Speech & Language Therapy in Practice, Winter 1999

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WINTER 1999

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I Yo" ,..was

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Contents W i n t e 1999- - *

1999 November)

1368-2105

Square1UL01561377415avrilnicoll@speechmag .com

ReidReid DesignFarm

Group Ltd7, Ed ison RoadIndustrial EstateParkBN23 6PT

RegMRCSLTand advertising:01561377415

of Speech & Languagece reflect the viewsand no tthe views of the publish

of advertisements isan endorsement of the adveror product or service offered.contributions may also appearInternet site.

picture:workshop page

2 News I Comment 17 Ethics" ... there is potential for conflict between parents andprofessionals when the parents wish their child to4 Life stories receive more treatment. The parents may feel that"Both professionals were able to monitor and support this should be part of the child's rights, and withhold-each other within the group. Speech and language ing such therapy is contrary to the just needs of thetherapists may inadvertently come across emotional child. The therapist, in disagreeing, does no t see thisissues with clients which they are unprepared I no t as an issue of justice bu t of clinical need. "

trained to address, particularly in such a group where Jois Stansfield and Christine Hobden find out ifissues from the past may come up. Therefore, it was an ethical perspective can help resolve disagreementsimportant to have a clinical psychologist present who about intervention.was trained to take on a counselling role. "Lucie Hamilton, speech and language therapist, andKaren McKenzie, clinical psychologist, share their 20 Reviewsthoughts on the advantages and limitations of life Head and neck, assessment, parental needs, visualstory work with adults with learning disabilities. perception, dementia, dysphagia, brain injury,aphasia, autism.8 Conference report 22 In my experienceAlways test what was best about a conference bythe things that are still going round in your head" "" . to be able to continue to deliver useful support to(Beryl Kellow). the patients, the inner motivation to helpThe Association of Speech & Language Therapy must be channelled through the mediumManagers' conference, Countdown 2000. of respect."

10 COVER STORYWorking with carers"We were able to develop some unique and sensitive measures to aidus in our attempts to evaluate the day These and similar measuresmay be useful for others engaged in providin g support and counsellingdays for people with communication disorders and their carers."Chris Code reports on an Action for Dysphasic Adults (ADA) pilot dayfor carers of people with aphasia.

bilingual community are explored.13 Further ReadingPsychiatry, staff attitudes, phonology, hearingimpairment, stammering. 30 My Top Resources"Do you know the names of the

members of 'Steps'? What is14 Assessments assessed Britney Spears' latest single? Whathappened this week on 'Home and

rigorous evaluation by practising therapists. Find out whatPublished assessments and programmes are again given a

Away' and 'Eastenders'? Who didthey really think of the Work Readiness Profile, Dysphagia Man Utd play this week?"Evaluation Protocol, Assessing and Teaching Phonological Audrey Richardson gives the lowKnowledge, the Burns Brief Inventory of Communication down on working withand Cognition and the Test of Pretend Play. adolescents.

IN FUTURE ISSUES dysphagia more assessments assessed autism more ethics cleft palate head and neck cancer voice transitions

Speech 8r. Language Therapy in Pradice has moved.All correspondence sho uld now be sent to : Avril Nicoll, Speech & Language Therapy in Practice, 33 Kinnear SquarE. laurencekirk. Abedeenshire, AB30 1UL tel/fax 01561 377415. For su bscribers in the UK, the FREEPOST a d d r ~ IS noYt Avril Nicoll. Speech & Language Therapy in Practice. FREEP05T 5C02255. LAURENCEKIRK. Aberdeensh ire. AB30 1ZL The magazine's complementary intemet site, speechmag, has also moved to http://www.5pI!echmag.come-ma ij a v r i ~ (Mail is being re-directed from the old address and callers to the old telephone number will hear a recorded message ...,m he fJ'o ' numbed Apologies for any inconvenience caused by these changes.

SPEECH & LANGUAGE THERAPY IN PRACTICE WIN TER 1999

Jan Roach reflects on her work inthe mental health field.

24 How I managebiUnguaUsmAssessment of pre-school minorityethnic children, creativepartnerships to bring benefits foradult clients and speech andlanguage therapy in a truly

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~ ~WorkingtogetherResearch aimed at improving support for children with speech andlanguage difficulties has been joint-ly funded by the government's education and health departments.Recognising the difficulties causedby the local health and educationauthorities' different legal andfunding responsibilities, and thevariation in services across Englandand Wales, the researchers are clarifying current provision. Therapycommissioners and providers, pastand present users and parents andteachers will then contributethrough interviews and meetings toa plan for better services.The team, led by Dr James Law,comprises researchers from CityUn iversity, the Institute ofEducation and Warwick University.A web site is under development:www.city.ac.uk.css.

Common sense forcerebral palsyFollow up care for children with cerebral palsy once they the specific advice on standards for speech and languageare discharged from paediatric services is criticised in a therapists drawn largely from Communicating Quali ty 2expert report. (Royal College of Speech & Language Therapists, 1996).The recommendations for minimum standards of health The panel recommends referral to speech and languagecare in children with cerebral palsy state that, without therapy should take place as soon as potential communifurther clearly organised provision for their care, a criti cation difficulties are identified, and that therapistscal period in their physical and social development can be should take into account "how much time the family has,missed. Lack of continuity of care is a general problem or is expecting, to provide to help their child. This .. . canfor parents of children with cerebral palsy which can be be the main variable when planning treatment."helped by the involvement of 'senior professionals'. The Supervision and specialist training should be available toimportance of a seamless, team approach and working in therapists working with this client group.partnership with parents and the voluntary sector is The report, which aims to improve equity of service, wasemphasised. compiled based on the best available evidence from ranThe expert panel who made up the report . included domised, contro lled trials, consensus among appropriateresearch psychologist Dr Carole Yude who has a 25 year experts and "the often forgotten factor in assessing proold son with a hemilegia and is chair of the voluntary fessional opin ion - common sense."organisation Hemi-Help. Speech and language therapist Available from: Bell Pottinger Healthcare, tel. 01932Debbie Onslow provided additional information, with 350005, e-mail [email protected] .uk

New networkAn innovative plan for an independent,charitable network of therapy, research andeducational services for people living withcommunication disability is to go ahead.A 2.5 million grant has been secured bythe CONNECT - Commun ica tionDisability Network - initiative from theDunhill Medical Trust, who will provide abuilding for the first Centre in London.This Centre will draw upon the expertiseof the City Dysphasic Group and will initially focus on providing services to people living with aphasia following stroke.In future, a network of regional centreswill be formed across the UK, funded inwhole or part by CONNECT, with theremit extended to include a wider spec-trum of communication disabilities.

The first Inte rnet global disability conference has highlighted the growing use A key concept of CONNECT is working inof the Internet as an information source for parents and clients. partnership with individuals, their familiesAt the time of going to press, the autism99 site had been visited by more par and friends, communities, volunteers andents than medical, social services and education professionals put together. students, health and social care decisionUpdated information on this will be available in the Spring 2000 issue. makers and providers of public services.Running from 2 - 23 November, the conference emphasis was on the practical Professor Sally Byng, Carole Pound andissues surrounding autistic spectrum disorder, with new research and thera Dr Susie Parr, who are lead-pies highlighted. ing the initiative, are keenPapers,included David Holmes discussing how the needs of adults with autism to hear from people interare both similar to and different from t heir needs as children and adolescents. ested in forming partnerThe success of the Picture Exchange Communication System was described by ships with CONNECT toAndrew Bondy and Lori Frost. Peter Vermeulen, who has produced 'I'm develop regional Centres (c/oSpecial', a method and workbook for introducing children, adolescents and Department of Language andyoung adults to their autistic spectrum disorder, says the "content and design Communication Science, Cityare compatible with an autistic style of reading, understanding and think University, Northamptoning." Partnership with parents was considered in Paul Bartolo's paper on Square, London EC1V OHB, tel.delivering a diagnosis. 0171 477 8290, e-mailAutism 99 was co-sponsored by The Shirley Foundation and The National [email protected])Autistic Society (tel. 020 7833 2299, http ://www.nas.org.uk).

www.autism99.org

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~ s & c o m m e n tbetter voice

is included in an extended specialistto

.British Performing Arts Medicine Trust provides free

in London and Manchester for performanceand illness. Osteopathy, the Alexander

and counselling are also available.. 020 7240 3331, e-mail.com

expandednational educational charity for children with

and language difficulties is expanding itshopes its training centre's move to a London

combined with provision of courses in morecourses more

accessible to a range of health and education. To support this, speech and language

has been appointed ascourses include detection and treatment of

ofand language therapy in multiprofessional

and special educational needs tribunals.CAN's Dawn House School has been

in an Ofsted inspection, with the successfuland speech and language therapists get

special mention.I CAN tel. 08700107088.

volunteersis looking fo r volunteers to help with

of its self advocacy project.initial funding through a Department of

aims to cover signs for bodywith bereavement, coping

violence and crime and possibly general health.01634 832469.

strokeis to investigate the number of children in

UK who suffer strokes.determine how the children are investigated

Association has welcomed the development of ation system fo r Sarah Chandler, unable to

after two severe strokes at the age of six and. BT worked with the Oxford ACE Centre to

of components includingspeech synthesiser, an Internet service

a high speed network link. The technology haslicensed to her school and could therefore be

for use by others.Stroke Association, tel. 0171 5660300.

Avril Nicoll,Editor

33 Kinnear SquareLaurencekirk

AB30 1 UL

tel /ansa/fax 01561377415

[email protected]

...comment. .. Respect .costs nothingA simple dictionary definit ion of respect is 'treat with consideraton'_Jan Roach's experience leads her to ask what sort of models for gooocommunication are we if we can't start our relationships with cl ient; aposition of respect?We know this is far from easy, as people and their experiences are so diverse..Two elements of the Ethical Grid, cited by Jois Stansfield and ChristineHobden, specify respect - 'respect persons equally' and 'respect autonomy .Using an approach grounded in ethics gives an added perspective to decis iomaking. Not only can it increase your confidence in what you are doing andguide you in making it explicit, it can help identify opportunities forcompromise and working together with parents, carers and other disciplineswith whom you may have little in common.Respect means recognising and responding to different needs. Chris Code andcolleagues found out what the participants in a carers' day hoped to gain,planned the day accordingly and measured how far it had met expectations.We need to be in the habit of routinely checking what people want from us at least then we can be open with them about what we can actually provide.We have to make an effort to get on the same wavelength as the people wework with; as Audrey Richardson says, 'street cred' matters when it comes tecommunicating with her adolescent groups.Fear of the new or challenging puts up barriers to respect . In sharing theirexperience of working with bilingual clients and families, Jane Stokes, RitaThakaria and Christine MacLeod inspire readers to approach such clients {an open mind and honesty. Although resource constraints make a nonse nseof 'equity of service', we can at least offer equity of respect.Like adults with learning disabilities, many of our clients have huge ga ps .their understanding of self now, self in the past and future self. For speechand language therapists wary of venturing too far into potentia lly'emotional' territory, Lucie Hamilton and Karen McKenzie's life story "serves to remind us of the support offered by multidisciplina rystarts from a position of respect.Lack of funding for equipment and service development is a n s t . a nreal challenge. While addressing this, we mustn't forget the most ',,..,,.,..-=resources such as respect cost nothing and have a high ra:e of re, IL

SPEECH & LANGUAGE THERAPY IN PRACT1C.E ER 99'l 3

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II

Life story work offers individuals with a learningdisability the opportunity to review both the positive

and negative aspects of their lives, in a format thatallows them to take control over those aspects which

they wish to share, reflect upon and discuss. Followinga joint group, Lucie Hamilton, speech and language

therapist, and Karen McKenzie, clinical psychologist,share their thoughts on the advantages and

limitations of this approach.

t has been suggested that the need to reviewone's life is universal and required to help theperson reach a sense of completeness aboutwhat has been achieved (Butler, 1963). Anumber of techniques have been used to tryand meet these needs in different client

groups, including reminiscent work and lifereviews with older adults (Butler, )963) and lifestory work. The latter arose from work with children who had been in long-term or foster care,with the aim of helping them make sense of theirdisrupted past (Hussain & Raczka, 1997).More recently, life story work has been introducedto individuals with a learning disability. Previousresearchers have reported on the use of thisapproach with individuals who live in hospitalwho are in transition from institutions to community residential homes (Hussain & Raczka, 1997;Hewitt et ai, 1997). This work notes that most ofthe information available about clients from thesesettings arises from clinical reports in casenotesand may be sparse or irrelevant. As many clientswith a learning disability have communication difficulties (Department of Health, 1995) and cognitive impairments which may lead to difficultieswith memory and sequencing, it may be hard forthem both to link their past to the present and tocommunicate it to others.These communication difficulties impact on anumber of levels. There has been increasingrecognition that individuals with learning disabilities may have greater difficulties than non disabled people in recognising and identifying emotional states in themselves and others (Moffat et

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team working

Rojahn et ai, 1995). The recognition and professionals and group members involved.of feelings associated with past events Each professional had different roles within the

pose additional group. The clinical psy-chologist'swas to ensurec ~ ~ c : ~ ~ ~ t i O ~ ; , .. individuals with the group was emotion

outwith the ally therapeutic and tohere and now" may learning disabilities may monitor the emotionalimpact on the individu

199B). Such als within the group.have greater difficulties thanhave been The speech and lanwith the expres guage therapist's roleof challenging was to ensure eachon disabled people in

(Moffat et group member could1995) . There has understand and respondrecognising andbeen an to what was being dis

recognition cussed and to graphicalthe importance of identifying emotional states ly record discussions.

of Both professionals wereof individuals in themselves and others able to monitor and supa learning disabili(Gardner, 1997).

as offering a therato explore emotiona l themes

1997) as well as a way for individuals to sense of their history (Hewitt et ai, 1997) . ry work therefo re offers a means of allow

clients to make sense of their past to record which is personally relevant to them

that this brings (Atkinson & .

gapslife story work with clients who live in com

settings arose from the realisation thatsame difficulty of making

of their past as has been reported aboutwho have lived in hospitals (Hewitt et

1997). The aims for the group were to allowparticipants to explore issues relating to their

safe environment, to record their experiin a form that would enable them to com

to others and to provide an opporgroup members to look at the similari

in their life experiences. Inwas also hoped to identify if individu

had gaps in their memory or information aboutin their life and, if so, that these could be

was run weekly by a speech and lanwas beneficial for both of the

should be working with other probu t rarely how people go about doing

point for this group was toeach other's different backgrounds

to identify areas of differentof overlap . We had regu

for the group;for long-term planning and then short

what to do before each session andit went" after each session . These meetwere extremely important to ensure therecontinuity and development for both the

port each other withinthe group. Speech and

language therapists may inadvertently comeacross emotional issues with clients which theyare unprepared / not trained to address, particularly in such a group where issues from the pastmay come up. Therefore, it was important tohave a clinical psychologist present who wastrained to take on a counselling role. From theclinical psychologist's point of view, the speechand language therapist was important to ensurethat the members understood what was beingsaid and were able to express themselves, particularly to communicate their feelings - a requirement for any "emotional therapy" .Predictable and safeEach session was run for one hour and had a similar structure with the aim of creating a predictable and safe environment (Hussain & Raczka,1997) . The members were welcomed and the initial group rules were developed. These includedconfidentiality, listening to others and turn -taking. The group members were reminded of theserules at subsequent sessions. They were thenasked to mark how they were feeling on a visualanalogue scale which ranged from "good"through "OK" to "bad". This was repeated atthe end of each session to give a crude measure ofthe impact of the group on the members.The group were reminded of the last session'stopic to help aid memory and to enable cont inuity of the work before the current topic was introduced. Individuals could either work on theirown with support or in the group setting, buteveryone would return to the main group to dis-cuss the results of their work and compare theirown experiences.All the individuals had communication and memory difficulties and, as a result, each aspect of thegroup work was supplemented with symbols,drawings, photographs, pictures chosen frommagazines or anything that helped put the individual's story in context for them. Each new topicwas introduced, initially in the form of a question,

for example, "What sort of things did yo u 0 as achild?" Such questions usually produced ve Ii eresponse so it was necessary to introduce pictu es/ objects for discussion to help prompt responses.All responses were recorded . Each in dividua l vasasked to try to draw / w ri te down their re5pOlSe'Swith support from the group leaders. One of egroup leaders also graphica lly recorded the mainthemes of the group disC1.Jss ion. Once disrus - osabout a particular topic had finished, e " d-ual and group records were combined and a emore formal using symbols and tindividual an overall record of the gro p_the record 'formal ' made it possi cgroup member to share informa 'on J (cate about what had happened in e 9gave what they had talked about more s tEothers (see figure 1).Initially, each piece of work was placed 0 a . _line. This consisted of a long piece of pcanchored at one end with a photo of -me as ababy" and at the other with a picture of -menow". The group members, however, appea edto find the presentation of so much information a:one time confusing. The time line was t hereforereplaced by a life story book, with a ne agebeing added at each session and placed in the co '-rect sequence to represent that individual's li fe.Life changesThe group covered a variety of topics sim ilar tothose outlined by Hussain and Raczka (199n,However, an emphasis was placed on he lifechanges associated with the transition from childto being an adult. The themes broad ly rangedfrom birth to childhood, school and family to adolescence, friendships and places we have lived andour current life . Group members were a sooffered the opportunity to discuss how they leiabout each period of their life.While previous authors have acknowledged so -=of the potential disadvantages of life story rincluding the disruption to the individua l's e ' ing concept of their life (Hewitt et ai, 1997),has been little discussion of the problems erein this work which result from the individ cognitive and communication difficu lti es.A number of themes and difficulties arose d -the life story work, and the ways in hich hE: ___ics were approached had to be ad apted Of ~carded to meet the needs of the client5. ~ticular, it became apparent that the grot:some difficulty with abstract concepts the concept of time itself. For examp Gsuch as "what did you look like as abecame irrelevant until the group ..erEdifference between a baby, a childAll discussions had to be related to aor picture to make them more me M 'keep the participants' attention 'ocContinuous processSome group members also had their memory of th eir h'st I'f . .

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team working "*Figure 1 - Examples from a Life Story Book. (Written information has been made less sThings that I did I had as a child

...eacn aspect01 the group

work wassupplementedwi th symbols,

drawings,photographs,

pictureschosen from

magazines oranything that

helped putthe

individual'sstory in

context forthem.

5 0 + 5:; 14' ,~ , ~ ~ \:::Y

iT

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~ ~ ! = I m work::i'-"ng"-__ _ _

done I do I would like to do. now. as a grown up... Do the housework at home.I r : I ~ ~ u : a ~ ~ e m o u t h this year ego dishes. making my bed.

I( 11 Watch vldeos. ego HaryPloy tennis and squash with : Popplns. Lion King. ;;::=:;:;;;:;::::=:-:-:t1l Aintstones.If :::::::::J. eo!

0 Made a vase. ~ Don1 go fishing.Dressed up as a witch. I worea pointy hat and a black ~ Sometimes wash staffcoat. ~ members' cars.

() ~ ~ ~ Don1 do computers. bul . ~ Go swimming in ___ _ .: :: : would like to. ~ or ________~ Get my hair cut In ~ with my mum. Do some gardening at home...

Go shopping for clothes, music and food. Don't like sometimes take _____ 's shopping If It's busy. dogs for a walk.

e e c e Went to hospital when I broke going on trips In the cor.e c c e my leg.

story work may be unclear to clients and require clar of Learn ing Disabilities 26, 6266. from hospital to community based se " .ification or teaching as life story work progresses Butler, R.N. (1963) The Life Review: an interpreta' Journal of Learning Disabilities for Nun =- time to obtain information before the group, tion of reminiscences in the aged. Psychiatry 26, Health & Social Care 1(3), 105109.for the group itself, and to help the individuals 368378. Hussain, F. & Raczka, R. (1997) Life Sto ryput the resulting information in a format which is Department of Health (1995) The Health of the People with Learning Disabilities. Bri tishuseful \lnd meaningful to them. Nation a strategy for people with learning dis of Learning Disabilities 25, 7376.

abilities. HMSO, London. Moffat, c.w., Hanley, M. & Donnellan.Lucie Hamilton is a speech and language therapist Dwivedi, K.N . (Ed) (1997) The Therapeutic Use of Discrimination of Emotion, Affective enand Karen McKenzie a clinical psychologist at Stories. Routledge, London. Taking & Empathy in Individuals \ 'Roodlands Hospital, 9 Hospital Road, Haddington. Gardner, A. (1997) How Do We Stop Do ing and Retardation. Education and tra in

Start Listening: responding to the emotional retardation and developmental disaReferences needs of people with learning disabilities. British 7685.Atkinson, D. & Williams, F(1990) Know Me As I Journal of Learning Disabilities 25, 2629.Am. Hodder & Stoughton, London. Hewitt, c., Branton, J., Dunn, J. & Wil lcocks, A.Bradshaw, J. (1998) Assessing and Intervening in (1997) Life Story Work: issues and applications forthe Communication Env ironment. British Journal learning disabled people undergoing transition

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co n fe re nce report AvrilNicoll went.to fil

Information technolo

work, provides the data needed to makepurse str ings listen

8 ill Mutchbi eves anaspect ofcl in ica Igovernanceis managers \taking stockanddefining

)Va culturewhich ispatientfocusedand valuesstaff.

"The world Ismoving veryfast andthere is ananxiety to'get it alltogether'.There areso manyproblems inwo rk practice- JaneRichardsonand otherstalkedabout theimportanceof takingtim e toreflect andtake stockinstead ofhavingconstantknee jerkreactions."Jan Roach

\

Training - 'aculture ofenquiry'He advocates investmentin training and enablingaccess to information todevelop staff to their fullpotential and adopting a'no blame' approachwhich lets everyone learnlessons when things don'twork out. Gill Edelmanpoints out that there arealways gaps in learning,and always new things tofind out.

The bigger pictureManagers are charged with interpreting and implementing governmentpolicy. They need to be aware of 'thebigger picture' . The conference beganwith discussion of the implications ofdevolution, and delegates and speakers were from all over the UnitedKingdom.The value of the networking opportunities of a conference are inestimable a chance to step back from everydaywork and exchange ideas about management with people working to thesame agenda but in very different settings and circumstances .We need to be aware of the influenceof developments such as the Interneton the awareness of the general publicand make sure we keep working tomake our message heard.Pat Oakley offered delegates astrategic view, recognising speech andlanguage therapy as a small service ina period of extreme change. Shechallenged delegates to take time toreflect and focus on what we areactually trying to do with the profession.

"We have tothink abouthow weavoId \ '.\ tokenism in \staff andI professionaldevelopmentFor example,how does a /study dayactuallychangepractice?"Joe Reynolds

KateMalcomessfinds 1\clinicianscan identifytheir owntraining )needs whenthey have / access to asuitable ITsystem.

"We need to wo rkwith others and crossbarriers - aninterchange of deas.We are enthusiasticabout this and wouldlike to do more of it,andare now beingactively encouragedto do so bygovernment policy. RJenny Wood

Bill Mutch says we need a massive investmenIT systems . The system in use by Irene Morrishours of input time wasted and no useful feEvan der Gaag slammed the waste of money However, as Kate Malcomess points out, peosay you cannot measure what you are doingmust be seen as valid and robust by cliniciansproduce data for change. Her Trust's systemclinicians on a daily basis which helps them rEpractice, and this bottom-up, continuous refcontinuous change,A system t hat rec ognises that caseload is ncworkload, and that there is much complex

Partnership

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confere n ce repof t

nee What re evance would theto therapis

out. AcknowledgementThanks to delegates LesleyCulling, Liz Duff, HilaryHood, Beryl Kellow, JoeReynolds, Jan Roach,Kirsteen Shilson and JennyWood for their insights.

systemsand

to

to find outmore aboutthe care aimsand carepartnershipsbetweenpatients andcarers theyengender as Iam veryenthused bywhat shesaid."Lesley Cu lling

User involvementBill Mutch on clinical governance again reminds us abouthumanity and humility and that self-regulation is a privilegenot a right. He asks, are we listening to patients and carers?Sally Byng concurs: if th e user perspective is not included,any 'evidence' is scien t fically flawed. Her qualitativeresearch found peop e with aphasia suffered from a lackof respect in attitudes of professionals. They ended updisempowered and passivised, typified by the statementfrom one client, "After a time he Ithe therapist) found Iwas doing alright."The research also highlighted the need for clients to begiven information over and over again about theircondition and therapy to make sure they get the opportunity to hear it at the t ime they are ready.

"/ shared this with all my staff, as it has a wider releva ncethan stroke . We have to think, how am I expla ining myself,what is th isperson's perception of me, have I made myselfclear? People felt humiliated by their speech and languagetherapy experience, which is an awful indictment."Kirsteen Shilson

-

Irene Morris' group have adopted user invo lvement to theextent that patients and carers are now an integral part ofthe selection process for key staff posts.

meaningfulbeen axed

Anna

you

"/t hill takenKateMa /eomess fiveyears 'heartand soul' to

l e m ~ n t hersystem. / want

Delegates at the (dinner were enfi? .Maire-Louiseharp and sng ;Kirsteen 5hils

Do you know your area and Power andSecondment is its culture - the populati0na useful influencend the economy? Do youapproach to "Irene Morris heads up anow who has the power, askspartnership consortia of small services likerene Morris? Who needs toworking and speech and language therapy.e cultivated? Who can helpcan help bring This is pertinent for me becauseou effect change? Transitionsabout the we have just merged with anoth-eed work. What partners donecessary er Trust and we - speech andou need to be collaboratingunderstanding, language therapy and otherith - social work, education,collaboration housing, user groups, volun small services - are working hardand ta ry sector, GPs, private sector, on influencing our new board."compromise. the public, another Trust? Beryl Kellow

SPEECH & LANGUAGE THERAPY IN PRACTICE :: :::; 9

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ee In x e a Ionswith

of people with any communication difficulty. Chris Code reports.

esearch over the years has highlightedthe situation of relatives of aphasicpeople. Every student is familiar withthe cliche 'aphasia is a family problem',but we are nevertheless very aware ofits truth. There is now clear evidence

carers and relatives of aphasic people canwith psychologi

and social adjustment. (For more details, recentof the research literature can be

(1999) and Johannsen-Horbach et ai, 1999.)acknowledgment of this, Action for Dysphasic

has been concerned to improve andof support for the partners,

carers of aphasic people. There is nowof literature on providing various

of support groups for the relatives and carersaphasic people, for example Rice et ai, 1987;

& Borenstein, 1989; Hoen et ai, 1997 .has developed an approach to provide one-of f

days for relatives and carers, with a pilotday taking place in Exeter in February 1999.

so it might easilyused as a model or framework around the

who make up the professional regional

arm of ADA, and other professionals engaged inrunning carers' support days. We were able todevelop some unique and sensitive measures toaid us in our attempts to evaluate the day. Theseand similar measures may be useful for othersengaged in providing support and counsellingdays for people with communication disordersand their carers.Eight employees of ADA, including five RegionalDevelopment Advisers, made up a two-day brainstorming workshop at City University, London,facilitated by Carole Pound. Here the group discussed and developed the topics and issues theyconsidered should be covered in a day for relativesand carers. This resulted in the development of arange of ideas and materials to incorporate into aresource that could be utilised by facilitators planning to run a Carers' day. The workshop participants identified the main domains of concern as:i. provision of information;ii. communication I conversation training;iii. emotional support; iv. practical coping strategies. The resulting resource manual, Conversation & Coping, is split into a trainer's manual and a participant's manual, with overhead transparencies and handout masters. It also includes the basic structure and content for three sample days for carers and relatives with a variety of aims:

1. developing confidence in conversation;2. developing confidence in coping and managingdisability;3. developing confidence in coping with emotional issues .The manual is also a flexible resource of ideas andmaterials. ADA decided to run a pilot carers'/relatives' day before introducing the model morewidely, and Exeter was chosen for this .There are a number of ways to decide what to putinto a support day of this kind. We could havedecided on the basis of our past experience or byreference to published reports on carers' supportdays. However, although this was to be a 'group'support day, we decided we would attempt to findout what the individual participants felt was important to cover, rather than us professionals decidingthe complete contents. We started with our pastexperience, the ideas we had generated at ourworkshop and our knowledge of the publishedmaterials available, so the broad domains of theday were pre-determined and planned from theperspective of our professional knowledge base .Maximising timeHaving established the broad topics to cover, animportant constraint is the limited time in a working day. How could we maximise the four hours orso available to us? We decided to ask the partici

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~ cover story1. Planning questionnaire Table 2. The seven topic areas and the overall percentage thatthe participants requested the day should cover.: Date:____date of my partner's stroke___ -----,- Topic Percentageread the statements on the following page carefully. Coping with Emotions 14.5each statement is a line with the words AGREE and DISAGREE The Nature of Aphasia/Stroke 9.5end. Please place an 'X' on the line nearest the end which Se rvices for My Aphasic Relative 18agree with. Community SUpport for Carers 17instance, for the statement, "I would like to spend time on the Developing My Own Personal Support 14.5talking about community support for carers of aphasic Coping 8. ProblemSolving 17you might agree just a ittle and therefore place the 'X' New Roles 8. Responsibilities 9.5the DISAGREE end. On the other hand, you might agree Table 3 Programme for Exeter Carers' Daythe statement quite a lo t You would therefore place your 'X'

AGREE end, like this: lOam Introductions__________ --"-___ AGREE 10JOam Outline of the DayStroke and Aphasia and Your Relative. (PARTICIPANTS' CONTRIBUTIONS What is your partner's aphasiaplease read through the statements first and then make your like? The differences between the spouses' aphasia. What happened when he/she had his/her stroke?Effects of brain damage.)llam Identifying Services and Supportwould like to spend time on the Carers' Day discussing feelings (PARTICIPANTS IDENTIFYING Services for People with Stroke and Aphasia; Stroke Association Ianger, stress and other emotions, and how to cope Dysphasia Support / Family Support, ADA, Community Groups; Community Help.)them . 11.45am Identifying Emotions_ ________ _____ ,AGREE (ACTIVITY Feelings' analysis, dealing with anger.)would like to spend time on the Carers' Day trying to 12 noon Lunchmore about the nature of aphasia and stroke. l2.4Spm Personal Support,______________ ,AGREE (ACTIVITIES to identify sources of personal support.)1.4Spm Identifying and Solving Problemswould like to spend time on the Carers' Day trying to(PARTICIPANTS ' ACTIVITY)more about the services available for my aphasic partner. 2.1Spm TeaAGREE AGREE 2JOpm Partner's Roles and Responsibilitieswould like to spend time on the Carers' Day on community (PARTICIPANTS Identifying roles before and after.)for carers of aphasic people. 3JOpm Close Educate the community_ _____________ ,AGREE (Advocacy, assertiveness, mutual.)145pm Closewould like to spend time on the Carers' Day on ways tomy own personal support._____ ___ ______ ,AGREE We decided we would attempt to find out what thewould like to spend time on the Carers' Day discussing ways toskills in coping and solving problems._ ____ ________ _ ,AGREE individual participants felt was important to cover, rather

would like to spend time on the Carers' Day discussing than us professionals deciding the complete contents.I have taken on which used to be my partner's.AGREE

how much time they wanted to devote to between the amount of time individuals felt they difficu lt, if practically possible at all. However, weand devised a questionnaire to would like to spend on a topic, and how impor can directly assess whether we have met the par

us (Table 1). It asked participants to rate, on tant or relevant that topic is to them. The pro t icipants' expectations. Given that we had askeddifferential scale, the degree to which gramme planned for the day (Table 3) was based them to contribute to the planning, we devised

agreed or disagreed with seven statements very closely on the participants' averaged ratings. another questionnaire, completed at the end ofa range of topics. Thus, about 17 per cent was devoted to coping the carers' day, to measure if the contents had

contacted by letter and problem solving and about 9.5 per cent to met with their expectations.by phone to establish if they would like to background information on the nature of stroke For the evaluation questionnaire we asked partici

. A comfortable room was provided free by and aphasia. pants to rate the same seven questions as before, butpic, the operators of The National The day had a main facilitator (Chris Code), a this time each statement was prefaced "From my

had parking and easy access . Stroke Counsellor (Jackie Byrne) and two more point of view, we spent enough of the day .. ," thus :spouses (seven females and 'neutral' observers . The observers' role was to help 1. From my point of view, we spent enough of the

males) living in or near Exeter in Devon us evaluate the usefulness of the day. One was day discussing feelings of depression, anger, stressaphasic partners ranged from very severe Regional Development Adviser Margaret Conan, a and other emotions, and how to cope with them.

and disabled . Most aphasic speech and language therapist with experience The mean responses for the group are shown inhad been aphasic for several years with working with Carers National Association, and the Table 4. The overall mean score was 8.3 out of 10,

most recent being 12 months post-onset. other was retired Chief Speech and Language suggesting that overall the day met 83 per cent ofsummed the questionnaire responses and Therapist Janet Howitt, with extensive experience the group 's expectations. The lowest mea n score

We then sectioned of aphasia. They did not sit outside the group, but (7 .25 out of 10) was for 'ways to develop my own4 hours 15 minutes available and planned participated in the activities. personal support'. Although this was he lowest.

that directly reflected their requests it still seems we met 72 per cent of expectations2). This indicates that, for the participants, Success) for this topic. The highest mea n was 9.25 for 'dis

for aphasia, community support for carers We wanted to assess the usefulness of the day so cussing feelings of depression, anger, stress andproblem solving were their main concerns. we could improve things for similar days that ADA other emotions, and how to cop e wi th them'.

and developing personal or others would run in the future in dif ferent Interestingly, despite the fact that \ e actuallyin importance, ' followed by parts of the country. Deciding if such a day was spent a large proportion of the day dis cussing

wledge of the nature of aphasia and stroke 'successful' depends on what the aims were. personal support, and li ttle t me discussing emo-taking on new roles and responsibilities. Establishing the difference it might have on the tions and how to cope wit h them, it was the parreasoned there should be a close relationship everyday lives of the participants would be very ticipants' group perception that we did enough ~

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cover story

on the latter but less than enough on the former.(Th e development of personal support refers tosuch things as phoning a friend when things getbad, talking to neighbours / doctor / vicar / family,enjoying 't reats' such as wine or chocolate cakeand involvement with a support group.)AgreementTwo facili tator/observers independently completed th e same questionnaire within a couple ofdays. Their overall averages were very close (7.71and 7.57) suggesting excellent agreement thatthe day had been between 76 and 77 per cent successful in meeting their expectations. Both scored'developing my own personal support' and 'discussing ways to develop skills in coping and solving problems' as being covered the least satisfactorily. This agrees well with the relatives.What have we learnt for future days of this kind?1. Participants appeared to get a great deal fromthe day. Despite the fact that many had husbandsand wives who had been aphasic for many years,the day met some of their needs.2. We provided a great deal of 'paper' information in the way of leaflets, addresses and namesand phone numbers of organisations, agencies

and individuals whomight be useful tothem. While we wereunder no illusions thatall or even much of thismaterial would be

e ections:Do I consider

read, participants werein encouraged to keepwith the information somewhere accessible as aresource.3. We were struck bythe amount of helpavailable in the community to support carDo I recognise ers and how little some

needs for participants knewabout the sources ofsupport. We wereequally impressed bythe amount of inforDo I find out mation some participeople pants already had andwere able to sharewith other groupd then check members.4. We decided beforehand on seven important domains thatexpectations? could be covered adequately and usefully in

one day. Clearly, a different group, at a differenttime and in a different place, might have come upwith different topics. We would have found itharder to meet expectations if we had decidedhow much of what to include without consultati on wi t h participants.5. Our method of evaluating the day provided us

Table 4: Participant's ratings on how they perceived thecontent of the day had met their expectations.Topic Percentage

Score (Out of to)Coping with Emotions 9.25The Nature of Aphasia I Stroke 9.12Services for My Aphasic Relative 8.25Community Support for Carers 8.0Developing My Own Personal Support 7.25Coping & Problem Solving 8.12New Roles & Responsibilities 8.12Total 58.1117=Mean 8.30(83%)

... despite the fact that we actuallyspent a large proportion of the daydiscussing personal support, and littletime discussing emotions and how tocope with them, it was theparticipants' group perception thatwe did enough on the latter but lessthan enough on the former.

Action for Dysphasic Adults (ADA) is the onlyBritish charity concerned solely with improving awareness and services for people withaphasia and their partners, relatives and carers . ADA has been concerned in recent yearsto increase the number of self-help groupsfo r aphasic people around England, and currently there are over 20 such groups withmore in the pipeline. There are now sixRegional Development Advisers employedon a part-time basis to provide support on aregional basis, covering all of England, aswell as parts of South and West Wales. Thereis also a completely independent ADA inNorthern Ireland with similar aims.ADA1 Royal StreetLondonSEl 7LLtel. 0171 261 9572http://ww w.ada-uk.org

with some clear information. If we had properlyreflected the participants' wishes for the amountof time spent on each topic, we would expecthigh agreement that the day had met expectations. The day appeared to meet 83 per cent ofthe group's overall expectations.6. Predetermining the areas to cover reduces thetime involved in planning. An alternative andmore time consuming procedure would be to askpotential participants to provide topic areas thatcan be narrowed down into a range which couldbe included in a day and could involve individualconsultation and interview.

7. We felt it was useful to tap not only the rela tives' perceptions on the day but also the sionals' to give us a broader view of its impact.There was a very high level of agreement.8. Given that the amount of time spent on deveoping personal support fell short byabout 17cent of participant's expectations, there may 'i .be an unmet need fo r the development of p-sonal support for the relatives and carers of aphasic people in the group. This is despite the faathat we spent as much time on the topic as theparticipants appeared to request. Of courSt-because we spent time on the topic does nomean we spent quality time on it. The issue s maonot have been covered adequately. The mismatcbetween the participants' ratings suggests perhaps we did not.9. We know that measuring people's perceptionsand expectations is a tricky process (CampbeJ1976), whether we are using interviews or stan.dardised questionnaires. For future relatives' acarers' days of this kind we need to consider ca rEfully possible mismatches between participantsperceptions and expectations .Chris Code is the Research Officer with Action forDysphasic Adults (ADA). The address for correspondence is Professor Chris Code, Schoo l o Psychology, University of Exeter, Exeter EX4 4QG,tel. 0136383900, e-mail [email protected] initial two day workshop, and the development of the resulting resource manua l.Conversation and Coping, was supported by tilePrudential Carer's Ini tiative.ReferencesConversation & Coping (1999) London: Acti on fOI Dysphasic Adults. Campbell, A. (1976) Subjective measures of w e' being . American Psychologist 31, 117-124. Elman, R. & Bernstein-Ellis, M.A. (1999 Psychosocial aspects of group communicat ion treatment: preliminary findings . Seminars in Speech & Language 20, 65-72. Hoen, B., Thelander, M. & Worsley, J. (199 7) Improvements in psychological wellbeing of pe ople with aphasia and their families : evaluation of a community based programme. Aphasiology 681-691. Johannsen-Horbach, H., Crone, M. & Wallesch, ( . W. (1999) Group therapy for spouses of aphasic patients. Seminars in Speech & Language 20,73 83. Rice, B., Pauli, A. & Muller, D.J. (1987) An eva luation of a social support group for spouses and aphasic adults. Aphasiology 1, 247-256. Taylor Sarno, M. (Ed.) (1995) Aphasia Recove ry: Family-Consumer Issues. Special Issue of Topics In Stroke Rehabilitation 2,3, 1-87. Wahrborg, P. and Borenstein, P. (1989) Famil therapy in families with an aphasic membe r. Aphasiology 3, 93-98. 0

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further readi n g

This regular feature aims to provide information about articles inother journals which may be of interest to readers.rther readinEditor has selected these summaries from a Speech & Language Database compiled by Biomedical Research Inde xing . Every article in over rl~ ~ -.is abstracted for this database, supplemented by a monthly scan of Medline to pick out relevant articles from others. --,- subscribe to the Inde x to Recent Literature on Speech & Language contact Chr istopher Norris, Downe , Baldersby, Thirsk, North Yorkshire ~ 1)4PP, tel. 01765 640283, fax 01765 640556.

Annual rates areDisks (for Windows 95): Institution .90 Individual 60Printed version: Institution 60 Individ ual 45. Cheques are payable to Biomedical Research Index; g.

S"",MMERINGPHONOLOGY Hancock, K., Craig, A., McCready, c., McCaul, A., Costello, D., Campbell, K. and Gilmore, G.Rvachew, S., Rafaat. S. and Martin, M. (1998)(1999) Stimulability, speech perception Two to sixyear controlledtrial stuttering outcomes for children and adolescents. J Speechskills, and th e treatment of phonological Lang Hear Res 41(6)124252.disorders . Am J Speech Lang Pathol 8 (1) This research is a long-term follow -up of a prev iou sly published, controlled trial on the effectiveness of3343. three stuttering treatments (intensive smooth speech. parent-home smooth speech, and intensive elec-The relationship between stimulability, speech tromyography feedback) for children and adolescents aged 11 to 18 years, who stutter. The pre viousperception ability, and phonolog ical learning controlled trial showed all three treatments to be effective compared to nontreatment after 12 mon ths.was examined in two descriptive studies. In This paper reports on the treatment effect iveness after an average of four years post-treatment. ResultsStudy 1, the children received nine group demonstrate that treatment gains were maintained in the long term, with rates of stuttering similar totreatment sessions targeting three phonologi the one-year postoutcomes. There were no significal processes using the cycles approach. cant differences among the three treatments inTreatment progress was not observed for long -term effectiveness. This controlled study sub-STAFF ATTITUDESounds that were unstimulable before treat stantiates the claim that the treatments investigatUpton, D. (1999) Clinical effectivenessent. Given stimulability, treatment progress ed will more than likely have substantiallong-terand EBP 2: attitudes of healthcare proas greater for sounds that were well per- benefits for the fluency and personality of childrenfessionals. elin Linguist Phonet 13 (1) 26eived before treatment in contrast with who stutter.30. treatment. In Study 2, the cycles approach was sounds that were poorly perceived before The concepts of evidence-based practice (EBP) modified so that each child received three and clinical effectiveness have become more brief, individual treatment sessions followed important within the NHS in recent years . In by six group treatment sessions. Each individ- order to enable suitable initiatives to be PSYCHIATRYdeveloped and for future policy to be shapedal session targeted stimulability of target Hoffman, R.E. (1999) New methodsand evaluated, it is important that the currentounds. using phonetic placement, and per for studying hallucinated 'voices' in

level of attitudes towards and knowledge ofeption of target sounds, using the Speech schizophrenia. Acta Psychiatr Scandthese concepts are ascertained. This surveyssessment and Interactive Learning System Suppl 395, 8994.recorded the level of knowledge of EBP andSAILS). In Study 2, good progress was The mechanism of hallucinated speech orclinical effectiveness and examined the attibserved for most target phonemes, including 'voices', a symptom commonly reported bytudes of a sample of 207 podiatrists, speechhose that were unstimulable or poorly per- schizophrenic patients, is poorly understood.and language therapists, occupational theraeived before treatment. We have undertaken two types of study -0pists and physiotherapists towards these con- explore the hypothesis that th is symptom aris-cepts. Results showed that the participants es from pathologically altered speech percep-rated their level of knowledge of evidence tion networks. The first consists of neural net -based practice/clinical effectiveness as poor, work computer simulations of narrati ealthough they expressed a positive attitude speech perception. We have shown hat "towards the concepts. In part icular, profes these networks are partially disconnectedR.T., Kirk, K.I., Svirsky, M.A. and sionals considered themselves to have poor undergo a 'monamine' neuromodula ory y.T. (1999) Communication skills in research and information technology skills turbance, 'hallucinated speech' (speechcochlear implant recipients. Acta and lacked an ability to undertake computer cepts occurring in the absence of p on ::::':(Stockh) 119 (2) 21924. literature searches. input) are simulated as well as spec j c ~ - . : : : ies of speech percep perception impairments. The latta'prompted us to conduct para lleljustified a significant change in the demographics of congenitally and prelingually deaf children actual schizophrenic patients using areceive cochlear implants. A trend toward earlier cochlear implantation has been justified by speech tracking' (MST) task. 5f r6: 0,in measures assessi ng these area s. To assess the influence of age at implantation on jects to track narrative speecage five years was used as a benchmark. Thirty-one children who received a Nucleus clarity of wh ich is reduceduse the SPEAK speech processing strategy and two children who received a multispeaker 'babble.' Hacochlear implant and use the CIS strategy served as subjects. The subjects were divided into strated speech percep -Olion age at implantation . The groups comprised children implanted before the age experimentally indlKed 1=- =J3 years (n = 14), children implanted between 3 years and 3 years 11 months (n = 11) and those which clea rly differe. u2: !--:1 : . : -lanted between 4 years and 5 years 3 months (n = 8). The children were further divided according hallucinators a dused oral or total communication. The earlier-implanted groups demonstrated sta support the hly significant improvements on measures of speech perception . Improvements in speech intelli ous productsas a function of age at implant were seen but did not reach statistical significance. The results ne tworks.the present study demonstrate that ear ly implantation promotes the acquisition of speaking andskills.

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assessments

assesseSpeech &Language Therapy in Practice readers continue to find out if the marketingspeak for published assessments and programmes matches the reality.Helpful teaching activitiesAssessing and TeachingPhonological KnowledgeJohn MunroAustralian Council forEducational Research$89.00 (Aust)

If you work in an educationalsetting and have an interest inliteracy, Helen Cheal suggests youcheck out this package.The introduction to this assessment proposes toserve two main purposes:1) to check children's readiness for particularaspects of reading teaching2) to understand and diagnose a child's readingdifficulty.The author suggests it is applicable fo r use withchildren in their first three years of schooling butalso for older children to assess the extent of theirphonological knowledge.A profile is compiled for each child based on theirassessment results, which highlights any areas ofdifficulty and the manual recommends specificteaching activities to target these. The author statesthis assessment / teaching package is suitable forteachers and / or 'educational diagnosticians '. It isnot therefore designed specifically for use byspeech and language therapists. The assessmentdoes not claim to be a definitive test of a child'sphonological knowledge and the author recommends using it alongside other tests of reading ability, vocabulary knowledge and language function.The involvement of speech and language therapists in literacy assessment / teaching is somewhatcontroversial and depends largely on the policy ofindividual departments and / or work settings.However, recent research (for example,Stackhouse and Wells, 1997) emphasises theimportance of phonological skills fo r both oralcommunication and literacy development.When I agreed to p ilot this assessment I was working in the Junior Department of a Language Unit

in addition to a community clinic with a paediatriccase load. I decided to use the assessment andteaching activities in the language unit setting asmany of the children there had literacy difficultiesand I was, therefore, more involved in this areathan with most of my community clinic caseload.CASE EXAMPLE: H (chronologicalage 8;11years)H presents with a phonological disorder with largely age appropriate language skills. His reading andspelling were approximately at a 6;6 year level.Before I began any assessment with H, I completed the accompanying Screening Checklist with histeacher which looks broadly at four areas: oralcommunication, pronunciation of words, readingaloud and spelling. It was useful to complete thisjointly and helped clarify H's strengths and weaknesses. However, some of the questions wererather vague, for example, 'Does the child expressideas in the appropriate way?' There is also a parent questionnaire which explores factors such asearly language development and family historywhich could be used to accompany a speech andlanguage therapy case history.Difficult to keep attentionThe actual assessment is divided into five maintasks and includes activities such as the identification of rhyme, alliteration, segmentation ofwords and manipulation of sounds in words.These are said 'to cover the span of phonologicaldevelopment relevant to early literacy development'. I found the assessment quite time consuming and it was difficult to keep H's interest,even though he has good attention skills and isused to doing therapy / assessment activities.The tasks involve a mixture of auditory and visualstimuli with line drawings and printed letters,words and non-words. All the pictures are verballylabelled by the tester which is just as well, as manyare quite obscure, for example, plank, tramp, twist.However, this means it is not possible to assess thefull extent of the child's own phonological representations as the tester is always giving the labels.The assessment was useful for highlighting somedeficiencies in H's rhyming skills, which I had not

been aware of during therapy activities. AlthoughH could detect rhyme easily and produce rhymingwords in isolation, he had difficulty generatingrhyming words in prose. The teaching section inthe manual provided some helpful ideas which Iutilised during therapy and discussed with histeacher to incorporate during literacy activities.I also discovered that H's production difficultieswith consonant clusters / blends was reflected inhis ability to segment words with clusters / blendsand read non-words containing them . This didnot come as a particular surprise but confirmedmy therapy aim to focus on these in more details.H could manipulate words with three sounds quitewell, for example, deleting sounds, substitutingsounds and blending them, but he began to fail whenanother sound was added. This was encouraging aswe had focused on blending three sound words intherapy for a long period and it appeared to havebeen successful. It also highlighted that it was nowappropriate to move on to four sound words.Although I feel the assessment did provide someuseful information, much of this could also havebeen gained informally. It does not cater fully for achild with a speech sound difficulty as many of thetasks rely on the child producing words / sounds andthere are no clear guidelines to testers about howto score the child's speech if it deviates because ofan articulatory and / or phonological difficulty. Itmay be useful to use the assessment alongside thepsycholinguistic framework developed byStackhouse and Wells (1997) to gain a deeperunderstanding of the child's level of functioning .I am no longer working in the language unit anddoubt I will have time to use the assessment in thecommunity clinic. However, I may select some ofthe assessment tasks and adapt them to my working practice. The teaching activities are helpfuland I will be able to refer to these for school programmes and therapy planning. I would recommend the package to therapists who work in anintensive educational setting who have a particular interest in literacy, but do not feel it is a vitaltool fo r community clinic work .Helen Cheal is a speech and language therapist withSandwell Healthcare Trust in the West Midlands .

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assessments

Easy to complete Work Readiness ProfileHelga A.H. RoweAustralian Council forEducational Research$70.00 (Aust.)

reservations, Suerecommends this profilefor use with olderand adults within a college of further education with stu

and learning disabilities). Although I amand language therapist, I am employed

my speciality being communication.people in this field, I am always looking

assessments for this cl ient group.comes neatly packaged in a folder and

a set of answer booklets, individualan instruc

some instruction manuals,is not enormous and was easy and quick

to read. The information in the first chapter isuseful as background to the assessment. Thenotes on administration were clear and my colleagues - less experienced than myself in theadministration of test material - found them simple to follow.The administration of the test itself takes only 10-15 minutes. Despite the fact that the authorclaims it can be self-administered, there were nostudents at my college who had the reading ability needed. However, this assessment is alsodesigned fo r clients who have physical disabilitieswhere self-administration would be appropriate.My teaching colleagues found it easy to completeon behalf of those students whom they were hoping to place in work experience. Following completion of the answer booklet, the scores are thentransferred to an individual record form and anaverage score for physical and personal effectiveness is obtained. Again, this took just a few minutes to carry out. The record form shows an individual's strengths and weaknesses and also thoseareas which need support and further training .We did not use the group record form as we werelooking at students' individual abilities.We found a number of drawbacks:1. A high level of reading competency is neededfor clients to complete the forms themselves.

Makes you think The Test of Pretend PlayVicky Lewis and Jill BoucherThe Psychological Corporation312.63the strengths andof this test, Alisonbelieves a checklist of skillssuggestions for suitablewould have been more

of Pretend Play (ToPP) is designed to testdifferent types of symbolic play:

' up to four items to represent someelse

an imagined property to an object or to an absent object, person or sub

. it assesses types of play not tackled by

For example, the Test of Symbolic Play and Costello) on Iy tests functional (repre.

section, plus a

useful structured observation sheet. The verbaltest, although recommended fo r three years andover, places heavy demand on comprehensionand I would only use it with older children. Forexample, it asks the child to "make the dolly godown the hill in a sledge into the snow."BoredI had expected the materials to provide a rich language sample. They in fact had the oppositeeffect, and the children became bored with thematerials. They have to interact with the doll forfive sub-tests and with the teddy for four. Theteddy does not have jointed arms or legs, whichmade interpreting the distinct movements forscripted play difficult. The section where the childis expected to pretend to be a tree, or cold, madethem very self conscious and it would probably bebetter to assess those skills informally.A five year old autistic boy refused to participatein any of the test, as he dislikes dolls and teddies.The test confirmed my clinical judgement on boththe three year olds I used it with : case 1 - three years old, language delay, mainlyexpressive - ToPP revealed age appropriate play case 2 - three years, four months old with possible general developmental delay in addition to

2. It can be difficult to come to conclusions aboutindividuals exhibiting patchy performances; however, this would also prove the case when otherassessments are used.3. Given the client group which the assessment isaimed at (learning disabled clients, those whohave "other" disabilities and those with multipledisabilities) there is a distinct bias towards thoseskills suited to manual types of work. At times theinstructions mention physically disabled clientswithout taking into account that their intelligence is often unaffected and therefore they maybe capable of more complex work.4. The sections relating to physical ability havesome discrepancies, for example, in the same section picking up a matchbox is equated w ith usi ngmodified computer systems.One of the main strengths of the assessment isthat it is easy to administer and score. The resultsusually corresponded with the observations wehad made about clients. The assessment can beused to monitor progress. This could be a usefultool when assessing prospective students for entryto college courses . Despite some reservations, Iwould recommend this as a useful addition to ourrepertoire .Sue Harris, a speech and language therapist, worksas a teacher at Oxford College of Further Education.

language delay - ToPP revealed a delay of aroundone year in pretend play.Would I recommend it ' It certainly assesses areasnot covered by other tests in a clear, structuredway, and the observation sheets are very useful . Itmade me think about areas of play I normallyignore. It would be useful to clinicians who workwith developmentally delayed children, wherestructured play targets are part of the therapyprogramme. However, I looked at it with a colleague, both of us experienced in work with children, and there are aspects we found difficultourselves and which we would find hard toexplain to a parent or carer. For example, you arerequired to elicit four 'substitutions', that is, fourdifferent things representing other th ings, yettoday so many of the representational toysaround are very detailed and do not require thesame level of pretenceA checklist of skills with examples of equipme nt youcould use would be more beneficial, as it fe lt veryartificial to try and elicit some of the beha '0 rs.Alison Webb is an independent speech and lan-guage therapist in Peterborough. She Ylon theTest of Pretend Play in the Reader Offer of theSpring 99 issue of Speech & Language Therapy inPractice.

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Thorough, but layout is poor Dysphagia EvaluationProtocolW Avery-Smith, A.B.Rosen, and D. M.DellarosaFrom The PsychologicalCorporation56 .00

While Elsje Prins found thisprotocol thorough and consistent,existing assessments may be asuseful to experienced cltnicians.How many times have we asked fellow clinicians,"What do you use as a bedside assessment? Haveyou got a formal I informal assessment - and canwe borrow it?" Most frequently the answer is"well, we have sort of devised our own." 50, itwas quite a novelty to be given the task ofreviewing this protocol, consisting of a 43 pagemanual, a spiral bound pocket manual , and afour-page record form. The authors are all occu

pational therapists, thereby reflecting that theassessment, diagnosis, and treatment of dysphagia is not the sole province of speech and language therap ists.The manual consists of four distinct areas: administering the protocol; guidelines for initiating,continu ng and halting a dysphagia evaluation;alternative administration of the protocol forconfused or non-communicative patients; and asection on validity and reliability which includestwo case studies comparing the protocol withvideofluoroscopy. The pocket manual providesguidelines for bedside assessment.My first criticism is that this American product hasnot been adapted for use in the UK. Americanterminology such as 'NPO/PO' or 'manual muscletesting' is used. Weight is measured in poundsrather than kilograms .SquashedMy main concern is not so much the content ofthe protocol but the way the record form isdesigned. The layout is confusing with little roomfo r recording information. Important information gets squashed together with little room torecord additional comments . There is no space

Try before you buy ,Burns Brief Inventoryof Communication andCognitionMartha S. BurnsThe PsychologicalCorporation137.00

Lynne Couzens finds thisassessment quick and portablebut of imited use.If you are looking for a screening assessment fo radults with acquired disorders which is broadranging and quick to administer, then this may bejust what you are looking for. It covers a widerange' of functional skills associated with : lefthemisphere (relating to aphasia); right hemisphere (abstract language, visuo-spatial skills,prosody) and complex neuropathology (memoryand attention). It is highly portable, containingeverything you need other than pens, paper anda tape recorder. The three inventories can be usedindependently to determine clients' interventionneeds in particular areas. Some sub-sections have'predictor tasks' - success on these eliminates theneed to administer the whole section, very useful

when pressed fo r time. Treatment grids cla ssifyskills deficits as severe, moderate (and most likelytargets fo r intervention), and mild. Whilst theauthor acknowledges that there is no substitutefor "knowledge and know how" she provides anexcellent rationale for each task and a very useful"goal bank" to be used as a guide, if needed, when setting functional goals. What is it like to administer? Just as it claims, it is 'brief'. The stimulus pictures and words are clearly drawn in black and white and you won't be searching fo r mislaid objects as you don't require any. The scoring system is simple, there are sepa rate record booklets fo r each inventory, each with a very clear treatment grid. The addition of subtests for memory, attention and visuo-perception extends the appropriateness of the assessment to those clients presenting with closed head injury or early dementing disease processes. DisappointingOn the negative side, those looking fo r a cogni tive neuropsychological approach will not find ithere. The language sub-tests on the left hemisphere inventory are disappointing . Some of thesub-tests require customising fo r use in this country and will therefore lose validity (unless ofcourse your clients eat 'grits' for breakfast or regularly visit the 'movies' - particularly if starringLucille Ball) . Some may find the 'functional goal

for a medical history or information on the resultsof procedures such as a or MRI scans.Having canvassed some colleagues and invitedthem to try out the protocol, their replies weresimilar to my own views: good to see that cervical auscultation is used,but the jury is still out on its effectiveness useful fo r a thorough examination with spacefor a summary and advice that can be passed onin written form. ..useful for clinicians new to dysphagia . helpful for training purposes. usefu l for the private sector as it provides consistent documentation. pity about the forms.The protocol does have a positive value in that itis thorough and will remind the clinician to beconsistent in the assessment of dysphagia . As atraining tool, it can have a ro le to play. It is a pitythat not more thought has gone into the designof a user-friendly record form. I am not sure thatan experienced clinician on acute wards will findthe protocol any more useful than the one s/hehas already designed or pinched from colleagues.Elsje Prins is a speech and language therapist atHarrogate District Hospital.

bank' useful; others may feel the inventories simply direct more in-depth assessment. Would we buy this assessment? We tried it with clients in long-stay rehabilitation following traumatic brain injury - the complex neuropathology inventory is standardised fo r thi s client group and did not find it particularly useful in this setting. However, those new to this area or working in more acute settings may find it useful. Colleagues working with adults with early dementing diseases such as Alzheimers were very interested in trying out the inventories, particularly those who had limited access to psychological reports. Our recommendation 7 1t is well worth looking at, but borrow it if you can before you think about buying it. Lynne Couzens is a speech and language therapistat the National Centre fo r Brain InjuryRehabilitation at St Andrew's Hospital inNorthampton.

Orders for The Psychological Corporation on tel. 0181 308 5750 and the Australian Council for Educational Research at http://www.acer.edu.au. tel . (03) 9277 5651. Under the spotlight in the future issues are the Hearing Attitudes in Rehabilitation Questionnaire, PETAL, Phonological Abilities Test, Clicker 3 and Earobics.

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ethics

before theyget t he services they wantto( their children , often feeling that'all is not well' long before any professional is concerned . A Record (orStatement) of Ne eds, once established,the minimum standard against

parents can measure serviceprovision and they are unsurprisinglyery protective of its contents.

Th e speech and language therapist'sjudgement is that Jack will not currently benefit from the type of intervention requested by parents. Atsome points, intervention with achild with learning difficulties caninvolve their environment beingmade more conducive to communication and there being support fromcarers, rather than direct work .Dilemmas occur when there is conflict between the parent's choice andprofessional judgement, and thespeech and language therapist has tomake decisions about how to addressthe parents' concerns while maintaining a principled decision about intervention whichdoes most positive good, in addition achievingthe best personal outcome as seen in the grid.3. Principle: nonmaleficenceJack himself is making it clear by his behaviour

ections:I make use

modelsclinicalwhen

I seek toonalent andl I client

I have anss of my

moral valuesthe influencehave on

decisionsoutcomes?

that the current typeof speech and language therapy inputis not to his liking . Initself this is not a rea-son fo r curtailingtherapy: changes inthe style of inputcould enable thetherapist to continueindividual work.However, it may infact be counter-productive to force a particular style of intervention upon thechild in these circumstances. There may bea discrepancybetween the therapist's or parents'judgement of beneficence and non-maleficence. Should Jackbecome completelyresistant to speechand language therapy, his attitude tospeech and languagetherapy and to communication in generalcould become negative, thus producing a

red levelgreen level blue level

Assuming that therapy which parents request is available and appropriate, difficulties arise when the child refuses to cooperate in therapy.

harmful outcome. On the other hand, Jack's parents are considering the therapist's advice asbeing potentially harmful to Jack and thus in itselfunethical.4. Principle: justiceIn moral reasoning we should serve the needs ofthe client before the wants. Consideration of theavailability of resources occurs in the last level ofthe Grid.Resources can affect who is taken on for therapyand when children are discharged. At times theintervention programme that a therapist wishesto use may create conflict because the resourcesare not available to do what the therapist sees as'best' for the child. The RCSLT Bulletin (1999) sug-gests that services to pupils with special educationneeds are being skewed towards the children ofarticulate or influential parents. Sometimes it iseasier to cite lack of resources than to risk confrontation by saying th at intensive intervent ion is,from the speech and language therapist's point ofview, clinically undesirable. It is, however, important for the speech and language therapist to tellthe truth as she sees it and be prepared to justifythat decision.

Potential for conflictIn this case, there is sufficient funding toallow for the best type of input to meetJack's needs, but his parents and hisspeech and language therapist have different perceptions of what the best typeof intervention is. Here, therefore, thereis potential for conflict between parentsand professionals when the parentswish their child to receive more treatment. The parents may feel that thisshould be part of the child's rights, andwithholding such therapy is contrary tothe just needs of the child. The therapist, in disagreeing, does not see this asan issue of justice but of clinical need.Once she had addressed the variousethical issues brought to the surface bythe parents' request for daily individualintervention, the therapist turned tothe RCSLT code of ethics. Here heractions were guided by recommendations on professional conduct andresponsibility towards clients.a. Professional conduct: abstain

from unnecessary therapyShe decided that she should abstain from unnecessary therapy, but that, to do so, she had to justify clearly why she considered individual dailytherapy to be unnecessary and what was a desirable alternative. She was able to use theCommunicating Quality guidelines on workingwith cerebral palsy (RCSLT, 1996 ppI00-105) todemonstrate that indirect classroom based workcould be valuable and effective in promotingcommunication and, in fulfilling the requirementsof the Record of Needs, could still be consideredto be speech and language therapy intervention .b. Responsibility towards clients: respect the needs and opinions of

the client ensure wellbeing of the client keep clients informedThe speech and language therapist found this arather more diff icult area to address. It was hard todecide whether Jack was resisting speech and language therapy input because he was frustrated, dis-tressed, afraid of failure, bored, unhappy aboutleaving his class, or for some other reason. He clearly still had a communication disability and there wasno question that he had a long term need for intervention. While Jack's parents were not actually theclients, their needs and opinions are also very muchpart of what the therapist needed to consider.Eventually, she decided to video her work withJack in individual sessions and the direct and indirect work on communication skills in the class-room as a focus for discussion with the parents.She sent the videos home and then arranged adate to view and discuss them with Jack's parentsin his home. Jack's parents suggested a number ofreasons for his resistance, in particular the therapist's pacing of sessions and the noise outside theroom. They, in turn, were able to appreciate the

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.'f ethics

of the classroom based work being carriedt by the teacher and classroom assistant to pro

Jack's abilities to communicate with chilwithin the school.

of this case was that Jack's parentsfor group work rather than

during the coming school term, butthat he be seen at home over the sum

holidays so they could be more involved in hiscontribute to the therapist's aware

of Jack's strengths as well as his needs. It wasthat the therapist would visit once weekly

r five weeks. They also requested that individschool would be reintroduced after

summer. It was agreed that, in the new schoolJack would have a term of once weekly indi

followed by two terms of groupwith clearly defined objectives which corre

with his individual education plan.the classroom videos Jack's parents also

itiated an after-school link with the local primaryschools, in collaboration with the

other parents, to encourage communiwith children from the local community. This

met once a week throughout the summer term.dilemmas

is not easy even whenfrom the Ethical grid or the RCSLT

of ethics. In discussing ethical issues it isto note that Jack's case may present

ethical dilemmas fo r different theraEach of us has a value system which is influ-

by personal life experiences, education,or culture. Moral values underpin all

the ethical decisi onswill influence the outcome of each case.

Stansfield is a senior lecturer and Christinea recent graduate from the Department

f Speech and Language Sciences, QueenCollege, Edinburgh.

T.L. and Childress, J.F (1994) of Biomedical Ethics. Oxford: Oxford Press. A.v. and Higgs, R. (1982) In That Case.

in Everyday Practice. London: MA and Arvedson, J.e. (1997)

in Paediatric Dysphagia. tn Speech and Language 18(1), 79-87.

house, D. & Lovett, L. (1992) Practical medical (1996) Communicating Quality 2. London : The College of Speech and Language Therapists.

(1999) SEN tribunal appeals rise. RCSLT 565, 1-2.

is available from Liberator Ltd, NG33 4PA. D

r- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

- and cu s

e-mail avrilnicoll@speem--,

Macintosh PI 5

Cambridge Adaptive Communication, Do

Win BoardmakerDo you need quick and easy accessto a wide range of picturematerial? Then this offer is fo ryou! Speech & Language Therapy in Practice has a copyof Boardmaker software to give away FREE to a luckysubscriber. courtesy of the Mayer-Johnson Co.

Boardmaker is a graphics database containing over 3000 Picture Communication Symbols. you to make communication boards - with or without text accompanying the symbol tomised therapy worksheets. You control the size, shape, content and layout. It normally ret ail s at 239 and the package includes a manual and an explanatory video. To enter, simply send your name and subscriber number / address marked 'Board maker' to Avril Nicoll, 33 Kinnear Square, Laurencekirk AB30 1UL, tel. 01561 377415, mag.com by 15th January, 2000. The winner will be drawn randomly from all valid entries and be required to review Boardmaker for Speech & Language Therapy in Practice. Boardmaker is available in Windows (3.1. or above) or Mac (System 7 and greater) format. You will need 4megs of RAM and 14 (22 for Mac) megs of hard disk space . The Mayer-Johnson company produces a range of augmentative communication products (PO Box 1579, Solana Beach, CA 92075-7579, USA, e-mail [email protected], http://www.mayerjohnson.com). Software distributors in the UK are Johnston Special Needs Ltd, Inclusive Technology and SEMERC.

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