ISSN 1368-2105

SPRING 

http://wwwspeechmagcom

Dysphagia
Finger on the pulse

Sure Start
The final frontier

Dysarthria
Automatic speech
recognition

Challenger
Skills for life

How I am
keeping
up-to-date Out of the
Winning
Ways
Enjoying the ride
woods:
My top A year of
resources
Child voice storytelling
S H A P I N G E X P E R I E N C E

Spring 04 speechmag
In need of inspiration?
Doing a literature review?
Looking to update your practice?
Or simply wanting to locate an article you
read recently?
Our cumulative index facility is there to help.
The speechmag website enables you to:
View the contents pages of the last four issues
Search the cumulative index for abstracts of
previous articles by author name and subject
Order copies of up to 5 back articles online.
Plus
The editor has selected some previous articles you
might particularly want to look at if you liked the
articles in the Spring 04 issue of Speech & Language
Therapy in Practice. If you don’t have previous issues of
the magazine, check out the abstracts on this website
and take advantage of our new article ordering service.
New!
The full version of Sally Millar’s ‘Communication -
by the book’ from the Winter 2003 issue, with
accompanying pictures.
If you liked...
Louise Frazer, see (116) Sage, R. (Summer 2000)
Reaching the parts other don’t.
Nicola Grove, look at (151) Park, K. (Summer 2001)
Interactive storytelling: A multidisciplinary plot.
Peter Roberts & colleagues, what about (161)
McGrane, H. & Stansfield, J. (Autumn 2001) Strength
in compromise.
Judi Hibberd & colleagues, you might be interested
in (038) Haynes, S. & Hibberd, J. (Autumn 1998)
Managing tracheotomy and dysphagia..
Barbara Clarkson & Angela Peel, check out (067)
Paulger, B. (Summer 1999) Therapy for real life.
(Reprinted in full on
http://www.speechmag.com/archives/barbara-
paulger.html.)
Lesley Cavalli, try (pre-dates abstracts) Hunt, J. &
Slater, A. (Human Communication, 5(4), Aug/Sept
1996) Child dysphonia - harmony and balance.
Alison Cooke & Dana Taylor, consider (134) Hurd, A.
& McQueen, D. (Winter 2000) The right things at the
right time.
Also on the site - news about future
issues, reprinted articles from previous
issues, links to other sites of practical
value and information about writing
for the magazine. Pay us a visit soon.
Remember - you can also subscribe
or renew online via a secure server!
www.speechmag.com
READEROFFERSREADEROFFERREADEROFFERSREADEROFFERS
Assessing and Promoting Effective
Communication (APEC)
Do you work with Special Education teachers and classroom assis-
tants? Have you longed for an off-the-shelf training package to
help you raise their awareness of the developmental nature of
communication, language and play, and how they can recognise
difficulties and support the children more effectively? Well, APEC
(Assessing and Promoting Effective Communication) could be
what you are looking for, and we have a copy to give away FREE
to a lucky reader, courtesy of author and speech and language
therapist Gillian Bolton (normal price £220 + p&p).
For your chance to win, send your name and address to Gillian
Bolton, APEC reader offer, 47 Bilton Road, Rugby, Warwickshire
CV22 7AN by 25th April. The winners will be notified by 1st May.
APEC aims to help teachers and classroom assistants implement
the acclaimed communication framework developed at The
Redway School by Clare Latham and Ann Miles. The APEC pack-
age includes a training video produced in association with The
Redway School, detailed session plans, handouts, follow-up activi-
ties, a written assessment and certificates. Feedback from teach-
ing professionals has been positive: “...the course has really made
me take a look not only at the children but also at myself. It has
made me change my approach in certain areas (using more simple
language, letting the children take the lead more).”
For more information, see www.apectraining.co.uk.
Win ColorCards®
Listening Skills:
Indoor Sounds
Looking for sound and picture match-
ing activities that reflect life in 2004?
Look no further, as Speechmark has
revised its 1995 indoor, outdoor and
sequencing sounds packs. Even bet-
ter, Speechmark Publishing Ltd is
offering a FREE copy of Indoor
Sounds Revised Edition to five lucky
Speech & Language Therapy in
Practice readers (normal price
£35.50 + VAT).
The revised cards come with a CD rather than a tape,
to make it easier to switch between activities. The 40 indoor
sound cards now feature activities like word processing, playing a
computer game and listening to a personal stereo.
For your chance to win, send your name and address to Speech &
Language Therapy in Practice - Listening offer, Su Underhill,
Speechmark, Telford Road, Bicester, OX26 4LQ by 25th April. The
winners will be notified by 1st May.
Indoor Sounds Revised Edition, Outdoor Sounds Revised Edition
and Sequencing Sounds Revised Edition are available for
£35.50+VAT each, along with a free 2004 catalogue, from
Speechmark, tel. 01869 244644.
Kim Williams was the lucky winner of the TROG-2 in the Winter 03
issue, courtesy of The Psychological Corporation. Peter & The Cat,
from Black Sheep Press, goes to Ruth Howes, Helen Vernon and
Helen Smith. Congratulations to you all!
 www.speechmag.com
SPRING 2004 Inside cover -0 You talk 2 but what does it type?
(publication date 23rd February) Spring
speechmag “The variability of some dysarthric speakers can
ISSN 1368-2105 Reader offers usefully be managed and accommodated by the user
Win APEC and ColorCards® Listening Skills: Indoor identification, as there is nothing stopping one user
Published by: Sounds. progressively establishing him/herself with more than
Avril Nicoll one user information set.”
33 Kinnear Square  News / Comment Peter Roberts, Malcolm Joyce and Claire Philpott
Laurencekirk
AB30 1UL examine the potential of automatic speech recognition
Tel/fax 01561 377415
Finger on the pulse software for people with dysarthria.
e-mail: “The literature is less convincing on pulse oximetry
avrilnicoll@speechmag.com than cervical auscultation so our hypothesis was that,  Skills for life
Design & Production: if pulse oximetry could be shown to be effective, we “We learn about teamwork, to believe in each other,
Fiona Reid could use the two tools together to create a valuable, express our thoughts and to share other peoples
Fiona Reid Design non-invasive bedside assessment system.” ideas...Learn to be patient so we can wait for people
Straitbraes Farm Although videofluoroscopy can identify dysphagia and to finish what they have to say so you don’t think that
St. Cyrus distinguish between penetration and aspiration on your ideas are the most important. We also have to
Montrose
swallowing, it is not always available or appropriate. respect each other.” (Year 10 pupil)
Website design and Judi Hibberd & colleagues investigate a possible Barbara Clarkson & Angela Peel join forces with
maintenance: alternative. their Year 8 and Year 10 pupils to offer ideas for
Nick Bowles providing effective support for secondary pupils with
Webcraft UK Ltd
specific language impairment.
www.webcraft.co.uk < COVER STORY
Printing:  Further reading
Manor Creative A year of storytelling Cochlear implants, autism, ADHD, stammering and
7 & 8, Edison Road voice.
Eastbourne “Silence for a year and a day is a good plan. When
East Sussex you are in the middle of the forest and feeling your
BN23 6PT way, it’s quite hard to explain to other people why 5 “Here’s one I made earlier”
you are there and how to get where you are going. Alison Roberts continues to generate low-cost ideas for
Editor: Now I’m emerging out of the wood, the year is flexible therapy activities: Eye instruct you, Emotions /
Avril Nicoll RegMRCSLT
nearing its end and I’m beginning to be able to see facial expressions dice and Road sign dominoes.
Subscriptions and advertising: where I’ve been and what it all meant.”
Tel / fax 01561 377415 Nicola Grove reflects on a year spent exploring 
How I am keeping up2to2date
different ways of storytelling with people with “Readers have asked for more feedback from
Avril Nicoll 2004 learning disabilities. conferences, courses and study days. Here, we hear
Contents of Speech & Language more about a toolbox for school-aged children who
Therapy in Practice reflect the
stammer, Johansen Sound Therapy and a variety of
views of the individual authors
projects in the North East of England.”
and not necessarily the views of - Sure Start: the final frontier
the publisher. Publication of Louise Frazer travels from Barbados to Las Vegas.
“During Sure Start team meetings it quickly became
advertisements is not an Meanwhile, editor Avril Nicoll goes from
apparent that they appeared alien to the other chosen
endorsement of the advertiser Laurencekirk to Edinburgh and Newcastle.
ones from around the galaxy. They had to work at
or product or service offered. being accepted. Rather than orbiting around the
Any contributions may also planet, they had to land on site regularly, especially in
Back Cover My top resources
appear on the magazine’s “Whilst the majority of speech and language
a social capacity (lunch-time).”
internet site. therapists working with dysphonic children will not
Alison Cooke & Dana Taylor report back on their
have immediate access to a Voice Clinic I would
joint mission to bring specialist knowledge of early
recommend that, whether they work in mainstream,
speech and language development to two culturally
special schools or community clinics, they identify the
diverse Sure Start locations.
location of their nearest Voice Clinic and ascertain
whether the team will accept paediatric cases.”
- Reviews
Lesley Cavalli specialises in the assessment and
Language development, adult stammering,
management of voice disorders in children and
management, child voice, language, education,
adolescents, as well as head and neck surgery.
collaboration, life skills, hearing impairment.

-
Winning Ways series () In future issues...
Enjoying the ride Sure Start
“After filling in the Wheel of Life diagram, Jennifer antenatal education
was able to pinpoint the areas of her life that she adult learning disability
needed to smooth out in order for her to be as dysphagia
effective a speech and language therapist as she autism
wanted to be.” hearing impairment
Cover picture by Paul Reid (posed by
As the wheel of life goes round, it’s easy to lose our collaboration
model). See p.7 balance. Life coach Jo Middlemiss encourages us to student training
find ways of getting things back on an even keel.

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2004 -

 news

Increasing Healthcare
awareness and the arts
Increasing interest in how the arts are being incorpo-
The overwhelming majority of nursery workers who responded to a poll of Nursery World readers rated into the delivery of health care to improve the
believe that the occurrence of speech, language and communication difficulties among preschool physical and mental well-being of patients and staff
children is growing. has been picked up by The Royal College of Physicians.
Problems observed include lack of concentration, not speaking clearly and difficulty following A new book from the Royal College covers literature,
instructions. When asked for their opinion on the reasons for this, respondents suggested a lack of the visual arts, music and architecture, including the
adult and child time spent talking together, the passive use of television and parents talking for influence of the built environment and how it can
their child. improve clinical outcomes. It also focuses on the chang-
Gill Edelman, chief executive of the charity behind the poll, said, “I CAN are pleased at the increas- ing doctor-patient relationship, and the how the move
ing awareness of children’s communication difficulties and would encourage speech and language from paternalism to partnership is changing the nature
therapists to keep working towards increased collaborative practice, particularly with early years of medicine.
workers and parents. We also ask that they support more research about whether specific and per- A spokesperson said, “This book is invaluable not only
sistent speech and language difficulties are increasing, and the underlying causes.” in providing a clear conceptual framework for under-
I CAN uses such devices such as this poll to increase general awareness of speech, language and com- standing the healing environment but also in providing
munication difficulties, and the pivotal role of professionals and parents in prevention and support. evidence and examples of good practice that are both
The UK-wide ‘Chatterbox Challenge’ is another example of how the charity is encouraging parents compelling and convincing.”
to talk more to their children. Through such strategies, I CAN hopes also to increase awareness of The healing environment: without and within is £15
the more specific needs of children with severe difficulties, and the importance of early intervention. (£18 overseas), see www.rcplondon.ac.uk, tel. 020 7935
www.ican.org.uk/chatterbox 1174, fax 020 7486 7038.

Professor appointed Express

In a major research expansion at the University of York, an expert in language
acquisition and language processing has been appointed as one of six new Chairs.
Professor Helen Goodluck is a psycholinguist whose research on language
acquisition has been mostly with preschool children and a range of lan-
yourself
In the Winter 2001 issue*, we reported on the
guages. Her most recent work has focused on special populations, particular-
Dundee Expression project, where six people
ly people with Down’s Syndrome.
with aphasia explored their feelings through
creating prints. The prints have now been pro-
QuEST
A new independent service set up by therapists and educationalists aims to
duced in postcard format to be used as a basis
for discussion to empower and inform people
with and without aphasia.
identify, target and address the factors that may underlie some
* Nicoll, A. (2001) Imprints of the mind. Speech
specific learning difficulties.
& Language Therapy in Practice Winter: 14-18.
QuEST is a diagnostic tool which looks at why someone might
A limited number of packs are available from
experience difficulties with reading and similar tasks, and then sug-
one of the facilitators, speech and language
gests how to help. A parental questionnaire is analysed and recom-
therapist Laorag Hunter, e-mail
mendations made to address the particular combination of factors
laorag.hunter@tpct.scot.nhs.uk.
(auditory / visual / movement, balance and coordination / deficits in
essential fatty acids) which may be contributing to the problem.
Independent speech and language therapist Camilla Leslie, who is also
a Johansen Sound Therapist, has set up QuEST with an orthoptist, movement
therapist and educationalist / psychologist.
www.questtherapies.com

Play review welcomed

A disabled children’s charity has welcomed a government commissioned review
of children’s play.
The Children’s Play Review for England and Wales sets out how best to invest the
£200 million from the New Opportunities Fund earmarked for improving children’s
play opportunities. The chief executive of the charity KIDS said, “We applaud the
emphasis on the inclusion of disabled children and young people. At present, play
is simply not an option for most disabled children and they are routinely losing out
on all the physical, social and developmental benefits that play offers.”
The charity adds that it is concerned that distributing funds purely on the basis
of geographical areas of deprivation will mean they don’t benefit all disabled
children. It also calls for a particular emphasis on training play work staff which it
believes is the key factor in successfully introducing inclusion into play provision.
See The Children’s Play Review at:
Pat le Prévost and Thelma Grove
www.culture.gov.uk/global/publications/archive_2004/children_play_review_report.htm

 SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2004


Access
improved
In a bid to prevent repetitive strain injury and
improve computer access for people with upper
body disabilities, automatic speech recognition
software has been introduced across the whole
of Cambridge University.
Scansoft’s Dragon NaturallySpeaking® dictation
software has been fully endorsed by both the
University’s Computing Service and Disability
Resource Centre. It allows the user to carry out
all computer activities by using their voice.
Distance
learning
Pupils unable to attend school for medical or
other reasons may be able to study via The
Satellite School.
Around half the students of the school have
their distance learning places paid for by their
-E Nicola Grove’s reflection on her year of storytelling (p.7) has already entered my
local education authority because they have
medical needs. Tutoring is e-mail and web
based.
www.thesatelliteschool.org.uk
Virtual Mentor
Audiologists in the NHS can now access training
on a virtual system.
Teaching methods offered by Mentor, from the
hearing systems company Phonak UK, include
an online interactive academy, a web forum
and an online knowledge catalogue.
One of the trialists commented, “As each training
session is recorded, the students are not
required to take notes and can have access to
the recordings and play back relevant parts.
This allows a greater focus on the content and
less time scribbling notes.”
www.phonak.com
Making musical
Headway
Partners in a year long project to provide music
therapy for adults and young people who have
suffered a head injury hope it will act as a pilot
for the rest of the country.
The Friends of Henley Festival uses funds gen-
erated from the yearly arts festival to help its
local community, in this case people who
attend Headway’s centre in Henley. The two
organisations are working in partnership with
the charity Nordoff-Robbins Music Therapy to
provide music therapy to 26 people per week
to help them find new ways to express them-
selves, develop new relationships and explore
their own creativity.
www.henley-festival.co.uk;
www.nordoff-robbins.org.uk;
www.headway.org.uk
news & comment
...comment...
Avril NicollA Shaping
Editor
55 Kinnear Square
experience
“Silence for a year and a day is a good plan. When you are in the middle of the
Laurencekirk
AB5 -UL
forest and feeling your way, it’s quite hard to explain to other people why you
are there and how to get where you are going. Now I’m emerging out of the
wood, the year is nearing its end and I’m beginning to be able to see where I’ve
tel/ansa/fax been and what it all meant.”
-E0- 5<<
collection of classics. An enduring children’s classic, Peter Pan, is associated with
Great Ormond Street Hospital where Lesley Cavalli (back page) works to help
e2mail
children find their voice. When Barbara Clarkson & Angela Peel (p.20) wanted to
avrilnicoll@speechmagcom
hear from their Year 8 and Year 10 pupils, they asked them to brainstorm their
Challenger social skills programme – and the resulting short stories are
published here.
While our new releases from Jo Middlemiss (p.14) and Alison Roberts (p.17) are
marking themselves out as best-sellers, Dana Taylor & Alison Cooke (p.10) bring
us science fiction. By comparing themselves to aliens, they could see how they
would have to adapt to fit in and be accepted by their community.
For many people, computer technology continues to have more mystery than
Agatha Christie. Our own Hercule Poirot, Peter Roberts (p.16), shows how we
can all use our little grey cells to modify automatic speech recognition to give
people with dysarthria the opportunity to tell their story. Also playing detective
are Judi Hibberd & colleagues (p.4), as they find the gaps in previous research
into pulse oximetry, and test out their hypothesis.
Following requests from readers, How I am keeping up-to-date (p.24) is devoted
to the philosophy, drama and even the occasional comedy (remember girls –
always wear your earrings) of conferences and study days.
Across the genres, in sharing their experiences, our contributors help you to
handle similar situations as they occur.
“He picked up a packet of dehydrated onion. ‘Stories are like these onions – like
dried experience. They aren’t the original experience but they are more than
nothing at all. You think about a story, you turn it over in your mind, and it
becomes something else.’ He added hot water to the onion. ‘It’s not fresh onion
– fresh experience – but it is something that can help you to recognize
experience when you come across it. Experiences follow patterns, which repeat
themselves again and again. In our tradition, stories can help you recognize the
shape of an experience, to make sense of and to deal with it.”
(From The Storyteller’s Daughter – Return to a Lost Homeland by Saira Shah
(Michael Joseph: London, 2003, p.8). Copyright © Saira Shah, 2003. Reproduced
by permission of Penguin Books Ltd.)
SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2004 5
 research
Read this
Finger on
Although videofluoroscopy
can identify dysphagia
if you want to
•carry out a literature and distinguish between
review
•test a hypothesis
penetration and aspiration
•identify non2invasiveA on swallowing, it is not
portable solutions
always available or
appropriate. Judi Hibberd
and colleagues investigate
the potential of using the
less invasive pulse oximetry
in conjunction with cervical
auscultation as a bedside
screen for dysphagia.
R
isk assessment in dysphagia manage-
ment considers the likelihood of the
client being harmed from continuing
oral intake, and the potential severity
of that harm. The key to risk assess-
ment is whether or not the client is
aspirating. So, how do we find out?
Videofluoroscopy is accepted as the ‘gold stan-
dard’ (Bastian, 1993). However, the procedure is
invasive, labour intensive and resource consum-
ing. Furthermore, it is not easily accessible and
cannot be performed at the bedside.
Other screening tools are cervical auscultation
and pulse oximetry, both of which are non-invasive
and readily available to most therapists working
with clients with dysphagia. Cervical auscultation
enables deduction of the point in the swallow
where the problem occurs. Pulse oximetry allows
instant and continuous monitoring of the oxygen
saturation of the blood, and a drop in saturation
may be an important indication of respiratory
compromise. As the airway is not directly
compromised either during a normal swallow or
penetration, it may be that saturation levels only
drop during aspiration, allowing the therapist to
distinguish between aspiration and penetration
at the bedside.
The literature is less convincing on pulse oximetry
than cervical auscultation so our hypothesis was that,
if pulse oximetry could be shown to be effective, we
could use the two tools together to create a valu-
able, non-invasive bedside assessment system.
A reliable tool
Research into the effectiveness of cervical auscul-
tation has firmly established it as a reliable tool.
Cichero & Murdoch (1998) hypothesised that the
sounds generated by pressure changes during
SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2004
aspiration are distinct from those made during a
normal swallow. Hirano et al (2000) added further
weight when they found dysphagia diagnosed by
auscultation demonstrated an 87.8 per cent corre-
lation with that diagnosed by videofluoroscopy.
Research into pulse oximetry is more contradic-
tory and less conclusive. So far there is no general
consensus as to the efficacy of the tool, as results
and their interpretation vary widely. Collins &
Bakheit (1997), using pulse oximetry in conjunc-
tion with videofluoroscopy, concluded that the
pulse oximeter indicated a two per cent drop in
saturation levels in aspirators. Zaidi et al (1995)
also found that saturation levels in aspirators
when eating and drinking decreased significantly
more than in non-aspirators. Sherman et al (1999)
too found it useful to a statistically significant
degree, commenting that, “These encouraging
study results indicate that pulse oximetry may
become an essential component of the manage-
ment of dysphagic patients.”
Conversely, Sellars et al (1998) found no significant
correlation between oxygen saturation and aspira-
tion. Leder (2000) did find a statistically significant
difference between aspirators and non-aspirators
but concluded that there was no indication that
pulse oximetry is clinically relevant. Colodny
(2000) found that, while aspirators’ saturation levels
drop during feeding, this was not significant and
that the two per cent drop suggested by Collins &
Bakheit (1997) would not be enough to predict
aspiration.
From this contradictory research, two points
caught our attention:
1) Controls and subjects
Pulse oximetry will only be effective in dysphagia
screening if it can be shown conclusively that a
person at no risk of aspiration does not experi-
ence a drop in saturation levels when eating /
drinking. Yet, in the research designs, numbers of
controls have varied from 0 (Sherman et al, 1999;
Collins & Bakheit 1997) to 77 (Colodny, 2000).
Leder (2000) collected all of his data from patients
in an intensive care ward; his control data cannot
therefore be assumed to reflect what is ‘normal’.
Another difference between studies is partici-
pants’ medical status. Sellars et al (1998), who
found no significant difference between saturation
in aspirators and non-aspirators, noted that their
subjects had respiratory difficulties. Perhaps those
with respiratory difficulties have different results
to those without them?
2) Establishment of mean baseline
Sellars et al (1998) calculated baseline saturation
measurements to one per cent and then noted
deviation from that point. They concluded that a
significant drop would be four per cent. This is in

the pulse
contrast with Collins & Bakheit (1997) who sug-
gested a two per cent drop was significant. We
wondered if the lack of consensus establishment of
significant percentage decrease could be due to the
original assumption of the baseline level as a single
point. If, on the other hand, oxygen saturation is
not fixed and stable but fluctuates within a band,
then the deduction of level of decrease from a
single point will not encourage statistically signif-
icant or useful results. For example, a patient who
is aspirating may drop out of their baseline band,
while a non-dysphagic may also experience a
decrease but remain within their banding level.
Taking into account these methodological prob-
lems, we aimed:
1.To use pulse oximetry to investigate whether
saturation levels drop in people with dysphagia.
2. To collect saturation data from non-dysphagics as
a large control group to compare non-dysphagics
with people with dysphagia.
3. To investigate if there is a significant difference in
saturation levels between those with neurological
and those with respiratory dysphagia.
4. To use cervical auscultation alongside pulse
oximetry to detect the point during the swallow
where the problem occurs.
Permission was granted from two local trusts in
March 2000. We categorised the 92 participants
(35 male, 57 female, aged 15-99 years) into one of
four groups:
Group A - normal controls (n=50)
Non-dysphagic volunteers from the local commu-
nity with no history of neurological or respiratory
problems who were non smokers or ex-smokers of
five years or more.
Group B - respiratory controls (n=17)
Non-dysphagics with a respiratory element
who were volunteers from a respiratory func-
tion test clinic at the hospital, and who had
no history of any neurological condition.
Eleven had chronic obstructive pulmonary dis-
ease and two had asthma.
Group C - respiratory dysphagia (n=5)
People with dysphagia which appeared to
have a respiratory base. One had chronic
obstructive pulmonary disease and one renal
problems.
Group D - neurological dysphagia (n=20)
People with dysphagia which appeared to
have a neurological base. Two had no con-
firmed diagnosis at referral and 18 had cere-
brovascular accidents.
Groups C and D were part of a clinical caseload
referred to us by a medical practitioner for a swal-
lowing assessment.
For all subjects two therapists simultaneously
collected data using the pulse oximeter and cervi-
cal auscultation. The same equipment was used
for all data collection and the two collectors did
not exchange information except for notification
of when a swallow occurred during the procedure.
Firstly, the finger sensor was attached and a read-
ing taken to establish the participant’s baseline. This
took two minutes timed by a stopwatch.
(Participants were excluded if the finger sensor could
not be attached adequately or if they were wearing
nail varnish.) The pulse oximeter then indicated that
the therapist could begin the clinical evaluation.
Cervical auscultation involved the participant
taking three sips of liquid and three teaspoons of
semi-solid food. Risk was assigned based on any
acoustic changes and without access to any infor-
mation from the pulse oximeter. Data was included
only if the therapist completed either a food or
drink assessment consisting of three swallows (De
Pippo et al, 1992) but the assessment was curtailed
if the therapist felt that the risk level was severe
before the three swallows had been completed.
When the therapist heard the participant swallow
she indicated this to her assistant who noted
down the exact time on the stopwatch which ran
continuously from baseline to completion. The
therapists then downloaded the participant’s sat-
uration levels at each of the times on the data
sheet that indicated a swallow had occurred. We
could therefore examine any changes at rest or
during swallows.
Where participants were part of the therapist’s
caseload, the bedside clinical evaluation was com-
pleted by communicating the results of the assess-
ment to the relevant multidisciplinary team.
When the therapist heard the
participant swallow she
indicated this to her assistant
who noted down the exact
time on the stopwatch which
ran continuously from baseline
to completion.
SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2004
research
Data was collected over a nine month period
and analysed using SPSS Version 9.
Fluctuation
The first significant finding involved the normal con-
trol group. Results indicated that normals’ saturation
levels did not remain static for the two minute base-
line establishment period but fluctuated by up to
three per cent. This fluctuation continued during eat-
ing and drinking but, significantly, never dropped
out of the three per cent band.
Having established a norm to a statistically sig-
nificant level, we went on to investigate satura-
tion levels in neurological dysphagics. Results
showed that, although the baseline level was
lower than the controls, all of the neurological
dysphagic group also had a baseline saturation
level within the three point band when at rest.
Thus we established that, for both dysphagics and
non-dysphagics at rest, oxygen saturation does
not necessarily sit at one point but fluctuates by
up to three per cent.
When taking fluid or food, the results strongly
suggested that those at severe risk of dysphagia,
unlike the controls, dropped out of this baseline
band. The results were not statistically significant
overall for this but were significant for the first
swallow of food and of liquid. This was the only
unbiased sample. The lack of significance for the
second and third swallows may be due to ethical
considerations preventing the therapist from con-
tinuing with the assessment when auscultation
indicated a severe risk.
Also significant was the finding that those
ascribed mild risk using cervical auscultation
tended not to drop out of the three point
band. This suggests that they may not require
clinical compensation.
The evidence for the two respiratory groups
followed the same pattern of the three point
band when at rest, with respiratory controls
tending to have a lower baseline than normal
controls and, in some cases, lower than neu-
rological dysphagics. This suggests that previ-
ous evidence that was not statistically signifi-
cant may have been adversely affected by the
inclusion of control data from participants
with respiratory compromise.
The data for respiratory dysphagia also
seems to follow a similar pattern as for neu-
rological dysphagia but, interestingly, some par-
ticipants’ saturation levels moved upwards out of
their baseline band when eating/drinking. Our
sample was very limited in number, but this sug-
gests that there may be a difference between
neurological and respiratory dysphagia, an idea
that further research could investigate. Is it possi- 
E
 research
..resources...
Signalong
Hands for Talking, a partnership of two media
professionals who are parents of children with
special needs, has produced a video to accompany
Signalong’s nursery rhyme book and CD.
Sign A Song, see www.handsfortalking.com,
£14.74 inc. VAT and postage.
And, if you are already thinking about next
Christmas, Signalong also has a book of
secular celebrations to complement ‘The Little
Star’ with its nativity and carols.
We Wish You A Merry Christmas, £11.75 inc.
postage.
www.signalong.org.uk, tel. 0870 774 3753
Computers and disability
National computing and disability charity
AbilityNet has released a step-by-step guide
on CD-ROM to help people with disabilities
access and make the most of the opportunities
offered by computers.
Successful computing for disabled people is
£45 + VAT, tel. 01926 312847,
www.abilitynet.org.uk.
Helping Children
with Feelings
Four new titles in Speechmark’s Helping
Children with Feelings series can be used by
child professionals and parents to help
children aged 4-12 resolve fear, low self-
esteem, loss and rage or hate.
Each guidebook has an accompanying
illustrated storybook (How Hattie Hated
Kindness; Ruby and the Rubbish Bin; Teenie
Weenie in a Too Big World; The Day the Sea
Went Out and Never Came Back).
£90 for all four sets, www.speechmark.net.
Bilingual assistance
A teacher support pack to boost the
attainment of minority ethnic pupils in
England and Wales will be released shortly.
Based on research carried out in Derby, the 30
card pack recommends the use of bilingual
language assistants in the classroom, introducing
dual language tests, raising confidence and
motivation, encouraging parental involvement,
ensuring effective leadership and introducing
elements of the curriculum relevant to the child’s
cultural background.
www.derby.ac.uk
Computer recycling
Tools for Schools is a not-for-profit
organisation that refurbishes surplus business
computers for low-cost sale to schools to help
them boost pupil computer access.
www.tfs.org.uk
0 SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2004
ble that the lack of significant difference between
controls and dysphagics identified in previous
research could be attributed to the inclusion of
both respiratory and neurological dysphagics in
the same group?
Statistically significant
We therefore reached two main conclusions.
Firstly, we established to a statistically significant
level that, when at rest, oxygen saturation levels
of all participants remained within a three point
band. The sample size was such that we can
extrapolate the results to suggest that all oxygen
saturation levels fall within a three point band
when at rest.
Secondly, all control subjects, and those at mild
risk of dysphagia, remained within that band
whether eating and drinking or at rest. A significant
number of those at severe risk of dysphagia
dropped out of the band when eating and drinking.
This was established to the highly statistically sig-
nificant level of p<0.001.
Thus our hypothesis that pulse oximetry may be
able to distinguish between aspiration and pene-
tration cannot be discounted, and we suggest
that, in conjunction with cervical auscultation, it
can be used as an effective and reliable screening
system at the bedside.
Judi Hibberd, Alison Shale, Stephanie Bowers and
Karen Miles are speech and language therapists
with the University Hospitals Cov and Warwick Trust
& Coventry Healthcare NHS Trust. Correspondence
to: Mrs Judi Hibberd, Speech and Language
Therapy Department, Gulson Hospital, Gulson
Road, Coventry, CV1 2HR, tel: 024 7624 6262.
References
Bastian, R.W. (1993) The videoendoscopic swallowing
study, an alternative and partner to the videofluoro-
scopic swallowing study. Dysphagia 8: 359-367.
Cichero, J.A.Y. & Murdoch, B.E. (1998) The physiolog-
ical cause of swallowing sounds: answers from
sounds and vocal tract acoustics. Dysphagia 13: 39-52.
Collins, M.J. & Bakheit, M.D. (1997) Does pulse
oximetry reliably detect aspiration in dysphagic
stroke patients? Stroke 28 (9): 1773-1775.
Finger on the pulse: dysphagia terminology update
Aspiration:
Entry of material below the true vocal
folds.
Cervical auscultation:
The placement of a stethoscope on or
near the cricoid cartilage to listen to the
acoustic signal generated by a swallow
sequence.
Oxygen saturation:
A measure of the amount of oxygen in
the haemoglobin at a particular pressure.
Colodny, N. (2000) Comparison of dysphagics and
non dysphagics on pulse oximetry during oral
feeding. Dysphagia 15: 68-73.
De Pippo, K.L., Holas, M.A., & Reding, M.J. (1992)
Validation of the 3 oz water swallow test for aspi-
ration following stroke. Arch Neurol 49: 1259 -1261.
Hirano, K., Takahashi, K., Uyama, R. & Michi, K.
(2000) Evaluation of cervical auscultation: the
accuracy and acoustic characteristics. Abstract of
presentation at the ninth annual dysphagia
research society meeting, Georgia USA.
Leder, S.B. (2000) Use of arterial oxygen satura-
tion, heart rate and blood pressure as indirect
objective physiologic markers to predict aspira-
tion. Dysphagia 15: 201-205.
Sellars, C., Dunnet, C. & Carter, R. (1998) A prelim-
inary comparison of videofluoroscopy of swallow
and pulse oximetry in the identification of aspira-
tion in dysphagic patients. Dysphagia 13: 82 -86.
Sherman, B., Nisenboum, J., Jesberger, B.,
Morrow, C. & Jesberger, J.A. (1999) Assessment of
dysphagia with the use of the pulse oximeter.
Dysphagia 14:152-156.
Zaidi, N.H., Smith, A.H., King, S.C., Park, C.,
O’Neill, P.A. & Connelly, M.J. (1995) Oxygen desat-
uration on swallowing as a potential marker of
aspiration in acute stroke. Age and Ageing 24:
267-270.
Acknowledgements
We are grateful to Rav Jayram, our research
supervisor, Bill Waine, our statistical analyst, Jan
Lacey, Development Nurse, Jenni Hibberd and
Russell Miles.
Reflections for research
• Do I base comparisons with the
‘norm’ on fact rather than
assumption?
• Do I consider potential
confounding factors when
grouping subjects?
• Do I seek expert assistance for
supervision and analysis?
Penetration:
Entry of material into the laryngeal vestibule above
the true vocal folds.
Pulse oximetry:
The measurement of the ratio of oxygenated
haemoglobin to the total haemoglobin in arterial blood.
Respiratory dysphagia:
A swallowing problem with a respiratory basis,
(chronic obstructive pulmonary disease; asthma) or a
respiratory consequence (renal failure; cardiac
compromise) rather than a neurological base.

Read this
if you are interested in
•the difference between
recounting and storying
•really listening to what our
clients have to tell
•developing your work with
groups
“Do you remember the
time...?” “I couldn’t believe
it when...” “And then she
said...” “A friend of mine
did that once and...”
We are all working to
ensure our clients can
make choices and
decisions, but what of that
most basic of human
needs, the sharing of
conversational stories?
Nicola Grove reflects on
a year spent exploring
different ways of
storytelling with people
who have learning
disabilities.
A year of
storytelling
O
nce there was a girl who was
put under a spell of silence
for a year and a day; and in
that time all she did was col-
lect the nettles that grew in
the churchyard and she
soaked them and retted
them, and spun them into flax and from that flax
she made.......
This is part of a much longer story that I haven’t
the time to tell you here.
Once there was a lecturer who was given a year
and a day to go out and collect stories from people
who don’t find it easy to tell ...
Actually it was a year, but this is poetic licence. I
was lucky enough to receive a mid career award
from the Health Foundation in 2002-2003, and I
spent it exploring some different ways of story-
telling with adults and children who have learn-
ing disabilities. Silence for a year and a day is a
good plan. When you are in the middle of the
forest and feeling your way, it’s quite hard to
explain to other people why you are there and
how to get where you are going. Now I’m emerg-
ing out of the wood, the year is nearing its end
and I’m beginning to be able to see where I’ve
been and what it all meant.
I worked with two groups of adults - nine people
with mild to moderate learning difficulties, and
six people with severe and profound disabilities -
and two families of children with special needs. I
also spent seven days working in special schools,
one for children with autistic spectrum disorders and
one for children with severe learning difficulties.
The main questions which drove my research
were:
• What kinds of stories are generated by people
with severe communication difficulties?
• How can people with disabilities and their families
SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2004
cover story
Picture by Paul Reid, posed by model.
and carers be helped to share experiences
through storytelling?
• What frameworks are most useful for assessing
and teaching storytelling skills?
Personal events
I was particularly interested in conversational sto-
rytelling (Norrick, 2000) about personal events. I
wanted to see what kind of stories people told
about their lives, and whether they could share
these stories effectively with others.
Some clear differences emerged between the
people I was working with, depending on their
ability to communicate. The first group of adult
storytellers all had effective verbal communica-
tion: only three of the nine could be said to have
significant difficulties in expressing themselves.
They told stories about themselves, stories based
on television programmes (EastEnders and Dad’s
Army being the favourites) and traditional stories
such as The Wizard of Oz. Falling off a horse, told
by Terry, is a typical example from the data of an
anecdotal third person narrative:
Falling off a horse
“I have a friend who fell off a horse. She tried to mount it from
a stool. She got on the horse, it jumped and she fell back-
wards. She never went riding again! Gave up the same day!”
This short story meets the criteria for conversa-
tional stories suggested by Norrick (2000). It is
told partly to convey information, but also to
build rapport, being a classic “response story”,
told after Sally had volunteered that she used to
ride and that she had never fallen off. I then
related an accident falling off a galloping horse,
and Terry then contributed his story. Sometimes,
however, narratives were what Norrick characterises
as diffuse (that is, the bones of the story emerge
gradually during the course of a conversation) 
<
 cover story

 and potential (where only one or two narrative

Figure 2 Storytelling analysis
elements are present). Children with autism who
(a) My Hamster (by Ed) were verbal were also able to tell stories, both real
A. She is called Naughty, because once she escaped from the house. and imaginary (see for example Wolves in figure 2).
B. I didn’t put the tubes together properly.
C. It was where I lived before.
D.I kept the door shut all the time.
Reliant on others
E. When I came home one day, I found her missing. By contrast, the nonverbal pupils in the two
F. I said, “Where’s she gone?” schools and the adults with profound disabilities
G. I put a board at each end of the sideboard so she could not keep running up and down. were reliant on others to construct the narratives,
H. She never escaped again. and here there seemed to be a real difficulty in
storying, as opposed to recounting, experience. I
Structure: elicited stories from primary carers of the six
Ed introduces the story with an abstract, summarising the story and explaining the name of the pet (A). He provides
background information (C, D), and then launches into the event sequence (E, F, G) finishing with a resolution (G) and adults with profound disabilities in the story-
a coda (H) which rounds the story off. The sequencing shows Ed veering from one time frame (general past) to anoth- telling group, and from teachers and parents of
er (local past), but this is not enough to derail the story from the listener’s point of view. It’s a rather bare narrative, children in the special schools. What emerged
which Ed could be encouraged to elaborate - for example by including more events such as his search round the room. was a strong bias towards recounts - description
He leaves implicit the finding of the hamster, so that the high point is actually at F, and the narrative is left hanging. of a routine rather than a story about a meaningful
experience. It was common in the interviews for
Affect:
events from the past to be placed in the context
There are a number of evaluations here. At A he says explicitly that the hamster is naughty. At B he explains his own
role in her escape - the inclusion of properly signalling that he was at fault. Ed uses his voice very effectively to main- of the present. Most informants used either the
tain listener attention, stressing “missing” and saying, “Where’s she gone?” with an exaggerated questioning intona- present tense, so that questions originally
tion and a half laugh at the antics of the hamster. He shakes his head as he says the coda (H). designed to focus on the past drifted into the
here and now; or the past continuous, describing
Form: habitual rather than unique events, as in the fol-
Ed uses relatively few rhetorical devices, but here there is patterning in the repetition of “escaped” from the first line
lowing example (N is me, M is the mother of the
in the final line, and the formulaic “running up and down”.
service user concerned):
Audience awareness:
N. And just thinking about the year - what would you say
Ed is extremely aware of the listener. He checks and monitors attention, uses stress, cues the listener into the context
are the key events for Shahela in the year?
(C, D) and provides explanations (A, B).
M. Christmas.
Figure 1 Analysing stories N. Right, what happens at Christmas.
(b) Wolves (by Izzy)
M. Because she has the Christmas tree and the carols.
A. I like the safari park.
She loves listening to the carols. So come around the
B. I see lots of animals.
beginning of December, you know, I start playing the
C. I saw some wolves.
carols at home, and she enjoys that. (.) And she likes
D. They look like me.
summer as well, the sunny days. She enjoys that.
E. They eat bones, your bones!
Those are her highlights of the year.
F. If we were out there, getting out, the wolves would eat our bones.
N. Can you remember any special Christmas - any time
G. They would hunt, they’d crunch and rip your top.
that stands out?
H. I can smell the bones.
M. The opening of the presents she likes, around the
I. I can smell wolves.
tree you know?
J. I hear the howls (makes loud wolf howl).
N. But there isn’t one that stands out?
M. There is one. On Christmas Eve I take her to (shop-
Structure:
ping centre), for many years we have been doing that.
This story, dictated to a teacher, counts as a potential fantasy narrative, because of the tense switches, the hypothetical
We take her there and we have lunch there and we look at
actions, and the lack of climactic event or resolution. There is some confusion in the referent of “getting out” (F), and
the decorations. And she likes that.
there is no logical event sequence as such: eating is mentioned first, followed by the events which would precede it
(hunting, then crunching and ripping).
There were some tantalising clues about why
Affect: this might be so - the impoverishment of many
There is powerful emotive content here, and Izzy leaves us in no doubt how we should be feeling. At (E) he switches people’s lives making reportable events the
from the generalised “bones” to “your bones”, then to “our bones”, including himself as victim with the listener. The exception rather than the rule, and assumptions
exclamation mark suggests he marked the phrase in some way with stress or pitch. He ends with a scarey sound. He that only simple accounts rather than stories will
chooses strong, specific verbs: crunch, rip. He does not, however, make any explicit references to feelings, so that the be understood. The answer may lie in the role of
evaluations are descriptive and evocative rather than personal in character.
the respondent in conversational storytelling.
Form: Where we receive no feedback from the listener,
The story may not be entirely coherent, but it is extremely satisfying, largely because of Izzy’s mastery of rhetorical and where the key person does not initiate a story
devices. He links ideas through patterned sentences and repetition (I like (A) / They look like me (D); I see (B) / I saw (C); by indicating that an event is significant to them,
They eat (E) / They would eat (F); I can smell (H) / I can smell (I)). The repeated phrases with “bones” are particularly we are unlikely to engage in extended storied
chilling, bringing the threat nearer and nearer. He also uses poetic forms: assonance (hunt/crunch) alliteration dialogue. Moreover, the current policy emphasis
(hear/howls) and internal rhymes (rip/top). The short sentences add to the sense of contained menace, with longer pat- on choicemaking (Department of Health, 2001)
terned sentences acting as the climax at F and G. The high point is thus rhetorical and formal, rather than structural.
may privilege some kinds of talk - notably the
Audience awareness: negotiation of wants and needs and decision-
As this is dictated, it is not clear whether the story was in fact constructed for a listener, or as a private fantasy. However, making - over the sharing of experience which lies
the shift in pronouns suggests that Izzy is in fact aware of his listener. at the root of storytelling.
I like this story just as it is, and wouldn’t change a word of it, but I would want to check out Izzy’s ability to structure
event sequences, and to use the language of feeling as well as description. Different approaches
Various different approaches were explored in

I SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2004


the course of the project - working with groups,
working with individuals using PowerPoint soft-
ware or tactile sensory books, and recording sto-
ries in scrapbook form, used with the families. I
will focus here on the value of a storytelling
group for the individuals concerned, the use of
co-narration, and interactive storytelling.
The setting up of groups dedicated to story-
telling definitely contributed to a sense of identi-
ty and to foregrounding the activity, as was evi-
dent in the following field note:
In a discussion about the party invitations, I asked what we
called ourselves - and Jim immediately said “storytellers!”
with an inflection that suggested this should be obvious.
As found previously (Grove, 2002) it seems very
hard for people with learning difficulties to have
the confidence and the skills initially to “take the
floor” and relate a story as monologue. What
works much better is a style of co-narration, where
a familiar story is constructed jointly, with partici-
pants invited to provide specific contributions.
Jim shows a picture of himself in fireman’s uniform. He is
unable to say much here, but the others help out - “He vol-
unteered”; “It’s a fireman”; “It was at the flower show”.
Once the group has supplied
the relevant details, they can Where we
collaborate in the telling of a
story. Jim, Terry and Ed, who all receive no
remembered the war vividly, feedback from
did a storytelling performance
in which I provided the skeleton the listener...
narrative, and they contributed we are unlikely
sound effects, gestures to show
the doodlebug overhead, and
to engage in
key lines of dialogue. extended
Interactive call and response
has proved highly successful in
storied
other contexts (Park, 1999) but dialogue.
is usually associated with tradi-
tional stories, literary stories and poetry. In this
project we used a similar style to construct quick
spontaneous storytelling about everyday events
after lunch in the day centre for people with pro-
found disabilities. The high level of rhetorical
devices - repetition, exaggerated prosody, use of
formulae often programmed onto switches -
seems to work effectively to engage the attention
of people with limited understanding of content.
Although this approach has the effect of ritualis-
ing what is normally a very natural and unaffect-
ed process, the difference between performance
storytelling and conversational storytelling is rela-
tive rather than absolute. Norrick (2000) provides
several examples of patterned language and for-
mulaic speech in his examples of anecdotes told
by adults to each other. There were signs that the
inclusion of a regular shared storytelling activity
could lead to genuine mutual affirmation, and we
saw service users beginning to take part and
respond to what was happening. It is, however,
challenging for staff, requiring a high level of self-
confidence and disinhibition.
cover story
Analytical framework (Adapted from ‘The Three Gifts’ by Helen
Broadbent in Fairy Tales for the Schoolroom,
Analytical frameworks need to fit the available
data: in this case, stories which are diffuse, partial Gresham Publishing Co Ltd.)
and co-narrated. I have drawn principally on the
social constructionist approach, deriving from the Dr Nicola Grove is Senior Lecturer at the Department
work of Labov & Waletzky (1967) and developed of Language and Communication Science, City
by McCabe & Peterson (1991). As well University, e-mail DrNicolaGrove@aol.com.
as the structural or referential compo-
nents of narrative - event sequence, Note: Keith Park and I have now
setting information, climax and resolu- As storytellers set up an organisation to coordi-
nate all the work we do around
tion - Labov emphasises the affective mature, they storytelling - ‘Storytracks’. Further
aspect. The teller needs to convey why
the story is significant and worthy of become more information and free resources
attention, and does this typically able to take can be found on our website
www.storytracks.com, or from 41
through affective signals and devices,
termed evaluations. These are both
account of the St Pancras Court, London N2 9AE.
verbal (for example, references to needs of their Acknowledgements
emotional state) and nonverbal (ges-
ture, intonation, stress). Norrick (2000)
listeners. The projects were supported by a
mid-career award from the PPP
identifies a third aspect, which is
Foundation, and would not have
rhetorical: formal devices used to cue
been possible without the help and cooperation
the genre and thus expected response, to secure
attention, and to give a pattern to the narrative. of service users, staff and families from Fieldways
As storytellers mature, they become more able to Centre and Rosa Morison Centre; pupils and staff
take account of the needs of their listeners. This is at Sunfield and Reynalds Cross Schools; and Karen
apparent in each of the three dimensions Powell, Martin Samuel, Rachel Clifford and
Brenda McConville, student speech and language
(structure / reference; affect; form /
rhetoric), and is represented in the model therapists.
by a shift from the centre (self awareness)
References
to the outer perimeter (awareness of oth-
ers). Figure 1 shows a diagrammatic repre- Department of Health (2001) Valuing people: a
sentation of the model, and Figure 2 new strategy for the 21st Century. London:
HMSO.
shows how the model can be applied to
the two stories, ‘My Hamster’ (told by Ed, Grove, N. (2002) Storytellers in the SLD school.
who has mild learning difficulties) and Paper presented to the Inaugural Conference of
IASSID Europe, Dublin, 12-15th June.
‘Wolves’ (told by Izzy, a child with autistic
spectrum disorder). Labov, W. & Waletzky, I. (1967) Narrative analysis:
Listening to stories - really listening to oral versions of personal experience. In J. Helm
(ed) Essays on the verbal and visual arts. Seattle:
what people who have severe communi-
cation difficulties want to tell - and find- University of Washington Press (pp. 12-44).
McCabe, A., & Peterson, C. (Eds.) (1991)
ing a register that feels comfortable for
Developing narrative structure. Hillsdale, NJ:
telling - is extremely hard work. I feel I have only
Lawrence Erlbaum.
been able to scratch the surface in my year of story-
Norrick, N. (2000) Conversational narrative in
telling, but I’m encouraged by the enthusiasm and
everyday talk. Amsterdam: John Benjamin.
interest of the many people I have worked with -
Park, K. (1999) Storytelling with people with sen-
day centre staff, school staff, parents, students
sory impairments and additional disabilities. SLD
from City University and people with learning dif-
Experience 23: 17-20.
ficulties themselves.
A King had three daughters, all born on the same
day, and he decided to send them out into the
world and give his throne to the one who brought Reflections
home the best gift. The first girl returned after a • Do I value opportunities for
week with a pearl of great price which bestowed silenceA listening and
eternal youth and beauty on its owner. The second
returned after a month with a dagger which granted
reflection?
certain victory over foes. But the summer slipped
away and still the third daughter had not returned. • Do I help clients share
One day in early autumn she was resting in a wood experiences and build
when suddenly a quaint little figure appeared, conversational stories?
dressed in motley. “Your sisters have brought home
great and wonderful gifts”, he said. ‘But what • Do I try to see the wood as
have you been doing all this time?” “Oh,” said well as the trees?
she, “I’ve been listening to stories....”
SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2004 J
 early intervention
Read this
if you
•have the opportunity to be innovative
•want to provide a community based,
inclusive service
•plan at a strategic or operational level
Alison Cooke & Dana
Taylor report back on
their joint mission to
bring specialist
knowledge of early
speech and language
development to two
culturally diverse Sure
Start locations in Sheffield.
W
e were asked recently what
our recommendations would
be for up-and-coming Sure
Start speech and language
therapy posts. Following a
year of joint targeting of
early language promotion in community settings,
our answer was: two speech and language thera-
pists working in a skill mix partnership. So, why do
we feel this is so crucial?
Just as the medical profession heard of The
Gatekeeper and the Wizard (Mathers et al 1989),
we thought a galactic perspective would be an
appropriate analogy to reflect our experiences
initially, before we give a more mainstream
account. So here goes...
A long, long time ago, in a galaxy far, far away
(Sheffield), a chosen one....no, actually two chosen
ones, were brought forth to fulfil their destiny as
speech and language therapists (well, speech and
language workers, but that comes later) within
Sure Start. The future had yet to unfold. Sure
Start, a new entity within the galaxy, remained
formidable and their task was to promote early
language development and early identification,
and to empower the community. The challenge
was indeed a great one but, together in partner-
ship, they knew they could rise to it.
In the early stages of their allegiance, the plan
was a simple one...to loiter with intent and let
themselves be known to the community. The aim
was to dispel the myths around speech and language
therapy and to ensure they were approachable.
Armed with little more than a packet of plasters,
they set out on foot (trainers at the ready) wher-
ever possible to drop in at community venues and
put names to faces. During their travels they
- SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2004
Sure Start:
the final fron
learnt of many tales of woe, as well as wishes.
Actively seeking out and listening to their com-
munity enabled them to develop a plan of action
at both a strategic and operational level.
The two chosen ones felt honoured to work in
partnership and be given the opportunity to take
on this challenge. However, they felt understand-
ably apprehensive about taking on such a diverse
role. They felt that a united front was a stronger
force than a divided one.
During Sure Start team meetings it quickly
became apparent that they appeared alien to the
other chosen ones from around the galaxy. They
had to work at being accepted. Rather than orbiting
around the planet, they had to land on site regu-
larly, especially in a social capacity (lunch-time).
Their title as speech and language therapists
merely functioned to isolate them from the team
and hence they came to be known as Sure Start
speech and language workers. Their apparel was
another obvious issue. They appeared very clinical in
their dress code, which affected their rapport with
the community. Fabrics such as cotton and wool
were replaced with denim. They worked together
to establish an allegiance with the entire commu-
nity, so that the success of their mission became
even more tangible and so the story continues...
............
Play & Say is a six week workshop devised to
promote speech and language development pre-
dominantly with children under four. It is aimed
at showing carers how they can help their child’s
speech and language development by having fun
together and playing. At present, we are targeting
the local parent and toddler groups. The workshop
was piloted with successful results in January to
February 2002 and we have subsequently completed
a further four Play & Say workshops within the
two Sure Start areas. These were five very different
groups and we therefore adapted Play & Say to
suit individual needs.
Loitering with intent
We started co-working in Sure Start in July 2001.
We were excited to have been offered such a chal-
lenging role, but at the same time a little apprehen-
sive. The Sure Start areas we work in are culturally
diverse, one having over 42 languages spoken in
one community. We therefore felt it was essential
to find out what the community really needed in
terms of communication before setting an agenda.
We subsequently spent approximately three
months ‘loitering with intent’ - visiting community
settings, being seen and talking to staff and families
about current opportunities to promote language
development and potential future partnerships.
During this time we got to know various members
of the community quite well and vice versa.
During visits to local nurseries we discovered
their concerns about the lack of verbal communi-
cation skills that children were displaying and
their lack of readiness for reading and writing.
This is consistent with the findings of Locke et al
(2002) in their study based in the local area. They
reported a link between poor verbal skills and a
difficulty acquiring academic skills. Teachers
reported a number of difficulties to us, namely:
limited vocabulary, sentence formulation skills,
attention and listening skills, turn taking skills,
knowledge of nursery rhymes and lack of ability
to participate in group times. They felt that a
potential contributory factor was a lack of verbal
interaction in the pre-school years and a lack of
attendance at or active involvement in parent and
toddler groups.
From here we decided to investigate the local
preschool provision. Again, this involved loitering
with intent and talking to the children and carers,
as well as observing. The environments varied.
However, there appeared to be a number of carers
viewing the group as support for themselves,
whilst they sat quite separately from the children,
who were left to play with little supervision and
minimal adult interaction.
From our observations it seemed that many of
the children showed restricted symbolic play skills
even at three to four years of age, with difficulties
not dissimilar to those noted by the nursery staff.
Snack time often had no set routine. In general,
children were given food and drink and left to sit
or wander around, whilst carers sat together.
When discussed with fellow Sure Start Workers
they reported the same findings and noted a lack
of motivation to be more active on the carers’
part. This was consistent with our discussions with
carers, which indicated that the carers needed
support from each other and adult conversation.
They did however show interest in our ideas for
activities to promote language, and responded
with positive comments.
As early intervention has been shown to have a
positive effect on children with general develop-
mental delay or more specific speech and lan-

ontier
guage difficulties (Glascoe & Sturner 2000), we
decided to take action and Play & Say evolved.
Inclusive
Our initial criteria were to run a workshop that
was community based and inclusive. We wanted
carers to have the choice of opting in or out. We
did not want to offer a ‘speech and language
therapy’ group. Following the ethos of Sure Start,
we wanted all children, regardless of their lan-
guage abilities, to be included.
As carers had shown an interest in our ideas to
promote language development, we wanted to
give them something that would benefit both
themselves and their child. We knew it had to be
realistic, so that they could take it on board and
generalise it to their own environments. We were
already aware that many of the carers we talked
to saw Parent Toddler Groups as a support system
for themselves, plus a chance for their child to
play with others. We therefore needed a way to
show carers activities that they could continue in
the group and at home, as well as continuing to
have adult conversation and some time out.
The aim is to demonstrate hands on strategies to
enable and empower carers to promote language
development and feel confident transferring
these skills to any environment. For example,
singing “hello” and “bye-bye” to the children and
“have a turn and pass it on” encourages social use
of language and makes them feel like a special
member of the group. Carers can then continue to
sing these at home, singing hello in the morning,
bye-bye to toys as they are tidied away or “have a
turn” while playing a family game. This promotes
interaction and the essential precursors to effective
everyday social communication. It also encourages
the acquisition of social tools that prepare a child
for their entry to nursery and make active partici-
pation less daunting.
Groups of approximately four to six children
(depending on ages) and their carers are taken on
a rotational basis. They are taken to a quiet area
within the setting. The carers are encouraged to
be with their child throughout the activities and
to Play & Say together. After each session the carers
are given a Play & Say home activity pack. This
contains ideas and games related to the theme of
that particular session, for example a nursery
rhyme activity booklet.
A typical workshop, including songs used, is
described in figure 1. 
early intervention
Dana’s son Dominik helps Alison perfect her technique!
Figure 1 A typical Play & Say workshop
Week One: Introduction
Carers are introduced to the idea of “playing & saying” in this week. They are given verbal and
written information about the aims and practicalities of the workshop. Carers fill in a consent
form, a snack time information sheet and a Starter Vocabulary Checklist (Locke, 1985) (with help
from us as necessary). Filling in the vocabulary checklist enables us and carers to monitor progress
of individual children. Additionally, it helps us determine what level to pitch language activities at.
Week Two: Nursery Rhymes
Each carer sits with their child and the “hello” song is sung to all the children. We then sing
“have a turn and pass it on” and the children are given a choice of two action nursery rhymes.
This is presented visually in the form of symbol cards for each rhyme. The children choose a card
(with / without naming the rhyme, depending on verbal ability) and place it on the choice board
(attached by Velcro). We model the key vocabulary for the children and sing each rhyme together
(with words available for those who don’t know them). We then sing “bye bye” to each child and
give them a reward sticker and a home activity pack.
Week Three: Listening & Attention / Animal Theme
Again, the “hello” song is sung. After singing the “have a turn” song, each child selects a small animal
picture from a bag and matches it to the appropriate larger picture (again, with / without naming the
animal). The animal words and noises are modelled for the children. We then sing the “have a turn”
song and each child selects an animal picture, which they wave in the air during ‘Old MacDonald’. We
finish the session by singing “bye bye” giving a reward sticker and a home activity pack.
Week Four: Snack Time Choices
A structured snack time is demonstrated, using a choice of two items of food and drink. These are
food / drinks that the group would normally have. Symbols for each choice are used to reinforce
these visually and to involve non-verbal children in making choices. The “have a turn” song is
sung and carers are encouraged to partake in this activity, supervising and interacting with the
children. This demonstrates how they can promote language by giving the children choices. The
symbols are exchanged for the requested item. The session is ended with the “bye bye” song,
giving of reward stickers and home activity packs.
Week Five: Body Parts
Fun with water week! Again, “hello” is sung. Children and carers are encouraged to bath dolly
together, the adult reinforcing body parts vocabulary and concepts. We then look at the body
parts lotto and sing “Heads, Shoulders...” and “bye bye”. Reward stickers and a home activity
pack are given.
Week Six: Evaluation (Play & Say Toys)
Evaluation forms are given to carers. Help is given as necessary to ensure that everyone is able to
express their opinion. There are opportunities to discuss follow up workshops and time for carers to
talk privately about any concerns they may have about their child’s speech and / or language. We
also talk about toys that help you to Play & Say with your child, and provide written information.
Favourite activities are repeated. Certificates are given to both carer and child.
Play & Say songs
Hello (made up tune)
Hello Meena, Hello Meena, Hello Meena,
We’re glad you came to play.
Have A Turn (“London Bridge Is Falling Down”)
Have a turn and pass it on,
pass it on, pass it on,
Have a turn and pass it on,
Pass it on to Jamie.
Bye Bye (made up tune)
Bye bye Max, Bye bye Max, Bye bye Max,
We’re glad you came to play.
SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2004 --
 early intervention
 CHILD VOICE
Well-known phrase
Play & Say has been successful. It is now a well-known phrase within the
community - in many different languages. We have been evaluating
Play & Say in a number of ways, namely through feedback forms, vocab-
ulary checklists, informal interviews and keeping field notes. By collat-
ing this information, we have been able to conclude that it has been a
productive initiative. We have used feedback in a positive way to adapt
the workshop to make it as effective as possible. Sure Start has received
a number of phone calls from carers requesting further information
and when / where they could attend. A waiting list has developed.
Monitoring suggests that word of mouth appears to be the main source
of community information regarding Play & Say. This indicates the impact
it has had on the community and the encouraging reviews we are getting
from local people.
In one area we are compiling Play & Say toy packs, consisting of sym-
bolic play items such as a doll and tea-set, that children will receive after
completing the six week Play & Say workshops. Workshops are continu-
ing to be run on a regular basis. Additionally, Play & Say is being piloted
in a nursery environment, with so far positive results. However, with
increased demands on our time, we are looking to train other people to
take on this enabling role. We have initiated a City wide training pro-
gramme. This includes initial training on Play & Say, which will be followed
by participants shadowing a workshop in order to be able to run them
independently. As we become involved with new Sure Start pro-
grammes, we are constantly extending the opportunities to Play & Say
and hope the momentum and success will long continue.
Working in partnership has been highly rewarding. Being able to
work in such an exciting and innovative area together has enabled us
to be more creative and effective than if we had been working alone.
It has facilitated the targeting of a larger population size and allowed us
to deliver speech and language information to a wide range of settings.
We have learnt a lot during this past year. We have learnt about trans-
disciplinary, interdisciplinary and multidisciplinary ways of working. We
have gained an insight and developed skills around working in a
diverse cultural environment. Tackling problems together has been far
easier than facing them in isolation and we have been able to reflect
on our experiences. This has enabled us to continually develop ways of
working that promote good evidence based practice and mean we
work with the community for the community.
May the force be with you!
Dana Taylor is a Specialist Sure Start Speech & Language Worker / Therapist
and Alison Cooke a Senior Sure Start Speech & Language Worker / Therapist
with Sheffield Speech & Language Therapy Agency Sure Start Team.
References
Glascoe & Sturner (2000) Surveillance and Screening: In Law, J.,
Parkinson, A. & Tamhne, R. (Eds) (2000) Communication Difficulties In
Childhood - A Practical Guide. Radcliffe Medical Press.
Locke, A. (1985) Living Language. Putting Words Together. NFER-Nelson.
Locke, A., Ginsborg, J. & Peers, I. (2002) Development and disadvan-
tage: implications for the early years and beyond. International Journal
of Language and Communication Disorders 37 (1): 3-15.
Mathers, N.J. & Hodgkin, P. (1989) The Gatekeeper and the Wizard - a
fairytale. BMJ 298:172-4.
Reflections
•Do I get out and networkA or do I expect
people to come to me?
•Do I take advantage of opportunities to work
with colleagues?
•Do I work with the community for the
community?
- SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2004
REVIEWS
AN EXCELLENT OVERVIEW
Working With Children’s Voice Disorders
Jenny Hunt and Alyson Slater
Speechmark
ISBN 0 86388 279 X £34.95
This book provides an excellent overview of child voice development and disorder
and should appeal to both the generalist and specialist therapist for its accessible
and practical format. It gives an overview of the development of the infant and
juvenile larynges and the contributory and maintaining factors of voice problems,
and practical advice is included for case history details, the assessment and evalu-
ation of the child’s voice and subsequent management strategies.
Layout is good with subheadings and bullet points to help the busy therapist. A
series of photocopiable handouts covering information about voice, exercises,
record sheets and letters provides a timesaving resource.
Recommended in terms of content and value to therapists who have infrequent
contact with paediatric voice problems. It should prove to be a very practical
resource in any clinic.
Karen Shuttleworth and Alison Taylor are Speech and Language Therapists work-
ing for Morecambe Bay Primary Care Trust.
LANGUAGE
CLEAR AND RELEVANT
Basic Verbs
ColorCards®
Speechmark
ISBN 0 86388 476 8 £25.95 + VAT
This pack contains 48 large format colour photocards presented in a sturdy box.
The photographs are clear with relevant subject matter and should encourage
vocabulary expansion in clients of all ages.
The background colour enhances rather than detracts from the target verb thus
reducing visual perceptual problems for some clients.
This resource would be beneficial to all therapists working with both individuals
and groups and it will help to encompass many therapy aims in areas such as verbal
comprehension, expressive language, sentence formulation and indeed general
communication skills. Children enjoy and respond well to the colour photographs
and we would recommend this set as a valuable asset to any therapist requiring a
set of action pictures.
Alison Taylor and Karen Shuttleworth are Speech and Language Therapists working
for Morecambe Bay Primary Care Trust.
EDUCATION
STRAIGHTFORWARD GUIDE
How to ... Identify & Support Children with Speech and Language
Difficulties
Jane Speake
LDA
ISBN 1 85503 361 5 £9.95
This straightforward guide for teachers, SENCOs and teaching assistants will help
them identify primary aged children who have speech and language difficulties.
Terminology is covered. There is an overview of the roles of education and speech
and language therapy plus a discussion of collaborative working. Inclusion of AFASIC
checklists provides a structured approach to observation and a basis for referrals.
The most useful section identifies strategies for support and gives specific ideas on
helping the child to manage in the classroom. Ideas on multi-sensory materials
and experiences are given and difficulties are linked to the curriculum. There is an
excellent section on ideas to underpin semantic development.
Well written and inexpensive, this is good on basic ideas but limited in follow-up;
speech and language therapy extension would be advisable. More resources and
more on IEP targets would improve it. A resource for therapists working in main-
stream schools to recommend if opportunities for training are limited.
Noreen Marks is a speech and language therapist in Essex.

LANGUAGE DEVELOPMENT
A USEFUL REFRESHER
Child Language Development - Learning to Talk 2nd Ed.
Sandra Bochner & Jane Jones
Whurr
ISBN 1 86156 379 5 £25.00
This is a comprehensive handbook for those working across the range of
early years settings, especially speech and language therapy assistants /
workers. It would also be a useful refresher for those returning to practice.
Every part of the programme rationale is supported by up-to-date and
referenced research, yet the authors manage to maintain an enjoyable,
readable style.
The book has three parts:
• the background theories upon which the authors based their
language programme
• the language programme, including a chapter on how to organise a
programme
• phonology, AAC, working with non-English speaking families,
working in groups and with families.
An excellent resource for any early years practitioner, and good value for
money.
Debbie Wheeler is a speech and language therapist with Sure Start Barrow.
ADULT STAMMERING
A CHALLENGING OPTION
Beyond Stammering: The McGuire Programme for Getting
Good at the Sport of Speaking
David McGuire
Souvenir Press
ISBN 0285636731 £12.99
This easy-reading user guide provides an understanding into the ethos
and method of the David McGuire Programme. Based on using costal
diaphragmatic breathing to control stammering, it emphasises drilling
this technique in a manner analogous to championship tennis. No compro-
mises are offered on the path to eloquence, its ultimate goal! It discusses a
holistic approach to dealing with the complexity of stammering, tackling
fear, avoidance and self-actualisation. Achieving its goal is by no means
an easy road and may well be beyond the scope of many. A worthy
resource and a challenging option!
Nicola Godfrey is a speech and language therapist for Brent PCT, London.
MANAGEMENT
EMINENTLY READABLE
Healthcare Management Directory
Annie Phillips
Radcliffe Medical Press Ltd
ISBN 1 85775 802 1 £21-95
Somewhat daunted at having to review a healthcare management dic-
tionary I actually found it eminently readable and extremely useful.
The author is a qualified speech and language therapist with extensive
NHS management experience. The communicative style is very clear pro-
viding hundreds of plain English definitions of clinical management
terms, acronyms and jargon currently in use within Primary Care.
As this type of text can date quickly, websites have been provided
throughout as a useful source of further information.
This very comprehensive reference book would be a valuable resource
for any department and in particular for newly appointed managers or
clinicians in leadership roles.
Good value for money, but will probably need updating / revision within
two years if the current rate of change within the NHS continues.
Angela Grant is Head of Speech & Language Therapy for North Devon
Primary Care Trust.
reviews
COLLABORATION
OFF-THE-SHELF PACKAGE
Speaking, Listening & Understanding
Catherine Delamain & Jill Spring
Speechmark
ISBN 0-86388-433-4 £32.95
This book contains a collection of activities, games and photocopiable work-
sheets for use with children in Key Stage 1 of the National Curriculum for
England and Wales. The three main sections are: ‘Understanding Spoken
Language’, ‘Using Spoken Language’ and ‘Activity Resources’.
Games and activities are designed for whole class use and are intended to fit
into the existing curriculum.
Each activity includes a clear aim, graded for difficulty, equipment and preparation
required, as well as instructions and additional ideas for extension.
A relevant resource for therapists covering busy mainstream schools, providing
an off-the-shelf package for teachers to support existing language therapy
programmes.
One small criticism - the illustrations and texts provided in the teaching resource
section could be more attractive.
However, good value for money and a useful tool to develop collaborative working
between teachers and therapists.
Ann-Marie Thompson is a specialist speech and language therapist for mainstream
schools with Homefirst Community Trust, Northern Ireland.
LIFE SKILLS
KEY REMINDERS
ColorCard® Simple Sequences
Vanessa Harrison
Speechmark
ISBN 0 86388 475 X £25.95
This resource can be used in schools for children at key stages 1 and 2 for a variety
of purposes in assessment and management of communication difficulties. The
pack comprises 48 large colour format photographs depicting familiar situations
with varying age groups participating.
Activities involving sequencing and extending ideas / possibilities as a basis for
discussion in a group are possible as well as using the pictures to address tenses,
opinions and use of language in descriptions. They could be useful as key
reminders for pupils learning familiar sequences in daily living events.
Janet V. Graves is a senior speech and language therapist with Conisbrough and
Denaby Main Education Action Zone in Doncaster.
HEARING IMPAIRMENT
BASIC AND PRACTICAL
Working with Children with Cochlear Implants
Published as part of a series of RNID Education Guidelines titles
Updated ICTOD guidelines included
RNID (tel 0808 808 0123)
ISBN 0 900 634 987 £5.99
Intended to support teachers of the deaf, this would be a useful resource for
speech and language therapists as well as mainstream teachers and parents. It
provides easily accessible guidelines including useful background information
for anyone new to cochlear implants. Discussing implants with the parents of
very young children and with teenagers are among the issues covered.
The main section deals with supporting children after implantation with the
emphasis on practical help. Advice sheets of ideas for parents and children from
Foundation Stage to Key Stage 4 can be photocopied. At the end of the book is
a particularly useful resource section containing addresses and lists of publications.
The Implant Centre Teacher of the Deaf (ICTOD) guidelines will make speech
and language therapists aware of the remit of teachers of the deaf.
Shirley Down is a speech and language therapist with the Conwy &
Denbighshire NHS Trust in North Wales.
SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2004 -5
 winning ways series ()
Enjoying
the ride
“ He has half the deed done,
Who has made a beginning.”
Horace
I never make any secret of
the fact that I believe my
work to be vocational and
spiritual. That is not to say
that religion usually comes
into coaching unless it is specifically part of the
work that my client wants to do. No, the spiritual
element of the coaching is just the acknowledge-
ment that we are all made up of mind, body and
spirit, and that each of these elements is hugely
important and simply cannot be ignored.
However, many people believe that we are get-
ting into slightly boggy ground when the spiritu-
al dimension is mentioned, and are inclined to
leave all that stuff to mystics, and off-the-wall
incense burning, tree-hugging wackos.
But close your eyes for a moment and ponder
the following scenarios:
1. The person who is your immediate superior
calls you into his or her office. They tell you that
your work is outstanding and that your profes-
sionalism and efficiency are an example to all.
What is your reaction? How do you feel? What
emotions are around for you?
2. Now - imagine that you are on top of a high hill
or mountain, that you have spent most of the
morning climbing. It is a glorious day, the sun is
shining, the sky is blue, and the temperature is
perfect. You sit down to rest and gaze around,
when suddenly and unexpectedly an eagle soars
beside you, unaware of your presence.
Now, can you describe the difference between
these two experiences? I would argue that the
first gives you mind and possibly body pleasure. It
is ego driven, however, and the mood change was
brought about by another’s opinion. The second
is experienced at a spiritual level, and conse-
quently touches us in a completely different way.
The first experience was earned, whereas the second
was given freely by nature and is available to all.
I start in this way because the main thrust of this
column is balance and, as you can see from figure
1, a life out of balance is an uncomfortable
experience, no matter how good some elements
of it are.
Symbiotic relationship
When I was approached to write for this maga-
zine my experience with the world of speech and
-
SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2004
As the wheel of life
goes round, it’s easy to
lose our balance. Life
coach Jo Middlemiss
encourages us to find
ways of getting things
back on an even keel.
if you
Read this
• have already broken New Year resolutions
• feel mindA body and spirit are out of
balance
• have a tendency to procrastinate
language therapy was limited but, within days of
agreeing to do it, I was asked to take on a deaf
lady as a client. Serendipity! Jean had some chal-
lenges in her life relating to confidence. I have no
signing skills at all but I do know about confi-
dence building so I wasn’t going to let a little
thing like ignorance get in my way. Also, there is
a statistic going around that says only seven per
cent of communication depends on words so I
thought I would have a go. Another element of
coaching is the sure knowledge that both coach
and coachee are helping each other and that the
relationship is entirely symbiotic.
Jean arrived from Glasgow with some trepida-
tion. She spoke incredibly well thanks to her own
determination and she taught me how to speak
to her in a relaxed yet focussed way. We also used
a flip chart for illustration and word clarification.
I had to set up the room differently, use signs and
actions and pay even closer attention to my client
than usual. However the story was really no dif-
ferent to many I had worked with. Dealing with
others’ insensitivity was the presenting problem
but the real issue was that my client was looking
outside herself for solutions. She wanted to
develop skills leading to a new and interesting job
but the work would involve speaking in public
and she carried with her the memory of being
laughed at in school, and one or two insensitive
teachers who had treated her as though she was
stupid.
In her adult life she was a successful wife and
mother not to mention a gifted sportswoman at
both riding and tennis. She did not rate these
talents as successes because they came fairly easily
to her. The coaching work was to take the confi-
dence she experiences when she feels powerfully
in charge of a horse and transfer that confidence
to speaking in public. She imagined each session
as a hurdle to be leapt over. Another challenge,
which faced her was that she was by nature a fun
loving and gregarious person. She imagined that
it was her deafness that got in the way of her
expressing her natural instincts. Jean accepts that
nothing can be done about her deafness but the
coaching has been useful in as much as she has
been able to address her attitude to herself and
other people. When she decided to put fear to
one side and actually ask people to slow down or
to say something again she was amazed to find
that they welcomed her interruptions and altered
their behaviours accordingly. Her fear of being
thought stupid made her critical and judgemental
of them. The truth was something very much
simpler.
Jennifer is a part time speech and language
therapist. She is a member of a newly created
out-reach team. She is a portfolio worker with
other part-time jobs plus time consuming family
commitments. Skilful balancing of all these
aspects of her life was Jennifer’s main challenge.
After filling in the Wheel of Life diagram (figure
1) Jennifer was able to pinpoint the areas of her
life that she needed to smooth out in order for
her to be as effective a speech and language ther-
apist as she wanted to be. Use of time and space

plus developing good relationships with her new
colleagues was Jennifer’s main concern.
One of the seemingly innocuous questions in my
first session form is: “What unfinished jobs and
unused items do you have using up your energy
and space?” Initially this had not been Jennifer’s
focus but when she realised that she could hardly
get into her study to get going on her plans and
make her decisions, she decided that she would
like to tackle that first.
Calm and productive
She was honest enough to acknowledge that
although she was always busy she was also a bit of
a procrastinator. Procrastinators are rarely lazy
people; they are just people who do not differen-
tiate between ‘urgent’ and ‘important’. They tend
to do the jobs as they come at them so life tends
to be like driving through a snowstorm with inef-
ficient wipers. It’s exciting and absorbing but you
never seem to be getting anywhere. There was so
much stuff in Jennifer’s office that she was con-
tinuously searching for and stepping over things.
So, somewhere that she would like to have as a
calm and productive place had become a place
she just wanted to close the door on.
I asked her to imagine her room with absolutely
nothing in it. How does that feel? Fantastic?
Jo: “Is it in decorative order that appeals to you?”
Jen: “Yes.”
Jo: “Now, in your imagination, start putting
things back in the order you need and want
them...”
Now followed a process of replacing only essen-
tial items. Computer table and computer, desk,
comfortable chair, bookcase and only half the
books from the bookcase.
Once Jennifer had a mental picture of a clear
and peaceful space to work she felt motivated to
clear that space and to get the work done that
she had been putting off. Unnecessary piles of
paper and unread articles were discarded, books
taken to a central base where they could be used
by others, and borrowed equipment returned.
Once she had a plan and had committed herself
to the job nothing could hold her back. The spin
off was that clutter in other parts of the house
was tackled also. Her children were enlisted to
help and her mood lightened when she realised
how oppressive all the excess stuff was. The sense
of satisfaction and success in this area encouraged
Jennifer to start tackling other areas of her life.
winning ways series ()
Figure 1 (see, for example, Whitworth et al, 1998)
Would you like to: Physical Environment Career
• Identify and achieve your dreams
Fun and Money
• Unlock your potential recreation
• Confront difficult decisions
• Shake off restrictive behaviours
and limiting beliefs Personal Health
growth
• Gain and maintain mental and
spiritual balance Significant other/
Romance Friends and family
• Be aware of and use your talent? The eight sections represent balance.
The centre is 0, the outer edge is 10.
Our series ‘Winning Ways’ with Rate your level of satisfaction with each section, then draw
Personal Life Coach Jo Middlemiss a new outer edge (example below).
How bumpy is your ‘Wheel of Life’ now?
aims to help you find out how you
can be better at what you do, and
better at being you.
To gather material to make the
issues - and their potential solutions
- as realistic and relevant as possible
for readers, Jo offers readers a
confidential and complimentary
half-hour telephone coaching
session (for the cost only of your
call). Although Winning Ways will always choices, because there is always more than
be based on what is raised in the one way to look at anything and there is always a
calls, you can be reassured that choice of attitude. And after everything else
details will be altered so that it will there is a call to action. What am I willing to do to
not be possible to identify individuals. change this situation and what am I willing to
stop doing to make this situation better? So let
CALL JO ON 01356 648329
this year be about solutions rather than resolu-
(www.dreamzwork.co.uk).
tions and then, rather than desperately worrying
about punctures or falling off, you will enjoy the
ride.
There was a good outcome for me too as I reor-
ganised all my books after my session with Jo Middlemiss is a qualified Life Coach with a back-
Jennifer. ground in education and relationship counselling,
Balance is important, and we all seek it. But tel. 01356 648329, www.dreamzwork.co.uk.
why? Firstly, balance is not a static state. You
know that the minute you try to stay still on a Reference
bicycle you will probably fall off. No, we need Whitworth, L., Kimsey-House, H. & Sandahl, P.
constant small adjustments and corrections to stay (1998) Co-Active Coaching: New Skills for
on the bike and on the path. ‘Out of balance’ is Coaching People Toward Success in Work and Life.
that awful feeling that one is being driven by cir- Davies-Black Publishing.
cumstances. When I see hearty people riding a
tandem it gives me the collywobbles - I wouldn’t
want someone else riding my bike!
When you feel as if you have no choices in any
Reflections
situation - know that the bike is beginning to
wobble. When you hear yourself saying things •Do I recognise and face up
like “I can’t.....I have to.... I need to......That won’t to my fears?
work because she would never...” - know then
that your ego, gremlin, lower self, call it what you
will, has taken over the steering of your life. •Do I know where I could
FEAR is its usual guise but, when your awareness release energy and space?
notices, then it’s time to stop, think and look for
options and to call on that part of you which is •Do I see what I need to
not hindered by past failures, fears or limiting
beliefs.
start 2 and what I need to
That is where your spiritual self comes in and
stop 2 doing?
gets you back into balance. No one can do that
for you, and no one makes it happen. There are
SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2004 -E
 guidelines
You talk -
but what does
O
Read this
if you want to find out how
•clients can benefit from new
communication tools
•technology can be adapted to
enable wider access
left to right: Malcolm Joyce,
•to choose software with
Claire Philpott, Peter Roberts appropriate features
-0 SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2004
ver the past 50 years, computer technology for automatic
speech recognition has advanced significantly. Low cost com-
mercial products are now available with good performance
in continuous speech recognition for people without speech
difficulties. Such software can give a new dimension to the
ability to use computers, including office tools, internet
access and even games.
We have been investigating the viability of automatic speech recognition use
by people with dysarthric speech difficulties. The key issues are the capability
of the software to adapt to the particular characteristics of the dysarthric
speech, and the degree to which the recognition can tolerate an increased
variability of certain characteristics of the dysarthric speech (Thomas-Stonell
et al, 1998; Blaney & Wilson, 2000).
From limited recognition of a small vocabulary of single words or digits in
the 1950s, speech research moved to new concepts in the matching of input
speech with stored speech databases in the 90s. Statistical modelling and
matching methods enabled the development of a series of viable products,
which gave continuous speech recognition with progressively increasing
vocabularies. Newer product technologies with what are called Hidden
Markov models, together with neural nets, allow effective and rapid ‘user
training’ of the inbuilt speech databases. This personalisation gives a high
level of recognition accuracy (95 per cent) across many speakers.
Earlier research with people with dysarthria was restricted by technology in
terms of both cost and performance. However, even with the early template-
based solutions, successful recognition of dysarthric speech could be achieved,
with closely limited vocabulary and tailoring of the speech model (Ahmed, 1985).
Ferrier et al (1975) showed good recognition in trials with one, and then
ten, dysarthric speakers, using early software. A panel of listeners also scored
the intelligibility of the speakers. The work demonstrated the value and
effectiveness of the Hidden Markov models learning/training process where
recognition accuracy increased from 30 per cent to 90 per cent over three sessions.
The poorer speakers displayed more variability in their speech, including that
caused by fatigue. This demanded longer automatic speech recognition
‘training’ sessions but, ultimately, similar levels of recognition were achieved
to the moderate or mild dysarthria. Further investigation of the causes and
characteristics of this variability would be useful, especially with larger numbers
of speakers.
Doyle et al (1997) also endorsed the effectiveness of the automatic speech recog-
nition learning with the newer software products (six speakers: two mild, two
moderate, two severe), especially for severe dysarthria where, after six sessions, the
automatic speech recognition was still displaying learning improvements.
Increasing viability
In the UK research continues with ‘STARDUST’ at Sheffield University and various
projects at Frenchay Hospital, Bristol. Our current work (Roberts, 2002) has
endorsed further the increasing viability of these software packages, certainly for
mild and some moderate dysarthria, and we have developed specific guidelines
to help the dysarthric user and their carers in the most effective configuration and
use of the facilities.
The computers and operating systems now available are well established
and give good value for money. As they are being marketed in a competitive
 guidelines

es it type?
situation, designers are continually looking to give equivalent and improved
Most people are familiar with the idea
of using a keyboard to type up a
document, send an e-mail or play games
on a computer. Automatic speech
recognition software can also be used to
facilities. This means there is considerable ongoing change and update to the do these tasks; as the adverts say, “you
products, with the risk of compatibility problems and change to appearance
and procedures. Different versions, or releases, of software do change aspects talk, it types”. But can this work when
that are of particular relevance to the dysarthric user. A good example is the
improvement in flexibility of the IBM speech training/enrolment process in
the user has a speech difficulty such as
release 10, from release 8. Further software releases may include changes to dysarthria? Peter Roberts, Malcolm Joyce
the advantage of people with dysarthria. However, a progressively increasing
capability has a down side of potentially increased complexity of use or com-
and Claire Philpott find out...
patability problems that may be a particular disadvantage for disabled users.
the remaining moderates and the severes could not use the systems because
Users need to maintain an awareness and alertness to these possibilities
they were not able to ‘enrol’ (the initial process to enable the systems to
when acquiring particular systems and ensure the use of appropriate profes-
recognise the specific voice). However, as you will see, we were able to follow
sional advice as necessary.
a series of procedures that improved on this initial recognition performance.
It is especially important that users and carers avoid the frustration and
errors of an impatient, unprepared start, and build up an understanding of Figure 1 Initial recognition performance
the features of automatic speech recognition systems. A range of self-train-
ing tools is included with the software and specialist training is also available.
In our research we used proprietary software packages from IBM (ViaVoice)
and ScanSoft (Dragon; Naturally Speaking) with Pentium 3 and 4 computer
processors, and Microsoft Windows 98SE, 2000, and XP. The conditions of the
Initial
various speakers involved in the research are in table 1. enrolment
cannot
Table 1 Speakers involved in the research enrol

patient ID severity M/F condition

mild1 mild male kennedy syndrome, slowly
progressive
mild2 mild male cerebellar ataxia, slowly
progressive
moderate1 mod male cerebellar ataxia, slowly progressive
moderate2 mod male stroke, static Satisfactory user speech input was achieved with the small headset and
moderate3 mod male multiple systems atrophy, slowly microphone supplied with the packages. The instructions included in the
progressive package guide the fitting and positioning of the headset. The use of these
moderate4 mod male kennedy syndrome, slowly microphones gave a good tolerance to the effects of ambient noise and
progressive acoustic characteristics of the surroundings. Some trials with hand-held or
moderate5 mod male cerebellar ataxia, slowly progressive desk-mounted microphones were less successful, as potentially improved
moderate6 mod female stroke, static quality of the microphone was offset by increased susceptibility to the effects
moderate7 mod male cerebellar ataxia, slowly progressive of surroundings. We therefore recommend use of the supplied microphones.
Once the software is installed, an initial set-up process is carried out. This
moderate8 mod male stroke, improving
enables the adjustment, usually automatic, of microphone loudness levels,
severe1 severe male cerebral palsy, static according to particular users.
severe2 severe male head injury, static Unique user set
severe3 severe male stroke, static At this stage a unique user set of information is initiated. A name is chosen
for this user, then subsequently re-selected as required in the future. The
control1 male
variability of some dysarthric speakers can usefully be managed and accom-
control2 female
modated by the user identification, as there is nothing stopping one user
control3 male progressively establishing him/herself with more than one user information
set. For example, if the person’s voice has differences between early morning
In the initial analysis (figure 1) people with mild and some with moderate and later in the day, with fatigue affecting loudness or pitch, then two user
conditions were able to make some use of the software. However, all of names would be set up. Careful choice of names for each user set helps man-
these moderates had recognition performances of less than 50 per cent. Also agement and avoids later confusion. 

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2004 -<

 guidelines

As initial set-up proceeds, the user is requested to progressively introduce
‘samples’ of their voice to ‘train’ the software in the particular characteristics
of their voice. This is usually called the enrolment process.
This area of set-up gave difficulty to some dysarthric users. Early versions
(such as release 8 of IBM ViaVoice) demanded complete and correct reading of
the prompting texts on the screen, but some versions (including release 10, and
all versions of Naturally Speaking that we examined) allowed the user to skip
sections that were proving difficult, and progressed to a point where sufficient
data was achieved. We therefore recommend the more flexible enrolment.
Where enrolment was still proving difficult (even after trying the various
alternative texts provided) we had the possibility of changing the actual text
to be read. Figure 2 provides an indication of where this helped as shown by
the data labelled ‘tailored enrol’.
Figure 2 Enhanced recognition performance
standard
use
tailored
enrol
reduced
vocab
cannot
enrol
When the speech recognition system is being used, the software is continually
referring back to a vocabulary database held in the system. This database is
generally a large and reasonably complete vocabulary as supplied with the
system and is adequate for typical use. Associated features that can be of
value to dysarthric users are:
1. Different variants such as US or UK English can be selected.
2. Different supplementary databases such as legal or medical can be invoked,
according to the application area of the users.
3. It is straightforward to add vocabulary. Words and phrases, specific to users,
are added either by specifying (and speaking) particular items, or by letting
the software analyse typical documents relevant to the user.
4. As the system is being used, the opportunity is available for correcting mistakes
in recognition. When this is done as instructed, it has the effect of improving
accuracy of subsequent recognition.
However, where dysarthria is significantly affecting the ability of the software
to recognise the speech, an alternative strategy may be of value. If the vocab-
ulary database is deliberately reduced to a minimum set of words used by the
speaker in particular restricted circumstances, it can give the automatic
speech recognition a better chance of selecting appropriate matches to the
spoken word. Figure 2 indicates where this helped, as shown by the data
labelled ‘reduced vocab’, but it does place an equivalent constraint on the
use to which the software can be effectively applied.
All the systems examined are supplied with a series of ‘commands’ built in
to the vocabulary, which carry out specific actions rather than just counting
as dictation words. The obvious needs are for commands for the speech dic-
tation, such as ‘newline’, ‘uppercase’, ‘fullstop’ and so on. Further commands
are especially useful for navigation, including on Internet pages when using
a web browser, like ‘back’, ‘forward’, ‘move down items’ or ‘close’. These fea-
tures are of potential value to disabled users, especially if keyboard ability is
difficult or limited.
With certain versions of the automatic speech recognition packages (usually
the higher specification / cost variants) it is possible for the user to add their
own commands and macros / shortcuts. These can be especially valuable to
disabled users, where a command can save considerable effort and time. For
example ‘myaddress1’ could insert the speaker’s full name and address auto-
-I SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2004
matically. Alternatively ‘contact1’ could generate all the text concerning a
wish to meet or contact at a particular address and time.
You will need to examine closely specific details of all these features in the
specifications or manuals for the package in question.
Ongoing improvement
All the systems have a range of features to enable ongoing improvement of
the vocabulary databases as the system is being used. As more recognition is
being carried out, especially in the creation of letters and documents, the
correction of mistakes / misrecognitions can be set to build up improvement
to recognition. Documents being produced can also be used to build up better
automatic speech recognition knowledge of the speaker.
In general, you have to deliberately activate the above features, and cor-
rections to recognition mistakes have to be carried out in a particular way.
Specific documents have to be triggered to contribute to vocabulary update.
We recommend the use of these features where practical for the users.
Also, as users become more familiar with the speech input capability, they can
progressively integrate the automatic speech recognition with other applications
on their computer. Spreadsheets, internet browsers, and even graphics packages
can be ‘speech enabled’ to give facilities especially valuable to a disabled user.
If you have a significant level of technical competence with computers, you
can make further changes and tailoring to enrolment and vocabulary. Be
warned, though, that incorrect changes at this level could disrupt the operation
of the software and the computer system as a whole, and can cause consid-
erable difficulty and frustration.
1. Changes to enrolment
For some dysarthric users, the available enrolment texts were not usable.
There was difficulty with certain words, or difficulty maintaining concentration
and interest in an enrolment process that was potentially very tiring. This
meant that enrolment was difficult, and in some cases not possible.
As an extreme test of this issue, we changed the enrolment text to a series
of much simpler texts used by speech and language therapists in the course
of their work. Figure 2 shows how this enabled successful enrolment for
speakers designated moderate5 and moderate6. The simplified enrolment
text also gave a better recognition performance for moderates 1, 2, 3 and 8,
although there was probably a limiting of the range of trained speech.
In another test, the text was changed to a passage more familiar to the
user, enabling a more relaxed and representative enrolment. Speaker desig-
nated mild2 in figure 2 shows the improvement in this case.
The change to enrolment text was carried out on the Scansoft/Dragon
Naturally Speaking packages versions 5 and 6. Initial searching is required to
find the file containing an existing enrol text (a datan.bin file) and carrying
out a series of cut and paste then re-save operations in the Microsoft
Notepad editor to replace with alternative text.
When these changes to enrolment are used, it is also important to watch for
any potential omissions in the vocabulary and to use the automatic speech
recognition vocabulary editor to fill any omissions relevant for the typical usage.
2. Changes to vocabulary
Automatic speech recognition systems come with various editors to enable
basic and more involved adjustment to vocabulary. You should consult the rel-
evant instruction manuals for more information.
To evaluate potential benefit of reducing vocabulary, we re-established the
speakers designated moderate 6,7 and 8 with a vocabulary limited to the simple
texts. This meant that, when using the software, the choices of vocabulary and
phrases likely to be spoken by that speaker were deliberately bounded. The
recognition tests were then also limited to those words and phrases.
Figure 2 shows the improvements in recognition accuracy achieved, but at
the cost of the heavily reduced scope of usage that is a consequence of the
limited vocabulary. For some dysarthric users, this situation may be regarded
as a benefit and improvement.
The vocabulary reduction in this test instance was achieved by using an
enrolment option with ‘empty’ vocabulary, for example in Naturally

Speaking, which is intended for specialist users to add specific vocabularies.
Some items of basic vocabulary are defined in the system so that they cannot
be deleted. We then had to ensure that the words of vocabulary needed for
the targeted use were added by analysing the relevant text documents.
We have summarised guidelines for the use of automatic speech recognition
by dysarthric speakers in figure 3. Our work suggests that current commer-
cially available automatic speech recognition products can be viable for mild
or moderate dysarthric users. This applies, to a reasonable extent, to even the
basic lowest cost options of the software (around £30).
Figure 3 Guideline summary
Key points
• use the microphones provided, and follow set-up procedures carefully
• ensure adequate preparation and understanding of the features
before starting
• take particular care and patience with enrolment
• set up more than one ‘user’ per person to manage variability
• improve the vocabulary database
• balance features and changes against potential complexity of use.
Specialist adaptations
• try simplified enrolment to aid initial set up
• modify the vocabulary database in a way appropriate to the user.
Peter Roberts and Malcolm Joyce are based at Lancaster University, Lancaster
LA1 4YR. Claire Philpott is a speech and language therapist with Morecambe
Bay NHS Primary Care Trust, Lancaster LA1 4JT.
Please note that we give guidelines in the context of the software examined,
and to a level of features considered appropriate. This should not be taken
as a definitive recommendation, or a criticism, of any specific manufacturer’s
package. The manufacturers and distributors involved are very willing to give
help and advice to disabled users, in order to assist their use of the products.
To get easiest responses you should contact them by email rather than telephone.
References
Ahmed, W.W. (1985) Computer recognition of cerebral palsy speech. Proc
speech tech conf, 205-209.
Blaney, B. & Wilson, J. (2000) Acoustic variability in dysarthria and computer
speech recognition. Clinical Linguistics & Phonetics, 14(40): 307-327.
Doyle, P.C., Lepper, H.A., Kotler, A., Thomas-Stonell, N. Oneil, C., Dylke, M. & Rolls,
K. (1997) Dysarthric speech: a comparison of computerised speech recognition
and listener intelligibility. Jour rehabilitation research & dev 34(3): 309-316.
Ferrier, L.J., Shane, H.C., Ballard, H.F., Carpenter, T. & Benoit, A. (1975)
Dysarthric speakers intelligibility and speech characteristics in relation to computer
speech recognition. Augmentative & Alternative Communication 11: 165-174.
Holmes, J. & Holmes, W. (2001) Speech Synthesis and Recognition. Taylor &
Francis, ISBN 0 748 408576.
Roberts, P.E. (2002) Speech Recognition Technology for Dysarthric Speech
(pp243-248). In: Advances in Communications and Software Technologies,
WSEAS, ISBN 960 8052 71 8.
Thomas-Stonell, N., Kotler, A-L., Lepper, H.A. & Doyle, P.C. (1998) Computerised
speech recognition: influence of intelligibility and perceptual consistency on
recognition accuracy, Augmentative & Alternative Communication 14: 51-56.
Resources
• AbilityNet at Warwick UK, tel 01926 312847 (http://www.abilitynet.co.uk)
• Lancaster University, contact pe.roberts@lancaster.ac.uk
Reflections
• Do I consider both positive and negative effects when
planning change?
• Do I read instructions to ensure I make the best use of
a product?
• Do I access help in the voluntary and academic sectors?
guidelines
...resources...resources..
Step by Step
Work on the StepByStep software for people with aphasia is
progressing. The developers welcome contact from anyone interested
in becoming a beta tester.
Jane Mortley, Steps Consulting Limited, e-mail
jpmortley@btinternet.com.
Get animated
New items in the 2004 Don Johnston Special Needs sourcebook
include PCS Animations, aimed at helping pupils to learn about verb
meanings and tenses.
The animated Picture Communication Symbols include washing dishes
and brushing your teeth. They can be imported into other programs
such as Speaking Dynamically Pro, Clicker 4 and BuildAbility.
PCS Animations is £78+VAT, tel. 01925 256500.
Stammering Research
The British Stammering Association is to publish an on-line
international journal, dedicated to the furtherance of research into
stammering. The editor is Peter Howell of the Department of
Psychology at University College London.
Stammering Research, see www.stammering.org/research.html.
2004 Directory
The Contact a Family Directory of Specific Conditions and Rare
Disorders 2004 includes 30 new entries. Every entry contains a
medical description of the condition with details of inheritance
patterns and pre-natal diagnosis, and relevant support organisations.
Print edition £35, tel. 0207 608 8700, CD-ROM £88.13 (single user),
www.cafamily.org.uk.
Afasic Helpline
A leaflet outlining the services offered by the Afasic Helpline includes
the opening times, recruitment of volunteers and the helpline
complaints procedure.
The confidential service provides support and information to everyone,
particularly parents, to enable them to secure appropriate help for
their children with speech, language and communication needs.
Copies from Afasic, tel. 020 7490 9410.
BSL software
‘Let’s Sign & Write’ is a new development to support British Sign
Language (BSL) in education as a separate and equal language.
Over 700 BSL graphics, in both plain line drawings and full colour, can
be used with Widgit’s Writing with Symbols software, or in other
programs such as Microsoft Word and desk top publishing programs.
You can use them to create individualised materials, either with signs
alone, or with symbols, finger spelling and text.
A guide book includes information on supporting signers, a glossary
of the signs and ideas for creating resources.
Let’s Sign & Write by Cath Smith is published by Widgit Software, tel. 01223
425558, www.widgit.com, £35 single user, £45 single geographical site.
Understanding Asperger’s syndrome
The author of ‘Autism and Creativity: Is there is a link between
autism in men and exceptional ability?’ hopes his book will help
people with autism be more understood and included in a society in
which everyone has strengths and weaknesses.
Michael Fitzgerald (Henry Marsh Profession of Child and Adolescent
Psychiatry at Trinity College Dublin) suggests that several high profile
men, including Socrates, Lewis Carroll, Keith Joseph and Eamon de
Valera, could have had Asperger’s syndrome.
Pub. Brunner-Routledge, £29.99.
SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2004 -J
 collaboration
Skills for
How can therapists and teachers provide effective
support for secondary aged pupils with specific
language impairment? Barbara Clarkson and
Angela Peel join forces with their Year 8 and
Year 10 pupils to offer some ideas.
O
ur secondary speech and lan-
Read this guage resource, based at a High
School which also has a 6th form
Read this if you are
interested in and language college status,
opened in September 1999, aiming
• metacognition to provide successful inclusive
education for pupils aged 11 years and over who
• promoting inclusion have severe specific language impairment. The
model of provision which has developed is based
• improving social skills
collaboration on pupils with specific language impairment
Angela & Barbara receiving their education within their peer group
in mainstream lessons for all subject areas except
modern foreign languages, supported by specific
specialist lessons within the resource focusing on
‘Learning Skills’ and ‘Challenger - Social Skills’. We
are now finding real evidence of this being a suc-
cessful practice. Our model is based on an 11 year
collaborative relationship as a specialist teacher
and a specialist speech and language therapist.
Our model is Our way of ‘doing’ social skills work with such
pupils through Challenger groups was our first
based on an 11 collaborative venture all those years ago, and
year collaborative now provides the foundation for all the other
relationship as a specialist support we provide for our current
pupils.
specialist teacher We believe that we are providing an opportunity
and a specialist for pupils to develop a clear picture of themselves
speech and ‘warts and all’ and to be proud of who they are,
to develop awareness of positive interaction within
language school with teachers and peers and the skills that
therapist. make it work, and to extend their metacognitive
ability to think about their actions in situations
and problem solve effectively. We started our
Challenger work following the outline provided
within the Social Use of Language Programme
developed by Wendy Rinaldi (see Rinaldi, 2001),
but found that we needed an ongoing curriculum
of social development which went beyond the
excellent foundation it provided. For pupils in our
resource, Challenger holds a permanent place on
their timetable, once every week throughout
their time with us. We cover basic skills of interaction
along with introducing self / other awareness in
Year 7 (a year of Social Use of Language
Programme work), and then extend these themes
through a more topic based approach in later
years (for example, bullying, rules and discipline,
friendship, repairing breakdown in relationships,
 SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2004
celebration of who I am, feelings and their
expression, teamwork and so on).
Role as facilitators
We believe it is the HOW of our lessons rather
than the content that makes the difference. All
pupils are supported in developing their own
thinking and evaluation skills right from the start
- we give them the responsibility for working out
solutions and see our role very much as facilitators
rather than teachers or therapists. We set the task
and then ask key prompt questions, constantly
feeding back the problem to the pupils so that
they make their own discoveries. We often find
that the lesson explodes in new and powerful
directions, ignited by the pupils’ own need to
learn and change. But what do our pupils think
Challenger is all about? We decided to take the
plunge and ask our Year 8 and Year 10 pupils to
brainstorm what they thought we were learning
in Challenger. Quotes following on from the
brainstorm are reproduced with pupils’ own styles
and spellings.
Barbara Clarkson is a specialist speech and lan-
guage therapist with Eastern Wakefield Primary
Care Trust and Angela Peel the specialist teaching
head of Wakefield secondary speech and language
resource at St Wilfrid’s Catholic High School, 6th
Form and Language College. This article was writ-
ten with the resource pupils from Years 8 and 10.
References
Rinaldi, W. (2001) SULP-R. Windsor: NFER-Nelson.*
Reflections
• Do I recognise that how I give
my input can be more
important than the content?
• Do I tap into a client’s own
need to learn and change?
• Do I give clients the
opportunity to say what they
think they are learning?
 collaboration

r life THINKIN
G
FRIE
NDS
HIP RESPEC
T CONCE
NTRATI
ON
“The games are there to improve our skills and to
“Challenger has a lot of activities that give us more confidence...The games also helps us “We play communicating games
well help you to make a lot of to concentrate and to be patient and different because it helps us better when
improvement to how you work in a ways to think. Also to use the right body language. were in conversations and other
classroom and at home. In most of the We also do brainstorms and the teachers do role- things.” (Year 8)
challengers lessons we work as a group play so we will know what to do and what not to
to improve each other. In challenger we do and to see if we can spot the mistakes what we
play a game at the start of the lesson might do.” (Year 10) CONFID
to get us to start think.” (Year 10) ENCE
WORK
T “The way I’ve think Challengers help GROUP
ONTAC is me is I’ve become more & more
C
EYE confident....I can having a “The skill in this activity teaches me how to
conversation where as 4 years I didn’t do eye contact better and it helps my
want to have conversation as much I memory remember things.” (Year 10)
E
ENC
show people what I know orally.
Another way Challenger has helped PATI
my is I’ve learnt to work as a group EXPRES
INCLUS SION
ION where as 4 years I use work on my
own as much as possible.” (Year 10)
“Social skills mean’s working with people not
“We learn about teamwork, to believe in alone all the time and we learn things when
each other, express our thoughts and to share “You can learn things by listen to we work together we take turns in listening
other peoples ideas...Learn to be patient so people and talking to people so to people and talk to people.” (Year 8)
we can wait for people to finish what they you can understand what they are
have to say so you don’t think that your ideas saying.” (Year 8)
are the most important. We also have to
“In all the challenger lessons we have this thing
respect each other.” (Year 10) ROLE-P
called a brainstorm. This helps us to write things LAY
down so we don’t forget them.” (Year 10)
GE
“You share feelings so that you
ANGUA
can have fiends to share with YL “We make new friends Because
you.” (Year 8) BOD we want to be mate and be
“...help each other as a
team because we are
nice to each other.” (Year 8)
REMEM honest, trusting and
TURN T BERING all friends.” (Year 8)
AKING “The challenger has leant us a lot of skills like
trying to us use eye contact...The activities teach
to us will help us to think about what we will
“I think that challenger has help me to think have to face in life and to get us to use them in
before I do something. In some of the lessons the lessons and when you are out with friend. “We learn things from Challenger by
we get to work in a group so it gets us used to The skills that we have learnt is eye contact and using it anywhere if someone in troble or
working as a team.....I think that challenger to use it when someone is talking to us. The got problems.” (Year 8)
will help people that have some problems to activities we have learnt is to help people how
think and to get them to work more if they have to get the help of people to get their ideas
NG
LISTENI
will play the game challenger.” (Year 10) across in a group so it lets us now what they are
thinking. When someone is feeling left out we
G
TORMIN try to get them to work as a group with us and
BRAINS to get them to get their ideas across if they
“We play games because it is to get us
want to help and work in a group.” (Year 10)
“Social skills help us with reading, writing, thinking about are lesson and get are
thinking and doing and the way people live brains started.” (Year 8)
and work together in groups.” (Year 8) PRACTI
CE

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2004 -

 further reading
COCHLEAR IMPLANTS
FURTHER
further reading further reading further reading further reading
Vermeire, K., Brokx, J.P.L., Van de Heyning, P.H.,
READING Cochet, E. & Carpentier, H. (2003) Bilateral
cochlear implantation in children. Int J Pediatr
Otorhinolaryngol 67 (1): 67-70.
This regular feature AIMS: to determine the benefit of bilateral cochlear
aims to provide implantation in a child on speech and language
information about development. METHOD: This child got her first
implant, a Nucleus 24-system, on the right side at the
articles in other
age of 2.5 years. The left side was implanted at the
journals which age of 4.4 years with a Nucleus 24Contour-system. On
may be of interest the right side she’s now wearing an Esprit 24-speech-
to readers processor (SPR). On the left side she has a Sprint-SPR.
The Editor has M. goes to a mainstream school and receives Speech
and Language therapy in a Speech and Hearing
selected these
Rehab Centre. The etiology of her deafness was
summaries from a hyperbilirubinemia. Auditory capacity and speech
Speech & Language recognition tests were performed for both ears sepa-
Database compiled rately and together. RESULTS: Aided thresholds give a
by Biomedical PTA of 28 dBA with the first implant, 22 dBA with the
second implant and with both implants we get a PTA
Research Indexing
of 23 dBA. Results for speech identification and
Every article in recognition demonstrated an increased performance
over thirty journals when both implants are used together. Speech and
is abstracted for language development was equivalent to the mean
this databaseA of age 4.5. At the time of testing M. was 4.8 years. At
this time the speech and language development
supplemented by a
show no delays with normal hearing children. CONCLU-
monthly scan of SIONS: bilateral cochlear implantation in children may
Medline to pick have additional value for their speech and language
out relevant development. Also, implantation may be considered
when auditory neuropathy is likely.
articles from others
To subscribe to the VOICE
Index to Recent de Jong, F.I.C.R.S., Cornelis, B.E., Wuyts, F.L.,
Literature on Kooijman, P.G.C., Schutte, H.K., Oudes, M.J. &
Graamans, K. (2003) A psychological cascade
Speech & Language model for persisting voice problems in teach-
contact ers. Folia Phoniatr Logopaed 55 (2): 91-101.
Christopher NorrisA Maintaining factors and coping strategies were
DowneA BaldersbyA examined in 76 teachers with persisting voice prob-
lems, and physical, functional, psychological and
ThirskA North
socioeconomic factors were assessed. A parallel with
Yorkshire YO<
PPA a psychological cascade model designed for patients STAMMERING
tel -<0E 0
I5A with chronic back pain was demonstrated. The major- Kalinowski, J. (2003) Self-reported efficacy of an all in-the-ear-
fax -<0E 0
EE0 ity of the patients were in a deadlocked situation canal prosthetic device to inhibit stuttering during one hundred
(phase 1 of the cascade model), for which the combi-
nation of externalization and unawareness of the sit-
Annual rates are
uation is the main risk factor. Subjective rating of the
CDs (for Windows voice problem was assessed by the Voice Handicap
JE): Index (VHI) and a visual analogue scale (VAS).
Institution LJ Patients in phase 1 of the cascade model showed
Individual L< higher VHI and VAS scores compared with the other
patients. For a high VHI score, the combination of
Printed version:
socioeconomic factors and being in phase 1 was the
Institution L< most important risk factor. Socioeconomic factors
Individual LE  were the most important risk factors for a high VAS
score. The term ‘chronicity’ is introduced, meaning
Cheques are that the problems are maintained, the patient finds
himself in a deadlocked situation, and is sliding down
payable to
into a chronic disease. ‘Chronicity’ is essentially dif-
Biomedical ferent from ‘chronic’, which refers only to the dura-
Research tion of the disease. Maintaining factors and (inade-
Indexing. quate) coping factors, consisting of emotional/psy-
chological, physical and socioeconomic aspects, are
considered as indicators for chronicity.
 SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2004
AUTISM
Charman, T. (2003) Why is joint attention a pivotal skill in
autism? Philos Trans R Soc Lond B Biol Sci 358 (1430): 315-24.
Joint attention abilities play a crucial role in the development of autism.
Impairments in joint attention are among the earliest signs of the disorder
and joint attention skills relate to outcome, both in the ‘natural course’
of autism and through being targeted in early intervention programmes.
In the current study, concurrent and longitudinal associations between
joint attention and other social communication abilities measured in a
sample of infants with autism and related pervasive developmental dis-
orders at age 20 months, and language and symptom severity at age 42
months, were examined. Extending the findings from previous studies,
joint attention ability was positively associated with language gains
and (lower) social and communication symptoms, and imitation ability
was also positively associated with later language. Some specificity in
the association between different aspects of joint attention behaviours
and outcome was found: declarative, triadic gaze switching predicted
language and symptom severity but imperative, dyadic eye contact
behaviours did not. Further, although joint attention was associated
with later social and language symptoms it was unrelated to repetitive
and stereotyped symptoms, suggesting the latter may have a separate
developmental trajectory. Possible deficits in psychological and neuro-
logical processes that might underlie the impaired development of
joint attention in autism are discussed.
ADHD
Friedman, S. R., Rapport, L. J., Lumley, M., Tzelepis, A.,
VanVoorhis, A., Stettner, L. & Kakaati, L. (2003) Aspects of social
and emotional competence in adult attention-deficit/hyperac-
tivity disorder. Neuropsychology 17 (1): 50-8.
Social and emotional competence were evaluated using self-report and
behavioral measures in adults with attention-deficit/hyperactivity disorder
(ADHD) and controls. Adults with ADHD viewed themselves as less socially
competent but more sensitive toward violations of social norms than con-
trols. Films depicting emotional interactions were used to assess linguistic
properties of free recall and perceived emotional intensity. Although
adults with ADHD used more words to describe the scenes, they used
fewer emotion-related words, despite rating the emotions depicted as
more intense than did controls. In contrast, no group differences for
words depicting social or cognitive processes were observed. Overall,
adults with ADHD appear more aware of their problems in social versus
emotional skills. Findings may have implications for improving the psy-
chosocial functioning of these adults.
hours of university teaching: an autobiographical clinical com-
mentary. Disabil Rehabil 25 (2): 107-11.
This manuscript outlines the lifelong battle with severe stuttering and
describes a new modality of effective amelioration of the disorder from the
standpoint of a university professor and researcher in the field of stuttering.
Childhood reactions to stuttering are discussed, along with the educational
and vocational impact of stuttering. Ongoing therapy was received
throughout the formative years and into adulthood, emphasizing reduced
rates of speech. The use of Delayed Auditory Feedback (DAF) was found to
induce fluent speech, but was considered only as a tool for decreasing the
speech rate to achieve fluency. When fluency under DAF was discovered to
be possible at faster speech rates, the possibility that the use of DAF and
other forms of altered auditory feedback could themselves have an inhibito-
ry effect on stuttering, without concomitant rate reduction was investigated.
An In-The-Canal (ITC) fluency-enhancing device was used that provided DAF
and Frequency Altered Feedback (FAF) to produce more fluent speech.
After 10 months of use, the author was relatively free from stuttering.
Speech was natural sounding, relatively spontaneous and unlaboured with
an absence of fear. However, further testing (that is currently underway at
various centres) is necessary before generalizations can be made.

Alison Roberts with some more
low-cost, flexible therapy suggestions.
“Here’s one I
made earlier...”
Emotions / Facial
Expressions Dice
“
This is a useful and fun activity for a group
of students with autistic spectrum disorder.
You can use it as a 5-minute ‘filler’ or extend it
into two 20-minute exercises.”
Materials
• mirror
• wooden, sponge, or polystyrene cubes
approx 4 cms, either from a toyshop, or
made yourself
• simple images of facial expressions
depicted on sticky labels
Brawn
You may need to saw off the cubes from a
length of timber. Take care over the
sanding, so that there are no splinters.
Artistry
You can copy the images of facial expressions
from various books on body language; or
from Asperger’s Syndrome: A Guide for
Parents and Professionals (Tony Attwood,
1997, Jessica Kingsley Publishers), on the
page headed ‘How are You Feeling Today?’;
or you can do your own artwork; or simply
write the emotions on the sides of the cubes.
It’s good to have two cubes, one with the
easier expressions (happy, sad, angry,
surprised, disgusted, scared), and one with
more subtle ones (confused, worried,
shocked, unsure, tired, disappointed).
In Practice (I)
1. Each member of the group rolls the cube
with the simple expressions. Just copy the
one you roll. Check in a mirror.
2. Repeat using the more complicated
expressions.
3. Roll both dice; make one ‘face’, then the
other one.
In practice (II)
Two people each have a cube; they roll, and
make the face, then, by looking at each
other (not the dice), swap facial expressions.
Road sign Dominoes
“This game promotes careful observation,
road safety, and conversation about road
manners (a form of self / other awareness!)
It is useful for clients who have grown out of
picture dominoes, but who find the traditional
black & white dots game boring. Also useful
for those who are current or potential drivers.”
Materials
• You need to buy at least two Highway
Codes. In fact four would be
better, as then you can use both
sides of each page. You need
two of each picture.
• Good quality card, or Taskmaster blank
cards (£5.75 for 200,
see www.taskmasteronline.co.uk). My
advice is not to scrimp on this, as you
need to present your (quite expensive)
pictures in the best possible way.
Brawn
Cut out the signs and keep together in their
pairs. Bear in mind that each card will need
to show two different signs. You will need
to line up the cards and stick one of each
pair of signs on the touching sides of
adjacent cards. The first half of the first
card will match up with the last
half of the last card.
In Practice (I)
Play as for other forms of dominoes.
In practice (II)
Stick pairs of pictures on different cards,
and use for a Snap game.
SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2004
here’s one I made earlier
Eye Instruct You
“This is a game to encourage eye contact,
and can be stretched to become a memory
game too.”
Materials
• 1 pair of spectacle frames (old sunglasses
with the lenses pushed out are fine), or
you can use your hands
• 1 foam or Koosh ball (or scrunched up
paper if you’re really skint)
In Practice (I)
1. One person (any of the clients, or the
therapist) wears the glasses. Another
person has the ball.
2. The person wearing the glasses indicates,
with their eyes only, another person in
the group to whom the ball must be
thrown.
3. Now a new person has the glasses, and
you start again.
In Practice (II)
You can extend this by looking at two
people, so the catcher throws to one person,
who then throws to the second one. This
involves everyone in close watching and
memory.
5
 how I
Louise K. Frazer left Scotland for
Barbados five years ago and works on a
private basis as a paediatric speech and
language therapist.
Further information on Johansen Sound
Therapy from Camilla Leslie, 10
Kingsburgh Road, Edinburgh EH12 6DZ,
tel/fax 0131 337 5427, e-mail
Camilla.leslie@johansensoundtherapy.com,
www.johansensoundtherapy.com.
For details of the North Eastern Speech
& Language Therapists Association see
www.nesta25.com. The Silver Jubilee
Conference ‘From Training to Practice’
was held on 12th November 2003
near Newcastle.
The tools of the trade
W
hen you are working on an Island
with only a few other therapists, it
is important professionally and
personally to attend gatherings of
other like-minded people. In July 2003 I was lucky
enough to go to the 20th National Lingui Systems
Conference in Las Vegas, along with a large num-
ber of paediatric speech and language therapists
from all over the United States and Canada. The
seminar that had most impact on my practice was
A balanced approach to school-age stuttering
therapy by Nina Reardon, a stammering specialist.
I am often at a loss over where to go with some of
the school age stammerers. Their therapy is usually
a long haul - they have sometimes had therapy
from an earlier age and no change has been noted.
Since attending Nina’s seminar, I have used the
‘tools’ she outlined with three different clients.
All three boys are aged from 8-10 years and have
not had any intensive stammering therapy before.
They have enjoyed discovering new things about
their stammers and have become experts about
stammering difficulties. They feel much more con-
fident about stuttering and within therapy sessions
there has been a noticeable decrease in their
stammers. The parents have also commented on
how much better their speech is at home.
We know that our goal is not for perfect fluency.
We should be aiming for more fluency. Do we tell
our clients and families this? Are they expecting that
miracle from us? We should be aiming to give our
clients effective communication. The child needs to
accept that they stammer and know that both stam-
mering and managed speech are OK. Therapy needs
to activate the child’s ownership of stuttering.
Therapy needs also to be meaningful to the child.
As therapists, one of the tools we can give our

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2004
How I
am keeping
Readers have asked for more feedback
days. Here, we travel to Las Vegas, Edin
about a toolbox for school-aged childr
Therapy and a variety of projects in the
For Louise Frazer, working
with school aged children
who stammer was a particular
challenge - until she found
the right tools for the job.
clients is to be their own therapist. During the
process of intervention it is important for speech
and language therapists to create opportunities
for long-term success from the very first moment
of therapy. So there is really no such thing as
transfer and maintenance activity - all the things
we do from the first moments of therapy are
transfer and maintenance activities (figure 1).
Before we start, we need to discuss our therapy
with the client, parents, teachers and others.
We do not need to count stammers - this is too
variable. It can be done on entry and exit to the
therapy programme but not on a weekly or daily
basis. Changes can be documented in a speech note-
book. Ratings can be given by therapist and client at
the end of each session: “On a scale of one to ten,
where do you think your talking was today?”
The underlying concepts of therapy are:
• Hierarchies - discuss what is least difficult / most
difficult. Draw ladders or stairs to represent this.
• Desensitisation - the fear of stammering
needs to be decreased.
• Self-monitoring, analysing and reinforcement
(Did I stutter then? Was that a hard stutter?) The
child is becoming their own speech and language
therapist, and monitoring their own speech.
• Variables to be manipulated, for example:
length and complexity of utterances, formulation
(imitation, picture naming, reading), model
(direct, indirect), reinforcement (immediate,
delayed, occasional, self), location (where is
therapy taking place), listener (who is present).
Talk about stammering with your client. Do
some stammering together. We need to be able
to stammer with our clients so that we can explain
to them how to do things either without stam-
mering or when you are stammering. Try out
some repetitions, prolongations and blocks. Play
with stammering and the level of tensions.
Secondary behaviors tend to disappear as the
child begins to ‘ease’ instead of ‘push’ (see page
26).
We should not be telling our clients that some
sounds are harder than others to produce. It is not
about the specific sounds - more about the per-
ception. Instead of saying which sound is hard to
produce, ask the child where in their speech
machine does it feel hard - lips, tongue and so on.
Nina introduced the idea of the Speech Triad. I
found this particularly useful when remembering
all of the goals that we should be working on. The
three sides are communication, beliefs and feelings
and speech management.
1. Communication
• Discuss turn taking, and make your client aware
that they have time to think about what they
want to say.
• Always introduce eye contact into therapy sessions.
Eye contact increases the speaker’s feelings of
confidence, as well as demonstrating that the
speaker is comfortable communicating. Try
activities during role-play. The children I work
with often have poor eye contact - especially at
the moment of the stammer. More eye contact
leads to more confidence and more confidence

ng up-to-date
ck from conferences, courses and study
dinburgh and Newcastle to hear more
dren who stammer, Johansen Sound
the North East of England.
leads to more eye contact.
• Teach the child how to resist time pressures - if
they are encouraged to use ‘wait-time’ prior to
commenting or answering a question, it will
decrease the rate of communication, increase
formulation time, increase the time the child
has to use the ‘tools’ you are teaching them
and, importantly, decrease the tension in the
speech muscles. Encourage the client to count
to two in their heads - slowly!
• Reflective listening is not a skill we are born
with. Repeating or rephrasing the message
delivered to you as the conversational partner
lets the client know that you have got the idea
but also that, if the message did not come
through correctly, they can repair it. Use reflective
language to your client like, “So what I heard
you say was...” or “You are telling me that...”
2. Beliefs and feelings
Beliefs and feelings need to be addressed. We
need to have a good rapport with our clients so
they will tell us how they feel about their speech
and their communication in general. The children
will experience more long-term success in dealing
with stuttering if we help them understand that
they can be great communicators whether or not
they stammer.
Let your client do some stammering research.
Tell them some internet addresses related to
stammering and ask them to find out ten things
about stammering. (Some good sites, along with
the British Stammering Association - www.stam-
mering.org - are these American ones:www.stut-
teringhomepage.com,
www.WeStutter.org, www.friendswhostutter.org,
www.stutteringhelp.org.)
how I
Figure 1 Checkpoints for success in transfer and maintenance
As a therapist, ask yourself at various stages of therapy:
• Have we established an awareness of fluency?
• Have we begun the process of acceptance of stammering?
• Have we activated the child’s ownership of stammering and the therapy process?
• Have we given the message to the child that both stammering and managed speech are OK?
• Have we used a conversational context as much as possible?
• Have we made therapy meaningful to the child?
• Have we got out of the clinic setting as much as possible?
• Have we worked through the variables that can be manipulated?
• Have we involved the client’s parents, teachers and others?
• Have we helped the child to self-monitor?
• Have we developed resistance to fluency disruptors?
• Have we prepared the child for possible relapse and told them that this is part of
stammering - it is not a failure?
3. Speech management sounds. Get them to say “ahla” then ask, “What
Speech management includes fluency enhancing did you feel moving?” then get them to say,
techniques, stuttering modifications and the inte- “Papa” and ask, “What is moving now?” Talk
gration of both. about the normal flow of speech and then talk
Before we start on techniques, we have to think if about what happens when this breaks down. Talk
the particular child needs every tool. Nina suggests about the tension in the muscles.
packing a toolbox with the client - draw one in the Techniques for easier speaking include:
speech book so you can add new tools as they 1. Light contacts
come up. A child needs many tools but, once they This helps keep the tension away by utilising softer or
have them, they can adapt and change them when lighter contacts between articulators. Demonstrate
necessary. Try and make therapy meaningful by tight / loose so the client can see and feel the difference.
thinking about the child’s interests, curriculum rel- 2. Easy starts
evancy (use classroom topics) and communication Encourages tension to decrease. You are not
environments. Always ‘check-in’ with your client encouraging the child to slow talk. Easy starts
by asking questions like, “How did you feel about decrease tension, increase sense of control over
that?” or “Do you like easy starts?’ speech mechanisms at the start of speaking and
We need to help our clients develop an under- indirectly decrease the rate of speech and commu-
standing of the process of producing speech. They nication. Demonstrate with a ball - throw it with a
should be aware of how speech is made and what lot of tension in your arm, now do it relaxed.
can cause it to break down. They need to understand 3. Pausing / Phrasing
speech before they can change it. To help with This is normal for all of us to do when we talk. Make
this you can draw a man and label the parts needed sure your clients know that we all do it. Using
for speech. Talk about the whole process - from longer pauses between phrases helps decrease the
lungs and vocal folds up. Let the child touch their rate of communication, increases the time to use the
throat when they make voiced and un-voiced tools and decreases tension in the speech muscles.

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2004 E
 how I
 This is appropriate whatever the tool.
We sometimes think as therapists that we will
eliminate all stammers. We have to rethink this
and remember that the child will still stammer,
especially once he leaves the therapy room, so
let’s give him some techniques to help him be
more fluent and stammer more easily. These are
techniques to ease out of a stammer, rather than
push through with it. The client needs to be
aware that they can fix it and they have a choice
- to ease out instead of pushing through:
1. Cancellations
This happens after the stammer has occurred.
Once they stammer, the child will pause long
enough to analyse the moment of stuttering,
release tension, and return to the word to produce
it in a modified way (such as with an easy start).
A sound therapy?
I
ntuitively it makes sense that auditory deficits -
not picked up through an ordinary hearing test
- could underlie at least some speech and lan-
guage impairment. Readers have been asking
for more information about auditory processing
and sound therapy and, having featured it in the
magazine (Robinson & Leslie, 2001; Treharne et al,
2002), I was sufficiently intrigued to sign up for a four
day Johansen Sound Therapy course with its founder,
Dr Kjeld Johansen, the Director of the Baltic Dyslexia
Research Laboratory in Denmark.
There are many different types of sound therapy
making a variety of claims, so consumers and
therapists can be excused for feeling a little con-
fused. The field suffers from two credibility problems.
Firstly, it is not generally accepted within the
mainstream academic community, so research has
been somewhat idiosyncratic. Secondly, because it
operates outwith the mainstream, it is usually only an
option if clients are willing to pay. Kjeld is however
unequivocal about the ethos of the Johansen approach:
“We want to help kids, not become millionaires.”
Kjeld’s rationale is based on the concept of central
auditory processing. While audiologists are interest-
ed in the ear and neurologists are interested in the
brain, sound therapy proponents are interested in
the system leading from the inner ear to the brain.
Right ear dominance is considered crucial to the
efficiency of input to language centres which, even
for the majority of left handed people, are located
in the left hemisphere of the brain.
If the balance between the right and left ear is
not correct, symptoms can include sensitivity to
background noise, difficulties discriminating
language sounds, hyper-sensitivity in the low
frequency range, too little sensitivity in the high
frequency range, fairly large differences in thresh-
olds between left and right ears, and left ear
advantage for language sounds and / or pure
0 SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2004
2. Blockouts
A variation of cancellations. The child needs to
take control during the moment of the stammer,
to learn to stop in the moment of the stammer,
pause (analyse, relax) then start again.
3. Pull-Out
Taking control during a moment of stammering.
This makes the stammer turn from something
involuntary into something voluntary. We can
imagine this to be like a slide. The stammer starts
at the top of the slide, and as we think of going
down the slide, we slide out of the stammer.
4. Voluntary Stuttering
Involves using purposeful, under-control stam-
mering to decrease fear, involuntary tension and
avoidance of stuttering. It also helps the client to
be more open about stammering and desensitises
Can CDs of music with certain
frequencies dampened or
amplified to stimulate an
individual’s listening skills
lead to improvements in their
speech and language? Avril
Nicoll sounds out Johansen
Sound Therapy.
tones. This imbalance is often found in children
and adults after recurrent middle ear infections in
the early years, and in people with reading and
spelling problems with a diagnosis of dyslexia.
Dyslexia is Kjeld Johansen’s main area of interest
but both he and speech and language therapist
Camilla Leslie (who oversees Johansen Sound
Therapy in the UK) believe it can bring at least
some benefit to all children assessed as requiring
speech and language therapy.
Audiometry is an essential part of Johansen
Sound Therapy assessment, so anyone following
through their attendance at the course will need
to purchase an audiometer (cost around £800). It
is unlikely that audiologists would be in a position
to do the audiometric assessment, as what
Johansen Sound Therapy regards as signs of prob-
lems with listening often fall Figure 1 The optimum hearing reference curve
within the ‘normal’ range of (See Tomatis, A.A. (1991) The Conscious Ear. New York: The Talman Company.)
hearing.
Ideal hearing curve
Thorough testing produces a
listening profile. This is con-
sidered against the ideal
hearing curve (figure 1) and,
if there are any deviations,
the child is a candidate for
Johansen Sound Therapy.
them to moments when they do stammer. You can
then ask the child how it felt to stammer.
So, you now have the tools and ideas. Adapt your
own techniques, add some of these - and good luck!
Suggested reading
Chmela, K. & Reardon, N. (2001) The school-age child
who stutters: Working effectively with attitudes and
emotions. Stuttering Foundation of America.
Manning, W. (2001) Clinical Decision Making in
Fluency Disorders. (2nd Ed) San Diego, CA:
Singular Thompson Learning.
Shapiro, D.A. (1999) Stuttering Intervention: A collab-
orative journey to fluency freedom. Austin, Tx: Pro Ed.
Zebrowski, P.M. & Schum, R.L. (1993) Counselling
parents of children who stutter. American Journal
of Speech-Language Pathology 2:65 - 73.
The profile of the curve is considered more important
than the level of hearing, although referral to audi-
ology would be made for a child showing a hearing
loss. The aim of the therapy is to bring the audio-
gram as close to the ideal profile as possible and the
effect of these improvements should be seen in lis-
tening and language skills, but may also be seen in
other areas such as motor skills and concentration.
Questionnaires for parents probe the current
attention, behaviour, coordination and language of
the child. Laterality of hands, feet, eyes and ears is
checked. Audiometry is used to establish a hearing
profile through monaural thresholds followed by
ear advantage through binaural pure tone
audiometry. This is followed by dichotic listening
tasks, where CVC combinations are played
through headphones into one or both ears. These
tasks include listening to and repeating a CVC
combination played into one ear without becoming
distracted by a different CVC combination played
into the other ear.
Johansen Sound Therapy normally takes nine to
eleven months to complete as, although short-
term, intensive training has an immediate effect,
this diminishes quickly and is not maintained. It aims
to “change the architecture of the auditory cortex”,
moving the hearing profile as close as possible
Optimum hearing reference curve......

towards the ideal curve. This is done incremental-
ly by listening for 10 minutes a day through head-
phones to a music CD which has had certain fre-
quencies dampened or amplified by a certain
amount according to the client’s individual profile.
Usually the right ear is stimulated more than the
left ear. Initially, and in other instances where a
reliable audiogram cannot be achieved due to age
or hearing problems resulting from a cold or glue
ear, standard rather than customised CDs are used.
Neutralised CDs are used for a few left handers
where you suspect language may be processed in
the right hemisphere. Children are reviewed every
six to eight weeks, with CDs changed as required.
A good quality CD player (personal or other) and
headphones are essential. The CDs cost from £13 -
£26 each, with the average number required
around four.
Caution is required in some circumstances, for
example with children who are left handed or suf-
fer from epilepsy, or when combining sound thera-
py simultaneously with other treatments that could
overstimulate a child. When listening to the CDs
children should not be eating, have background
noise or be doing any language-based activity. Kjeld
says Johansen Sound Therapy has the best chance
of stimulating the brain when clients are aged from
31/2 to 9 years. It has, however, been used with chil-
dren of all ages, adolescents and even adults up to
around 70 years of age, although with adults it
takes longer for the effects to become apparent.
Kjeld does not claim that Johansen Sound Therapy
is a panacea. The many factors which can contribute
to children’s difficulties - genetics, the perinatal peri-
od, health, socio-economic status, family, critical life
events, behaviour / personality and education -
mean that for each child a different balance of inter-
vention will be needed. An unexpected bonus of the
course was a fascinating presentation by orthoptist
Dr Alison Hood on the signs and symptoms of visual
Past meets present
“PLEASE STAND BACK TO LET OTHER PASSENGERS
DETRAIN”
(notice at Newcastle Station, 2003)
“Girls, girls, always wear your earrings - your face
comes alive, and people will talk to you.”
(Kay Morrison, Edinburgh lecturer, recalled by
Morag Horseman)
In 1978, the North East Speech Therapists
Association (NESTA) was formed to provide low
cost training in the north east of England and to
support newly qualified therapists, especially
those working single-handedly. As the examples
above also show, while our language and our
profession continue to evolve, sometimes the
anomalies which can contribute to reading failure,
and how these can be ameliorated.
Research encouraged
The American Speech-Language-Hearing
Association has put out a position statement
(2004) on what it refers to as Auditory Integration
Training (specifically including the Berard method,
Samonas Sound Therapy and Tomatis method). It
concludes that it “has not met scientific standards
for efficacy that would justify its practice by audi-
ologists and speech-language pathologists.” It
adds, “However, well-designed, institutionally
approved, research protocols designed to assess
the efficacy of AIT are encouraged. It is recom-
mended that this position be re-examined should
scientific, controlled studies supporting AIT’s effec-
tiveness and safety become available.”
It would be disingenuous to say that everything
we ever do with our clients is evidence-based. For
one thing the evidence we have access to and use
depends on many things - experience, training,
environment, beliefs, interpretation, peer pressure,
even (as Lord Hutton might say) the subconscious.
However, three speech and language therapists
were among the individuals attending the course,
and they had an open-minded but questioning
approach, constantly looking for verification of
effectiveness. Anecdotal evidence from people
who have extensive experience of Johansen Sound
Therapy - such as emerging sub-groups of hearing
profiles which match presenting features like autis-
tic spectrum disorder and specific language impair-
ment - is promising, but more specific research by
the speech and language therapy community is
needed. The changing audiogram is clearly useful
as an outcome measure and, because this approach
is so different from traditional therapy, one of the
therapists attending is planning to set up a control
group alongside her treatment group.
The North Eastern Speech &
Language Therapists
Association was formed 25
years ago to provide low cost
training for speech and language
therapists in the north east of
England. Avril Nicoll finds the
energy, drive and vision of the
founder members mirrored by
the current cohort.
underlying issues they address remain the same.
And at the conference celebrating NESTA’s Silver
Jubilee, training, support, skills, research and
development, collaboration and evidence-based
SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2004
how I
The other therapist there, Alison Taylor, is keen
to discover ways of helping her third child Emily
cope better with learning. She had been trying
another sound therapy with inconclusive results,
and I caught up with her recently to find out how
Johansen Sound Therapy is going:
“I must admit this must be the easiest and most
enjoyable form of therapy I have participated in.
Emily doesn’t need much prompting to go and listen
and is getting much better with left and right -
probably a result of putting the headphones on.
After listening to Waves 4LFR for 7 weeks I thought
her comprehension when reading to herself and
when I read to her had improved. This was con-
firmed by the audiogram. Initially there was a big
dip at 3000Hz but now the right ear is on the correct
line. Spelling has improved in tests. She used to be
in the bottom three in her year but actually won
a prize for the best term’s learnt spelling in her
group. She has made 12 months progress in 8
months, but still has a long way to go. Emily
appears now to be working things out more for
herself, as in jokes. It will be interesting to see
what happens after listening to a customised CD.”
References
American Speech-Language-Hearing Association
(2004) Auditory Integration Training. ASHA
Supplement 24 (in press).
Robinson, N. & Leslie, C. (2001) My Top Resources.
Speech & Language Therapy in Practice. Winter.
Treharne, D. (2002) From sceptic to convert, the objec-
tive way; Lane, C. (2002) A.R.R.O.W. hits the bull’s-ear;
O’Connor, K. (2002) Enthusiasm, knowledge - and a set
of headphones. All in ‘How I use therapeutic listening’.
Speech & Language Therapy in Practice. Winter.
Resources
Dr Alison S. Hood, Orthoptist, Eyescan (UK), tel. 0141 637
7503, e-mail Alison.eyescan@talk21.com.
practice were among the hot topics, with recruit-
ment and retention a strong sub-text.
Morag Horseman, one of NESTA’s founder mem-
bers, recalled the early days of her career. A
profession split between health and education
and isolated by the medical officer’s policy of
keeping speech therapists apart. Taking the bus
with a Grundig reel-to-reel tape recorder and
heavy bags, and fellow passengers - miners on
their way to work - carrying her bags along to one
of her schools. Her department’s policy in 1954
‘not to employ married women’ or, if they did, to
keep them on without any rights. No incentives
for married women with children to return to
work, and no refresher courses when they did. 
Going into a new post, and being handed equip-
<
 how I

 ment including a home-made metronome. The
excitement of the arrival of the Reynell
Developmental Language Scales, a revolution at
the time.
Morag says that, “The older you get, the more
important your past becomes.” This is as true for
the profession as it is for us as individuals. By
recording what we are doing, and sharing our
experience, we pay due respect to the pioneers
and pave the way for the speech and language
therapists of the future.
Sometimes, even now, members of our profes-
sion are pioneers. Sarah Glenwright has been set-
ting up a speech and language therapy service in
mental health. She says that, for a new service, you
need at least a month in post with no therapy
appointments. You need to find out from other
people what services already exist, and how
speech and language therapy might fit in,
although people are not always clear on this. She
suggests shadowing therapists in other areas who
are working with a similar client group, and con-
sidering a job share arrangement for this kind of
development rather than a single person. A specif-
ic interest group can also provide much needed
support and guidance. In Sarah’s case, the mental
health SIG is looking at organising a ‘buddy’ sys-
tem, and putting together a pack which will cover
funding, references and clinical issues.
Sarah has had to be very focused as it would
have been impossible to do everything at once.
Now that her service is up and running, she wants
to consider research into what it is that speech and
language therapists do that is different from other
members of the team. She also wants to look into
quality of life outcome measures which will show
where we have been able to be effective. As an
example, she quotes a 76 year old lady with mem-
ory and word finding problems who, following
her involvement, has the same problems but is no
longer avoiding situations such as going to the
hairdresser and using the phone.
Sometimes, whatever we try, we feel frustrated
and unhappy, and unable to see a way through
with particular clients. One of Jo Borrelli’s clients
would say, “I want to do _____, and do it now, and
this isn’t helping me.” She found they were both
battling to set aims and to be in charge. The
solution was transactional analysis, a counselling
technique which has concepts consistent with the
rehabilitation concepts of progression from
dependence to independence.
Sometimes we don’t know what a client is capable
of because we lack appropriate assessments, training
and multidisciplinary teams. Selena Mathie praised
the Sensory Modality Assessment and Rehabilitation
Technique (SMART) as a consistent and in-depth tool
for establishing whether or not a client is in a persis-
tent vegetative state. Her use of television material
featuring a young woman was a poignant reminder
not to make assumptions based on single visits, assess-
ments or reports. It also showed clearly the tremen-
dous value of music therapy, as music can ‘reach’
someone in the way other communication cannot.
Passion and determination
Sometimes the difference between success and
failure is down to our own passion and determi-
nation. This was the case for Mary Greetham &
Rachel Baker when they successfully introduced
the Picture Exchange Communication System
(PECS™) to secondary school aged children. Their
service delivery model can be applied to any sys-
tem not just PECS™. The speech and language
therapists initiated the idea with the head
teacher, who arranged the first meeting with
staff. Therapists showed the PECS™ video and
related it to children in the school. Targets were
set for staff, including having a PECS™ coordina-
tor in the school, and at the second meeting staff
identified four children aged from 14-18 years.
The therapists sent a letter to the head and the
class teachers giving the times of nine sessions
over six weeks with named therapists, the need
for a member of staff from the class, the room
size and a questionnaire regarding motivators for
that child. Staff took on board the need to make
resources and symbols for their own classes, and
the school have ordered PECS™ resources.
Sometimes a client group is significant, but thin
on the ground, and therapists with specialist knowl-
edge even more so, particularly in rural or less heav-
ily populated areas. The North East Regional
Dysfluency SIG (known as NERDS) provides support
for therapists at any level of experience who are
working with people who stammer. They meet
every two months, with the focus rotated between
paediatric, adult and joint issues. This SIG grew out
of a recognition that ongoing support was needed
and that, while specialist skills are not available in
every trust, access to such support is essential.
So far, the SIG has developed a telephone support
network and a fluency continuing professional
development module run by specialists which
aims to build a portfolio of skills and emphasises
practical activities. Eight areas across the north
east of England are involved. In future, the SIG is
planning to get accreditation for the module, to
develop modules for older children and adults,
and to run cross-district groups for people who
stammer.
Sometimes we have an idea but we can’t do it on
our own. Karen Dixon, Barbara Storey & Colin
Sawyer (a speech and language therapist, artist and
computer programmer) have developed a multime-
dia resource which they hope will be the first of
many. My own kids and their friends are computer
junkies used to games which involve television char-
acters and sell in their thousands. They have tried
out ‘Listening and Rhyming’ and really enjoyed it,
both on-screen and in printed-out worksheets.
There was a relaxed, informal, supportive
atmosphere at this conference, with speakers
given time to explore their topic and the audience
given time to ask questions about subjects of
interest. This was best in the adult-orientated ses-
sion I attended, where there were smaller numbers
of delegates. Poster presentations added to
knowledge of the area and the services it is devel-
oping, and exhibitors gave delegates hands-on
time with their products.
Sometimes a conference really works.
Resources
• Leaps and Bounds Multimedia Ltd: Phonological
Awareness Series Disc 1: Listening and Rhyming
is available for £45 tel. 0191 413 1818, e-mail
gill.blissett@btopenworld.com. Disc 2: Syllabification
will be available in Summer 2004.
• PECS™ (including courses): Pyramid Educational
Consultants UK Ltd, Pavilion House, 6 Old
Steine, Brighton BN1 1EJ, tel 01273 609555,
www.pecs.org.uk.
• Reynell Developmental Language Scales: Now
on their third version, completely revised by
Susan Edwards, Paul Fletcher, Michael Garman,
Arthur Hughes, Carolyn Letts & Indra Sinka, from
NFER-Nelson, £451.75, see www.nfer-nelson.co.uk.
• SMART: Sensory Modality and Rehabilitation
Technique by Gill-Thwaites (1997). Details from
Royal Hospital for Neurodisability, London,
tel. 020 8780 4568.
• Transactional Analysis: Eric Berne’s Games
People Play (1970), published by Penguin
ISBN 0140027688.

My Top Resources (back page): references
1. Access to the joint voice clinic
• Laryngograph Ltd, tel 020 7387 7793,
www.lx@laryngograph.com
2. Instrumental voice analysis systems
• Fourcin, A. (1986) Electrolaryngographic
assessment of vocal fold function.
Journal of Phonetics 14: 435-442.
• Laryngograph Ltd, tel 020 7387 7793,
www.lx@laryngograph.com
• Speechviewer from PAS UK Ltd, tel
01635 247724.
• Kay Elemetrics (1986) Nasometer manual,
Kay Elemetrics Corp. USA.
3. Normative voice measures
• Aronson, A.E. (1990) Clinical voice
disorders: an interdisciplinary
approach (3rd Ed) New York: Thieme.
• Baken, R.J. (1996) Clinical Measurement
of Speech and Voice. Singular Publishing.
• Wilson, D. (1987) Voice problems of
children. (3rd ed) Baltimore: Williams
and Wilkins.
• Mathieson, L. (2001) (6th Edition)
Greene and Mathieson’s The Voice
and its Disorders. Whurr.
• Andrews, M. (1986) Voice Therapy for
Children. San Diego: Singular Publishing.
• Andrews, M. (1995) Manual of Voice
Treatment: Paediatrics through Geriatrics.
San Diego: Singular.
4. Voice therapy concept cards
• Dean, E.C., Howell, J., Waters, D. & Reid, J.
(1995) Metaphon: A metalinguistic
approach to the treatment of phonological
disorder in children. Clinical Linguistics
and Phonetics 9 (1). (This forms part of
a clinical forum on Metaphon, pages 1-58.)
5. Vocal Profile Analysis Training
• Laver, J., Wirz, S., Mackenzie-Beck, J. & Hiller,
S. (1988) Vocal Profiles of Speech Disorders.
Research Project. Phonetics Laboratory,
Dept of Linguistics, University of Edinburgh.
6. Access to the internet and library resources
• KA24: http://stlis.thenhs.com/hln/ka24/
• UCL library: http://library.hcs.ucl.ac.uk/
• ICH library: http://www.ich.ucl.ac.uk/library/
10. Augmentative communication systems
• www.makaton.org
• Kapitex Healthcare Ltd, tel 01937
580211, www.kapitex.com

I SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2004

 Subscription form for Speech & Language Therapy in Practice

IMPORTANT NOTICE PERSONAL RATES AUTHORITY/DEPARTMENTAL RATES

Subscribers should contact the ■ £25 personal UK ■ £45 authorities UK / Europe
■ £21 part-time (5 or fewer sessions) (UK only) ■ £50 other overseas authorities
publisher if they have not received ■ £18 student / unpaid / assistant (UK only) Bulk orders (sent to any single work address):
their magazine(s) within two ■ £30 Europe personal ■ 2 copies for £52 ■ 3 copies for £72 ■ 4 copies for £88
weeks of the publication date, or ■ £34 other overseas personal ■ 5 ■ 6 or ■ 7 copies for £20 each. Total price £
if there are any problems with the
magazine itself. Tel: 01561 377415 EUROZONE RATES
Note: Cheque and direct payment only. Credit card payments can only be deducted in sterling at the rates advertised above.
Speech & Language Therapy in Practice is ■ €42 Personal Bulk orders (sent to any single work address):
published on the last Monday of ■ €34 student / unpaid ■ 2 copies for €73 ■ 3 copies for €101 ■ 4 copies for €124
February (Spring), May (Summer), August ■ €63 Authority / department ■ 5 ■ 6 or ■ 7 copies for €28 each. Total price €
(Autumn) and November (Winter).
IBAN NUMBER: IBAN GB44 BOFS 8020 0608 3990 01 SWIFT BIC: BOFSGBSIEUG

SUBSCRIPTION FORM SUBSCRIPTION FORM SUBSCRIPTION FORM

EVENTS
Pain: Passion, Compassion, Sensibility
Special offer for personal subscribers - Introduce a colleague* to Speech
& Language Therapy in Practice and you both get an extra issue - free!
Now until 20 June 2004 The new subscriber fills up their details on the form and puts your name in the ‘recommended by’ space. Once their
Over 170 objects and artworks from the original collections payment has been received, they will get 5 copies for the price of 4 in their first year’s subscription, and you will be
of Sir Henry Wellcome. notified that your subscription period has been moved on by three months.
Includes the changing cultural place of pain, medical attempts
to deal with pain, and our reactions to the pain of others. So, tell all your friends the advantages of a personal subscription to Speech & Language Therapy in Practice.
Science Museum, London Remember - you will get an extra issue for every new subscriber you bring in.
Free admission.
*Must be a NEW subscriber to the magazine.
Poetry Workshops
March 2004
Globe Theatre Cheques payable to AVRIL NICOLL BUSINESS.
For groups of pupils from secondary schools for pupils with
severe learning disabilities in conjunction with local OR Please debit my Visa / Mastercard / Switch card:
mainstream schools. (Card payments cannot be accepted without a signature.)
A Midsummer Night’s Dream -
March 8th & 15th
Romeo and Juliet - Card number:
March 12th & 19th
Therapists wishing to observe or participate should contact
Keith Park (keithpark1@onetel.net.uk). Expiry date: Signature:
Floor Time
29-30 March 2004 Switch only:
Dr Stanley Greenspan’s Developmental Individual differences
Relationship (DIR) Model of working with children with Issue No. OR Valid from date:
special needs. (if issue no. not available)
Galway, Ireland
Details: tel. 00 353 915 38111, e-mail trainingwaysgalway@eircom.net. NAME:
Parkinson’s Awareness Week RECOMMENDED BY:
18-25 April 2004 (if applicable)
‘Committed to making a difference’
www.parkinsons.org.uk HOME
Connect ADDRESS:
Connect conference
6th May 2004 (London)
Or 6th July 2004 (Sheffield)
Life After Stroke: evidence and examples of access to long
term services:
Speakers include Dr Tony Rudd, Prof Pam Enderby and Dr
John Young POSTCODE:
A toolkit for making information stick
14th May or 16th July 2004
Make information and environments accessible and relevant. HOME TEL.
Gain confidence and practical skills.
Ideas for working with groups of people with aphasia WORK
19th May 2004 POSTCODE:
Learn about the benefits and effectiveness of group therapy. ADDRESS:
Details: Carole Cross, tel. 020 7367 0846, events@ukconnect.org
Fragile X Society
15 May 2004
Scottish Family Conference, Stirling WORK TEL.
Fragile X: Behaviour (Dr Jeremy Turk)
Fragile X: Genetics (Dr John Dean)
12 June 2004 e-mail:
AGM and National Family Conference,
Birmingham
Details: tel. 01371 875 100, www.fragilex.org.uk
Please note acknowledgements and renewal notices are sent automatically.
Return to: Avril Nicoll, From outside the UK,
Speech & Language Therapy in Practice, the address is:
Contributions to FREEPOST SCO2255 Avril Nicoll
Speech & Language Therapy in Practice: LAURENCEKIRK 33 Kinnear Square
Contact the Editor for more information and / or to Aberdeenshire
AB30 1ZL Laurencekirk
discuss your plans. Tel/fax +44 (0) 1561 377415, e-mail avrilnicoll@speechmag.com Aberdeenshire
Please note: www.speechmag.com AB30 1UL
• articles must be of practical use to clinicians It would be very helpful if you could complete the following information:
• use case examples and list useful resources
• length is generally around 2500 words Job title(s):
• supply copy on disk if possible Name of employer /
• keep statistical information and references to a university:
minimum Topics you would like
to see covered
• photographs will be returned

Your personal details will only be used for the purposes of Speech & Language Therapy in Practice
magazine and will not be passed to any third party.
MY TOP RESOURCES
Lesley Cavalli works as a
member of the speech
and language therapy
team at Great Ormond
Street Hospital in
London She specialises
in the assessment and
management of voice
disorders in children and
adolescentsA as well as
head and neck surgery
Children attend Great
Ormond Street for
second opinions and for
management of both
common and more
unusual voice problems
Lesley also lectures in
voice at University
College London
Detail from Edmund Caswell’s Peter Pan
mural at Great Ormond Street Hospital.
Reproduced by kind permission
of Henny King.
1. Access to the joint voice clinic
Laryngeal examination of dysphonic
children is challenging and yet essential to
rule out airway disease and to confirm the
dynamics of voice production. I am fortu-
nate to work in a dedicated Voice Clinic
with an ENT Consultant who specialises in
the medical and surgical management of
children’s voices. We see five children per
clinic, aged from three years old. Our joint
opinion results in a coordinated diagnosis
and management plan. Keeping the clinic
list limited to only five children allows us
to provide the necessary preparation time
for successful examination. We aim to use
a rigid laryngoscope, which provides
excellent views of the larynx and tends to
be tolerated well. This is linked to the
LaryngoStrobe 2 System (Laryngograph
Ltd). Some children will require flexible
nasal fiberoptic laryngoscopy. Whilst the
majority of speech and language thera-
pists working with dysphonic children will
not have immediate access to a Voice
Clinic I would recommend that, whether
they work in mainstream, special schools
or community clinics, they identify the
location of their nearest Voice Clinic and
ascertain whether the team will accept
paediatric cases.
2. Instrumental voice analysis
systems
Many of the children I see have very disor-
dered voices. Identifying the affected
components of the voice (pitch, quality
and so on) using perceptual skills alone is
tricky. A good tape recorder is essential. I
use a Digital Audio Tape (DAT) recorder
for collecting voice samples as this
maintains a good recording frequency
range and allows for dual channel
data collection. I use the electro-
laryngograph (Fourcin, 1986)
with the majority of my
patients, mainly as an
assessment tool, for con-
firming measures such as
fundamental frequency,
but also as a biofeed-
back tool, for example
when working to re-
establish voice with
children with psy-
chogenic voice loss.
The Speechviewer pro-
grammes can also be
very helpful in providing
the necessary encourage-
ment to very young children
to provide any voice sample
at all! Some of the children I
see may also need assessment of
their nasal airflow, for example with
nasometry. Video recording can also be
helpful for raising children’s awareness of
their posture and for skills training with
the electrolarynx and so on.
3. Normative voice measures
I constantly need to refer to normative
measures for pitch, maximum phonation
time, s/z ratios, across the age groups and
sexes. Relevant measures can be difficult
to come by and will need to be considered
against the child’s growth measures if they
are to be interpreted meaningfully. See
reference list for useful texts.
4. Voice therapy concept cards
Voice can be quite an abstract concept,
particularly for young children. Children
can find it hard to tune in to their own
sensory feedback systems and thus master
control of a specific aspect of their voice. I
have found using paired pictorial concept
cue cards very useful in developing chil-
dren’s awareness and control of a specific
vocal parameter or skill such as ‘soft onset
phonation’ vs ‘hard glottal attack’ or
‘loud’ vs ‘quiet’ voice.
Drawing is not my forte and I have thus
tended to develop my set of contrastive
picture concept cards for voice therapy
from systems marketed at phonology like
Metaphon.
5. Vocal Profile Analysis Training
I have found the Vocal Profile Analysis
Scheme (Laver et al, 1988), the most com-
prehensive perceptual assessment tool to
use with children’s voice, despite the fact
that the training and the assessment form
are based on analysis of post pubertal
voices. The system considers voice as a
product of the entire vocal tract and is
really helpful in treatment planning. I
don’t use the entire form with every child
as appointment scheduling does not allow
this and neither is it necessary unless we
are collecting research data. I have had to
modify it a little to include some more
unusual voice characteristics that we see as
a bi-product of airway reconstruction, for
example ventricular band voice or other
supraglottic type voices.
6. Access to the internet and
library resources
I try to keep up-to-date with new books
and relevant papers as they come up. I
find the libraries at University College
London and the Institute of Child Health
very helpful in refining searches on partic-
ular topics. When more unusual cases are
referred I try and prioritise the time to
search the internet for an article that
might guide my management. I would
access a system such as KA24 (a round the
clock service for local NHS employees) to
assist my search. I usually find the time to
read articles on the bus to and from work.
The speech and language therapy students
who work with me on research projects
and clinical placements frequently direct
me to new information and keep me on
my toes!
7. Supervision and clinical
support networks
Many of the dysphonic children I see have
a history of prematurity and a significant
population have a co-occurring diagnosis
of speech and language delay, behaviour
or attention difficulties, dysfluency, dys-
praxia and so on. I have had to develop
skills in screening for co-occurring speech
and language and cognitive problems to
ensure that my assessment of a child’s
voice is based on knowledge of the ‘whole
child’. I regularly call on the skills of team
members to assist in complex assessments
and / or seek their advice through supervision
systems. Speech and language therapists
working with a child at a primary care
level are also an invaluable source of
support and information. By working
collaboratively and sharing assessment
findings we can arrive at a robust diagnosis
and realistic treatment plan.
8. Developmentally appropriate
toys and reward systems
My toy cupboard is finely tuned! Favourite
toys for eliciting a voice sample from the
younger children include dolls and a tea
set, cars and miniature farm and zoo ani-
mals. Older children respond well to being
involved in the interview process and
those that are more easily distracted tend
to enjoy drawing. Toys for blowing such as
bubbles and whistles are really helpful for
looking at breathing and for developing
breath control in children post airway
reconstruction. Reward systems tend to be
basic. Children love choosing stickers at
the end of a session and marble runs and
posting boxes are effective in building
voice therapy skills through structured
behavioural reward systems. Time spent
researching voice on the internet or working
through a simple project on voice can be
fun and educational for older children.
9. A quiet clinical room
This can be difficult to come by with all the
building works going on around us at the
moment, but is essential to obtaining
good recordings for reliable perceptual
analysis.
10. Augmentative communication
systems
Children who have no voice or a severely
disordered voice may be at risk of devel-
opmental speech and language delay as
well as communicative frustration. It is
important to consider mechanisms that
will assist their communication and its
development. Very young children may
need to develop skills in a signing system
such as Makaton. Many children with
tracheostomies are now routinely fitted
with speaking valves. Older children may
need to learn to use an electrolarynx and
children with pathologically quiet voices may
benefit from a voice amplification system.
Many voice aids have been developed for
adults and their use with children will
require careful consideration. Individual
assessment is always required to ensure that
an aid can be used successfully by the specific
child. Supply companies such as Kapitex
Healthcare are usually very helpful in attend-
ing assessment sessions with the child and
their family before a product is purchased.
References are listed on p28.