Speech & Language Therapy in Practice, Winter 1997

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The bigbreakthroug hon a smallscale

T

he new DynaMyte is a lightweight,

capabilities which introduces a new dimension to

augmentative communication by offering greater

freedom to the ambulant user.

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

portable device with powerful communication

DynaMyte is just half the size of DynaVox 2 and yet it retains all its

The DynaVo x 2features a system of alarms capable of performing a varietyugmentative

communication aid of preset tasks. A clear, easy to operate touch displayhas introduced 0 provides access to the full range of DynaMyte'snew era of freedom to

communication power. Its long life battery and durable,eople of all ages whohave speech disabilities. rubberised casing guarantees easy to carry communication

fo r 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 .

For full information and demonstration, contactDYNAMICDYNAMIC ABILITIES LTDA ~IM IT E D THE COACH HOUSE, 134 PUREWELL

CHRISTCHURCH,DORSET

BH23 1EU

TELEPHONE: 01202 481818~ ~ FAX: 01 202 476688



CO N T E ~ N ~ T S i i i i E F lWinter 1997

(publication date 24th November)

ISSN 1368-2105

Published by:

Avril Nicoll

Lynwood Cottage

High Street

Drumlithie

Stonehaven

AB393YZ

Tel/fax 01569 740348

e-mail [email protected]

Production:

Fiona ReidFiona Reid Design

Straitbraes Farm

St. Cyrus

Montrose

Printing:

Manor Group Ltd

Unit 7, Edison Road

Highfield Industrial Estate

Hampden Park

Eastbourne

East Sussex BN23 6PT.

Editor:

Avril Nicoll RegMRCSLT

Subscriptions and advertising:

Tel I fax 01569 740348

©A vril Nicoll 1997

Contents of Speech & Language

Therapy in Proctice reflect the views

of the individual authors and not

necessarily the views of the publish-

er. Publication of advertisements is

not an endorsement of the adver-

tiser or product or ser vice offered.

Cover pictLlre:Auditory sequentialmemory by Maggie Johnson

News/

Comment

4ActivatingPotentialforCommunication

,; ,---. . ...... - . . ,deficits have a particuSpeech and language

and occupationaltherapy staffoutline the benefitsof a packagedprogramme for theelderly.

Counselling NLP 9Studying Neuro LinguisticProgramming has made asignificant impact on the way

Caroline Skelton works as aspeech and language therapist.She explains how.

Special Debbie Wilcox ,Sarah-Janefeature - clinicalBurns andAnitaMdadzean

In two reports, Ann Parker

teaching 13

who rundescribes group placements early

in pre-school centres with communicationKeena Cummins, then for adults groups list the tenwith a learning disability with resources they could notSarah Farazmand. do without.

218

COVER STORYAuditory segu.entialmemory defiCitsMemory involves all the senses, but

auditory memory

lar impact on languagedevelopment. MaggieJohnson shares theapproach adopted atGap House School.

Reviews 22Outcome measures, symbols,neuroanatomy, phonology,sensory motor developmentand AAC.

How I managespeech sounadifficulties 24Three opinions on the speechand language therapymanagement of an eight year oldboy, Mark.

MyTopResources 30

SPEECH & lANGUAGE THERAPY IN PRACrJCE WI HER 1997 1

mailto:[email protected]




N EWS & COMMENT

Forging partnershipsAs therapists we want to work with people to empower them,

but many feel our training does not eqUip us adequately.

However, an imaginative partnership of tutors, Clinicians and

outside bodies has enabled groups of speech and language

therapy students at University College London to gain

valuable, real-life experience while providing direct andindirect input to people who would otherwise not receive it.

Ann Parker at UCL would like to hear from service providers

keen to work with her on other such innovative projects.

Maggie Johnson is also keen to ensure her students -

children with specific language disorders - are equipped for

the real world. Group teaching brings particular benefits in

helping the children understand and accept their residual

auditory sequential memory deficits. Parents, teachers and

children are all advised of their part in compensating for the

difficulties these cause. This is an article bursting with practical

strategies for assessment and intervention, many applicable

to other client groups too . More specific practical suggestions

for eliciting velar plosives appear in How I manage speech

sound difficulties, but the more general process of case

management decision making can again be extrapolated.A speech and language therapy / occupational therapy /

nursing partnership is much in evidence in the Victoria

Infirmary Trust, where the special skills each discipline can

bring to the implementation of a standardised programme,

Sonas aPc , are demonstrated. Anyone who has worked with

elderly people in continuing care knows there is often

frustration and a sense of helplessness involved. However,

Lois Brown and the team show that, when the basics of

communication through touch and other senses are

addressed in a systematic and repetitive way, real gains in

quality of life can be expected and recorded. At the other

end of the age scale, children in early communication groups

can benefit from imaginative - and often 'home-made' -

sensory stimulation given in partnership with parents, asexplained in My Top Resources.

The importance of the senses is also fundamental to Neuro

Linguistic Programming, an approach based on using specific

linguistic patterns to challenge thought processes and bring

about change. Caroline Skelton provides a practical guide to

how it can help speech and language therapists build

rapport and give clients the confidence and the means to

work out the nub of their difficulties and address them.

A book on outcome measures, co-authored by Pam Enderby,

features in Reviews. In a recent lecture on the future of the

profession, Professor Enderby's warnings included the

implications of ever-shifting demographics,

epidemiology, technology, consumer

power and political landscape. All the

authors here show their commitment toforging partnerships and updating skills

to keep up with these changing

demands and needs.

Please give me a call if you too are

involved in interesting projects and

would be willing to share your

experience and resources with your

COlleagues through this magazine.

Avril Nicoll

Editor

Lynwood Cottage, High Street, DrumlithieStonehaven AB39 3YZtel/ ansa / fax 01569 740348e-mail [email protected]

SP [[CI 1& LANGUAG E THERAPY IN PRACfICE WI i'<'TER 1997

Books forschoolsIn a five yea r initiative, WHSmith is providing aro und half

a million free readin g books to

over 400 primary schools inthe UK.

The company is working withthe Department for Educationand Employment and teachers

to ensure the bookJist is best

suited to the educational needs

of the children. The schoo ls

chosen have all alreadydemonstrated th eir commi -

ment to improving li teracy.

Secretary of State for

Education and Emp loyment.David Blun ke tt, described it as

"an exce llent example of how

this government and business

can work together to achieve

objectives for the good of allparts of th e community and Iam con fiden t th at it will help

fu lfil the target for li teracywhich we have set for 2002 ."

Advances inpsychiauyAll exhibition at the Museum

of London raises questions

about the way people with

mental hea lth problems are

seen by soci ety.The co ll abo rative venture

between the Museum and

Bethlem Royal Hospital is oneof the events ce lebrating the

750 th annive rsary of th e hospital, the world 's oldest caring for

people with mental diso rders.It runs until 15 March [9 88

and includes an interacti ve CD

ROM covering the latestadvances in psych iatry.

Dewit,: MuseulIl o( London , tel .

0171 600 3699.

Fll.1encygamsAl l unforeseen benefitor speech recognitiontechnology fdr peoplewho stammer has

been noted by IBM.

People who stammerhave often foundcommunication bykeyboard less

cha llenging thanspeak ing, but thepaus ing and slowerspeech ra te currelltlynt>cessary to usepeech recognition

technology has helpedat least two usersimprove their fluency.IBM manufacturesthe VoiceType speechre ognition word

processing software.Deta ils: DUllcan Ross,IBM Speech BusillessMtJrltlgel; lei. 011256344741.

Pre-schoolprojectA new project willdraw togetherinfonnation andresearch on therelalionship betweenspeech, language andliteracy problems,

inves tigate preventionand arly interventionand d e Y ~ l o p are ource package ,1l1d

rra in ing.1 he joint pre-schoolYt.'1Uu re between,\IASIC and th eRrili h DyslexiaAssociation is beingfu nded bv GlaxoW dD lails: AFASIC, tel.01 71 236 6487.

TuberousSclerosisgeneRecent research has

uncovered the sec-

ond gene involved

in TuberousSclerosis, a co ndi

tion occurring in approximate-

ly 1 in 6000 new-born babies.

Although the tumours it causes in many parts of th e bodyare usually benign, they can lead to med ica] problems

including epilepsy, learning difficu lt ies and au ti sm. It is

hoped DN A test ing and reliable genetic counse ll ing wil l

now become possibl e.

Details: Th e Tuberous Sc/elosis Associalio l1 , Liule Barnsley

Fa rm , Catshi lL , Bromsgrolle, Worces lersh ire B61 ONQ.

2



hnslmas ca talO(lue 1997

AFASIC CHRISTMAS CA

Christmas card catalogues (" also including gift ideas), are

available from many organ! atio ns including:

• The NatioIUlI Autistic Society ' , 393 City Road, London EC 1VINE .

• 'Ine Stroke Ass ociation", tel. 017l 4904773 or write to Stroke Associalion (Trading) Ltd, Stroke

House, Whitecross Street, London ECl Y 8]1.

• AFASIC, teL Dl7l 236 6487(Reu,lers ml1y u·ish !O note that at lrust 0111' a r i l ADA , hIlS disrontillued its Christmas card suits 115

they failed 10 raise income, the charity belieJ'es as II result of Ille market TellChing saturation.)

TJupplementsuccessParents are claiming a

nutritional supplement can

help children with the

symptoms of dyspraxia,

attention deficit/hyperactivity

disorder an d dyslexia .Efalex contains a combination

of thyme oil an d the essen tial

fatty acids docosahexaenoic

acid, arachidonic acid an d

gamma linolenic acid. It is

believed it acts to maintain

eye and brain function,

compensating for unusual

biochemistry, and can be

taken by children from two

years old.

One parent of a twelve year

old boy with clumsiness, a

short concentration span,

lack of focusan d

atendency

to fidget said, "When Efalex

Preventing recurrent strokesAs part of Stroke Week, the fo llowing information was made ava il

able by the Stroke Association.

• New research shows 14 per ce nt of people who have had strokes

are not taking aspirin, even though it could reduce their risk of hav

ing another stroke. The Association wants to encourage wider useof long-term aspirin treatment and is urging GP practices to main

tain a regi ster of all their patients who have had strokes and to

assess each patient's sui tabi lity for aspirin treatment. They wou ld

also like to ensure that advice on reducing a lcohol intake and cig

arette smoking is clearly given. (Report: Preventing recurrent strokes:

are opportunities being missed?)

• A new leaflet to help people wh o have had a sLIoke reduce the

risk of having another has been produced (Keeping well after YOllr

stroke). It stresses th e imporlance of understanding the type of

sLIoke and treatment and the need to take medicines regularly, as

well as highlighting the value of regular blood pressure checks and

lifestyle changes. Details: The Stroke Association, tel. 0171 490 79999.

EWS

Business anddisabilityThe charity Scope and Talk

Radio have combined to survey

how businesses are ser.ving

people with disabilities since

the Disability Discrimination

Act came into force.

I! is unlawful for businesses

to refuse to serve disabled

people or, compared with

non-disabled people, to offer

goods an d services with a

lower standard of service or

at less advantageous terms.

The results of the survey will

be used to educate business

es, lobby Parliament an d

influence business and trade

bodies by highlighting areas

of good and poor practice .

Details: Scope / Talk Radio

Illfonllation Lille, tel. 01908

200022.

- /

SCOPE fOR P[OPLl WITH PA LSY

Cerebral palsydevelopmentA new module to develop

professional skills in the

diagnosis an d management

of people with cerebral palsyis being offered as part of a

Masters degree at City

University.

Gillian Nelms (ACE Centre in

Oxford) and Nicola Grove,

speech and language therapist,

will contribute to the

programme which is receiving

funding from Scope. Topics

such as motor patterns and

health issues, social aspects of

cerebral palsy, oral motor ski.lls

and communication an d MC

are included .

Details: Scope, tel. 0171 636

5020.

was launched we wondered

whether it might make a

difference. As pa ren ts

you will try virtually

anything to improve

lot of your child

an d it's all too easy to

think you've spotted an

improvement where

none actually exists. In

this case, however, we

struck gold ."

Efalex is available in

Boots, pharmacies,

health food stores an d

leading supermarkets.

Details: EfamollllformatiollLine, tel. 01483570248.

@ ~ n a ~ ~ P e 2 ~ developments are reponed in the annual

review of Action for Dysphasic Adults (ADA).There are now 13 affiliated self-help groups wi t.h fiv e o thers in process.CommUlliCilte workshops, which offer standardised tra ining to a range of

care professionals, are con tinuing and a medical teaching pack is availablefor use with medi caI students and professional s. The charity has alsobecome more involved in advocacy and empowerment. and held a training day on the subject in February.This year will see the publicalion of the 2nd edition of the NationalRegister of Language Opponuniti es, a systematic di rectory detailing allthe resou rces ava ilable across the country to people with dysphasia; it

will also be available on disk. ADA's regional co mmittee has a lso establi shed a working party to study the effec t of th e DisabilityDiscrimination Act on people with dysphasia .

Action fOl Dysphasic Adults, 1 Royal Street, London SE1 7LL, tel. 0171 261 9572 .

SPEEC H & L ~ N C L l A G E THERAPY IN PRA Cn CE W1N- I'ER 1997 3



TH E ELDERLY

Actlvatln Potential

Co fused, disorienla ed and

s o d a l ~ deprived elderlypeo Ie are ofle n ~ l e c r e d ascfiem g ~ ups. Sonas aPc is aackaged programme designedto meet their needs. Speech

and language and occupationaltherapy staff of the VictoriaInfirmary nRS Trust 0 Ine Itsimplementadon a benefits.

Sonas aPc was devised by Sister MaryThreadgold, a speech and language thera

pist in Dublin. Sonas is Gaelic for 'well

being' and aPc represents 'activating poten

tial for communication'. The multisensory

packaged programme on audio tape uses

music, singing, touch, smell and taste to

Rromote interaction and a sense of well

being amongst participants.

Training in the use of the programme was

offered to a group of professions allied to

medicine (PAMs) an d nursing staff in

Glasgow in 1996, in two half day work

shops run six weeks apart. The programme

provides for a group and a one-to-one

approach.

We now have groups of approximately

eight confused or socially isolated (often

dysphasic) clients attending with two facil

itators, in this case a speech and language

therapist an d occupational therapist. Eachgroup lasts 45 minutes to 1 hour and

groups are run at least weekly in four dif

ferent care of the elderly units with the

same clients attending. Some have contin

ued for 18 months while others are recent

ly formed. Some clients were known

already to ou r departments having had

therapy input and others were referred by

nursing staff, family or self-referral.

Clients are invited to attend and the choice

is theirs. Twenty five per cent of patients in

most of the continuing care wards attend.

FamiliarityAn audio tape takes the group smoothly

through a 45 minute session, commencing

with a signature tune and personal wel

come by the facilitator. The groups rely on

repetition, triggering memories an d

encouraging interaction. A group developsits own character as the weeks progress,

and a feeling of shared experience an d

familiarity benefits therapist and client.

The same tape is used every week. We have

not found this too repetitive either for

clients or ourselves, but the second side of

the tape provides a change in songs, cued

speech and music, allowing variety when

necessary.

The programme includes:

1. gentle exercise

2. singing

3. massage based on the simple 'metamor

phic' technique taught during Sonas aPc

training. Shoulders an d upper arms are

massaged gently by the facilitators moving

round the group, accompanied by music.

'The skin is ou r first medium of commu

nication" (Montague, in Sonas manual)

SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 1997



TJ IE ELDERlY

and touch is thera ' remark how " , " peU!lc. Clients often

nICe the ex 'notice other cli " penence is, and4, a rh ' rlhm' ,entsenjoYlng it too,

TU I Ica sect ion

5, a taste and smell sec tith e tape all ows the t: .,. on , For the latter,

~ o m e perfumed 0' 1 ' ao Hators time to rub

lfOllowed b), ha d ,IntO each client 's handn exeroses and '

ment to sll1elllh o ' I A' enCOurage_cOl, t !JOles '

very confu sed I' , ' a passive orc lent WIll fli

on the propenies of J.- 0 er a commentI " " uleo!/ 'Th' ,y , It sme ll s Il'k I - IS IS love-

e avender" "1me of a good soa " , t reminds

6, cued Speech _ ,proverbs ple!lon of we ll- known

7, a shon p 1' oem a lOwi ng I ' ,

!lm e after more acu' , ,«I mm g, llstenillo8 \ e secUons b

, an 0pponun ity for individ ' , 9, a closing song, udl pan lCJpation

MOdificationWe can modify o ur aaCCOUnt of In j ' 'd pproach to take(JVI lIal n d Itaped programme is £i ee s a lhough the

hard of hea ring I ' Ixed, We ensure ac lell[ IS s d

tape reCorder 'n d , ea te near th e, " p r o v I de

wllh Easi -comms for lh some elienlsIndi vidua ls if 1/ e seSSIO n, We ask

massaged, as n ~ ? ~ v : a n t Iheir shoulders

touched, A blind ryone enjoys being

approoches explained vma n has al/ the

liy sla nled and a I ' erbaily as he is eas " c lenl wah a h 'IS aSS lsled wilh P ' ' emlplegia

, asslve movem C

exerCise sections Th ellIS lor the' ose who abJ / are given lhe 0 0 ' re non-ver_

Channels of O l l 1 i l l ~ ~ i nunlty 10 use o lher

humming or rh'rlh ca li on, for example"

h

JU lilll

t e smg lng parts,

Ca l lap , ,

p ing dunng

ParticipationAs Ihe clients b

ecome'

{; 'I 'programme 010 , am i lar with Ihe

, re POSitive "nOled and a de ' , paIllopalion is

' crease In neo 'obVIOUS, Some /' ba!lVe aspens is

c lell[s are p "aII seclions ofc ' artlCJpatory ill

, ,ermg 10 'rem in isce Ol ho SlOg, dance and

' crs are 'but may enjoy on e secti qUI!'1 an d passive,On e lady is very ' , on 10 pan lcu lar,

, , aruuous andnlCa!lv(' Ulllil th ' lIncommu_" e exercises \ '1 h '

'

A em ersnother lady has her e ' ,

the early pa n of th yes !lgh tl y closed fore session b 'fi IIu y along wi lh the ta .' UI sings tune-

and will make "0 d pe In a srnall voiceO

th9nk the facill,b eye COntact. sillile a ndtalors at the d

t who is severel d en , l chatter and ,Y emenled uses con- '

in any s was ma la lly unable to pa rectlon Til ch '

nd sh h .. e altenng has, e as Improv d

th ' ,e turn taking, ,section , e ~ t r o d u C t l o n of the rhyt h_ '

of tOUche a a ~ a e a r s 10 enjoy the

eye Contaa and 'I taste, She main-ml

ernotionally labil: es rnore often,

the ea rly aCIIV't' CVA el lent cries dur, , l i es bu t co 'lclpale and ' n!lnues to

the' on comp letion, says shegroup,

AppendiX 2 Bt. Areod! • enef/rs roclienr YmOde, ponobl oClllrororsrime fo:r:,P ond Which c::rogromme effect;

i ! d 1 I f l e x i b l l ; : : ; ~ r e s P o n s e . be repeored ove:: ~ : ~ ~ h I S n ~ g l e c r e dvdUol cltenr lime ol/oWin oJ penodof;xperience. needs, deve/oPI'g corelulmOdili .0;': r : ~ ~ ~ l o r Conrlnued fa

~ " : : £ ~ : : : n n Q = n : ; : ~ ~ : ' / C r : : , ~ ~ u r e s . : " ~ : : ! n ' : ~ ~ ~ 5. Aforum for

oryreom. ng re/orions wirh ,,.

some field. . diSCUSSion . rilemeering rh,s hos e n o b l e ' ~ ~ orher rheroPisrs

i : d : ~ USint 0 1 : ~ : r ~ o n r h s . ro form on i n r e r ~ : ~ r s e s in rhe

onses wirhln rh lonol form WeVlduOIsresp ono/ observof oJroup

Appendix 1 Benefits to clients1. Arelaxed, Informal atmosphere to encourage freedom of expression.2. Time to share enjoyable experiences In asafe, empathetic

environment. 3. Freedom of choice to attend, with no expectations of performance.4. The opportunity for group members to develop and build relationships through tIme. S. Freedom to use any communication channel - verbal or non-verbal, touch, gesture, facial expression or eye contact. 6. Therapists' obsenation of the individual's preferred sensorychannel and reinforcement of Its use in activities of dally living.7. Aroutine and predictable sequence of events allowing severelyconfused clients to become familiar with the material and the othermembers.

8. Reduction in tension and increase in confidence and self-esteem.9. Acknowledgement of personal Integrity in confused people.

. ng ond e n r i c h i n ; ~ : : ~ for

rhe need forUor/on oVer rimeRcrtonol ossessmo/orm ond o n f ~ r m o l o s s e s s m ~ n 0 norurol e n v i ~ n r , observorion

10 vIgorously and 1h len s e joins

'rhythrn ' ~ l i s s l ' O en co nt rib utes to theh ' n seClion B ,l -

S e appears relaxed and I _ ' , y U,e end egroup OVer r i m ! ~ n rroce onhe other group rn b lappy, smiling at

Appendix 3• Considerations1. Illness and disability in the group can cause inconsistentnumbers, or disruption of client mix.2. Appropriate accommodation is important; aquiet room,large enough to have acircle of up to 10 people, some inwheelchairs, with facilitators moving around to assist inexercise and perform shoulder / arm massage. One of ourclients likes to dance during the music programme and spacewithin the circle for this tobe done safely was necessary.3. Avoid interruptions during the group.

4. Staff shortages can interrupt continuity.S. Time is needed to prepare and transport clients to theSonas room.

SPEECH & LANG ' , , VAGI: lH LRAPY IN PRA

en.F



THE ELDERLY

Appendix 4 - Speech & Language Therapy record sheetSonas ape

name diagnosis

ward communicationmental state/mood

~ a t eeye contact

smiling

vocallslng

talldn! -touching

e ~ r c l s l n !~ i n g

rhythm lcaillovement

nonverballnitlatlol of communication

verbaflnltlatlon of co..munlcatlon

sleeping

shouting

hitting out

~ r y l n ! l m o a n l n !purposeless movemnt

cJosed eyescryln!lmoanlng

obsenatlons of pos ltll. partlctJation

observations 0' ne!atlve r t l c l ~ a t l o n

_.

codesparticipation mood/communication

o did not participate in activity P passive/ little or no spontaneous communication

1 required assistance/prompting to participate in B bright/chatty

activity A agitated/verbally agg ress ive

2 responded spontaneously

One-to-oneA second twe nty minute audio tape is

designed for use on a one-to-one basi s

with clients. It cont a ins timed sections of

music, so ng and poetry whid] lead the

faci litator through gen tle massage of th e

c l i ~ n t s hou lders, back of neck, hand s and

head.

This individual approach is very useful

with severely dement ed or withdrawn

clients o r those with very disruptive behav

iour who may no t be able to attend group

sessions. We have used it successfully to

red uce agi ta tion in a severely confused

client. Typically clients become visiblymore relaxed during the massage an d

spontaneously cha t to the facilitator, per

ha ps pro mp ted by familiar tunes an d

mem o ries invoked by the music or poetry.

OutcomesBenefi ts to clients an d facilitators are listed

in Appendices 1 and 2. Through tim e,

clients demonstrate improved well-be ing,

self-co nfidence, se lf-esteem a nd IIU St.

The behavioural signs of we U-being are

discussed by Kitwoo d (19 96 ) and are

observable following repeat ed Sonas gro up

attendance:

a) demonstrating pleasure

b) bodily relaxation

c) assertivenes s

d) exp ress io n of a range of emotions

e) sensi ivity to the emotional needs of others

f) humourg) crea tive self expression (su ch as singing

an d dancing)

h) helpfulness

i) affect ion

j) self respect (such as concern aboutap pea rance)

k) acceptance of others wh o also have a

dementing illness, or other disability.

Alth o ugh difficult to mon itor objectively,

care staff an d relati ves have noticed gene r-

a ll y improved alertness, happin ess and

relaxa tion following the gro up in so me

individuals and quality o f life is improved

at th e time of the gro up . T he progra mm e

can "m anage" behaviou r in some noisy,

distracted, disrupti ve or sleepy cl ien ts.

Clients have demonstrated their trust by

their continued free choice attendance ove r

a long period of time. Individ uality in

responses is allowed. Dysphasic clientshave benefited from the socia l and com

municative aspect of the group and all

have tolerated the mixed memory ab ilities

and physical limitations of othe r clients .

SPEECH & LANGUAGETHER APV IN PRACTICE WINTER 1997



-- -

---

TJ IE ELDERlY

Appendix 5 - Occupational Therapy record sheetSonas ape

name diagnosis

ward communication mental state/mood

elat. 1i$POIiDED -o SI6UTUII mE

-

PARTICIPATED IlIlmo SOIiG

PARTICIPATED III WICISES

)!mClPAnJ III SIIiG AlOIiG (0 J IIJOYJD MASSAGE. DIIIII

PDnCIPATlD WITH IIiSTlUfjEIiTS

AIISWERED pROVE.as

OFFEIED PARTY PIECE

P A I T I ~ P A l E D III SlIIG AlOIiG PAIIIClNnD III nOSlliG SOIiG

IISPOIiSE TO SWIOII (+VE OR - VE)

MOO D/COMUILICATlOIL

codesQarticiQation mQod/communication

0 did not participate P passive or no spontaneous communication

1 required assistance/prompting to participate in B brighUchatty

activity A agitated/verbally aggressive

2 responded spontaneouslyI

Appendix 6 - Grouprecord sheet

SOllAS oPcgroup record sheer tor

Adaily reCord of chan '. wordcommunication as a r ; s e u : ~ ~ e h a v l o u r interaction and

The programme's implementation has a Sonas diary, sum- Ch 0 attending 'SONonge may occur In any ot rhe tol/ Wi AS aPe' grouphighlighted potential for enjoyment marising the aims of

0 ng areasthrough well-being activities for the more the group an d atten

confused patients. Other such options dance details, to I DATECOMMEllrSye conroct

include privately arranged aromatherapy, involve carers andsmilingan therapy (in two units), social activities relatives - panicu

and outings run by occupational thera- larly useful for the VOcal/singpists, music in hospital, relaxation, latter when they ro/klngTherapet service an d reminiscence . can only visit in

rouchlngthe evening or at

exercisese elopments weekends. Some

We are continuing with ou r groups and relatives or singingmore staff are being offered Sonas training friends, includingrhythmical movemenr

workshops to allow further groups to stan. a local minister,

The Sonas aPc training is suitable for all have sa t in on a making aconrrlburloncarers including nurses, volunteers and day group bu t this using musical Instruments

Inreracrlng In rhe group

USing gesrure

complerlng proverbs

responding ro

IJ massage

2) rosre

3) smell

4) music

cued speech

centre staff. Running the groups requires has to be han

commitment and consideration died with care.

(Appendix 3) but the rewards keep us Some of the

motivated, as do interdisciplinary meet- e v a l u a t i o n

ings and contact with Sonas aPc trainers. forms we have

We are keen to maximise the potential for developed are

staff involvement and carryover. To this in appendices 4

end, we exchange information on clients' - 7; the speech

strengths at the end of the group, attempt ilnd language

to provide a written repon on client atten- therapy record

dance approximately every 10 weeks, dis- sheet (4) , the

playa client list in the ward with group occupational

aims boldly presenLed and disseminate therapy

information at social rounds with ward record sheet

staff. We are developing record sheets an d (5 , a group

SPEECH & LANGUAGE THERAPY IN PIMCTICE WINTER 1997 7

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http://slidepdf.com/reader/full/pROVE.as



Appendix 7 - Performance Evaluation sheet

Sonas aPc . Performance Evaluation

nAME: WARD:

- - - - - - - 7 ~ - - ~ ~ - - - - 4 - ~ - - - + - - - T - - ~ ~ -O. Too III/absentI. Refused2. Required encouragement3. Passive

4. Came willinglyIOrientation/memory

O. PoorI. With prompting2. Good

I Interaction/relationshipsO. Offered nothing

I. Spoke only to leaders2. Interacted with one another3. Interacted freely4. Helped others

IContribution

O. Offered nothingI. Disruptive2. Contributions Inappropriate3. Contributions appropriate

record sheet kept in case notes (6) an d a

Performance Evaluation sheet (7) left in

multi-disciplinary team notes in the nurs

ing notes in the duty room.

This holistic programme is proving a wor

thy tool for use by PAMs with confused,

disorientated an d socially deprived elderly

people. As therapists we feel we have skills

in observation, interaction, running

groups, communication and diagnosis

which allow us to implement it very effec

tively. For us, Sonas aPc is a quick and

effective way of creating rapport an d giving

a greater insight into an individual's needs

and potential. 'it allows us to respond to

these needs and to have informed an d real

istic exchanges with nursing staff, relatives

and other disciplines.

Lois Brown is a Speech and Language

Therapist, Pauline Dunsmuir and JulieLoudon Occupational Therapists andRhona A1ontgomery a Speech and

Language Therapy Assistant with Victoria

Infirmary NHS Trust in Glasgow.

Iinterest/panlcipation

O. Offered nothingI. Unco·operatlve2. Joined In whh persuasion3. Actively panlclpated

I Enjoyment/humour

O. Showed no signs of enjoymentI. Occasionally showed pleasure2. Enjoyed majority of session

3. Thoroughly enjoyed session

I level of activity

O. Persistent restlessness

I. Intermittent restlessness2. Appeared calm and relaxed

IConcentration/tolerance

O. Poor

I. Patchy2. Good

ISens!dv!ty to emodonoi needs of others

O. PassiveI. Insensitive2. Sensitive

Summary

A version of this article has been submitted

to the British Journal of Occupational

Therapy.

References

Kitwood, T. (1996) Not Them and lis

Simply Us Training Pack. Dementia

Services Development Centre, University

of Stirling, Stirling FK9 4LA, tel. 01786467740.

Threadgold, Sister M. (1995) Sonas aPc

manual. Dublin.

Further information about Sonas aPc is avail-

able from

Rosemary Hamill (MRCSLT, Dip. ACS, CMH)

Training Development Officer

Sonas aPc

Belvedere Place

Dublin 1

tel/ansa/fax 00 353 1 8366874

Sonas aPe facilitator:

Questions ~ A n s w e r s What are the benefits of a Familiarity for this client group builds confidence,repetitive programme for•••MiW"IWJ.MI reduces tension, leads to pOSitive participationelderly confused peo ple? and triggers memories.

How is Sonas aPc im proving A natural setting allows more accurate assessmentspeech and languager l . I I " I ~ I * L \ \ ~ ' ~ ~ of individual needs while therapeutic skills in

therapy provision? assessment, diagnosis and interaction enhance the

benefits of the set programme for the clients.

Are developments As well as highlighting the benefits of 'well-being'

I I I I I I I I activities for this client group, opportunities foraking place as a result ofthe programme's involving relatives and carers are Deing followed up.im prementation?

SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 1997

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COUNSELLING

Neuro Linguistic

Pro ramming Speech &

Languae

-"'-hera i 'sStudying

Neuro Linguistic

Progranlming

has made a

significant impact

on the way

Caroline Skelton

works as a

speech and language

therapist.

In thisarticle she shares

its principles

and how she is

putting it

into practice.

~ u i d e have always been interested in using counselling approach

es and psychological models within speech and language

therapy. In 1994 I took a short course in hypnosis and,

when I started in a specialist voice and fluency post in

Chesterfield later tha t year, sought supervision through the

psychology department. I was lucky to be offered this by a

Consultant Health Psychologist experienced no t only in

using trance states but also in Neuro Linguistic

Programming (NLP). I have found NLP extremely useful and pow-

erful in my work, and feel I am only just beginning to tap the huge

potential it offers for speech and language therapy.

What is NLP?Neuro LinguistiC Programming began in the 1970s In Ca liforn ia. It

linked observable linguistic patterns to neural (thought) process

ing to find new ways of understand ing behaviour and to pro

gramme (facilitate) change .It was conceived by John Grinder. a linguist, and Richard Bandler,

a mathematician and psychotherapist. who were interested in

human excellence.They stud ed a number of therapists who were

outstanding in their field to distil the crucial elements of their com

munication.Their aim was to model expert behaviour and lan-

guage patterns. Bandler and Grinder's work identified interesting

patterns of language and non -linguist ic communication, and also

led to the understanding that these patterns represent the super

ficial expression of underlying thought processes. Grinder and

Bandler realised the therapists were using spec ific language pat

terns to challenge their clients' thought processes in order to open

up their thinking and make change possible.

As NLP developed, it focused on the processes and structure of

thi nking: how we perceive the world and how we organise ourexperience, memories and learning. By studying these processes

in high achievers we can model their skills , and by understanding

faulty or ineffective processing, we can begin to make positive

changes - for-ourselves and others. NLP is now taught w idely, and

SPEECH & LANGUAGE THERAPY IN PRACTI CE WI'lTER 1997 9



COUNSELLING

the basic principles of modelling have been app lied to bu sine ss

and spor'ts as well as therapy and education.There is a growing

resource of NLP technology for therapeutic use, with change pat

terns designed to tackle particu lar types of difficulty such

dysfluencyCase 2 - CFCF referred herself for therapy for a stammerShe presented with mild d y s ~ u e n c y

characterised by repetitions and blocks

as phobias and weight loss. with high levels of avoidance atBasic Principles dysarthn'a ~ word and speech levels. SheWe often interp,-et other people's " " attended for eight therapybehaviour intuitively; a certain look . r - ~ e I LN ."'" sessions, working on aor tone of voice gives us a feel- / \..-d.::) - ~ block-modificatIOning about the person's state of LN was referred fo r speech and language therapy, " ' \ approach. CF mC!dE

mind. IncreaSing the accur!- for mild dysarthna resulting from a brain tumour. LN s .\ good progress In

cy of our Interpretations speech had a fast rate, was larrcely intelligible, but occasionally reducingthrough good use of sen- I d Th fi d . h d. . 'd dsory acuity is fundamen- Surre . I erapy ocuse on sowing t e rate an Improving avol once ontal to the p,'actice of articulatory accuracy. LN made good progress with the ImprovingNLP By improving our exercises, but still reported difficulty in slowing his . ate . . . ~ u e n c y contrcobservation of sub tle particular Situations, resulting In frustration and loss of Intelligibility. However ShE

ch ange s in others, LN contrasted his VAKOG experience of "good" versus "bad" reportedwe can ma ke con- speech. In describing good speech attempts, LN was visually aware of continuedsc ious and less sub- his listener, auditorily aware of his own voice, and aware of planning / difficulty wiljective in tel-pret a- I htions ba sed on an sentence construction in his mind prior to actually speaking. In the bad teep oneindividual's unique speech attempts, LN's visual awareness was extremely limited, he had calls at wo'and minute varia- no auditory representation of his own voice but was acutely aware of when shet ions in behaviour. unpleasant tightness in his chest and generalised body tension. Having was requireNLP also supports elicited VAKOG data in some detail, we "mapped across" sensory to repeat athe premise that representations from bad to good, for example by expanding visual specific

~ ~ t i : ~ r ~ e ~ ~ _ awareness and filling in the absent auditory channel. messc:!e. Sheingful communication, Interestingly, during this process, LN linked his feelings of frustration blockeand gives the therapist to similar feelings experienced as a child when, as one of uncontrollably,add itional too ls to bu ild seven children, he had had to compete for attention and and sometimes trapport with even the most had not been "heard" to his satisfaction. LN felt that the phone downchallenging clients. NLP IS expe- NLP therapy had been an important part of his without saying a singriential rather than theoreticaLbut process in modifying his speech, and was word.there are a number of basic princi- " positive about general ising the gains he We discussed in detailpies or pre-suppositions which need to had made. He will be seen on a exactly 'vI/hot CF wasbe understood. Here are a few:I. We experience the world thmugh our review basis. visua/ising, hearing and feelingsenses, ie .visual, auditory, kinaesthetic. olfactol-y and each time she mode the call. It

gustatory (VAKOG). Our language and vocabu lary re nect became apparent that even before ShE

our sen sory processing in a literal manner (eg. " I see what you started to dial the number she was "hearingmean", "this sounds interesting","1 fee l sure", "that stinks", ' 'I've got herself stammering on a particular consonanthe flavour of that"). I We used on NLP swish pattern to change2. Our learn ings and mem ory con sist of VAKOG data. Changing this unconscious rehearsal of the stammerthe qual ities of our sensory representations (size , colour. pitch, volume etc.) wi l change the qu ality of t he experience. into the desired smooth speech, so that eac3.

W e use our exper ience to create our own map of the world. time CF dialled the number. she automatical,Each of us operates from our individual ma p. The "map" is not the imagined saying the words ~ u e n t l y . We alsosam e as the "te rr itory". used a circle Of excellence which helped CF

4. Ou r behaViour is goal-dl-iven. (athel- than sim ply responsive to to approach the situation in a calm state. Cst imulus. All behaviour has a posit ive intention (conscious or filled her imaginary circle with coloured lighrunconsc ious) and at any given time we ma ke the best choice avai l- representing relaxation and confidence. Byable to us. I'

S. Most of our behaviour is carr ied out unconsciously. Ou r con- stepping into her circle prior to making scious minds can process only a limited amoun l of information at telephone calls or entering other stressful any one time. situations, she was able to access a 6. W e are limited by the choices we perce ive, therefore it is help- controlled state, ful to w iden our percept ions to increase the range of options Six months later. CF reported that she was avai lable to us. able to make the phone calls with only7. All the resources we need al-e availabl e to us from dwect or I d d

occasiona easy soun repetitions on , mol"indirect experience. C

importantly, with a feeling of control. Fcontinues to be seen on a long-term reviewrinciples into practiceI attend ed an NLP Practit ioner (OUI'se in 1996, and hope to com Ibasis.plete my Master Practitioner training in January 1998. In co mmon

10 SI'I'I'CH & LANGUAGE THLlv\l>Y IN PRA CT ICE WINTER 1997



CO U SE LLlN

At 62 years old. AM suffered a severestroke with right-sided weakness andmild dysphasia. This came as a seriousblow to AM and her husband who

were looking forward to retirement inthe country. She was using a wheelchair, was dependent on ner familyand had been forced to give up abusy social life. Nine months after the

stroke. AM had only occasional word

finding difficulties resulting in hesitancy.but t his was made significantly worseby anxiety and lack of confidence. AMad it ted she was avoiding speaking-it a Ions and limiting her return tosocia lsi g because of this anxiety and

lackof

corfidencein her

speech.In a light trance. AM identified the

resources she needed to tackle socialspeaking s ations. She was able torecall t imes In her life when she hadfelt the determination and courageshe presently lacked. With guidance.AM accessed these resources fromher past memories. was encouragedto re-experience those strengths int he present and to picture herselfusing them in identified situations inthe future. In the weeks following the

session, she did in fact tackle severalof the previously feared situations.She reported that although herspeech had not been fully fluent. shehad a different attitude and herconfidence improved through copingwith the challenge.

was referred to the speech and language therapy department with a three month hi story of severe dysphonia'flu, which meant she had been unable to perform her job. She worked in personnel management in a largeundergoing major change. Her department was short-staffed and LJ had been under a lot of pressure, but

was reluctant to accept her persistent dysphonia might be stress-related.attended four therapy sessions to work on relaxation, deconstriction of the larynx and vo ice facilitation. She was

to achieve good voice quality on single so unds within the first session, but after four weeks was still unable tovoice beyond phrase leve l.

session was spe nt on an NLP reframing p,attern. This technique assumes there is a positive intention fo r allIt also relies on the metaphor of "parts '. The client is asked to set up a communication with the part of

w hich is controlling the unwanted behav iour, i.e. the dysphonia. The client then asks this part what its intentionIn a I ~ g h t trance, LJ was able to access this part. Its initial response was concerned with slowing down, which LJ

x ing. After further questioning, she realised the underlying intention was to look after her health. LJ

thi s as a wo rthwhile aim. and we then talked about other options for pursuing this aim in a more adaptiveLJ came up w ith new choices and negotiated w ith the part to relinquish its original strategy in favour of a

w alternative. The final step is an ecology check, to ensure the new strategies are acceptable and appropriate.completed the reframing, LJ's voice started to improve rapidly, and after the following session she was put on

later, LJ reported that her vo ice had been "normal" in the interve ning period. She had chosen towork on a part-time basis. and had been able to talk on the telephone and in Important meetings without

She was discharged.

SPEECH & lANCUACE TI-iERAPV IN PRACTICE WINTER 1997 11



COUNSELLING

with the best of my own learning experiences, NLP has been Caroline Skelton is a Specialist Speech and Language Therapist for

familiar enough to support and explain what I already know, whi lst Chesterfield Royal Hospital NHS T r u s ~ cha llenging limiting beliefs and allowing me to expand my learning Calow,

further. Derbyshire S44 5BL,

Four case histories are described (Cases I - 4) to illustrate how I tel. 01246 277271.

have begun to use NLP in speech and language therapy. Some of

the change patterns are more effective using a trance state simi lar Further information on NLP training from:

to deep relaxation . I always discuss this with the patient first and ask Centre NLP

them to sign a consent form for hypnosis. My clients are all adults PO Box 178

with acquired disorders or dysfiuency, and I have tended to use Leiceste r

NLP patterns where I already have a counse lling role. However, LE38ZU

the use of sensory acuity and rappor t ski lls is cen tral to all thera- tel. 0 I 16 2873356.

peutic intervention, and equally applicable to any client group.

I have been fortunate in attending the courses and receiving Recommended reading:

supervision for my work but, for anyone interested in finding out Bandler, R. and Grinder, j. ( 1979) Frogs into Princes. ISBN 1more about NLP. there are a number of tr aining companies who 870845-03-X.

offer introductory courses and most good bookshops now sell a O 'Connor. j. and Seymour. j, ( 1990) Introducing NLPThorsons.

reasonable range of titles. I look forward to hearing other thera McDermott, I. and O'Connor, j. (1996) NLP and Health. ISBN 0

pists' experiences of N LP 7225-3288-1.

This article is the first in a short series looking at how speech and language therapists have used training in other fieldsto assist their work. Personal construct psychology and family therapy will be featured in future issues.

Questions AnswersWhy does NLP work? NLP observes patterns of communication, relates

them to underlying thought processes and uses

language to challenge ana open up the mind to change

How can NLP inform111i'MfMllinterpreting behaviour become more honed tnrough

• tiI• • • The skills of tuning in to a client, building rapport andspeech and language '

therapy at a basic level? NLP training. What does NLP add to NLP recognises the importance of confidence andtraditional speech and attitude in overcoming communication difficulties and

1 rMU allows people to identify and prepare positively foranguage therapy approaches?II.!! difficult and stressful situations.

RESOURCE UPDATE. _.RESOURCE P D A ~ . .RESOURCE UPDATE..

effect of Down 's Syndrome on

DysfluencyA booklet Dysfluency, Stammering &Down's Syndrome has been producedby the British Stammering Association

and the Down's Syndrome

Association.Written by Monica Bray, Leeds

Metropolitan University, the booklet explains dysfluency and the

language and fluency and usesthe demands and capacities

model to explain how people

can help (£3.50 for 10 or 40p

each inc. pap).The BSA can also supply copies

of other books, includ ing a new general text

The Stammering Handbook, by Jenny Lewis (Vermilion) andCoping with Stammering, a self-help book for adults, by Trudy

Stewart and Jackie Turnbull (Sheldon Press).

Details: BSA , tel. 0181 983 1003 / DSA , tel. 0181 6824001 .

12 SPEECH & lANGUAGETHERt\PY IN PRACTICE WINTEH 1997

Signalong S a f e ~ for newTheSIGNALONG AT

motHersWORK series continuesAn updated leaflet on safety at work

with the publication offor new and expectant mothers has

General Retail (£17.50).been issued by the Health & SafetyThe vocabulary isExecutive.aSSOCiated with super-An amendment introduced in 1994 tomarkets, DIY stores,1992 legislation means if particulargarden centres, illingrisks cannot be avoided by otherstations, dry cleaners

and hairdressers, means, employers need to make

Changes to the working conditions or

safety, equipment, hours of a new or expectant mother

tasks and job titles . or offer suitable alternative work, or if

The next book in the this is not possible, give her paid leave

series will deal with for as long as necessary to protect her

Horticulture and health and safety or that of her child.

Agriculture and The leaflet is aimed at employers,suggestions are employees and representatives.welcome . Details: Kay Ref The Management of Health andMeinertzhogen, tel. Safety at Work (Amendment) Regulations01634832469. 1994, ISBN 0-11-043021-2, £1.10.

including health and



SPECIAL FEATURE

In two papers, the

Speech and Language

Therapy Service of the

Camden and Islington

NHS Trust and the

Department of Human

Communication

Science, University

College London (UCl)

report on joint

projects combining

genuine service

requirements with the

need to offer highquality, supervised

cHnicai practice for

students.

A service-

I.Groupp'lacements

in Under Fives

Centres

2. Groupplacements

With adults with

a leamingdisabilityyAnn Parker and

Keena Cummins

I. Group placements in Under Fives Centres This project was designed to solve two well-known problems. Thefirst. limited staffing resources, is sometimes given as a reason for the

second, a shortage of clinical places for speech and language therapy

stud ents, but we aimed to combine effective use of limited clinical

resources for children under five years of age with a consistent. well

sup ervised and high qualiry learning experience for stud ents.

§ ® N ~ ~ ® ~ ~ ® ~ d J ~•

In reassessing the available resources wi thin the Camden and

Is lingto n N HS Trust Health Centres' team, it had become increas

ingly apparent that a policy of prioritisation was required . The

available literature outlined the importa nce of ea rly intervention

and its positive effect on prevention of secondary emotional disor

ders, language difficulties and ultimate cost effect iveness (Ward

1992), an d so the system for speech and language therapy within

local Health Centres had been tailored to focus on parent interac

tion using video play-back (Kelman and Schneider 1994).

Howeve r, it was felt many children continued to be missed fw m

the process, particularly in some catchment areas where failure in

attendance was still high. A development was therefore required to

address th e needs of th ese children, without diluting service delivery within Health Cen tres where parental involyem ent was a pri

mary target. an d without increasing waiting lists by relocd ting staff.

l ~ ~ ~ D i j ~ ~C O p p © r t ~ f f l l ~ ~ ~ ~ ~A review of clinic-based learning opportunities available to the

Department of Human Co m muncation Science, UCl, ha d high

lighted the value of facilitative, adult lea rn ing mo de ls (Marson

1990) in develop ing s tuden ts' confiden e. Where students were

given a range of genuine responsibi lities they were helped to

achieve a realis tic picture of the role of the speech and language

therapist, in terms of both work with clients and general clinical

management.

While the learning environmen t nee ded to be supportive and struc

tured, and provide a hierarchy of learning, experience with paired

an d group placements - more unusu al in service settings but stan

dard practice for university-based clinics - seemed to indi ca te co n

stant one-to-one supervision, while va lued at many stages, was not

SPEECH & LANGUAGE THERAPY IN PRACflCE WINTER 1997 13

5



SPEClAL FEATURE

necessarily the ideal for every placement. Feedback from our stu

dents matched reports from other initiatives (Grundy, 1994;

RCSLT, 1996). Placement in a group of peers seemed to offer a range

of additional opportunities, such as learning to work in a team, use

of peer support and feedback and a degree of responsibility for a real

task which supported confidence in problem-solving approaches.

Group placements in a singl e department provided a consistent

experience for the students and a greater number of placements

under the supelVision of a sma ller number of clinicians. They also

offered a view of the student team as a resource, rather than a drain

on the resources of the speedl and language therapy service.

l P U l l O ~ ( Q ) ~ © ~ L l l Y .The underlying philosophy of the student learning process for this

particular project was that of a hierarchy of learning, making use of

a didactic language enrichment programme in association with an

introduction to the interactional model through student self-analy

sis. The Let's PIa), Language Scheme (Barnell an d Fletcher (985)

was chosen because of its definition as an enrichm en t programme,

rather than a therapy tool, its strengths being provision of a basic

screening procedure, with identification an d differe ntiation of children at risk of communication difficulties, an d structured group

activities provided in a specific daily programme.

The students were to take responsibility for lea rning through gener

al peer support, regul ar video-recording for daily peer feedback and

review and constant telephone access to supelViso rs Video equip

ment was an essential tool for the project and the key support sys

tem was a weekly tutorial , provided jointly by staff of the Camden

and Islington Speech an d Language Therapy SelVice and UCL.

P j ( Q ) ( C ® ~ ~PreparatOlY work for the project included meetings and policy

decisions between the Educmion Department concerned, the

Camden and Islington te am, UCL clinical tutors and the Heads of

Nurseries, as well as obtaining parental consent for both the pro

gramme and the use of video-recording. Four Under Fives Centreswere selected thmugh identification of the highest ratio of children

considered to be at risk of language delay.

1r[jatUlill l f(iJg[n addition to checking the students' e.,xisting knowledge of a range

of relevant formal non-verbal and communication assessment pro

cedures, their direct preparation for the project included two train

ing days during the first week of the block placement. interspersed

with two days within the placement environment. Staff members

from the Centres and UCL contributed to both training days to

emphasise and support the cooperative nature of the project, but

the content was primarily devised by Camden and Islington teams .

Day on e focused on orientation, aims, expectations and anxieties,

Health and Safety issues and uaining in use of the Let's Play

Language Scheme. For the second day, each student was requestedto bring one video of themselves interacting with a child and on e

video of a group of children.

Day two focused on interaction and problem solving. Students

were introduced to child an d adult interactional styles (Weitzman,

1992) and the parent-child interaction model as described by

Kelman and Schneider (1994) with specific relationship to parents.

,This system was then adapted for student use . Subsequent group

tutorials provided support for individual student 's assessment of

their own interaaion abilities, abstraction of an adaptational aim

for the next stage of wo rk and problem-solving focused on situa

tions which had arisen within the working environment.

~ ~ © l ( C ® m ~ l I l l ~Each pair of students spent the first week of the four-week place

ment screening all children within the Centres. Their second week

involved setting up a timetable, appropriately grouping the chil

dren and embarking on the programme. The third an d fourth

weeks involved continuation and extension of the group activities

from the programme, adapting activities where relevant, monitor

ing development through note-keeping, re-screening and comple

tion of a summary report. All therapy was videoed and individual

video interaction sessions were carried out on a daily basis

T l U I ~ ( Q ) [ j ~ © l ~ §Tutorials were held in a weekly, hair-day session and focused on :

i. Feedback and problem-solving.

ii. Feedback of each student's personal child-adult interaction,

including identification of a new individual aim.

iii. Group video: discussion of behaviour management an d adap

tation of activities.

[n this way students were introduced to case presentation, an d were

encouraged to discuss issues that might lead to resista nces, blocks

or obstacles to learning (Boyd Webb, 1984) an d thereby limit the

efficacy of their worl<.

f o \ ~ § ® ~ § W r J ® I i l l ~Throughout the programme students completed a Personal

Professional Profile which included personal skills, clinical skills

an d professional behaviour as demonstrated. In addition , subse

quent to the placement, they completed an assessment question

naire an d were provided with personal assessment grades. There

was also a closing summary meeting in which th e process was

reviewed , identifying goals which were met successfully and those

which would need to be adapted in the future.

O [ U ] ~ ( g ( Q ) m ® ~At reassessment all the children had improved since screening.

Those children whose rate of change was reduced were recom

mended as needing to be referred to the speech and language ther

apy selVice. Feedback about the process was provided in writing

through individual forms tailored for students clnd nurseries.

The students reported they had benefited from having insight into

the working nursery environment, experience of liaison with and

support from Centre staff with in-depth knowledge of children, the

opportunity of learning about organisation an d time managementin association with working with children at a range of develop

mental stages. They also appreciated the opportunity to gain expe

rience of children with and without communication difficulties,

both within groups and on an individual basis, an d to give lan

guage support to children who normally might not have the chance

to attend speech and language therapy.

The nurseries reported they had benefited from being provided with

assistance in identifying or confirming children with language diffi

culties, a model of speech and language therapy, and the process of

additional language enrichment. They noted the children benefited

from structured and specific input in regular sessions, more close

contact work and an increase in confidence and general skills. The

students were also said to have provided a positive contribution to

organisation and record keeping. All Centres reported they would

like to be included in any further pilots canied out.

lE1flf@ ~ ~ ~ ®®(ffi [j[JU [JUg

Pine & Horne (cited in Boyd Webb, 1984) olltline some specific

prerequisites for effective Jearn ing. They sta te the learning environ

ment should

a) encourage people to be active

b) emphasise the persona l nature of learning

c) accept that difference is desirable

d) recognise people's right to make mistakes

e) tol erate imperfection

f) encourage openness of mind and trust in self

g) make people fee l respected an d accepted

h) facilita te discovelY

i) plll emphasis on self-eva luation in co-operation and

j) permit confrontation of ideas.

Ou r discussion with th e students indicated that group placements

with a genuine purpose, structured as a team project, can offer a

14 SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 1997



SPECIAL FEATU RE

strong model in all of these areas, with experience that is comple

mentary to that provided by individual placements.

A d d ~ ~ ~ ~ r r 1 © l ~ § ~ N ~ { c ®The students provided an additional service, augmenting existing

support for the needs of the children within the Centres, providing

an essential link and model to Centre staff and paving the way forfurther training and input addressing more specific communica

tion difficulties. In adopting an interactional model, the therapists

were also able to learn about transference of skiJls from one caregroup to another, in preparation for empowering Centre staff

through this technique. It was exciting to work with such a highly

motivated group of students who were open and prepared to takerisks with ideas and questions, and willing to learn from mistakes

in order to develop their personal sl<ills.

C ( Q J I n l ~ ~ ~ ~ ® I n l { cLiaison and continuity 0 interaction between lecturers and supervis

ing therapists were optimum. The experience obtained was con is-

tent for each student, making assessment of progress easie.r and more

definable, and the mutual understanding between those irl\ h· dmore explicit and detailed. A larger number f students provided with a strong experiential learning environ ment an I the range of

experience and responsib il i[ enrourag d an inCIease in students'

confidence. The establ ishme.nt of a commitment to a group placement with joint aims means that a more consistent relationship,

with more frequent contact and discussion, can be formed betweena University-b ased tutor and the speech and language therapy ser

vice, to the benefit of all the panicipants in the project.

ih® [ F u ~ ~ [J®While modifications and improvements will undoubtedly beinvolved, we are continuing and developing this approach in further

under fives centres and other settings. Specific developments

include extension to other groups of students and provision of

workshops in under fives education centres by speech and languagetherapy to augment understanding of the needs of children withspeech and learning difficulties through an interactional model.

At University College London, we have built into our placement

system a stronger focus on paired and group placements, withdevelopments such as workshops for our students to help them

make the most of opportunities to work in such teams. Other

workshops for supervising therapists and University-based tutorsenable discussion of ways to support the development of students'

skills, autonomy and confidence in such settings while providing

high quality supervision. It is hoped all our students will have the

opportunity to learn in paired and group service-based settings as

part of their clinical experience.

References Barnett, M. and Fletcher, s. (1985) Let's Play Language. Cambridge:

LOA publications.

Boyd Webb, N. (1984) From Social Work Practice to Teaching the Practice of Social Work. Jorll"lll1l of Educlltion for Social Work 20 (3).

Grundy, K. (October 1994) Peer placements: it's easier with two.

CSLT Bulletin.

Ke!man, E. and Schneider, C. (1994) Parent-child Interaction: an

alternative approach to the management of children's language difficulties. Child l.ang1lage, Teaching and Therapy 1 (1).

Marson, S. (1990) Essentials of Management: Creating a Climate

for Learning. Nursing Times (86).RCSLT (1996) RCSLT Forums on 7ilwring for ExpeJiential Learing:

fillal report of the RCSLT Illitiative, 1995-6. London: Royal Collegeof Speech and Langauge Therapists.

Ward, S. (1992) The Predictive Validity and Accuracy of a Screening

Test for Language Delay and Auditory Perceptual Disorder.Ellropeall Joumlll of DisordeJ·s of Communiclltion 27.

Weitzman, E. (1992) Learnillg LlIllglwge and Loving It . Hanen

Centre Publication.

SPEECH & LANGUAGE THERAPY IN PRACTlCE WI! -ER 1997 15



••

- - - = = = = ~ = = ~ = - ~

SPECIAL FEATURE

2. Group placements with adults with a leaming disability

This project was concerned with fulfilling a genuine service needwhile offering a group placement for students in a spedalist area of

work, adult lea rning disability. The aims were to;

• provide clients with an appropriate service respons e to their com

munication need

• provide the four students concemed with an opportunity to

respo nd to a genuine referral from its o nset

• prepare the students for the particular nature of the placement

before starting

• give an opportunity for peer support in the group and in pairs.

In addition, it was possible to avoid one difficulty therapists in this

team had experienced; this placement was specifically desig ned for

a group of students who had requested to work with ad ults with

learning difficulties an d was offered in a block placemen t period

designated for adult work. When the focus of placements for a par

ticular year group had been work with children, students placedwith the team had viewed the placement at best as a welcome

alternative and at worst as a poor subsUtute for the unavailable core

placement.

I P r r Q ) ~ ® ~ ~Four third year students who had expressed an interest in working

with this client group attended a two-week group placement block

within the Speech and Language Therapy Learning Disability

Service, based in two multi-disciplinary teams. The students' main

focus was to work in pairs, following through two speech and lan

guage therapy referra Is.

In preparation for the placement, a college-based orientation ses

sion was jointly led by th e therapy tea m leader and th e co llege

placemen ts' coordinator. This session provided an opportunity for

the students con cerned to gain an overview of the placement and

to discuss th eir previous clinical experience and current skills and

needs. The aim was to prepare the group for the nature of the place

men t and to emp has ise the collaboration between the college and

the placement tea m. Th e responsib ility an d degree of student

autonomy in the programme was to be. balanced by a careful struc

ture for peer support , with group supervision by the therapy team

on a regu lar basis throughou t.

week-One• otlentation to location and timetable

1. Three clients had been referred from a local day se rvice and were

o n the speech and language therapy waiting list. Key workers had

requested an assessment of their communication with the aim of

identifYing strategies to support each client with a focus on group

dyn amics.

2. School pupils attending a Link Course at a local Further

Education Co llege required a communication screen to identifY

their needs and enable therapists to plan their provision for the

forthcoming full-time course.

[ E ~ ~ ~ ~ © l ~ ~ © 1 r UDuring the final feedback session the students listed the ski ll areas

in which they felt they had had an opportunity to deve lop:

1. int e ra cti o n skills with a new client group 2. observation

3. precise note tak ing and rep ort writing

4. gathering and pooling of informa tio n

5. developing a framework for screening and assessment

6. drawing conclusions

7. time management

8. collaboration

9. introducing self to staff an d clients

10. negotiating with staff

11. fitting into a Se rvice and team

12. independence and flexibility

13. evaluating own work and int eract ions

14. problem-solving sk ills for specinc situa tions, such as clients

absent during planned assessment tim e, general time constraints,

other priorities for staff and unpredictabl e events.

Each studen t was also asked to complete a detailed individual eval

uation of th ei r experience in thi s placement. All fo ur students list

ed a range of advan tages of this type of group pla cement, that is,

one with a specific task . From their evaluations, certain themes

emerged:

1. Peer placement offered support, shared knowledge and ideas,

reciprocal learning, a less daunting experience, "someone at your

•joint visits with speech and language therapists, meeting people who have alearning disability

• assessment workshop• meeting with other professionals based within the service• development of a screening assessment to be used with clients• discussion of strategies to use with clients/carers during the placement

Week Two

• visit to referral locations• presentation of draft assessment process to peers and then to therapists• completion of screening assessment

• analysis of assessment results• presentation of assessment results to peers and therapists• end of placement evaluation.

16 SPEECH & IANGUACL ·11-fERAPY IN PRACfICE WINTER 1997



SPECIAL FEATURE

Answers

A p a r t ~ n e r s h i p is required between education• • • • • •8 ...establishments, speech and language therapy service

managers and clinical tutors, providers of potential host

services and students; client consent is also needed.

M . . .U • .,NI Adequate orientation sessions, tutorials, telephonei M ~ , " • • •"1 access to tutors, video equipment, time with each. , .. . . M ~ other and protocols for self-assessment are required"!'I for maximum benefit.

~ _ Group placements develop team working, peersupport and confidence as a result of responsibilityM l w t W ! J . . ~ 1 or real-life problem-solving, can provide a service

in

under-resourced areas, and allow clinical supervisors

to concentrate on delegation and management.

own level ". Two students expressed a preference for peer place

ment, while the others found this "equally enjoyable" to an indi

vidual placement.

2. Group support from therapists provided useful direction, a

wider perspective, opportunity to question and helpful feedback in

a non-threatening context.

3. The single focus provided by the specific project was preferred by

three students and all felt they had the same opportunity to gain as

broad a pioture of the service as in other placements.

4. Support from UCL was seen as more indirect, but available when

required.

One student commented that potentially group placements might

give a less committed student the opportunity to opt out and rely

on peers, although this had not been a problem on this occasion.

All students questioned the necessity for the pre-placement

preparatory session, and in this respect (see below) this compo

nent was more beneficial to th e service than to the students.

l . The students were far more independent on a peer placement

compared with those on single placements because of the support

they were able to offer one another.

2. Support for the group from therapists was seen as time-effective

with the focus on facilitating the student team in problem-solving

and less need for didactic teaching.

3. The single focus provided by a specific project enabled an

increase in output from the service. Careful selection of referrals to

be followed through was seen as essential to the process.

4. The preparatory session, jointly led with the university depart

ment, focused the student group, gave recognition to the relevance

of the placement and accelerated the typical student adjustment

period for this area of work. Before this, the planning stage had

included a half-day workshop for the speech and language therapy

team, which renewed enthusiasm for student placements andenabled the staff to consider strategies for supporting a group

placement.

Group placements are not a new idea. They have been operated for

many years in university-based clinics, where the advantages are

acknowledged to be different types of learning opportunity, not

only an increase in available-placements. Service-based placements

can also offer this type of learning experience, with the same range

of specific advantages for the students involved. The focus on spe

cific projects allows the students to be seen (and to perceive them

selves) as a professional resource. All four students enjoyed and

learnt from the placement, an d three reported a particular interest

in working with the client group in the future. The speech and

language therapy team continue to offer peer placements and are

planning further group projects, and the UCL placements team

continue to be enthusiatic about group placements focused on a

real service need, as a basis for high quality learning opportunities

for students.

The authors

Ann Parker, Senior Lecturer in Professional Studies at the

Department of Human Communication Science, UCL wrote the

first paper with Keena Cummins, Principal Speech & Language

Therapist working in Parent/Child Interaction for Camden &

Islington Community NHS Trust and the second with Rachel

Farazmand . Therapy Team Leader with the Camden & IslingtonSpeech & Language Therapy Learning Disability Team.

Acknowledgments

The authors are grateful to Al ison Ruddock (Principal Officer for

Under Fives) and her colleagues, the Heads and Staff of the Under

Fives Centres and Further Education College and the Learning

Disability Service staff. Thanks also to our colleagues in Camden &

Islington, especially Sarah Hulme, Rob Spence, ClaireTopping, and

those at UCL, Myra Kersner, Rachel Rees and Maggie Vance. We

should also like to thank the families and clients concerned and the

students themselves, now qualified speech and language therapists.

Note

UCL's Department of Human Communication Science

would be interested to hear from any Speech and

Language Therapy Service Managers who would like to

develop similar projects with groups of students. Please

contact Ann Parker, Department of Human

Communication Science, Chandler House, 2 Wakefield

Street, London WClN IPG.

SPEECf-1 & LANGUAGE THERAPY IN PRACI'lCE WINTER 1997 17



COVER STORY

Memory involves all the

senses, but auditory

memory deficits have a

particular impact on

language development

given the transient,

sequential nature of the

spoken word.Here, Maggie Johnson

describes the approach

adopted at Gap House

School for addressing

auditory sequential

memory deficits in

children with a

developmental speech

and languagedisorder.

Lost•in a

movingstream -

audrtor.sequen lal

delerts

Memory is fundamental to the process of language acqui

sition and involves:

• immediate recall (shon term memory)

• recall of serially presented information (sequential

memory span)

• retention of information while processing and acting on it (work

ing memory)

• storage of information for future use (long-term memory)

Talking to parents

It is often difficult for parents to appreciate the difference betweenlistening memory, which is sequential, and visual or experiential

memory. Assessment findings may seem contradictory; "But he

remembered exactly where we used to collect conkers when we

went back five years later - he's got a better memory than me! ".

It is imponant to explain these differences early on in simple terms,

for in complex language disorders residual auditory memory

deficits are likely to persist into adult life. The Generation Game

conveyor-belt analogy is a useful one which captures the now-you

see-it-now-you-don't aspect of sequential memory - images which

seemed so clear a moment ago are quickly lost in the moving

stream of casseroles and cuddly toys ........ How much harder it

would be if you had to recaIJ those prizes in the same order as the)!

had appeared - yet in spoken language with its phonological,

morphological and syntactic sequences, that is exactly what is

required.It is also necessary to explain the difference between rote memory

which is generally associated with a good memory span but

requires no comprehension, and verbal memory of which compre

hension is a vital component. Most people can recall no more than

18 SPEECH & LANGUAGE Ti l ERAPY IN PRACTICE WINTER 1997



s ix

or seve n

words in

II. Long-term Memory

or many presentations.

(a)

Can you say that

again a bit at

a time please?

COVERSTO R

weakness (Fig.I) .

(ii) individual learning

(i ) direct work on extend

ing memory spa n / improv-

ing retention

(ii) classroom support

(iii) co mpensatory suategies.

At Gap House we tend not

to work directly on extend

ing auditory memory span

(i.e. gradually increasing

from two to three to four

items and so on) beyond

seven to eight years of age.

This is when basic auditory

memory span (as measured

by digit repetition) tends to

plateau, but verbal memory

(as measured by sentence

repetition) continues to

increase as the child's com

prehension and syntactic

ability improves. Instead,we concentrate on using

semantic organisation, visual

imagery and cueing strate

gies to improve retention of

verbal information, and

bu ld up co mpensatory

s:tTlIlegies to prepare chil-

dreJl for when they leave

the school.

l1 troughout their time at

Gap [ l ouse, children are

helped to recognise and

ac ept their problems. It

can make n enonnous dif-

ference to know they are

not gelling it wrong, they

simply ca nnot remember.

The focus is then on find-

ing a wa y round the diffi-

culty rather than feelings of

failure. All wo rk is done in

groups so that the children

can learn from and support

each uther. As a general

rule they are discouraged

sequence i f pre

sented randomly, bu t

they will manage 20

words perfectly, if pre

se nted in meaningful

sentence-form. Children

with comp rehension dis

orders do not have this

advantage and ca n there

fore hold very few ideasor key-words at anyo ne

time. They may have a

well developed rote-

memory for vocabulary

and sentence patterns

however, leading to com

paratively flu ent expres

sivelanguage .

This article will describe

the approach adopted by

therapists at Gap House

in addressing auditory

memory limitations.

The children are aged

between 5 and 11 years

and present with a range

of speciftc and comp lex

spee ch and language di s

orders. They fall within

the broadly average

range of ability overall.

Experience shows these

children are unlikely to

find a 'cure' for their

poor auditory sequential

memory. Our aim there

fore is to extend memory

span as far as possible

and then hei r develop

compensatory tech

niques which can be carried into adult life.

Assessment

Assessm en t will include

both formal and infor-

ni'al measures, and

involves identif ying:

(i ) areas of strength and

Figure 1: Assessment I Observation Checklist

Short-term auditory sequential memory - immediate recall for

spoken word.

(a) Digit Span, eg.3-5-1

(b) Word Lists . ego cup-horse-bike

(c)Sentence Repetition, egoThe dog barked at the cat.

- information is committed to memory after a few

Rote-sequences

• nursery rhymes, familiar slory

• days of week

• seasons

• months of year.

(b) Comprehension of rote-sequence

• answers questions about rhyme/story

• knows what day it is I what day comes after Thursday I

when goes swimming, etc.• knows which season their birthday I Christmas is, elc.

• knows what month it is I whose birthday comes first , etc.

III. Working Memory - continuation of short-term memory traces

while information is processed and acted on.

(a) Digits

• time-lapse, ego write down sequence of digits after 30 seconds

• mental arithmetic, ego write down digit plus 2 (i.e. I say 4, you

write down 6) .

(b) Words

• time lapse, ego Pass on 'shopping list' to person in next room

• time lapse plus distractors, ego Hunt through box for these 3 items ...

• syntactic processing, ego sentence formulation I narrative using

two to three stimulus words

• semantic processing, eg - Odd-Man-Out: which word doesn't belong?

(word relationships) - Similarities and Differences: how are

'orange' and 'apple' the same, and

how are they different?

(c) Sentences

• time lapse, ego "At the end of the session can you tell

Daniel it's his turn please?"

• verbal absurdities, ego say why sentence doesn't

make sense : " I kept my hands in my pocket and blew my nose."

• deductions, ego What Am I? (child uses three

clues to deduce answer)

• inference, i.e. Uses own knowledge to supply

missing information, ego "There was a loud

bang and glass in the road. What had

happened?"

strategies (Fig.2). hates the story-tapes we got for the ca r - from guessing unless the adult asks them

This seco nd aspect is parti cularly signifi- there are no pictures to follow ". to guess (they'll need to do th i s during for

cant for its implications in planning inter mal c1SS oss ment , for example). They learn

vention, and helps tu ex plain apparent dis Intervention it is mo re effective to say "I forgot what youcrepa ncies in performance. One parent said", ask for repeti ti on or seek confirma

com mented after di scussi ng her child's Intervention can be thought of in three tion ("Did you say .. . 7"). Conversational

;}SSE'SSmen t flDdings "S o that's why she main strands: repair of this type plays a large part in

SPEEC [ [ & lANCUAC E THERAPY [N PRACl'ICE W[NTER [99 7 19



COVER STORY

Sorry, I can't

remember

all that.

oping com-

pensatory strategies an d

this is documented in more

detail in "Functional Language

in th e Classroom" (FLIC) under

the chapter on Active Listening (Johnson,

1996),

Figures 3 and 4 outline the main tech-

niques used at Gap House,

especially the

Continued

needs to

way process

teachers

to check

standing

modify

delivery if neces

sary, an d

dren pr epa red

to let teache rs

know th ey are

having diffi-

culty,

children will

need confi-What next?dence to do

this howevOn leaving Gap Ho use, the children's par-

er, an d thisents an d receiving schools are providedinvo lv e swith an advice shee t on compensatorymo re th anstrategies (availabl e from AFASIC, Glossarya rm i n gSheet 26 ) . It is im perative tha t any resid-th e mual auditory memory limitations are recog-

~ - - - - - - - - - - - - - - - - - - - - - - - - - - - - ~ ~ - - - -Figure 3 : Intervention Strategies

Key Stage 1

STRATEGY

nised by all involved,

child ,

support

be a two-

with

preparedun de r-

an d

their

chil-

Figure 2 - Learning S

QUESTION trategies

Has Ch' lIdgo t ;sPo ken in ' ,mmedlateIs Child' ormation? recall far PROCESS

s memo ' A IIMPLmarginally i ry for lists of Udllory Me ICATION

tg, CUP-blue"troved by add70rds only C mary Span

,s Im medi Ig Vs. big_ b ng meanin? omprehe 'recall impro Iue-cup g , affeCting v e n ~ o n prOblems

What t IS presente If r al memoe f t e C t i / e ~ e of ViSUal su d VISually? ViSUal me ryC ' PPOrt i a man"

an child s mOst Pproach ' T , multi-sensa

Are lest malery Out a spoken ' Slfjning, sym ' ry

,Whl'e inslrUClnals available ,instrUC tion? ,v:rttten W0n:1 ChaOIS

, Picturess P IOns ' lOr s ' verb I ' rts '

, 9rtorrnanc , given? canning M a Compre" , COIourCOc/iChild has e e (,) better .. ay be USin 'ension ng

Instructlon/es Shut wh ile WO rse if (Chunk i n f o r m ~ t ~ / S u a l cUe to

en/ng 10 I eXlemaJ IOnso /m c!Jstraclors

Th e after tl/ne_l Out sPoke ma/en I ViS ualCan Child

carry

(ii) proved ab'l, remoVed,of was refiant on Iy to mentallse

task and s perform POOrl WOrking I'll

Does Child apSe? n InstrUction f o r m l i O ~ s to i n t e ~ n nalWayS ha lJddenly 'Click , toBI start ofthan Va to be d a task

emory

WOrking I'llCan expla in ed? emonslrated S

child h I rathe,emory

Order to dad verbalinformat ef/ve fUrther ormation Ino Ian Cre meaniOes Child a atlvely? ng I USe SemantiC I S

mformatlon . a beNer On ab prOCeSSing y,n/aCtic I Phonol '

(eg, can do preSented v aVe tasks If P Us WOrkin 0g,caJ

but not If h dd-Man-ou ISUally?ears WOrds) t IVlth Pictures So can C Working me

E/I/n ' g memoryinates

Of) oncentrat maryproceSSing e

EXAMPLES / COMMENTS

Basic listening / attention skills

Left to right (L -> R) sequencing

Basic auditory sequential memory span expansion using visual

memory reinforcement, increasing from1-4 items at child 's pace

Retention of sentence patterns using colour-coding as prompt

Rote-sequences / lines in play using motor-cue s (finger-spelling / Cued

Articulation / signing), visual support (pictures / symbols / words) or 'chaining '

Teach awareness that messages can 't always be understood.

Following spoken instructions - adult uses various suppor t strategies which children

learn to identify.

(i) non-fade prompts (pictures/symbols)

(ii) fade prompt (signing)

(iii) chunking' - use pausing to separate information into meaningful units for child

to absorb / visualise / act on before hearing next chunk

FOllowing spoken instructions - child employs various

strategies which they learn to identify.

(i) draws own pictures (need to identify key-words)

(ii) 'chunking' - pick ou t 3 words / ideas they have to remember

(iii) rehearsal (repeats key-words only)

(iv) rehearsal (sign and speech)

(v) rehearsal - is order important? Do they need to remember

actual sequence of words or key-words in an y order?

Clarification Strategies , ego ask for repetition / ask for Signing / say ' I can 't remember'

Gather children in a circle before presenting Class Instructions to whole group:

(i) children leave circle with non-fade prompt

(ii) children tell adult what they have to do before leaving

the circle. Adult repeats as necessary.

Circle Time:

(i) Newstime - all children primed to remembe r another child's news; later to

remember evervone's news(ii) Give all children a simple command, then see if they can

remember everyone else's, not their own!

Discrimination, location, selective listening,

"Good listening" from FLiC (see resources).

Provides visual framework for retaining

sequences of sounds / words.

Visual cues (to be gradually phased out):

pictures , symbols, signing.

Language Through Reading Colour Coding Scheme

(see resources)

Chaining: pictures in L -> R sequence , Cover first,say from memory and then 'read ' rest; cover firsttwo pictures, say from memory and then 'read' rest, etc .

ego Go to the bottom of page / and draw a circle

around / the jar with the most sweets.

eg oL - > R symbols on Flashcard

Key questions [When / Wh o / Where ?] to

structure narrative and aid recall. FLiC "organisation"

20 SPEECH & LANGUAGE TH ERAPY IN PRAGnCE WINTER 1997



Could you write

that down

for me please?

COVER STORY

Figure 4: Intervention Strategies

Key Stage 2

Clarification Strategies - gradually become more sophisticated

ego 'Can you say the last bit again please?'

Rehearsal

(i) introduce delay before children carry'out instruction (eg. wait for buzzer/run round playground/draw a house, first)(ii) give information which has to be retained until next day / next session / next week Combine with next two techniques

Visualisation techniques (Buzan, 1986)

(i) retaining list of items in correct order using multi-sensory ego if the first two items are 'red' and 'orange' start

imagery and thematic linking. Useful for lists such as planets in solar system. story off by imagining a ripe squashy tomato

crashing through the window and splatting you inthe face. You wash it off with ice-cold orange juice ..

(ii) retaining items from a shopping- list I key-words from astory / series of commands in correct order uS ing ' one's-a-bun" technique

Mnemonics - let children make their own up !

Chunking - children make up own rules for learning phone numbers 312653 = 3 - my age (12) - my door number (65) -3 again

Note-taking - children practise noting main pOints using symbols I Enquiry and Elimination games

drawings or written word to aid deductive reasoning Short StoriesVerbal Absurdities

Identikit descriptions.

Class Instruction - provide reminders and opportunity for using ego each child has personal timetable to fill inclarification strategies with week's events. Children have to let teacher

know if they get lost.

Preparation for leaving

(a) Personal Plan for most useful learning techniques and AFASIC Glossary Sheet 26.clarification strategies

(b) Advice sheet for parents / receiving school

Please say that

slowly while I

write it down.

strategies

adults in

their new school

Why do parents of'••lIllt can be difficult to separate out different aspects ofchildren with a language memory - auditory sequential, visual, experiential.

disorder often feel theI. . . . ~ r o t e , verbal - and realise which a child is using.

will need to give permission for the strate

gies to be used as appropriate.

Maggie Johnson is employed by Canterbury

and Thanet Community Healthcare Trust and

leads the Thanet Paediatric Speech and

Language Therapy Teqm. She is senior therapist

Questions

child has a good memory?

When should direct

intervention stop?

How can children behelped to understandtheir difficulty?

at Gap House, an L.E.A. primary school for

children with specific speech and language dis-

orders.

Acknowledgement

Grateful thanks to the Speech an d

Language Therapy Team at Gap House:

Caroline Emby, Julie Gore, Ruth Watsonan d Tracey Hull .

References

Buzan,T. (1986) Use Your Memory. BBC

Books, London.

Resources

AFASIC, 347 Central Markets, Smithfield,

London EC1A 9NH (0171-236-3632)

Johnson , M.(1996) Functional Language

in th e Classroom. Available from

Manchester Metropolitan University

(0161-247-6394) f7.25 inc. p & p.

As auditory memory span is unlikely to expand after achild is eight years old, any direct work should besupported by the group teaching of compensatory

nniques and advice to teachers.

e children have to recognise and accept they arenot

• ng, they simply cannot remember, then be confidentand prepared to seek specific help as required.

Language Through Reading, ICAN Book

sales ( 0 1 7 1 - 3 7 ~ - 4 4 2 2 ) . Passey, J.(1993) Cued Aniculation, Stass

Publications.

Canterbury & Thanet Verbal Reasoning

Skills Assessment Pack. Available from SLT

Dept, Kent & Canterbury Hospital, tel.

01227766877, f1 2 inc. p&p.

SPE EC If & lANGUAGE TlIERAPY IN PRACTICE WI NT ER 19 97 21



REVIEWS

NEUROANATOMY

Excellent illustrations, littleinformation

Brain Dissection and SurfaceAnatomy for Communication

Sciences

Douglas B. Webster

Singular

ISBN I 56593 855 0 {I 950

Thi s manual is designed to show the

3-D organisation of the brain with

particular emphasis on communica

tion disorders. The manual is divided

into two main sections.

The first, Surface Anatomy of the

Brain, gives an overview of the ma in

structures of the brain with accom

panying illustrations in the form of

labe lled black and white photographs.It describes the position of structu res

of the brain in relation to other struc

tures and occasionally mentions the

functions of these structures.

The second section, Dissection of

the Brain, describes how to go about

dissecting the brain to revea l it s

internal structure and organisation.

This section again contains many

photographs to illustrate structures

described in the text and show the

physical relationship of adjacent

structures. This part of the manual is

geared to hands-on dissection and

clearly describes the different partsand textures of the brain and how

best to remove 01- dissect t hem to

achieve the best resu lt.

The manual does provide excellent

illustrations of cerebrum, dien

cephalon, brainstem and cerebellum

but contains little or no information

about the function of these regions

of the brain or the structures con

tained within them. It makes only

fieeting· reference to the structures

involved in communication and

speech and spends as much time

discussing those involved with vis ionand sme ll.The manual may be a use

ful library resource for speech and

language therapy students studying

neuroanatomy but has little to offer

the practising therapist.

There are two vid eotapes (not avail

ab le for review) which go along with

this manual and are designed to show

the dissection of a human brain, with

voice-over explanations, demonstra

tions of techniques and structures and

close-up views. Th ese may again be of

most use to the student speech and

language therapist studying neu

roanatomy to show the brain and helpin the identification of rts structures,

Fiona Dennis is a speech & language

therapist at Dundee Royal Infirmary,

AAC

A must for every department

Handbook of Augmentative and

Alternative Communication

Sharon L. Glennon and Denise C. DeCoste

Singular

ISBNI-56593-684-1 {HOO

This new book written by Glennan and

DeCoste with contributions from other

authors provides an up to date extensive

review of the field of Augmentative and

A lternative Communication, It covers

most topics in depth starting from the his

to ry of the field, service del ivery models,

assessment techniques and use of MC

with a large variety of consumer groups,

Each chapter offers the reader a wealth

of information and th is reviewer foundquite a lo t of food for thought in each

and every chapter, For example, the idea

of expand ing the team concept from a

multidisciplinary team to a tru ly collabo

rative team w ill help in seeking to

improve our service to our consumers.

Glennan and DeCoste coin some new

phrases such as "arena" assessments but

the se are explained well. The second half

of the book is divided into consumer

groups and accompanied by case stories.

These cases, although at times long, are

well wr itten and convey the re ality of

implementing an MC system into a con

sumer's life , Account is taken throughoutof the views of many different profess ion

als and fami ly members and the concept

of "fami ly centred" services is introduced,

A few chapters and most of the appen

dix is geared for the American market

and, although interesting to note different

types of American legis lation and its

impact on the delivery ofMC systems , it

really is not very valuable to the UK pro

fessional. However,there is a useful list of

World Wide Web sites on disability an d

a few e-mail addresses of suppliers,

These will prove useful to those who

have access to the Internet.

This book is inva luab le for any profes

sional involved with Me. It is not an

introductory text and readers will need

to have som e knowledge of the fi eld

either through courses or other read ings

to get the full value from it It is a must

for every department, cen t re, or institu

tio n which has a consumer base using

Augmentative and Alternative

Communication strategies, This book is

tru ly a "handbook" of the fie ld of Me.

Thi s reviewer welcomes it who lehearted ly,

Debo rah Jans is Coordinator and Specialist

Speech and Language Therapist at

KEYCOMM-Lothian Com munication

Technology Service, 29 Bryson Rood,

Edinburgh EH I I I DY

AAC

Practical examples undermined

Literacy through Symbols: Improving Access for

Children and Adults

Detheridge, T and Detheridge, M. David Fulton Publishers ISBN 1-85346-483-X {13.99

This A4 paperback is packed with practical exam

ples collected by people who are rea l enthusiastsfor symbols. The book is well laid out and sign

posted with introductions and summaries t o each

chapter. and a w de margin contain ing headings.

There are use fu l addresses and lists of materials

and resource s at the back

I would be glad to have this book because it does

contain some interesting and useful information

but I do have some reservations about it The ti t le

makes no claim to other than literacy. yet a great

dea l of the text is tackling issues which are much

more to do with communication in a w ider sense .

Too many of the issues involved remain un spoken.

For a newcomer to symbols, it needs to be sup

ported by a framewo rk which takes into accountindividuals' differing levels of language abi lity. There

is a worrying lack of explicit attent ion to th is fac

tor: although the authors discuss whether or not

to use word-by-word sym bolisat ion or just to

symbolise key words, the issues they cover seem

to me to be politica l rather than to do with indi

vidual needs, For me, one of the most powerful

ways of helping som eone take a more active part

in communication is for communicative partners

to adapt to the person's level of understanding

why sho uld this be any less Important when lan

guage is being communicated through symbol s?

Yet we are presented w ith examples of symbol

use that to me seem dogmatic in their symbo l-for

every-word approach. For example, on page 9 1 we are shown an aide-memoire for a sw imming

kit, which is clearly a list, and wou ld be wr itten thus

by anybody who was writing It for themselves, yet

in the examp e it is presen ted as a full sentence,"In

yo ur sw imming bag you need: sw im suit, towel, tal

cu m and comb," with full text and every wo rd

symbolised: not only visua l clutter but lack of

attention to the message's real-life use .

The advantage s of the authors' use of practical

examp les was somewhat undermined for me by

the confusing range not only of different sym bol

systems but of the different sizes, clarity and qua ity

of the images. There are some quite ghastly

Blissymbols on page 10 and I hated the room labels

on page 40 which had all sorts of unnecessary com

plications in them. I think some ed itorial comment

from the authors here would have been welcome.

I reckon the book will be most seful for those

wo rki ng with ch ildren and youn people in educa

tion: those working with adults may find it less use

ful, as it does not really tackle the issues involved

in introduci ng symbols to he enviro nments of

adults whose educational history and commun ica

tive opportunit ies m y be very diverse.

Jennifer Re id is a sp ech on d language thempist with

Fife He al thcore currently lorklng with children with

speCiol nee ds in mains ream and special schoo ls.

Reviewsin

this issue were provided by thera-pists attending an RCSLT Scotland study day.

If you are interested in doing a review, contact

the Editor, 01569740348.

22 SPEEC H & LANGUAGE THERAPY IN PRACTICE WINTER 1997



REVlEWS

SENSORY MOTOR

DEVElOPMENTWell-presented andpractical

Sensory Motor Activities

for Early Development

Chia Swee Hong. Helen Gabnel

and Cathy St JohnWms/owISSN 0 86388 15 3 X £29.50

This is a pradical and ea sy to

read non-academic spu-al

bound book wrrrten by

Occupationa l Therap ists. tt

primarily targets the newly

qu ali fied therap ist and Cdl-er

For the purpose of review,

the book is divided into

three distinct sections.

Section I

Four chapters covering senso

ry and body awareness, basic

movement, hand skills and spa

t ial and ear ly perceptual skills.Each of these four ch apters

has a sma ll but concise intm-

duction defining normal

development and the difficul

ties which childl-en can face if

thiS area of development IS

delayed. The activities sug

ges ted for treatment are

pract ical and stimulat ing with

the materials required easily

accessible by al .

Section 2

This co ntain s twelve examples

of small group sessionsThe aim,

materials and development of

the sesSions are clearly defined

and pmvide an excellent pho

tocopiabie resource for a ther

apist imp lementing gmup work

lhemse lves or for other pmfes

sionals / carers to run.

Sect ion 3

This provides an alphabetical

subject resource list, eg ani

ma ls, clothing, shapes. Under

each of these subjects are

the foUl ' headings (as men

tioned in Sed:Jon I ) and

methods by whiCh specificaims can be achieved.

This book is wel l presented

both in layout and graphiCS

produci ng an Invaluable

resource for any therapist

work ing wi th children who

h(lllc spe ci fic diffic It ies in t he

areas Indicated above.Aileen Il/leForlane IS SeniorOccupouonol Th erapist - ChildHealth, Robert Henr-ysonSchool, Dunrerm lme. Fire

OUTCOME MEASURES

Simple, clear, demystifying

Therapy Outcome Measures - Speech and Language

TherapyPam Enderby, Alex John, Manno Sloane and Brion Petherhom

SingularISSN I 56593-807-0 £3350

Thel"apy Outcome Measures, (TOM) consists of two manuals:

the User Manual and theTe chnical Manual, plus laminated cards

of outcome measures fo r ten cl ient groups.

n) e ai l ) of the apprO< lch is to "assis l with the practical Imple

men anon of gathering outcome data on patients receiving

treatment' fOCUSing on the use of one tool to assess the

pa t ient and hiS/her neecs In a holistic way.

Even t h e r a fro fear die term 'outcome measure' cannot

fall t o app","clate the 5.1fT; :l"ar way the man uals are written

an d to ili lmediat ely see ho i 1hIS apprcach is directly applicab le

to a speech clnd language tJ- eraplst's .....-ark. It IS an important

step for the speech and language theraoy profession to have a

way of evaluating what therapIsts see the " Jcb €"tallfng allow

ing the clinician to evaluate the "quail 'o f care ~ n to dlents,

The Technical manual covel's various measun:s (L Tently avail

able to evaluate health status and goes on 0 e plain that traditionally therapists have measured change In speec ar'J lan

guage deficits on ly, although realising that thel"apy should have

an impact on many other areas of a client's life, As a result

TOM uses the parameters of impairment. disability, handicap.

(follow ingWHO International Classification) with the add lDon

of the pal ameter distress/wellbeing to refiect the multitude of

areas therapists are Involved with. TOM is based on the behef

that the above parameters are all of equal importance in ev al

uating therapy outcomes.

The Technical manual goes on to detai l t he development of the

outcome scales, the pilot study data collection . the reliability

and validity studies and outcome /·esults. The limitations of the

study are cleal' ly stated, (eg. sho rt time sca le for data collec

tion) as are the strength s.

One hundred and th il"ty two thera pists from eight sit es wereinvolved in developing measures I'elating to im pairment dis

ab il ity etc, after three hours of t l'aining. Data from 1, 17 1

patients from t he eight sites was an alysed and showed the

TOM approach as reliable (when bas ic t rain ing and practice is

given), val id and sensitive to cha nge .

Th e ia l-ge number of thel-a pists involved I-esulted in a common

language for the core rating scale; however the inclusion of a pri

mary core scale allows therapists in an area to devise specific

scales if necessary.

The core rating scales for each communication disordel- allows

scoring of 0.5 points, taking the basic 6-point scale to a possi

ble I I points, allOW ing a senS it ive I"ating scale.

The user manu al gives conCl"et e detai ls on the procedure for

usingTOM such as which pa t ients to use TOM with and prac

tice needed before.begin ning data collection.

As Enderby states, t rying to capture and refiect clin ical Judgement

is difficult however; this approach a lows for outcome measure

ment "i a practical , reliable. achievabl e and communicable way".

Every speech and language thera pist should have access to this

invaluable tool which demystifles outcome measures, making

what can often be a difficu lt procedure to approach and carry

out much easier It gives a sta rt ing point for each therapist or

depa rtment (if they haven't done so already) accu rately to

I"ecord Intervention.

Andrea Jones IS a Speech & Language Them 151 working WIth Adultswith Learning Dsabilities In Lanarksh ire Health Care NHSTrust

PHONOLOGY

Immense value

Children's Phonology

Sourcebook

Lesley Fynn and Gwen LClnCClsterWinslowISBN 086388 156 4 {J950

A photocopiable sourcebook of this

type is always a welcome addition to

any paediatric speech and language

therapy department where therapy

programmes and materials are con

stantly in demand. To be able to use

them as part of a parent programme

pack which enables parents to help

their own children who have phono

logical diffiCUlties, is of immense value.

The information pages within the

boo k en capsulate the advice given

to pal"ents on a one to one basis in

most speech and language therapy

clinics and as such co uld be used to

prOVide speech and language thelapyservice delivel"y In d iffe rent w ays, for

example as home progra mmes, in

ser ice t lalning to Nursery and

PrImary Sch ool teachers and, as in

our paedlatic department part of a

parent group programme fo r the

parents of ch ildren w fth phonological

dll'ficu "'tho are on th e waitmglist '0 1 therapy.

To support the ideas and thera py

matenals In their b...ook the authors

have given a I ide ovel iew of

resea l'ch evidence dealing Wth

phonological acqUisition at all levels of

inp ut and :;uggest a meaningful minima l CQ.1trast therapy and an audito ry

input app roach to Intervention.

They also underline, in chaptel' 7.

the impOl'tan ce of finding ways of

auditing the effectiveness of our

intervention st rat egJes and provide

a summary of studies comparing

the efficacy of different approaches

to phonological therapy.

The theoretical co mponents of this

book are useful but I have to say

that some of the technical ter-m in oJ

ogy use d (post vocalic obstruent;

canonica l shape) was difficultto

follow even for the IllOst recently

trained speech and language thera

pists in my department

Neverthe less , my view of thiS

sourcebook is a posrtJve one and Iwould recommend It as a use ful andinformat ive herapy resource.

Ma rgaret Sibbald IS 011e[SpecialiseSpeech & Language Therapis t(Paedlotfl(S) In the Monklands ICumbernauld DiviSion o( Lonarkshire

Heolthcare NH STrus t.

Note {rom Singulor Publishing re - Articula tion and Phono loglcol Disorders,by Ken Bleile, reViewed In the Aurvmn 97 Issue:

"This book is a second edi tion and does not replace , as the reV ieWE r Implies, Ken Bleile's other work. Manual ofArtlcuiatJOn andPhonologica l Disorde rs. Ra ther, this second edition has been rewi/teen to (ol/ow the JI;1onua('s format to enable users to work With bothtitles .As the reviewer nghtJy surmises, thi S book o( exeroses IS de signed (01 students, the tVlonual IS de51gned as a cllmcal reference(although it is widely adopted os a student textbook)."

SPEECH & L \N CLJ i\c r TllrcRAPY IN PR;\CTICE WI, I U( 1997 23



sounddifficulties

Speech and language therapists, given the case history

information opposite, set out their management of Mark.

Morag Ogilvie is a speech and language therapist

working with children in community clinics in Edinburgh.

At the time of writing, Rachel Osenton worked for

Thamesl ink Healthcare Services NHS Trust, but has since

become Rachel Stanbury and is a senior speech and

language therapist with Northern Devon

Healthcare NHS Trust.

Pam Williams, Juliette Corrin, Sarah J. Colebourne, Shula

Burrows andSarah Friel are the speech and language

therapy team at the Nuff ield Hear ing and Speech Centre,

Royal National Throat Nose 8 Ear Hospital, london. This

specialist centre offers assessment and treatment to

children with speech, language and hearing difficulties.

24 SPEECH ... LA. UAGE TI l ERAPY IN f'RACllCE WI ITER J997

MarkMark is eight when hemoves to your area. Thespeech anCilanguagethera)?y transfer recordsshow He was late to talkbut language de'!elol?mentwas age a p p r o p n a t ~ byfour years andl1eanng

difficulties have been ruledout He was in distress atbirth with the cord roundhis .1eck but generaldevelopmenThas beenunremarkable. Fromconversation and schoolprogress it is clear he is anIntelligent child. His olderbrother attended therapyfor a few phonolowcal .difficulties all of wf1ichwere sorted out by the timehe was six.Mark uses f for th andI for r. Therapy for initialstopping was successful but

he has persisting velarfronting (all worll positions).He is unable to producevelars even in isolation. Hismother reports hesometimes used to confusetlk/dlg when spellin butno longer does so. ark isco-operative and

motIVated to improve hisspeech but is becomingdespondent.



HOW I...

. . •onTom has a tongue which can bend to showfalveolar or velar placement. \Nhen Tom says aMorag Ogilvie chooses the Metaphon

Sick Children's back sound or a front sound for Mark to idenapproach to tackle Mark's diffirufties tify, Mark can see exactly what Tom's tongue isNHS Trustand ouUinesatherapy dream scenario - doing, while I express the action verbally

and the other one.

Welcome to Edinburgh, home of Metaphon , where clinics echo to

the sound of small children charging from the back to the front of

the room while blowing long/shon bla IS o n \\Oh i tJ (loudly or qui

etly), Metaphon therapy is my usual first cho ice or pho nologi cal

problems, but would I use a Metaphon approach with il. l, rk - do es

a child who can't say /k / at age eight have a phonologi cal pro lem'!

AssessmentMark and his Mum are offered a 45 minute appointment at his

local clinic. After some general chat and a history, I move on to

more formal assessment. In spite of some irritating features

we've coloured that pointy sun in yellow bu t they all still call it a

'star' - I find the Metaphon Screening Assessment gives a good

quick impression of a child 's phonological system, I never use thesummary sheets, bu t do sometimes use the process specific probes,

I also do a consonant imitation test and an oral exam , Mark has

good tongue movement an d no obvious abnormalities,

I'm interested in Mum 's report that Mark used to spell the way he

spoke, but can now spell properly. Does this mean his phonolog

ical representations are intact, or has he learned to compensate?

I'm interested, but not enough to investigate further at this point.

I succumb to the temptation to get on and do something,

Targeting therapyMark has two inappropriate phonological processes operating, We

should be able to sort ou t /r / -> /1/ without much trouble, which

would give Mark a feeling of achievement. However, he is more

conscious of the velar fronting, After all, he can't say his own

name, To help Mark have some control over his therapy, 1would

"Tom's tapping the top of his mouth with the

back of his tongue, He's making a back sound,"

When Mark has to take turns producing front or back phonemes,

he is still unable to produce /k/ or /g/, but I accept any 'back sound'

from his coughing/gagging repertoire,

We begin word-level activities using the pair tar/car (so the /k / will

be facilitated by an open vowel) and Mark sees the communicative

impact of a change in word initial phonemes, Week three there is

no clinic because the therapist has a meeting, When Mark returns

in week four, Eureka! - he can produce velars, Over the two weeks

so me thing has clicked and Mark is now able to raise the back of his

tongu e to command (honestly, this does happen), Now alongside

the /I..t tapho ll programme (example of game in figure 1), we play

velar-onl -games to encourage less effortful articulation, At the end

of eight weeks Mark is using velars in clinic tasks and when reading

aloud, He is put on review to be seen again in three months in theexpeoation that veJars will have transferred to his spontaneous speech,

The other scenarioIn spite of ou r best efforts , !lark shows no signs of velars, He needs

more help so he doesn't begin to feel a failure, Time for the

Tongue Gym, I explain to "lark that just as I can ' t do press-ups

(demonstration an d collapse) his lOngue muscles need some help

to make back sounds, He gets a tongue work-out sheet an d a chart

to keep a record of his practice (see Certificate of Achievement,

Figure 1), Metaphon aOivities continue, with me trying to shape

Mark's back sounds closer an d closer to velar placement. By the en d

of eight weeks Mark is producing an effortfu.l / k/ which he can use

in clinic tasks with a big gap (Mar - K), Mark is given a two month

break, and comes back showing little change, At this stage I would

consider targeting theask him which process he would prefer to tackle first.

Mark opts for the fronting, and he's offered a block of eight week

ly therapy sessions, At the en d we will take stock and decide what

should happen next: Because Mark is already self-conscious about

his speech, he gets on e of ou r precious after-school appointment

times so he is not embarrassed by being withdrawn from class, As

Mark has moved to a new school, I would want to liaise with his class

teacher so that s/he understood Mark's speech sound system and that

Mark could no t be expeoed to decode reading words accurately for

sound at this stage,

To Metaphon or not?In Mark's case there are three things

that would persuade me to go the

Metaphonway,1. Fronting is no t the only process

operating, This suggests a generally

delayed phonological system of which

fronting may be only a particularly firm

ly frozen part,

2, Mark seems a bright kid wh o should be

able to benefit from the opportunities

Metaphon therapy gives to reflect on his speech sound system,

3, Mark knows he "can't say" certain sounds, With Metaphon,

Mark will be able to experience success in his first few sessions of

therapy which wiII hopefully give him the confidence to persist if

things get a bit tricky,

The dream scenarioMark enjoys the Metaphon aCUvJlles and produces a series of

/r/->/I/ process so Mark

does not get too dis

couraged, When this

had resolved, we would

return to the velaI's for

more slow progress,

If Mark were to con-

Certificate of A C h i e v ~w. heRb) pro_,

, Mark's Tongue"'Jib Ibi, CcniIic.te '

IClIleY.melll i : ~ t : t : : : h l of ilS

Back Sounds

••""'"

Figure 2

coughing and gagging noises for 'back sounds', Because I know communication,

Mark is going 10 have problems making velars, at Phoneme Level,

I use Tom the cardboard crocodile to feed Mark very precise artic Reference

ulatory information about how the speech sounds are produced, Howard, J. & Dean, E, (1994) Treating Phonological Disorders in

SPEECH & Li\NGUi\GETHERAPY IN PRACTICE WINTER \997 25



HOWl . .

NORTHERN DEVON

healthcare_?_:w M iM !•••

on

Rachel Stanbury has tipsfor eliciting velars and suggestsan

intensive school holidaycourse of therapy.

Children. Whurr. London.

Following Mark's referraL he would

first be offered an init.ial assessment

appointment. The information

gained from this would be vital in

determining the management plan

an d the nature of any intervention

offered. The session would consist

basically of a case history taking

and an in-depth assessment of his

speech sound difficulties.

Given that the basic information

about Mark's early history is alreadyavailable, I would want some fur-

ther details regarding his therapy

thus far such as "Which approaches

have already been employed, in

what way and with how much suc

cess?" This information might come

from either Mark's parents, his pre

vious speech and language therapist or even from Mark himself.

While taking the case history, I would take note of any regional

accent used by Mark's parents and bear this in mind along with

the accent prevalent in th e area the family have recently moved

from. After alL it would nO l be appropriate to target the fjth

contrast if 'th' is no t used wi th in that accent .

During the se-h i tory taking, Mark' paren ts' level of concern

may become apparent.1

his is also going to be a considerat io n

when plan n ing the form of in tervention a it may affec t both

thei r auendan ce at the clinic and the amou nt o f support given

at home.

My assessment of Mark's speech would fOGI on ~ e v e r a l 'lsped.s

of speech production . Firstly, I m igh t ad m in ister the SfAP

( outh Tyne ide Asse.s!lmenl of Phonology; STASS Publkatlons)

10 give me an overview of his spont.1neous sp ech sound use,

albeit at tlle single word lewl. J would follow tbis by looking at

Mark's ph on o logical awarenes with regard to the s o u l l d ~ with

wh ich he has di fficu lty. l'his could involve several differen t tasks

such as:

• discrimillillion between the ounds leg L/r) ill iso lation

• dis rimination between the sound s in word in itia l position

• right / wrong judgements from my produ ction , eg I would say

'Iabbit' and ask Mark is I h ad pronounced the word correctly

• silent sorti ng, eg Mark would have d seledion of pictures

, ." ' " " " ~ 6 Aspecialist op'

beginning with T and 'r' and he would

sort them according to what he

believed the initial sound to be.

This would be an important part of the

assessment because, if there is a problem

at this leveL work on speech production

alone is no t going to be effective.

Finally, I would try some elicitation of

the problem sounds. For the sound jk j for example, this could

include using his finger to hold down the front of his tongue

while he attempts the sound. Alternatively, he may be able to

produce a velar fricative from which the plosive might be elicit

ed. A third strategy would be to try and develop tbe sound from

the velar nasal which most children use even if they do not use

jk.gf. This would be by asking Mark to produce an extended 'ng'

sound holding his nose part way through to build up the intra

oral air pressure and this release an oral velar plosive.

Having completed t.he case-history taking and assessment, I

would then formulate a management plan with the parents and

Mark. It is very important at this stage that all parties are happy

with the final plan as the motivation and cooperation of everyone is needed. A number of factors would now need to be con

sidered. These include:

I. Mark's age and the fact he is at school full time.

II. The availability of parents and/or others both to bring ,"lark

to the clinic and to work with him between sessions.

III. The outcome of the assessment and elicitation.

One option which I feel might be very suitable for Mark is a

block of intensive therapy. This could be arranged within the

school holidays thus avoiding the problem of missing school. It

ma y also be easier to maintain Mark's motivation over the

course of on e week rather than several. The block would consist

of on e session every d ay for a week with each session lruillng 45

mi nutes to an ho u r and with rein forcement activities to be car

ried ou t ill home.. The aims and content of the block wou ld be

determined by the outcom e of th e asses ment but I would liketo target the /k,g/ sOllnds for speerh soun d productio n if at all

possible du e 10 their high frequency. Soun d discrimination and

phoneme awareneSl> work co uld covcr a broader ran ge or co n

trasts.

Each session would ind ude bOlh work on chscrimimllion Ol nd pro

duction and would p r o g r e s s ~ · tem atic.ll ly from the single sound

level througb the word level JOlI unto SC'ntence level and generali

a tion . '[he follow-up aruvities lor each day w mid be aimed at

consolidating the skills achic\'ed during that day's session.

Finally, I would follow up the block with a report to Mark's

s hoo l and if possible a telephone call to outl ine the in pu t he

had received, his current presentation in U! mlS of speech and

any ways in \,'hich further progress could be encouraged in

school. Mark's parents would also be advised on how to co ntin

ue some work with him at ho me and a review appointment

would be planned .

nTherapists at the Nuffield use in-depth

! assessment to ensure targeted treatmentand rapid progress.";

vVe were pleased to

receive a referral for

'Mark from his GP

in his new locality. The referral was instigated by

bis current speech and language therapist who had

seen him once and, in the I ght of his transfer records, had decided

she would like an opinion from a specialist centre on Mark's CUf

26 SPEECH & LAN GUAGE TJ-JERAPY IN PRACI'JCE WINTER J997

rent presentation and future management. It was very helpful to

receive copies of speech and language therapy reports and school

progress reports.

After approximately three months on ou r waiting list, Mark was

offered a co-ordinated appointment, seeing on e of the speech and

language therapists in th e morning and the Consultant

Paediatrician in the afternoon.



HOW!. ..

AssessmentThe speech and language

vides visual feedback of

tongue-palate contact. It

therapist carried ou t a

detailed three hour diag

nostic assessment with

Mark's parents present. During the session, the therapist first took a

case history involving information from both I\ lar k and his parents.

Then a detailed assessment batterv was ad m inis tered. In the light of

Mark's ongoing speech diffi cu lties an d h i, his to r;. of lan guage an d

spelling difficulties, it was felt ap propriate at thi s stage to rc -;mess

his language functioning, h.is re ad ing and spelling level s ,md h is

phonological awareness skills in addition to h is sp eec h sk ills. -Ihe

following formal an d informal assessments wne administered:

1. Language Assessments

British Picture Vocabulary Scale (Dunn, Dunn, Whetton an d Pint ilie)

Clinical Evaluation of Language Fundamentals I1evised (Semel, W ii g,

Secord)

Renfrew Word Finding Vocabulary Scale

2. Literacy Assessments

Schonell Graded Word Reading Test

Neale Analysis of Reading Ability Scales

Vernon Graded Spelling Test

Assessment of Phoneme/Grapheme knowledge

3. Psycholinguistic Assessment of Mark's speech difficulties, inves

tigating his processing at input, internal representation and output

levels.

a) Input tasks, ego • auditory disu-imination of complex non-words

• auditory non-word rhyme detection

b) Tasks involving internal representation

• real-word rhyme detection

• lexical decision

• sound blending

• syllable identification

• rhyme string production

• alliteration string production

• spoonerisms

c) Output tasks, eg .• spontaneous speech sample

• NuffIeld Dyspraxia Programme Assessment,

which investigates:

• oro motor movements

• single sound production

• single sound sequencing

• naming an d repetition of single

words (at ev, ev ,evev, eeveand multisyllabic levels) an d

phrases an d sentences

• Repetition of non-words

FindingsEvaluation of the assessment battery revealed Mark's primary area

of difficulty now is with speech output. Al though h e may well have

experienced input difficulties in the past (which would have affect

ed the precision of his phonological representations of some

sounds), evaluation of his input processing, phonological aware

ness an d spelling skills suggested th ese difficulties ha d largely been

overcome. In terms of output, his use o f I f/ for <th> was attributed

mainly to local accent an d therefore did not wa rrant inte rvention.

However, he was unable to produce /k/, /g! an d I r! sounds even in

isolation. He also appeared to have poor kinaesthetic awareness of

his lips an d tongue, although he had 110 obvious oromoto r dys

function an d no structural or organic diftlculties.

RecommendationsIn the light of Mark's speech profile, age an d apparent resistance to

conventional therapy, it was felt that he would be suitable for thff

apy using electro palatography (EPC). EPG is a technique that pro -

involves the wearing of an

individually-made artificial

plate (similar to a remov

able orthodontic appliance), which has 62 electrodes embedded in

its surface. As the tongue touches th e electrodes they create a two

dimensional display on a computer screen. In this way, the wearer

receives immediate visual and kinaesthetic feedback of the position

of the tongue. This technique is particularly helpful for older chil

dren, as it offers an added dimension to articulatory therapy.

It was decided to offer Mark a course of ten weekly one-hour ther

apy sessions which would include the use of EPG an d other tech

n iques . A report was written detailing all the assessment results an d

recom m end ations and was sent to both his local speech an d lan

guage the rap ist an d school. His local therapist was invited to visit

lh Olre to beco me acquainted with the EPG approach. A dental

examinalion was ar ranged for Mark, which involved the taking of

den ta l impr io ns of th e upper and lower teeth. These plaster casts

were necessary for the manufacture of the EPG plate, which took

approxim a tely an e month .On ce I\ \ark's pl a te ...."ali recejwd an d fitted, a detailed speech exam

ination Llsin g Ere \ -as ca rried o u t. This re\'ealed that Mark was

using a double a rticula tion for lh e p roduction of velar sounds but

ha d a normal pattern for the prod u ction of alveolar sounds.

Although he incorporated ve.lar co ntact into his articulatory pat

tern, the release of th e plosi \'e occurred in the alveolar position. He

was registering an articulato ry co ntrast fo r /tl a nd / k/ but without

the necessary acoustic differences - he nce he had a primary pho

netic problem with phonologica l impl ia ltjons.

ATTENTION-DEFICIT / HYPERACTIVITY

DISORDER (ADfHD)

AD/HD'98 - University of CambridgeWe ar c pleased to announce ADfHD'98. a four-day residential

conferencc at the University of Cambridge. 6th - 9th April. 1998.

International key speakers inelude Prof. Russell Barkley, Dr Tom

Brown. Dr Michael Goldstein, Dr Sam Goldstein. Prof. Philip

Graham (Chair of the National Children's Bureau). Prof. Peter Hill

and Prof. Mel Levine.

Papers. symposia an d posters ar e inyited,

An Intensive Training Day for Health and Education

Professionals on ADfHD

Speaker: Je nny Lyon, Chartered Educational Psycho logi t (f I 00 plus VA T, including course pack / text book and buffet lunch)

University of Manchester - 7th November

Charing Cross Medical School, London - 5th December

Napier University, Edinburgh - 6th February 1998

John Moores University, Livcrpool- 2nd March

A list of audio/video recordings from ADfHD'97 (held a t L ni vc rs it\ of

Oxford. 7th - 9th April. 1997), is now available on requ t. utge th er

with the official conference publication (published a t £16. in d ud in "

postage, softbound - ISBN I 901906000)

Further details ar e available from Angela Ra nde ll

IPS (International P sy choI\tg) Sen;ces)

Freepost SEA 1132 (no UK po s tage r equir d)

17 High Street. Hurstpicrpoin t, W est Sus se 8 !\ 6 9STelephone 012i3 835533 Facsimile 012 3833250

SPEECH & lANCUACE TIIERAI'Y IN PR. Cl IC[ IV tNH R 199 7 27



NEWS &> EVENTS

TherapyMark's therapy concen-

trated on

1. identification an d

perception of the differ-

ences between the adult

model production of

aJveolar and velar

sounds , in isolation and

in word positions.

2. production of velar

sounds, in isolation and

then in word positions.

Mark's therapy was sup-

ported by th e use of

lhree complementaty

approach es:

(1) EPG palterns

(2) pictorial symbols

for speech sounds and

minimal pair pictures atCV, CVC and CVCV lev-

els from the Nuffteld

Dyspraxia Programme

and

(3) alphabet letters.

Once Mark was able to

produce a velar sound,

he was given 'home-

work' of picture materi-

als to support his thera-

py in between his ses-

sions.

Practical points1. For an older child, after-school or intensive summerholiday appointments can be offered to lessenembarrassment about therapy attendance.2. Work on speech production may not be enough andassessment and therapy must identify and address anyinput and internal representation problems too.3. The opinion, age and accent of the child, frequency of asound and perceived ease of remediation will all influencethe decision about which sound to work on first.4. Elicitation techniques for velar plosives include use of apuppet to demonstrate positioning, a finger to hold downthe front of the tongue and working from strengths, eg a

velar fricative or nasal, or coughing I gagging.5. Preferred assessment and therapy techniques includeideas from Metaphon, Nuffield and psycholinguistic theory.6. With an older child, the primary work will be with thechild, but parental support and an understanding class

teacher influence attendance, home practice and outcome.7. If instrumentation is available, electropalatography canbe motivating and informative.8. If progress is not good, referral to a specialist centreshould be considered if possible.

Mark made rapid progress

and was soon able to pro-

duce Ikl as a single sound

and gradually in word posi-

tions. He also soon gener-

alised his new articulation to

Igj. Mark was delighted with

his ow n success and was

motivated to go on to work

on establishing Ir/. Using

EPG , he was able to identify

his articulatory confusions

wilh III and the Irl sound was

rapidly incorporated into

simple CV and CVC words.

The remaining sessions were

spent consolidating work at

phrase and sentence level.

ReferencesConnery, Y.M. et al (1992)

Nuffteld Centre Dyspraxia

Programme. London: Rt'lTNE

Hospital.

Hardcastle, W., Jones, W.

(1974) Electropalatography -

Reading IBM System.

Stackhouse, J. an d Wells, B.

(1993) Psycholinguistic

assessment of developmental

speech disorders. European

Journal of Disorders of

Communication. 28 (4).

RESOURCE UPDATE. . .RESOURCE UPDATE.. . .RESOURCE UPDATE.. .

Voice careThe Voice Care Network, a national

group of speech and language

therapists and specialist voice

teachers , continues to press for voice

awareness training in initial teacher

training. The Network provides

workshops and advice packs (see

examples below).

Roz Comins, Network coordinator,

welcomes information from DynaMytespeech and language A small augmentativetherapists on numbers of communication device suitableteachers on their for ambulant users is now availablecaseload (new from Dynamic Abilities.referrals, current The DynaMyte, a smaller version of thetreatment, review). DynaVox 2/ 2(, is suitable for.all ages.•.voice and the Software includes a concept associatedTeacher pack, £12.00 42000 word prediction and search capability,

(payable to Voice reinforced by 2600 visual symbols. Both

Care network) can be personalised and messages can beprinted. A long life battery, protective

with a Warm-up on screen cover and a rubberised case

Audio Cassette, £5.50

• Keep in Good Voice

with shoulder strap and handle are

(payable to Roz Comins). provided. Details / demonstrations:Dynamic Abilities, tel.Details andfull publications list:

07202487878.Roz Comins, Voice Care Network, 29 Southbank Road,

Kenilworth ev8 7LA, tel. 07926852933.

28 SPEECH & LANGUAGETH ERAPY IN PRACf ICE ~ V l N 1997

Led"amb,ml"ity' t ' ,lsa lrammg

AforU1coming training pack is

aimed at helping staff workingwith people with learning dis-

abilities on parenting.First Steps to Parenthood(£55.00) includes struduredinterview sessions to help staffassess the knowledge andrequirements Of their clients at

different stages Of parenting.Details of his and othertraining resources fram:Pavilion Publishing, tel. 07273

623222, W'NWpavpub.com.

Nursery ProjectsA new bi-monthly magaZinededicated to under fives educa-

tion has been launched byScholastic.Nursery Projects includes

adion rhyme and role playideas, photocopiable adivitysheets, advice on planningthemes and information on the

latest nursery resources.

Details: Scholastic Magazines,

tel. 07926876250.

http://slidepdf.com/reader/full/W'NWpavpub.com

http://slidepdf.com/reader/full/W'NWpavpub.com



EVENTS University of East AngliaPostgraduate Courses

January

Aphasia Therapy - A State ofthe Art

Tutors: various Fee : £95

February

The Lidcombe Programme

of Early Stuttering

Intervention5 days - details on request

9-10 March

Communication in Children

with a Severe Visual

Impairment

Tutor: Ian Bell Fee : £95

Venue: University of East

Anglia , NorwichDetails: Sally Wynne, Course

Co -ordinator, ContinuingVocational Education Office,

The Registry, University of

East Anglia, FREEPOST,Norwich NR4 7BR.

SPRING '98 published23 Feb 1998

IN FlffiJRE ISSUES

•working with parents• integration

•family therapy

• Retfs Syndrome

•aphasia group therapy

•working with carers (AID)

A Singular offer with your

clinical companion ... until

31 /1/98, new subscribers toSpeech & language Therapy

in Practice are entitled to a£10 voucher towards their

next purchase from Singular

Publishing. Singular has

kindly extended this offer to

existing subscribers. VOUChers are available

following application to: Avril Nicoll,

Publisher,

Speech & language

Therapy in Practice, FREEPOST S(02255

STONEHAVEN

AB393ZL

tel/ fax 01569 740348,

e-mail [email protected].







6. Photographs

Although there are manbenefited greatly fro m .. e a ~ ~ O d commercially available h~ ~ ' ~ ~ I : ~ I ~ ~ ~ i ' ' h ~ d , ! , ~ ~ ~ ' : : : h : h : f , : : 7 , m ' ; ' ' ' ; , ~ ~ o ~ ~ ; ~ ~ ~ ; , , ~ ~ ~ ~ ~ " ~ h " l t group

' ,"od,a0'1' ,'cd; " , 'd" ,', pho,o, h". b . wo '"p'" of , , 'h phoro . " '0 ,ookgames, I.e . hello songs. een used every session in were mounted on

BlanketO . .S activity Th

ouraged to r . e child islift the eled on the blanket, and two

d n sand ge I .e to side. Thl nt y sWing from. . s encourages ' .

. 10lnt attentioncommunlca . T '

. tlon. his is par-

I ren who are d'ffj I 109 non-verbal'ld lor motlvat'

d I ICU t to enun this activity gage.We haved non-verbal co e n c o ~ r a g e s both verbal

I mmunlcat' .ready steady gol and Id lon In responseI I d own/. Children

! go an lagain, again .....

a v i : g d ~ ~ a m / gluck

Ulerapists ce fromactivities A,we have i n t r o ~ C C U P a t i o

sk'ills ong With encou u ~ e d these I

....... It gives h' raging PI" I:"7 to part ie' c Ildren th e- io... nlch som Ipate in ta e °PPO rru

tendy e children ' ctile activo -aVoid Ch ' In the gr 'tieso t h e ~ Ildren are oups coosls_

SO th s play if th encouragedems elves ey are not k tofoam ' . een to

t IS spray dray. Gluck . e Onto aconsists of IS made in a sh IItable orto Corntlo a ow r .-

a smooth b ur and cold -. . ,.se t in th Ut solid waterup will e tray, but wh paste. It w/f

Thseem t" en mo·- '"

is is oft 0 melt" . ....of ou en used i and ue,co,'nA.,.

.- ••- - r faVOUrite st r n nurseries andS:ch as plastic relievers!

re prOvide utlery andfor " d. Thes .

child W h ~ ~ / t a t i o n as w:" gIVe

I shaving (. IS reluctant t ast t 1 J l .. r oam to b ' 0 touchegm exploring

See h - : ; ; - : ~ - ......t rougihplay balls / ..

" . b • _OH<' """d " """ p',ddp,b"' I" <h. "o,p. C"'" ," " ' " ,. . . .d ' " ........ die~ w o r d s__ of chei' , , , ' " ' , . "d '" "" ,b , I" , Imm.dl," CO ,h . wk ." ' " won!, . . . """"" . . . . . -..- '" "'e dlon< ,co,p ,nd """,1" wl,h ,p,,\fi, .mph"" 0 ' ,ho," won!, , , , ,d" homO,

,,!uP, bo1d Ion<"" "Iett.d"d ,'n,l. won!,,.d ph"'" we" p,I,,,d, m",meed and Jom\IWOI'II

Oft <ani, Th<oe wo,d, w ." ,ho"n pO' "b"" , .d ,Iott.d Inco d. .' pi""' pod<.u on AS ",,,s.

Th'" we" pl".d on ." w,\I b, " ,h ,ttl,l" '0' " f . " ' " by "'-.u..on4repetition of these key words was enc:ouraaed

Debbie Wilcox and Sar e speech and I arah-Jane BurnsAnita Mcfadze anguage therapists and

an a spee htherapy assistant with language

Children's NHS lim urgh Sickrust.

These resources are in rout-patient clinic at the Regular use in an

Ch ildren in Edinbur h h oyal Hospita l Jor Sickweekly basis. The g w ere groups are run on a

d

groups are staffi d by

an language thera . e two speechassistant. Althou h plSts and a multi-talented

different levels t ~ e s e w run groups JOT children atr. , r esources ar d 'JOT early communicat ' e use pnmarily

IOn groups k'carers and their ch'ld WOT Ing with

Th ese children are at a I rentheir development and m :e- lzngu lstlc stage In

children present h ny are non-verbal Th ed ffi wit varying d

1 lCUItY, autISm spe f I egrees oj learningd I ,Cl lC angu d

eve opmental dela 1 S age lSorder andd' . orne have bWgnOSIS and reqUIre not een gIVen a

Carers attend WIth the cha

penod oj assessment.actwitles TherapIsts Ihldren and work through

are t ere to dreqUIred. Groups b a VIse / model If

I d egln and e d . he acttVl ttes, eg, hello son n WIt th erapISt

We hope you Jind some oj mde game/ Singing.have as mu ch Jun ese Ideas useful and

as we do uSing th em.

during activities.

bubbles

pop

again

(name's turn)

ready, steady, go.

stop

9. MUsical taThe ins . pe for bodcom ~ / r a t i o n fo yawareness

· merclally r theIt was too 10 available LOA tape Was froto make ng for our c/' tape.Whilst m the

. Our 0 lent excellenJoyabl Wn . The . group and ent.The a e and with d fjmuslc had to b We deCidedand r SSIstant chose efjm/te rhythms e very simple

ecorded Ive si ' .lng the ins these played mple pieces of

each piece trumental and a keyboard ~ U S i cWe ch . r ythmieal ffi' c ang

• rock the followin e ects for

• sw . ogether g movement .109 arm • s.

• b s move fjru hand Ingers

Ths tog th • stam '

e childr e er p leet.

to c en Werea opy or obser encOUraged bIfproximate/y f j v ~ e the actions. T{ their ca rers

you can't play mmutes. IS tape lasted

teer. If no Yourself e .available o n t , ~ ~ r e is P l e ' n ; " s ~ a willing vo/uto the th / tape. 1m 0 fantastic mmarching ; ; :e music f r o ~ g l ~ e rocking ~ : : cStripes" _ I a band play ' The Piano" y

et your ' Ing "Th orImagination e Stars and

go!

Ji(t,alIab\e from Nottingham Rehab, ref L II I, £. I05 .~ e version was just under £20. Firstly you must decide on the largest s\J.e SW_·'. . . . child. . . and " ,. '1"" In ,h . dlnl', S"I. 0" , . ' " . , ' ,,,on!'ngiy. Fo' 0", dink

the triangular template to cut ou t 12 separate sections. We used cheap lining m:I.tIll'\al..bl lit.1: ,G. . . . . . was 3 metres.

quor., "",."'1 will ,,,,,d 'P co mo'" w"" "d " " .Th.lOO, ,;d" on ,\11,' -......... ,".,.,",,,,,,h Seam" fo, ,,,,,n,,,,.Th. m,,,n,1 " <h. " " " " of ....

rom Step B Jingling pIag Estate Yo y Step Ltd L y ball

200, ref pp ' ate, Bristol ' avenham Rdlarge i 5098, £ I3 95 Bs 17 5QX • Beechessmall c e.ar ball (50' ex VAT. ' tel. 0/454

_ ... . . _ " ' heavy, so cut ou t a small circle in the centre ofthe parachute about 15 cm in diameter and replace

vftth twO larger circles of material sewn on either

side.Tum under edges and hem.This can be as easy or

c.ornpIlcated as you like, using many colours, fewer sec

Speech & Language Therapy in Practice, Winter 1997

Documents