum with around 2,000 Introdudng a births per year The successful Health Gain Fund bid for 00,000 was used to create two fu l! t ime speech and language therapy posts to cover the whole district. preventative Involving health visitors Health viSitors playa key role in WI LSTAAR and it was impor­ tant to have their support We were fortunate in havi ng a very approach good relationship with our health visitors. Several years previ­ ously we had audited our speech and language therapy refer­ ra ls. The outcome had led to the introduction of a two and a quarter year screening check, a comprehensive programme of health visitor training in t1e use of this sc reening check and broader t rain ing in speech, language and communication diffi­ culties in pre-school children (Bowers and Oakenfu II , 1996). In order to make the 3pplication for Health Gain Funding, it was necessary to diSCUSSit with and win the agreement of the health visitor management Several meet ings were ar-ranged with the General Manager and Locality Managers and they agreed to support our application, pl-oviding we were willing to continue on-going training of health visitors. In July 1995 I attended a training session with Sally Ward and Deirdre Birkett at the University of East Angl ia. Armed wi th the information from this tr-ain ing course I came back to my man­ ager; Tricia McGregor; who started t o prepare the application w hich was in two parts. Applying for funding . The initial application form was quite straightforward You had to I . state what area of health would improve 2. give a brief desc ription ofthe project, the resources required and the cost, and t he t ime scale A health visitor asking Wilstaar questions 3. list other agencies involved and 4. explain how you would demonstrate that health has improved due to the project intervention. WILSTMR is a detection and We stated, as the area of health improvement. the early detec­ intervention programme for use tion of and intervention in language difficulties and the conse" quent gain in overall development skills and progress. with children under a year old. In the brief description of the project. we emphasised the cost effectiveness ofthe preventative package. We stated the figures In 1996, following a successful from the initial WI LSTAAR research for 30 per cent reduction in 'failed to attends', a 60 per cent reduction in the treatment Health Gain Fund bid, Epsom time and treatment length and that 95 per cent of children reached normal levels of language development Healthcare Tlust was awarded For other agencies involved we included health visitors, and for £70,000 to fund a WILSTMR demonstrating that health had improved due to the project intervention we had two points - that we would be able to project. Project Co-ordinator Sue show improved health firstly by the assessment of language lev­ els of infants in the project and secon dly by the measul-ement Oakenfull details how the project of our referral rates later on, which should reduce. The full effect on the referral rate will take longer than the two years came about. of the Health Gain Fund to gauge, but we would wish to con­ tinue to monitor outcomes closely over a longer period of up to five years,

14 SP EECH & LANGUAGE THERAPY IN PRACTICE SUMMER 1997 ISSN (online) 2045-6174 www.speechmag.com COVER STORY

We heard very quickly that our application had been looked how best to pass the information on to the large number of upon favourably and that we should be well prepared to move health visitors in the district. It was decided we would try to to the second stage. In this final pha se of the application you get a slot on an annual event called Partnership w ith Parents have to give a more detailed description, including a project w hich is organised by our consultant community paediatrician. plan with reference to how it will be managed and monitore d The timing was perfect as this event was due in a few weeks' and who will implement it, and the target group, including the time. By complete coinc id ence the next day we received a number likely to benefit. telephone call from the consultant community paediatrician. For the evaluation of the project we said detailed information asking if it would be possible for the speech and language ther­ would be collated on apy department to talk at Partnership with Parents. ", the numbers of children screened, the lo cation and age We took the opportunity of suggesting an introduction to the * t he numbers of chi ldren entering the programme and the W ILSTAAR project and this was agreed. We were very lucky; assessment scores it saved an enormous amount of organisation of meetings and. " the amount of time taken for remediation. as Partnership with Parents is a three-line whip for health visi­ In addition, tors, we targeted about 95 per cent of them presently work­ " children in the project would be identified so that we could ing the district. Partnership with Parents also targets clinical follow them through the system and check for later referral to medical offi cers, local GPs, clinical psychologists and other speech and language therapy healthcare professionals. * a patient / health visitor satisfaction questionnaire wou ld be Two main is sues were raised at this meeting: used I. How W ILSTAAR would be administered to parents w here i, a sample of children would also be followed up for re-assessment. Engli sh was not the spoken language. In the early months of 1996 we heard our application had 2.The ethical dilemma of not telling parents that their child may been successful. be at risk. (WILSTAAR is presented as an acceleration pro­ gramme and at no stage IS the parent made concerned about their child's performan ce .) The WIlSfAAR team These Issues were taken fO lward to the Manchester meeting (see later). At the end of this health visit ors' training session, health visitors were given a pack we had prepared, with an outline of the W ILSTAAR project and the forms and questionnaires neces­ $, ry for them to start. Each cl inic was also provided with a mOl'e detailed pack of informat ion as a reference resource for health visitors. We also produced a letter which was sent to all GPs, clinical medical officers and other healthcare professional s in the diS­ trict t o let t hem know about WI LSTAAR and that it was about to start in their area. 'vVe received only one correspondence from a GP follow ing thiS Circular. Several weeks into the start ofW ILS TAAR, the therapists made drop-In vis its to local community health centres and clinics to talk to the health visitors and to answer any questions th ey had. Follow-up Once the Health Visitors had completed the questionnaires they were sent back to the W ILST AAR therapists for interpre­ tation. Those babies identified as being at risk are visited at (clockwise from top left) Frankie, Sue, fo and Claire home by two speech and language therapists for a full language and development assessment then, if appropriate, invited to The next step was to advertise and appoint two full ti me speech take part in the language remediation programme, An and language therapists. We decided that we would split their appointment is se nt to the parent with a standard covering let­ posts so that two of the ten sessions could be spent in general ter. Many of the standard letters needed are provided in the community work. I felt this was Important for the therapists' WILSTAAR manual. We tran sferred t hese onto Epsom future development as it might become too nanrow a field to Healthcare Logo paper. concentrate on WI LSTAAR alone. In September 1996 the team As the questionnaire forms started to return to the therapist s, was formed. W e appointed Jo Stanhope and Frankie Ramtin. we reali sed there was no designated place on the form for Claire Finlay. who was already working in the district, took up telephone numbers, We therefore had to contact all health two sessions and I took the other two sessions as co-ordinator. viS itors again for these to be included. We. were very fortunate in being able to train together during Health viSitors found the form took longer to complete than the summer of 1996 with Sally Ward and Dierdre Birkett at St. the two minutes suggested. To save time, they arranged them­ Christopher Place, where Sally now works. This was a perfect selves for the clinic co-ordinators to complete the patient opportunity to start to build our team. (Frankie and Jo had details when the hearing tests were booked in. agreed to come to the training session out of their own time as If we were setting up the service again we would use the train ­ their posts did not officially start until later on in the yea r. ) ing session to go through the questionnaire forms in more detail and spend some time with the cliniC co-ordinators 'Partnership with Parents' explaining the project and gaining their support. well before The next stage was to train the health visitors. We decided to the start of the project. do th is in two parts. First, we met with the four senior health Jo and Frankie attended a WILSTAAR meet ing held in visitors. We described the WILSTAAR project and asked them Manchester recently. The meeting provided a valuable oppor-

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1. For non-English sReaking families, we will [unity to ask questions and brainstorm problems. As a result provide a letter explaining why it is not we have been able to make several decisions (Figul"e I). p,ossible for then1 to be a part of th~roject . Positive response lIn this area there are Very few non-Ei1gltsh It is now four months since we started W IL STAAR. still too ~eaking parents and auf of 1,600 creens so soon to eval uate outcomes, but soon enough to know t hat tar we have had none.) the initi I responses from both health visitors and parents are very positive. We have definitely raised awareness of the importance of early in teraction and the benefit of parents play­ 2. The ceiling age for providing the ing with their babies. remediation programmewilJ De one year. The professional role 3. \;Ve are following \rVlLWARguidelines on the It has been suggested t hat W ILSTAAR could be provided by way the project is presented to parents -any heal h visitors or speech and language herapy assistants. We feel unable t o suppor1 t his suggestion at present as speech and hcilth VISitor feeling strongly aDout tile issue of language therapist s are high ly trained in he development of not telling parents that theIr child may be at risk communicat ion skills in yo ung children an d it is this profe ssion­ will be aBle to withdraw. al training that offers the breadth of knowledge an d practical skill t o wO I-k closely w ith parents, to think quickly and accu" 4. Our future plans will take into aCCowlt the rately in order to answer questions. and subt ly change an activ­ evaluation measures outlined in the HealUl ity so t hat the child and parent expenence success. WILSTAAR offers a different approach for delivering a paedi­ Gain bid proposal. We will also be arranging alric speech and language therapy service. It has required further health visitor training, to cover the great sensitivity and fi exibdrty and we are all enjoying the pre­ anival ofnew staff to tile diStrict ven tatJ e aspect of the programme.

5. We are looking for an alternative language Sue Oakenfull. Jo Stanhope, Frankie Ramtm and Claire Finlay are assessment to the REEL (Bzoch & Lea~le, the WILSTAA R Team at Epsom Health Care Trust. Epsom Clinic. Church Sireet Epsom KT 17 4PP 197] ), the l~).RUage assessment used with cL Rarents ofch.lldren who have been identified « through the so'een. vVe find it difficult to References ~ present thi without leading the parent Lo give Bzoch, K. & League , R. (197 1) The Receptive Expressive ~ a response they feel we want to heal: Emergence of Language Scales (REEL) . NFER . Baron-Cohen, S, Allen, & Gillberg, C (1 992) CHAT Th e :J J. B 6. We are aJso vety interested in the Checklist Checklist for A utism in Toddlers. British Journal of Psychiatry I 61 . Bowers, R. & O akenfull. S. ( 1996)The role of health visitors in ~ for Autism in Toddlers (CHAT)(1992) as the speech an d language therapy. Health Visi tor 69 (8) . .~ researdl for this insmunent has been extended Ward, S. & Blrken, D. (1 992) The predictive vali dity and accu­ .~ into an epidelIDological study of 18 month racy of a screenin t est for language delay and auditory per­ ~ oids in tHe South East ThaInes r~on and ceptual disorder. European Journal of Disorders o( . ~ health visitors from Epsom HeaItll Care Trust CommunicotlOn. 27( I) 1: are taking pan. We would be interested to see Details of WIL STAA R training (rom Dr Solly Word, The Speech. if any children g!ven a diagnosis ofautism Language and Hearing Centre, Christopher Place, Chalton Street ~ USll;g CI~AT_h~ llievigusTy been identified as London W I IJF, tel. 01 71 3833834. Manuals and (arms are u: at nsl< USll1g WllSIMR available fol/owing training and accreditation W ith WILSTAAR

Questions Answers What is WILSTAAR? WILSTAAR is a screening, assessment and language remediation / acceleration programme used in a preventative way with children under a year old and their families.

How did Epsom go Support of health visitors was obtained and a about setting up a two-stage funding bid quoting data from the original WILSTAAR project? WILSTAAR study made to the Health Gain Fund.

Why should WILSTAAR Speech and language therapists are the profession­ accreditation continue to ars with the training and practical skills to work be exclusive to speech effectively with parents on the development of com­ and language therapists? munication skills.

16 SPEECH & LANGUAGE THERAPY IN PRACfICE SUMMER 1997 ISSN (online) 2045-6174 www.speechmag.com H O Wl...

Bert . Two months a20, Bert had a mila stroke but clidn't need to be admitted to hos ital. Although his sp ech Howl went cO Jete) at th . time, i cam back ClUlckl.V and. evervone ifssunred hl~ rec<1Very age would continue. GP has now r err d • · to 0 as Bert IS embar asse4 bv the a wav he contlnlIes to slur words, seems to l1av~ too much saliva n,'DDIDOSI'le. set out their management of Bert. In hiS mouth and Is Adult Co-ordinator for the Speech and enerallv sounds a senior speech and language therapist in Ult roff. He tells fi'4W'lorrfln:::atnr of Speech and Language Therapy ou can't speak as ou ) as he L6ed to Moor is a speech and language therapist an t at he won't at Glasgow Royal Infirmary. ~nswer the ~hone case I not Pradical pollTts 1. StartiITg a11 assessment with a relaxed chat over coffee buIlds rapport un ers 00 . and allows j unctional assessment of dysarthria and dysphagia. For moreformal assessment, the Frenchay is preferred. Bert, ~ho i~ it 78 year 2. It is Important to listen to the patient to find out their expectations, gld retired 10lner fears, needs and wants, so you can respond appropriately. Checklists may also help. Itvin2 with l1is wife 3. The client must be motivated and willing to take responsibflity or he Is unlikely to benefit from therapy; it is also important to kITow if the who's hard of spouse wfll be supportive. 4. Providing literature and summarising wlwt has been discussed earin also reports ensures patients and their families can understand the problem and e cou sand agree management. 5. Business cards are easily kept provide important contad details and splutte s more than can have appOintments written on the back. 5. Individual therapy, therapy groups, groups for carers, maintenance l1e used to when groups and volunteer groups can all be appropriate at different stages. drinkin . Together witb th spe'ech. diffl~ultle~, this IS puttJng him off 20ing to hiS IQcal as uSOal on a Friday night.

SPEEC H & I.A NGUACE THERAPY IN PRACnCt SUMMl::ll. 1007 17 JIOWJ.. ISSN (online) 2045-6174 www.speechmag.com

Afunctional a roach Fiona Hewerdine fin e packages of care prepared by her department a useful basis for building information for individuals.

My first session to help address observe the frequencies ofsecretion swal­ Goal setting and time-frame planning at Bert's problems wou ld be a joint lows. J would record these while he and the beginning of treatment is motivat­ interview for Bert and his wife his wife gave a run down on what diet he ing, rea listic and avoids protracted bar­ at the Hospital Out-patient could tolerate. gaining over when treatment should Department. Initial visits take At the end of 45 minutes I would have end. If Bert opts for all of the above I'd about three-quarters of an been able to gauge th e severity of his be looking at three to four weeks of hour and are vital for base­ dysarthria and the level at which it work, a month off and a review with a . ~, \l.' I' \ ~ ,\\.\ line gaining and goal set­ impacts upon his life. J would also have view to discharge. This final session ,, \\ ~,\".... " \ 1', 1. \ . , ting. My current approach been able to make judgements about the would include looking back to where , ,\ with clients is very functional - I do nature of his dysphagia problem. Bert was, ,;That he has achieved and how a lot of li stening and detailed observing Regarding a prognosis I would have this may help him to look fOIward and and find out about the patient's insight. insight into Bert's level of understanding maintain his level of competence and expectations, fears, needs and wants. and motivation and his goals and self-esteem. I always provide contact Areas I ,""ould wish to cover include Bert's whether he faces his problems alone or if point details on the package of care on self-evaluation of his speech, his wife's his wife is a team player. discharge but this safety net is rarely perspecti ve and description of need and Now we can talk treatment. I always clar­ needed or accessed. Bert's view on her competence as a Iis­ ify that speech and language therapists Letter two now goes to the General tener. J would also want to know what do not wave a magic wand for a cure and Practitioner to let him know how Bert Bert and his wife know about strokes, my role is to facilitate the patient's has minimised his dysphagia and sal iva and if they belong to The Stroke potential to maximise his communica­ problems and has maximised his com­ Association. Questioning would elicit tion skills and swallowing competence. munication potential. details about the effects of fatigue and So I describe therapy options which for A summary of how I would manage anxiety. To attain sta ndardised baselines Bert fall into four ca tegories: Bert's case is in figure 5. I sti II like the Frenchay Dysarth ria test; 1. prepared package of care on dysarthria this would represent the second secti on (figure 1) Reso urces of information gathering in the session. I 2. adaptation and equipment (figure 2) The Stroke Association, CHSA House, might also take a small taped sample to 3. interaaional dynamics (figure 3) Whitecross Street, London ECIY 8)), tel. compare against a second tape in the 4. safe swallowing strategies (figure 4). 0171 4907999. final review. At this point a chilled half-pint in a dys­ Dysarthria clinical advice leaflet, Royal Once Bert felt comfortable and rel axed in phagia 'tankard', drunk with a chin tuck Co llege of Speech & Language the initial session I would watch him and no peanuts or crisps but mini ched­ Thera pists, 7 Bath Place, Rivington drink and perhaps eat a biscuit and pos­ dars would be a lovely way to end thera­ Street, London EC2A 3D R (f 12.50 per sibly take some thicke ned py - however, back pack o f 50). fluid . I would precede this by 2. Adaptation and Equipment to reali ty. After Amplifiers from Stanton (Addvox Il), an oral/facial examination Work on 1. over four weeks th is session, I tel. 01942 517920 / Toby ChurchijJ, tel. and dysphagia review. Over a may dispel the need for modi­ write to the 01223576117. period of five minutes I would fications; however. I'd like General Thick & Easy thickener, Fresenius, tel. Bert to tackle the phone Practitioner to 01928579444. again. What about an answer thank him for his Kapitex Health Care Ltd., Kapitex House, phone so that Bert can screen 1. Prepared Package of Care referral a nd I Sand bach Way, Wetherby, West on Dysarthria to whom and when he talks? describe our Yorkshire LS22 7GI-I, te l. 01937 580211. This Includes:-­ This minimises failure and a) Instructions of PNF allows for rehearsal. Strategy planned strategies (proprioceptive neuromuscular two. the use of an amplifier. ofself-help. fadntatlon) There are lots to choose from: b) The new Royal College of Addvox / Lion / Toby 4. Safe Swallowing Strategies Speech a Language Churchill's adaptation to 3. Interactional Dynamics Thistopic will include a look at Therapists' leaflet Ughtwriters / Amplicords. Bert·s message passing salvia control, texture, tempera­ c) Work on lip seal and oral One of these may be a big success rate will be greatly ture, mixing of foods and fluids, agility bonus to Bert's daily interaction. Improved if he: knowledge of a safe swallow d) Positioning prompts, to phone use and pub visiting. a) takes his wife to a specialist technique, a chin tuck and teach Bert to keep his mouth As Bert is not an in-patient. he for a hearing aid possible need for Thick a Easy shut. nose breathe and to train may need lots of details b) trains his listeners to tum and special dysphagia cups (see himself to swallow saliva regarding cerebrovascular down / off the television I Kapltex catalogues). regularly to reduce pooling acddent, The Stroke racUo / hoover when talldng Our department has produced and tilt his head backwards. Association, local information q trains his listeners to come a package of care for all I Hke to personalise instructions centres and special neigh­ to his level when talking dysphagic patients. Th/s Ike Utese, and help clients see bourhood resources. A short d) learns to alert potential Includes a section on a normal how this can be applied to spell at a high level dysphasia listeners to his planned swallow. Information that themselves, eg. I would get group, perhaps attending as a message by equips the patient to feel more Bert's son to move the helper, may help him socialise - a touch on the arm In control is always most helpful. television onto a higher table again and regain his confidence - a clap, whistle, wave etc. 111ese packages of care are so that in the evening when and self esteem. Some e) chooses his location to sit In really useful and time effIdent: Bert Is tired, he will naturally personal details in 'his wallet the pub, away from the juke they represent a reference tilt his head backwards while on a switc'h style card box and door and at a small resource to the patient, a ready IooJdng at the television in irs attached to a small alphabet round table so his listeners are prepared topic for the therapist new raised position; this will chart may minimise the risk near him, at his level and have and a summary of clinical tips drain the secretions and keep of communication breakdown a good view of his mouth, face to prompt the patient and his clothes dry. and failure occurring. and non-verbal cues. maximise carry over. Figure 7 - Prepared package ofcare Figure 2 -Adapation and equipment Figure 3 - Interactional dynamics Figure 4 - Safe swallowing strategies

18 SPEECH & LANGUAGE TH ERAPY IN PRACTICE SUMMER 1997 ISSN (online) 2045-6174 www.speechmag.com J-IO'vV I..

Swallow/Saliva Management Communication Exercise/PNF· Packages of Care Diet/Texture/Temperature Support Groups Facilitating Adaptation and Realistic Expectation Answer phone· Amplifier· AAC? Safe Swallowing Ch in Tucks and Positioning Interactional Dynamics

Environmental Positional

Mo dified Cups Hearing Aid for Wife?

Figure 5 -Summary of case management An exercise in emnowennent Richard Jouault believes patientf"en joyment of therapy can be a better indicator of success than quantitative assessmen(

Ben attended ul e William language skills. It also highlighted Bert 's frequently lose track of who they h ave Knott Day Hospital with his perception of his difficulties and allowed seen and what they did. wife as an out patient for an him to explore his feelings about his initial speech and language speech. !:lert's wife was included in this Dysphagia assessment therapy assessment. He process as I feel it is imperative to gain the The case hist lY allowed me an opportu­ would have been seen at spouse's perspective and identify their nity to investigate Bert's swallowing diffi­ home if he or his partner needs. They can be as much ofa barrier to culties further, ensuring that he had not had found it difficult to progress as they can be a fac ilitator of recently experienced any chest infections attend clinic or if his change if their needs are ignored. or problems with other consistencies. speech / language prob­ I then carried out a 'bedside' swallowing lems were in some way Summarising assessme nt with a free liquid, biscuit and specific to the home Before movi ng on, I su m marised for Bert yoghurt. Particular attention was paid to environment. and his wife what they had told me, to voice qualit) and coughing post-swallow Fig,ur e 6 On meeting Ben and his wife, ensure that nothing had been omitted. with any incid ence being recorded. Ben's I offered Ulem a cup ofcoffee and started to This went as follows description of his voice and swallowing e11at to them about meir journey to clinic, • Bert was embarrassed about his speech problems tended to suggest an abnormal­ me weather etc. I used this time to observe because it was slurred. ity / incompetence at laryngeal level how Ben dealt ,vith drinking whilst dlatting • His voice was gruff and too quiet. although possible ph,uyngeal pool ing and how he and his wife interacted verbally. • He coughed on free liquids and seemed could not be ruled out at this stage. to have too much saliva in his mouth. Various postural techniques and swallow Rapport The impact on his life was as follows: modiftcations were attempted on subse­ 1 find this time is velY important in devel­ • He was no longer using the phone. quent swallows to eliminate coughing. oping a rapport with the patient and their • He was avoiding social situations. Particular attention was paid to Bert's partner. A subtle balance between med­ His problems were exacerbated by: ability to adduct and abduct his vocal ical/ professional and confidante / friend • His wife's hearing difficulties. folds, ensuring complete laryngeal clo­ is required to inspire confidence and I find a summary is helpful to ensure that sure during swallowing. Had these modi­ encourage openness. Light refreshmem all parties concerned are clear o n what fications fail ed to alleviate Bert's prob­ can promote a relaxed environment and has been said. A great deal ofinformation lems, I would have referred him for vide­ thus encourage optimum performance. emerges during case history-taking, and ofluoroscopy. r explained to Bert that today was an subsequent assessment can be a b ewil­ Reponed increases in oral secretions assessment session which would last for dering whirlwind experience for the first required observation of spontaneous about 45 minutes. In that time we would time attendee. I try to ensure they leave swal lowing and c()nsideration of current discuss what difficulties Bert experienced from their fiN appointment knowillg m edication. and what he could do to alleviate them. what we have discussed and what we are g0111g to do next. I ask patients if tiwy Dysarthria Assessment Responsibility have any questions and will usually ask a I then carried out an informal ilsscssmcnt I use ulis approach to set out fl"Om the few of my own if non are forthcoming to of Rert\ speech. Thi s encouraged him 10 start the patient's responsibil ity or their ensure there has not been any misunder­ ex periment wilh contrastillg loudness, own therapy. This serves two functions. standing. phonation and rate. By varying Ili s speech Firstly, it presents the therapist as a facili­ by these paramete rs, Rert began to experi­ tator and not a magician and, seco ndly, it Clarifying er lCt' control ()ver his disability and the r·e­ reduces dependence on the Illerapist, I write their next appointment on the fore fel t less of a victim of his impairmen t. making the 'weaning' / discharge process back of a business card which also shows In I·his way, assessment becomes an exer­ more effective. my name, titl e, qualifications and contact cise in ell1powC'rmellt. I started the assessment by taking a case number (figure 6). J am ama7.ed at how a Followi ng til is, I administerpd lhe history from Bert and his wife. To supple­ simple business c,nd can be so effective ill Frenchay Dysarthria ssessmelll ,I, a ment this, I had his medica l notes avail­ clarifying who they have seen and when baseline measure prior to therapv_ able, paying particular attention to any they will be seen again. Business cards I explained my initial find ing!. to Ben pre-existing medical conditions and any seem to end up on kitchen pinboards or his wift' medica tion prescribed. The case history in wallets ""h ilst appointmellt cards seem • /-lis rate and rtl1l8L' ortol/gue mCWP17It'11f) provided an opportunity t() examine to disappear into the ether. Also, during l.iJere Tedu ced lv/ril h Intide his speech informally Bert's receptive and expressive multidisciplinalY assessments, patients .IlL/ned.

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• It was as yel unclear why his oral secre­ communicalive confidence in a social set­ apy. I then repeated his Frenchay lions were increased and lhis would require ting. Specific telephone praClice could be Assessment. This provided me with an fUTlher invesligmion. Likely causes were incorporated into this. objective and subjective evaluation of either reduced spontaneous swallowing or a 7. Information regarding the local stroke Bert's speech and language therapy. side effecl of medication. club. I then asked Bert what he wanted to do. • His gruff voice was a likely resull of abnor­ Bert and his wife were happy to take this He felt that he did not need any more mal laryngeal movement and possible vocal course of action. Appointments were therapy at present but may want some in abuse. J went on to explain thal he may have booked and an initial report was written the future. I explained I would contact strained his voice trying to compensate for to the GP referring agent with a copy to him in six months for a review appoint­ his reduced intelligibility and his wife's ENT, plus covering referral letter. The ment. If he did not want a review, I hearing loss. initial report outlined Bert's medical would discharge him from my caseload • His reduced volume was a result of poor diagnosis, his speech difficulties, the fur­ with the understanding that he could breath control and weak phonation. ther investigations I had initiated and self-refer in the future if he had any fur­ my plans for therapeutic intervention. ther concerns. Action Therapy attempted to encourage and J recommended the following course of reassure both Bert and his wife and to action for Bert: make maximum use of his remaining Style 1. Refenal to an Ear, Nose and Throat spe­ potential. It encouraged him to monitor What is more difficult to write about ­ cialist regarding his voice to rule out any his speech and to learn to listen to him­ and what is perhaps far more interesting sinister patholog)'. self, look ahead and anticipate difficult - is the style in which we deliver our 2. RefelTal to the on-site Hearing Resource phonemes and words. therapy. I am sure we are all fairly simi­ Centre for Bert's Wife to ensure she is fitted Many aspects of therapy are transferable. lar in what we aim to achieve with our with the appropriate hearing aids. I frequently find myself using tech­ clients but the manner in which we do it 3. A short course of individual speech and niques that were originally developed is often very different. I seem to use a lot language therapy targeting swallow modifi­ for completely different client groups. In of humour in my therapy and 1 am cation, articulation, phonation and respira­ Bert's case, a hierarchy of difficulty in aware this is not apparent from reading tion. using the telephone was identified and the above' r always try to appear enthu­ 4. A home programme Wilh exercises for the role-played as frequently done with siastic and jovial, even after a night of above. clients with dysfluency. disturbed sleep compliments of my nine 5. Written advice regarding over-pronuncia­ Following the ten sessions of group ther­ month old daughter. I find laughter is tion, reducing race and red ucing back­ apy, Bert was seen for an individual ses­ perhaps my most utilised tool and ground noise in lhe home. sion. He was asked to fill in a self-per­ sometimes feel that a patient's enjoy­ 6. A course of group therapy to follow on ception questionnaire looking at his ment of therapy is a better indicator of from the individual lherapy to develop feelings about his speech following ther­ success than quantitative assessment.

ImJ?ainnent and handicap Angela Moar focuses on the psychosocial implications of dysarthria through client anacarer groups.

Following a brief period on our indicated from the initial clinical infor­ vide clients and their relatives with con­ 'neuro waiting list', Bert wouJd mation. crete information to take home, as it can be offered an initial assess­ be difficult to remember all the infor­ ment appointment, most Self perception mation discussed. likely attending as an out­ I would consider it vital at this stage to t.. "" patient. Domiciliary assess­ establish how Bert perceives his own Responsibility ~ ~~. . ment could be arranged handicap - how does his dysarthria From the case history information given, ' ~ )' should out-patient atten­ affect his conversations with others ? r anticipate Bert does perceive his '.~~:, - dance prove problematical. how does it inhibit his social interac­ dysarthria to be a considerable handi­ Bert's wife would also be invited tion? - as this has considerable cap, given that he is not answering the to attend. implications for future manage­ phone / going to the pub. Therapy The initial appointment would include ment. Should Bert have no con­ options would therefore be an assessment of speech, discussion cerns regarding his communica­ discussed in some regarding the level of the impairment / tion, then further therapy may detail. Both individual disability / handicap, and the various not be indicated at this stage. and group therapy can therapy options available. be offered, and Bert's 'Initial speech assessment would involve Concrete information wife would be encour­ an informal dysarthria assessment / oro­ Dysarthria would aged to be involved in facial examination, the Frenchay explained and discussed both. I would emphasise Intelligibility subsections, and a tape using our departmental at this early stage that thera­ recording of conversational speech. dysarthria leaflet for refer­ py offers practical strategies Given that Bert is reporting some swal­ ence (figure 7). This cov­ and exercises, but that the lowing difficulties with fluids, his swal­ ers topics such as 'Normal responsibility lies with Bert to lowing would be assessed using clinical speech production', employ these. I question how evaluation in the first instance, and What is dysarthria?', much direct therapy can offer a appropriate advice would be given. A 'Strategies to control client who is not prepared to videofluoroscopy could be organised speech', and 'How friends and take an active role in rehabilita­ and carried out on site, should this be family can help'. I find it is useful to pro­ tion.

20 SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 1997 ISSN (online) 2045-6174 www.speechmag.com HOW I. ..

I envisage that Bert would benefit from • think about breath support mal 'Knowledge of Dysarthria ' ques­ both individual and group therapy. • plan what to say before making the tionnaire and 'How I Feel About Talking' Individual therapy includes specific call. checklist. The results of these help iden­ advice and practice on breath support, Role play would use a variety of situa­ tify the areas of difficulty to be targeted reduced rate and so on, and group ther­ tions with an increasing hierarchy of dif­ in the group, and are also used for apy tackles some of the wider psychoso­ ficulty, initially phoning each other reassessment post-group. cial issues associated with dysarthria. within the department and progressing Bert's CP would be kept informed 'of his Psychosocial issues to making outside calls to unfamiliar lis­ progress via written repol1s. For all Recent dysarthria groups held in our teners, ego the bus station to find out clients, reports are sent to acknowledge department have run for six to ten ses­ timetables. A similar approach would be the initial referral, following the first sions either once or twice weekly. taken with the issue of going to the pub, appointment, and on discharge. Reports Clients attending are generally those to however, due to physical logistics it is contain information on levels of com­ whom dysarthria is felt to be a consider­ unfortunately unlikely we would be able munication, strategies to help commu­ able handicap, regardless of level of to practise specifically in the pub! nication, intended therapy and, on dis­ impairment. Some of the topics includ­ charge, success of intervention. Reports ed in the group are: Carers group are also sent to any other interested par­ • revision of the impairment of When resources allow we also run a car­ ties such as the medical consultant. dysarthria ers group concurrently with the Following therapy, Bert may feel ready • self analysis of level of breakdown dysarthria group. The carers group runs for discharge, or he may wish continued • issues such as listener reaction for three to four sessions. There may well advice and support. • feared situations. be some communication breakdown The group would also give Bert the between Bert and his wife, and therefore Maintenance opportunity to address and share feel­ she may benefit from attendance at the We have very recently established a ings associated with the communication group. SimiJar topics are included in the 'maintenance group' for dysarthric loss. carers group, and again specific advice clients who have already gone through Clients are encouraged to identify situa­ and strategies on how to help their rela­ both individual and group therapy, but tions in which they find it difficult to tive j friend are identified. Obviously feel they still require some support from communicate and brainstorm strategies some of these issues would be tackled speech & language therapy. The group is which may help. 'fhese situations and earlier such as how Bert's wife's hearing held approximately every three months. strategies are then practised in role play loss may also be contributing to com­ Also, within our area the local Volunteer and, when possible, real life situations. munication breakdown, and how this Stroke Scheme Chest, Heart and Stroke Bert has identified specific concerns could be resolved. Croup runs weekly, and several of our about using the phone and going to the dysarthric clients have gone on to pub, and these may be ideally tackled in Checklists attend. Both groups would be available the group. Using the telephone is a com­ Bert's progress in individual therapy to Bert should he wish. mon fear within the group and strategies would be evaluated by repeating the ini­ frequently suggested include: tial assessments and through discussion. References • ensure good posture Pre-group, Bert's knowledge and percep­ Enderby, P. (1983) Frenchay Dysarthria • reduce rate tions would be assessed using an infor­ Assessment, College Hill Press.

. . . NEWS... NEWS. NEWS.. . NEWS... NEWS... NEWS... Stammering controversy I ADjHD Awareness Theatre ofthe The British Stammering Association has reacted to Queen Deaf Margaret College's decision to refuse a stammerer entry to their Week Students from speech and language therapy training. A multi-modal approach to work­ Reading University Tessa Clark received a letter in response to her application stating ing with children with Attention have presented their the College would not accept "anyone with a disorder of speech, Deficit j Hyperactivity Disorder deaf theatre project language or hearing, even if it is a well-controlled stammer". was the emphasis of a conference at a conference ­ The BSA believes applications from people who stammer, like marking a National Awareness Therapy and Theatre those from fluent people, should be considered on their merit Week. - in Poland. and is hopeful policies may be reviewed in the light of the recent The European Conference for Wall of Glass is a Disability Discrimination Act. It is writing to all speech and lan­ Health and Education dramatic exploration guage therapy training establishments to ask for detai Is of of the nature of admissions policies. Professionals held in April at Oxford University examined how language. The tutor ADjHD related to other areas of on the degree course special need including dyslexia, Theatre Art, New healthcare magazine speech and language disorders, Education and Deaf The UK is the unhealthiest country in western Europe according autism, Asperger syndrome, fragile Culture also led a to a new quarterly business publication. X and emotional and behavioural workshop on the Healthcare International, from the Economist Intelligence Unit, difficulties. Speakers included nature of non-verbal aims to analyse and interpret trends and changes in the $3 tril­ speech and language therapist communication for lion global healthcare industry. Jackie Harland. those attending who The first issue also reports on the forthcoming Kensington exper­ The awareness week, aimed to included people who iment in London which will provide a one-stop medical shop educate professionals and the speak a variety of for 100 000 patients and on the decline of the US health insur­ public about the highly controver­ languages, are deaf ance industry, forecasting that more than 16 per cent of the pop­ sial disorder and issues surround­ and hearing and one ulation will be uninsured by 2001. ing treatment. who is blind.

SPEECH & LANGUAGE THERAPY IN PRAGnCE SUMMER 1997 21 REVIEWS ISSN (online) 2045-6174 www.speechmag.com

• VOICE revIews Inspiring and motivating Organic Voice Disorders Edited by Brown, W S, Vmson. BP & Crory, MA SOCIAL SKILLS VOICE Singular A highly practical tool An additional resource ISBN 1,56593-2 68-4 [45.00 The idea of yet another American bOOK on voice Talkabout Vocal Pathologies - Diagnosis. failed to Inspire me to make that cup of cocoa Alex KeJly Treatment and Case Studies Winslow Dworkin. JP & MeJeco, Rj and sit down for a good read . If I had not perse­ ISB N 0 86388 1/;6 7 [32.50 Singular vered past the first chapter. t hen I might not have Tal kaboul is a useful and practical ISBN 1-5 6593 -623-X £33.95 had Lo find th e slice of humble pie and ad mit that package for th erapists working on Th iS book ai ms to provide a com­ thiS turned out to be an excellent voice textbook developing co mmunication an d prehensive guide to t he diagnosis, w hich I thoroughly enjoye d ("ead ing social skill s. The package se s out treatmen an d gen enl management The fi rst chapter oniy distracts from the standard worksheet s w hich would com­ of a wide r'ange of voice dlsol-ders. It of t he rest of he t ext, making me want to whis­ bine eas dy with existing social is a well pr"oduce d book which con­ per to the authors my own 'helpful' comments skills progra mmes. These sheets tains two COs of speech and voice su ch as "pl ease stop waffling" and , despite t he his­ ca n be phot ocopied for instruc­ samples to accompany lhe fifty one t orical interest "what IS the relevance of Greek tional use , an essential feature of case studies which make up half the philosopher or a Padua anat omist to my typical any practical therapeullc tool. It is text. nodule pa tl entl " Should it have been omitted good to see a resource which It contains numeroUs photographs of altogethel") from the ou tset acknowledges laryngeal pathologies an d, In th e case Organic Voice Disorders is an academic textbook tha t the therapeutic process stud ies, pr-e and post therapy exam­ pr oviding a weal lh of informallon for th e profes­ needs to be responsive and does ples arc Included.Te xt IS Interspersed si onal w orking With or interested In voice. The not prescribe eithel" ol'der or w ltn clear illustration, examples of chaptel's are presented in such a way so as to structun2. assessments and useful algorithms focus the re ader on the tOPIC being dlscLisseci . The package i well designed a d for as pects of voice therapy and The level of detailed information sets the sta n­ the use of various cartoon fi gures management The iliustraLi ons of dal-d as the 'all encomoassi ng, illl si nging, all danc­ allows informa ion to be present­ vocal fold anatomy, neuro logic al ing' voice source bookThis can make the re ader ed In a plctonal framework which palhways for phonation and phono­ feel somew hat dallilted but rt is Important with IS adult and not patronising. I par­ surgery were particular-I y helpful thiS book to remember that rt is obviously pl'e­ Llculal'ly Irked the cclrtoons Jnd The case studies of different vocal sen Ling an 'Ideal ' level of knowledge an d pl-actlce facial expressions on the passive . pathologies are supporled by pho which perhaps th ose of us working within N HS assertive, aggressive rating scale. tographs. history details, examination Trusts can only dreclm of The clinician will, how­ Sel f-assessmen t of skills 15 Integr-a l. findings , therapy ,"esults and discLls­ ever, benefit f!'Om the level of expertise docu­ encouraging clients t o monitor" si on as well as th e vO ice samples on mented Within thiS book therr own development and ­ CD. I was unable to dViu l mY5elf of For such all amazing level or in formatIOn. the pl"e­ hopefully - improvement from the benefll of the latter as I do not sentatl01 of the wrrtten text was aesthetically t he beginn ing have access Lo a CO pl ayer dull. The Illustl'ations were however generally of This r-esource would be useful for In diSCUSSing therapy and manugement high standar"d an d appropl"late . Certain chapters either adults or school age ch il­ there was an undel'SLandable bias su ch as that concel"nlng anatomy and phYSiology dren with social communication towards l\J orth Amel'ican Nays of wel-e incredibly de tailed and yet easy t o re vis e difficulties. It should be borne In working I felt the aulhor-s were over­ rrom. The chapter looking at lifespan changes mind, lhough. that despile the use ambilious in cl uding Laryngectomee w ithin the larynx would also help th e pm fession­ of c r toons there is sull a high Reh abllrtation alongside all the 0 her al wilh a typical vOice caseload . reliance on the use of the wn tten ocal pathologies, r'e ducing such 3 vast This book IS obviously aiming for a thom ugh word. ThiS Will r'cstrict or need subject to eight pages There were ovel'Vlew, but some of t he measurements taken the therapist to adapt t he mater­ some unfortunate generalisatiOns eg In analYSIS of voice, es peCially w rthin th e aerody­ ial fur her fo r those w ithout I[ter­ laryngectomees .' were remanded to namic and acoustic r'dnge. would not be r'outine­ acy skills. mastenng use of an artificial larynx" Iy available Within BrITish voice cliniCS , let alone A s a res oLJ(ce It will be useful not (my rtalics) , when the use of an elec­ the [ N T or" speech an el limguage thp.riJ py depar·t­ only t o speech an d language lher­ tronic larynx can be the optJon of mentsThese chapters are not for the faln t-healt­ aplsts but also t o colleagues In chOice for some laryngectomees ed. O ther chap ters assume a cel-tain level of occupational t herapy, educati on Despite the excellent illustrations and mec' ical know ledge. It IS also Important to con­ and sOCIal work establishments. It photographs the book would not sider the differences between A mencan and w ould fOl'm a good basIs fo JOint provide enough depth and guidance Bri tl<;h ter'minology. planning and discussion. for therapeutic planning for Inexpen­ In summary, thiS book does Inspire an d moLlvate ' Ta lkabout is a highly practical. easy enced cirnlclans. It would, h owevel~ be the l-eader. It co uld have been presented in a mme to use reSOUITe an d I expect my an excellent source book for Visual interestmg manner With a mOI"e rel evant begin­ curr'ently pristine copy not to feedback both In th erapy an d educa" ning 0 0 not be put off by cel"ialli reference lists remain li ke that for long; it will be tion of sLudents, and would be an w hich can be terrifyingly long. This book w ill well thumbed. ad drti onal resoul-ce for" a department encourage each person t o take therr knowledge which already has access to other base further w ith voice assessment and treatment. voice th el"apy texts. An excellent book. Lois Camero n, speech and Ion guoge th erapis t. 15 Team Leader fo r fryl Evans IS He Ci d or Speech and Je anette Tyler ;s a speCi alist speech and lon.f?uage ther­ Learning Dis obtiity in Centrol Language Therapy at Single ton apist In vOice and dysphagia working (or Mid Angli a Sco tland Healthcore Hosplwl (or Swansea NHS Trus t Communrty NHS Trus t at the West Suffolk Hospi tal.

22 SPEECH & LANCUACETHERAPY IN PRAcnCE SlIt'viMER 1997 ISSN (online) 2045-6174 www.speechmag.com REVIEWS

GENERAL DYSLEXIA ELDERLY Excellent 1981-1996 - Has anything changed Discovering creative impulses stimulants for client and family? Creative Groupwork with Elderly People: ColorCards: This book doesn't make sens·ceRS-SllS-SC€+l-S­ DRAMA Emotions / What's sense: Reissue Madelme Andersen·Warren Missing? Augur,). Winslow Winslow Whurr Publishers ISBN 0-86388-/47-5 0 5. 95 £2375 each ISBN I 897635 133 £1095 This is a practical manual for people working These new boxed with the elderly in a variety of settings. The Dyslexia - Parents in Need emphasis is on self expression both physica ll y cards have clear, Heaton, P colour pictures with Whurr Publishers and emotionally, through movement and up-to-date styles ISBN I 89763573 7 £11 .95 drama. The author intends it for use by those and multi-racial con­ without specialist know ledge of drama or cre­ tent. Two books. One written in 1981 from a dual per­ ative methods of working, but then recom­ I tried both sets of spective, that of mother of dyslexic children and mends an yone planning to lead creative groups card as part of infor­ mainstream teache~ The other written fifteen years should attend a basic leadership course to "dis­ mal assessment and later and based on the answers to a questionnaire cover one's own creative impulses" before in direct therapy and completed by parents of dyslexic children. attempting to work with others'. Having read found they were The former (Augur), written for parents and teach­ the manual, I would not feel at all comfortable received well by el-S, adopts an anecdotal style using an honest and leading a group of this type without further adults and older open narrative to describe the formative years of guidance and know ledge of the theory under­ children. the authors' sons. It follows the confusion leading up lying this approach, even though I quite happily The 'What's to diagnosis and problems faced following it.The lat­ run a weekly group for elderly people with dys­ Missing)' set were ter (Heaton) uses a question and answer format to phasia. excellent stimulants address issues such as how dyslexia has affected The manual is usefully divided into three sec­ for description and family life, advice, language skills and provision. tions.The first provi des an overview of dramat­ also challenged Both books give useful insights into the more poor­ ic art and Its possibi lities with all age groups - in many clients' ly perceived characteristics of the dyslexics such as fact, I feel the title of the manual is potentially assumptions with clumsiness, lack of organisational skills and higher misleading, as the activities do not seem to be many stating what level language difficulties. This is one of the features specific to the elderly and could be used with they expected to which would make these books particularly useful other populations. It goes on to explore bene­ see and not what for undergraduate teachers alongside a useful sec ­ (its specific to the elderly population. was actually missing. tion in Augur's book covering hints on how to help The second section, consisting of carefully Emotional develop­ dyslexics and how not to correct their work! structured and photocopiable group activities, ment and life expe­ Perhaps one of the most striking things about the left me with mixed fee lings. Although there rience are particu­ experiences portrayed in these books w as the dif­ were some excellent ideas, many activities I felt larly difficult areas ficulties parents had when dealing with profession­ were potentially patronising and I personally for people w ith als. Although the experiences of the parents inter­ would feel unable to use them with any client learning disabilities viewed in 1996 were a little more positive, many group. There was a suggestion at the beginning who li ve in long­ felt that their early concerns were too readily dis­ that such groups may be appropriate for peo­ term hospitals. The missed. ple w ith mental health problems or neurologi­ situation cards in the A whole chapter in Heaton's book is devoted to cal impairment such as dementia, but this was­ 'Emotions' set were 'early signs'. Later in talking, speech problems and n't followed through in any detail, and I was left particularly useful to difficulties with rhymes and naming are all men­ with a feeling of great uncertainty as to the help explore differ­ tioned. The author concludes that "the well 'type' of elderly client who would benefit from ent feelings, describe informed can recognise traits long before school". such activities. It would have been helpful to what they saw and However; speech and language therapists are not have had much more specifiC guidance from the consider their own mentioned amongst these and, in fact, do not figure author regarding the selection of group mem­ reactions in a similar throughout the text. With the current interest in bers. situation. phonological awareness within the profession, per­ The third section is a collection of relevant con­ Using the haps this might change if the author were to repeat tacts and addresses. ColorCards, my the study in two years time. I don't think this book offers speech and lan ­ clients had a chance The familiar incidence of dyslexia is highlighted in guage therapists anything over and above those to consider; discuss both books and the common scenario where the designed for group work in general, and cer­ and explore differ­ father and sons are dyslexic was brought home to tainly felt it inappropriate for use with dyspha­ ent situations and the reade~ What struck me was how difficult it sic clients. However; it did make me stop and emotions in a clear; must be to organise a family like this - perhaps think about the possible psychological and often light-hearted something we should bear in mind. emotional needs of groups of elderly people and non-threatening I would recommend both books for parents; who have difficulties other than communication way. although Augur's book is a little dated it remains an disorde~ easy to read book with a positive message. This is potentially a very useful resource for Lorraine Gillies is a Heaton's book contains many handy hints on prac­ trained professionals wishing to offer a ore speech and language tical management and how to obtain the necessary creative therapeutic environment both phys c I­ therapist working support for these children as well as useful Iy and psychologically to their client g ·OlJD. I with children and addresses and materials. found it both interesting and thought-provo. · ~ adults with learning Kathleen Cavin works (or Central Scotland Healthcare. disabilities (or Central Her caseload involves workJng With children with learning Kate Rush is a speech an d language errJptS Scotland Healthcare. disabilities as well as Recorded children in mainstream. Weston General Hosp ital, Weston-svpeJ-MC?fC

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Linda AmISbOlIg and Michelle Brogan argue 1hat scoring picture naming respDflSeS as conect I ilK:OITeCt gives inadequate infonnation to thel~ devising b'eatment plans and monitoring clinical change in with word finding diIficuHies.

Analysis of the picture naming performance of people with I. NOR: a group of normal elderly people, sought from a shel­ aphasia has provided important insights into our understanding tered housing complex in central Scotland and tested by the of the cognitive and linguistic processes involved in normal and second author impaired word finding. The variety of picture naming errors pro­ 2. ANO: people with mild / anomic aphasia duced by people with aphasia suggests naming failure may be 3. WER: people with moderate-severe / Wernicke's aphasia. related to a deficit at any stage in the process from visual recog­ The people from the two groups with fluent aphasia were sub­ nition to phonetic realisation. jects in a previous investigation (Armstrong, 1993) , in which The speech and language therapist employs a range of cueing selection criteria are described. techniques to provide the client with additional information to assist in the immediate facilitation of word retrieval.Typically this Testing involves either providing a description of the target - semantic The subjects were given the Armstrong Naming Test (1996) . If cueing - or prompting with the initial sound - phonemic cueing. a subject failed to name a picture correctly, a semantic cue was Numerous studies have investigated the effectiveness of various given first, either the function, location or a description of the types of cues as they differentially facilitate naming in different item. If the subject still failed to name the item correctly, a types of aphasia. phonemic cue was given, the initial (C)(C)V of the target. Testing Stimley and Noll (1991) argue that examination of the changes was discontinued after five consecutive failures to name despite in the frequency of error types people with aphasia produce in cues. During testing, transcription of responses was made and response to semantic and phonemic cueing 'has the potential of the sessions were audio-recorded to obtain a permanent record providing a better understanding of the naming process, its of these responses. impairment and the effects of cues'. They established that For scoring purposes the following responses were considered: semantic cueing elicited different types of errors from those i) uncued picture naming responses (correct or incorrect) produced following phonemic cueing. ii) correct responses produced following semantic cueing and Semantic cueing was associated with an increase in error cate­ phonemic cueing gories such as semantic paraphasia and decrease in phonemic iii) error responses following semantic and phonemic cueing. paraphasias and unrelated words. Stimley and Noll also found Errors were assigned a type (Table 2) using a classification sys- subjects produced more non-specific responses foilowing semantic cueing. Table 2 Error classification system Their examination of the types of Specific error types Broad classification error produced following phonemic cueing showed there was a significant increase in phonemic paraphasias and a corresponding decline in semantic paraphasias. Questions Our investigation sought answers to the questions (i) what patterns of error responses, and modifications or shifts under cue­ ing conditions, do normal elderly and fluent aphasic speakers produce l (ii) how does this information inform clinical practice! tem based on the methodology of Stimley and Noll (1991). We analysed the types of picture naming error responses of Additional error categories, adapted from Armstrong (1993), normal elderly and fluent aphasic subjects produced: were introduced to account for the types of naming errors a) uncued reported in the literature as being commonly produced by nor­ b) following semantic cueing mal elderly subjects in picture naming tests. and c) following phonemic cueing. ~hree subject groups were included in this investigation (Table I) . Attempts at picture naming The three groups were clearly differentiated by their mean test Table 1 Subjects details scores. As a result of different numbers of unattempted pic­ tures, different total attempts at naming emerged. For NOR, ANO and WER, a total of 500, 318 and 138 attempts at naming were made. Of these, correct responses were made on 94 per cent, 64 per cent and 21 per cent of the attempts respectively. Cueing Responsiveness NOR responded better to semantic cueing than phonemic cue­ ing. However, because of the high number of correct responses, the numbers involved are very small; 30 cues in total were given.

24 SPEECH & L.ANGUAGE THERAPY IN PRACTICE SU MM ER 199 7 ISSN (online) 2045-6174 www.speechmag.com A PHAS IA

The reverse pattern was observed for the aphasic groups. Fifty Effect ofphonemic cueing on naming en'OI'S per cent of the phonemic cues given to ANO resulted in cor­ Examination of the distribution of the types of errors produced rect naming, compared to only seven per cent of the semantic by NOR following phonemic cueing (Table 3) indicated a cues given . However,WER derived very little benefit from either decrease in the proportion of semantically-related errors and an form of cueing (85 per cent failure rate), with phonemic cueing increase in 'did not know' responses and tip-of-the-tongue having a slight advantage over semantic cueing. responses. A significant correlation was found between the types of error responses produced after semantic and" after Error Analysis phonemic cueing. Incorrect responses produced prior to and following cue admin­ For ANO, under the phonemic condition, there appeared to be istration provided the opportunity to examine whether seman­ an increase in the category of phonemically-related errors, a tic and phonemic cueing influenced the types and proportions decrease in the categories of semantically-related and non-spe­ of errors produced. WER have been excluded from the follow­ cific errors, and a reduction in the number of tip-of-the-tongue ing analysis because of the relatively small number of pictures responses. No difference was observed in the proportions of they attempted. unrelated errors and did not know responses. For ANO, there Table 3 Number and type of incorrect responses produced by NOR and ANO Effect of semantic (as percentages in brackets) cueing on naming en'OlS NOR ANO NOR ' ANO NOR ANO Of the 14 incorrect responses produced by Error categories Uncued Uncued Following' Following Following Following semantic semantic phonemIC phonemIC NOR following semantic cue cue cue cue cueing, 13 were produced Phonemically based errors 0 59 (33) 0 16 (11.3) 0 45 (60) by two subjects aged 85 and ­ 95 years. The types of Semantically-related errors 20 (66.7) 57 (32) 11 (78.6) 28 (20) 3 (43) 9 (11.8) errors produced by NOR Non-specific errors 0 32 (18) 0 69 (49) 0 8 (10.5) prior to and following Tip-of-the-tongue 0 11 (6) 2 (14.3) 25 (18) 2 (28.5) 7 (9.21) semantic cueing (Table 3) Did not know 1 (3.3) 4 (2) 1 (7.1) 2 (1.4) 2 (28.5) 4 (5.27) showed the same pattern of Unrelated errors 0 8 (5) 0 2 (0.7) 0 3 (4) error type distribution pre­ Visual misperceptions 9 (30) 6 (3) 0 0 0 0 dominated, mainly semanti­ cally-based errors. Total naming errors 30 177 14 142 7 76 Prior to cue administration, ANO produced errors in all error categories with semantically­ was no significant correlation between types of errors produced related, phonemically-based and non-specific errors accounting after semantic cueing and following phonemic cueing. for 83 per cent of the total errors made (Table 3). Following semantic cueing, a different pattern of responses is Clinical implications evident. There was a decrease in phonologically-related, seman­ This investigation utilised small samples of group data from tically-related and unrelated word errors and an increase in the healthy elderly people and people with fluent aphasia as the proportion of non-specific and tip-of-the-tongue errors, where basis for a detailed quantitative and qualitative analysis of picture the subject indicated recognition of the target word but was naming errors made prior to and following semantic and phone­ unable to retrieve its name. Often s/he would describe the tar­ mic cueing. (WER were excluded from the main analysis get using gesture, or give some relevant physical detail. because of the paucity of data they provided.) Accompanying comments such as "I know what it is but I can't It has provided some useful implications for the clinical use of get it" or "It's on the tip of my tongue", combined with shakes cueing in the facilitation of naming in aphaSia . In terms of seman­ of the head, are typical of this error type. As with NOR, no visu­ tic cueing, this strategy seems to inhibit visual perceptual misin­ al misperceptual errors were produced following incorrect terpretation and responses which are not related to the target. response to semantic cueing, presumably as semantic cueing If clients respond to the cue in a non-specific manner (eg. "oh facilitated the correct recognition of these previously misper­ yes" or "yes, but what's it called!"), it is unlikely that repeated ceived items. presentation of the same or a similar cue or will provide the additional information the client requires for successful naming. The effect of semantic cueing, in picture naming at least, may lie more in facilitating picture recognition, that is, the early process­ es involved , than word finding per se. The argument for the use of phonemic cues - despite recogni­ tion that the effect of phonemic cueing on overall naming per­ formance is not long-lasting - is strengthened in that this type of cue facilitates not only correct naming but also a closer phone­ mic approximation to the target response. While the target may not be accurately produced, it will often be more recognisable to the listener. Furthermore, this investigation has reinforced the contribution that error analysis makes to permitting identification of the level at which the process of naming has been disrupted; scoring

, ~ /(jJ)! ~~~

Excerpts (rom Armstrong Nammg Te s~ reproduced \ '--______.....J courtesy o(Whurr Publishers.

SPEEC H & LA NGUAGE TI-IERAPV IN PRACTI C E SUM MtR 1997 25 APHASIA ISSN (online) 2045-6174 www.speechmag.com

responses as correct/wrong only means much information is lost. More accurate Client HP, with anomic aphaSia, attempted to name 45 of the pic­ diagnosis of the level at which errors are tures. She managed to name o.,ly 12 correctly without cues, being made and of which types of cue which seems to indicate a severe picture naming difficulty. facilitate naming in an individual client will However, when her cued performance is examined, a much more allow therapists to devise more accurate positive account is evident and Indications for management of therapeutic aims and to target their ther­ naming difficulties are made possible. apy more exactly (case example in figure I). Uncued Following Following semantic cue phonemIC cue Measuring effectiveness Correct responses 12 1 12 Speech and language therapists now have Error responses 33 32 20 to devote considerable time to evaluating Error type:­ whether their treatment is effective. This Phonemically-based 15 6 15 study has provided further evidence of the Semantically-based 3 6 15 benefit of cueing and helps to demon­ Non-specific 7 18 3 strate how naming performance may be Tip-of-the-tongue 4 0 'j positively influenced by cueing either in Did not know 1 1 1 the production of a correct response or a Unrelated 3 1 0 Visual misperception 0 0 0 still incorrect but closer-to-target response. Effective treatment may be measured more easily by evaluating It is clear that semantic cueing did not help HPj Indeed, response changes in types of errors or modifica­ to this strategy - along with her lack of visual misperceptlons ­ tions in naming errors made by clients served to show her difficulty did not lie in recognising the picture. with aphasia under different cueing condi­ The increase in non-specific responses, ego "yes, but what's it tions rather than by using scores on nam­ called?", or repetition of the semantic cue and reduction In ing tests alone as an index of improve­ phonemic errors, mirror the findings of Stlmley and Noll (1991). ment, since these are often too crude to demonstrate clinical change. After phonemic cue, the pattern reverts, with the number of phonemic errors increaSing again (75 per cent of total errors References made after phonemic cue). Superficially then, it seems that, Armstrong, L. (1993) Distinguishing although phonemic cueing produced another 12 correct respons­ Fluent Aphasia from Early Alzheimer's es, there remained almost half of the pictures (20) still incorrect­ Disease Using Language and Memory ly named. tests. PhD. Thesis, University of Closer examination of these however revealed that most incolT8Ct Edinburgh. responses were now very close to target, with only one or two of the target phonemes wrongly selected or sequenced (and so Armstrong, L. (1996) Armstrong Naming probably intelligible for everyday conversation). For example, for Test. Whurr, London. picture 1 (pencil), her final response was (pentick), compared with her initial response of

Questions ~Answers Do right I wrong 5coring It i5 difficult to draw up individual treatment plan5 with­ 5Y5tem5 in naming out knowing accurately where errors are being made and a55e55ment5 have how different cues help. Iimitation5?

What may be the main Semantic cueing seems to help visual recognition, an effect of 5emantic cuein~ early level of the picture naming process. in picture naming. How can error evaluation Changes in a client's naming errors and response to cues contribute to mea5urinq over time can indicate progress which may not be shown treatment effectivene55~ by test scores.

26 SPEEGI & LANCUACE TH ERAPY IN PRAcneE SUMMER 1997 ISSN (online) 2045-6174 www.speechmag.com INFORMA110N

I FOR UTO ech &ISd:guage Writingfor Speech T. herapy. & language In ractlce Therapy in Practice

Every magazine and journal has a specific and consistent style on which its readers depend. This feature addresses common queries from potential contributors to Speech & Language Therapy in Practice.

This magazine has a general readership within the speech and My top resources language therapy profession and aims to bridge the gap (starts Autumn 1997) between theory and practice. A certain amount of technical A personal account by a speech and language therapist. A brief knowledge can therefore be assumed. Every attempt should be job summary is followed by descriptions in up to 100 words made to provide a practical focus and examples. each of why ten commercially available or home-made Writing an article resources are indispensable in everyday practice. Anicles are received in one of three ways. Reviews l. The editor approaches potential authors with an idea. Reviews should 2. Therapists contact the editor to discuss a possible article. • be concise - 250 words up to 450 maximum 3. Unsol.icited articles are received by the editor. • be relatively jargon-free (Please note that the editor has to reserve the Checklist • contain an overview of the item, not a list of right, for whatever reason, not to publish 1 AJ"ticles must be i-I.,.....,A contents . articles received.) . .' . ....Jr":". • be a personal response - how the Item If it 15 atall pc>55lble to gend your or parts of it changed your thinking article on di5k, P.!~~ do 50, prefufably one and informed your practice, or Regular 5uitable for a PC. Di5k5 w;1I be retumed. failed to do this features 2. One copy 5hould be sentto Avril Nicoll. AIway5 keep • contain information Focus on ... a copy yourSelf in case of 1055 and to compare with the about who would find the item usefiJl and why. A speech and language edited vereion. therapy department 3. PhotograP,hs and iIIUstration5 are very useful fur ~kit19 up Please bear in mind describes its philoso­ t&tana biit19ing itto life and 5hould be included if pD55ible. the fact that readers phy and structure PhrrtfVJra~5 will be returned. may well use youtor """-";::I t::'" comments and gives up to 4. Length fur general reature5 i5 u5ually up to 2500 ~5 butthi5 i5 decide whether or eight examples flexible. not to buy an (around 250 5. Stati5tica1 information should be ~ to a minimum and put in table5, item. You should words each) of and the practical imP.'ication5 Of it 5ummari5ed in the t&t. not feel therefore projects or devel­ 6. ftok;Ie fun referel1Ce5 in alp-habetical ott:ler. (Exam~ of required that you have to ~:c 0: ~ a~ ~ i ~ g content and referred Iavout are overleaf.) be positive about photographs and 7. Please try to meet d ine5 ifatan ~bIe. tt allCJ\.Y5 time fur the the item if you diagrams are wel- editorto request further information ana furJoOO to ~thi5 together. If have not found it helpful. come. Total length yoU kno.v you are goit19 to be unable to meet a deaaline, please letthe is usually up to edrtorkno.vas500nasyoucan. 2500 words. Key 8. ArticIe5 5ubmitted to Speech & Language Therapy in A-actice TIt points are listed by must not be 5imultaneously 5ubmitted to any ather publication e the'editor. without the edrtor being advised. Please aloo inform the editing H I edrtor ifyou have 5ubmitted article5 on the 5ame 5U~ect process pr~~es'" a personal from different angles to ather publicationa Articles are edited and response by three therapists to 9. fto..ide your full working title as you would 1iI

SPEECH & LAl\JCUACE THERAPY IN I'RACJlCE SUMMER 1997 27 INFORMATION ISSN (online) 2045-6174 www.speechmag.com

More specific infonnation Departmental resources Examples are drawn from recent issues of Human [f you mention resources from your own department, could Communciation. you make copies available to readers? Ifso, give an address, cost and information about cheques. References Therapists in SOllth Tees have developed a range of advice and infoT­ mation leaflets about their service. They would have to be adapted for References should be provided in alphabetical order, with con­ use in otheT areas, fOT example by changing the logo, but are photo­ tent and layout as follows: copiable and available as a set at a cost of £10.00 payable to South Aitkens, S. and Buultjens, M. (1992) Vision for doing. Moray Tees Community and Mental Health NHS TTust from The South Tees House: Edinburgh. Speech & Language Therapy Service, 157 Southfield Road, Best, A. (1986) Implications of visual impairments in: Ellis, D. Middlesborough, Cleveland. (FraseI; Vol. 5 (2)) (ed.) Sensory Impairments in Mentally Handicapped People. Croom Helm: London. Park, l<. (1995) Using objects of reference: a review of tbe litera­ Diagrams ture. European Journal of Special Needs Education. 10 (1). Diagrams which summarise therapeutic procedure are a useful Ware, J. (ed.) (1994) Educating Children with Profound and reference. Multiple Learning Difficulties. David Fulton: London. It became obvious during data collection that a preliminary swdy to (Selected references from HendTickson and McLinden, Vol. 6 (2).) deteTmine a more realistic standard should have been canied out before starting (Figure 2). (Nollice, Vol. 5 (4)) Case examples Whatever you are writing about - an assessment, a therapy Identify area for approach, liaison - try to use case examples when possible to development show how this worked for an individual client. These will prob­ ably be short and needn't include background detail. While it can mislead to use cases for whom only partial infoTmation Set standard is provided, two examples may show how caTer questionnaire respons­ es and test results ca n be used togetheT when planning advice OT intervention (FiguTe 2). Some of ER's test results and carer responses have been described. They indicate that the day carer recognises some degree of comprehension difficulty while the home carer thinks ER's difficulties lie in expressing a response rather than in understanding. The ABeD score indicates her difficulty with longer more complex instructions so in this instance, both carers could be advised to use shorter sentences when asking ER to carry out particular daily Figure 2. Audit Cycle activities based on verbal instructions. With reading com­ prehension, it appears from test performance that, although ER is still able to understand single words, her Voluntary organisations ability to understand sentences has deteriorated severely. Give details of voluntary organisations where appropriate. Her carers could be informed it is unlikely that she reads The GendeT Tn/st is available to help anybody who feels trapped in the newspaper but she may well be able to understand the wrong body (gender dysphoric). They offeT literature, information some headlines and if she appears interested in this activi­ on available counselling, a contact system for support and a helping ty, it could be encouraged. hand fund for people on welfare. FiguTe 2 - ER: Practical implications (Armstrong & Borthwick, Vol. 6 (2)) The Gender 111lst BM Mermaids (under 185) Questionnaires and checklists OT BM GentTUst (oveT 18s) London WC1N 3XX If you mention a questionnaire or checklist that you use, include tel. 01305269222 before lOpm. (Clark, VoL 6 (1)) a copy or at least a couple of examples of questions / points. This has two advantages: a) the reader knows exactly what you mean b) the reader can make use ofsomething which has already been Doing things differently tried in practice rather than Don't be afraid to say what you would like to have done under MULTISYLLABIC WORDS: having to start from scratch. ideal conditions or feel you could do differently if you were in a PICTURE FINDING To provide us with further similar situation again: NAME: Date: information about theiT lexical To draw full conclusions about the pTogTession of VC's condition, it TARGET RESPONSE processing skills we devised a might halle been helpful to initiate assessment fOT clinical depTession, 1. CALCULATOR 4 picture naming (.ask of mOTe to establish whether this could have influenced the downturn in moti­ 2. PYJAMAS 3 complex multisyllabic wOTds vation. It would also have been useful to have assessed communication 3. JIGSAW 2 (Figure 1). We selected fre­mOTe rigorously using the same items throughout and to have had fur· 4. PRISONER 3 quently occuning words of 2, 3 ther psychological assessment to establish whether some ment.al func· !j. DETECTIVE 3 ... and 4 syllables which could be tions Temained unimpaiTed. Howeve1; VC's motivation was such that 50. PROPELLER 3 easily TepTesented in pictuTes. she declined further assessment and we felt we had enough infoTma­ (Clark & Makin, Summer tion to advise family and staff (Walmsley & Evans, VoL 5 (3)) FiguTe 1 Supplement, June 1996) Advertising Resources Advertising is vital for keeping subscription costs down and providing readers with information. Authors should be aware If you mention any commercially available resources, make it that potential advertisers are contactcd rcgularly with details of easy for readers to access them by Iisting the manufacturer / the contents of the magazine and invited to advertise. This is supplier, telephone number and cost. Dysarthria clinical advice leaflet, Royal College of Speech & done after contributions are agreed / received. (Publication of advertisements is not an endorsement of the advertiser or its Language Therapists, 7 Bath Place, Rivington Street, London EC2A products or services by the publisher or contributors.) 3DR (£12.50 per pack of 50). (Hewerdine, Sum meT 1997)

28 SPEECH & LANCUACETHERAPY IN PRACTICE SUM MER 1997 ISSN (online) 2045-6174 www.speechmag.com

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