Prime and

Predigest:
Inspiration from
Jane Austen
N U R T U R l N G T A l E N T
ISSN 1368-2105
sprng oo
http://www.speechmag.com
From reaction to action
A preventative approach
Sensible solutions or daft ideas?
A search for answers
Once upon a time...
The power of narrative
Group therapy
Working with
bilingualism
Barbie and Ken
An unequal
relationship
How I am
negotiating
care pathways
My Top Resources
Early feeding
Newy avaabe
n the UK!
Up and running with your therapy multimedia PC
but lacking suitable software for your aphasic
clients? Speech & Language Therapy in Practice
has TWO fantastic FREE prizes to help you out,
courtesy of Propeller Multimedia.
Firstly, worth 404.50, four programs (all
Professional versions which include a 5 PC site licence):
APHASIA TUTOR 1 WORDS: over 700 exercises in 8 lessons can be
used independently to improve recognition and retrieval of
letters and single words, both nouns and verbs.
APHASIA TUTOR 3 STORY READING: over 700 questions in 7
lessons can be used independently to improve word-retrieval
skills at word and sentence level through multiple choice, fill-in,
matching and completion tasks.
UNDERSTANDING QUESTIONS: Over 5000 exercises in this new
program provide practice with understanding questions who,
what, when, where, why and how by displaying a question and
up to four answers.
CATEGORISATION AND WORD RELATIONSHIPS: Over 200,000
questions in 6 different lessons use techniques from simple category
completion and naming to deductive reasoning to determine
word relationships. Suitable for clients from 12 years with high-level
aphasia, traumatic brain injury and language-based learning disabilities.
Secondly, Propeller Multimedia is offering another reader the
opportunity to benefit from the Aphasia Tutors 1 and 3 described
above - worth 210, but FREE to the lucky winner.
You have nothing to lose and a great deal to gain by sending your name
and address marked Speech & Language Therapy in Practice - Bungalow
offer to Gordon Russell, e-mail gordon@propeller.net. The closing date for
receipt of entries is 25th April and the winners will be notified by 1st May.
Entrants MUST be able to access a multimedia PC for use with clients.
Theres no need to wait, though, to sample Bungalow software.
FREE demo disks are available from Propeller Multimedia - see the
enclosed flyer for more details.
Bungalow and other software is available through Propeller Multimedia and
can be purchased online at www.propeller.net/rehab or contact P.O. Box
13791, PEEBLES, EH45 9YR, tel. 01896 833528, e-mail enquiries@propeller.net.
vn Semantc
vorkbooks
Do you wish you had easy access to hun-
dreds of illustrations and written words
organised for use in semantic therapy?
Help is at hand in the form of Semantic
Workbooks, a set of photocopiable books based on the cognitive
neuropsychological model of language processing. Although the
authors designed this resource for use with adults with aphasia,
many of the picture exercises would also be suitable for children.
The six workbooks cover odd one out, circles, verb circles, verbs,
spoken word to picture matching and word association.
Semantic Workbooks normally retail at 90 but Speechmark
Publishing Ltd (formerly Winslow Press) is making THREE copies avail-
able FREE to lucky readers of Speech & Language Therapy in Practice.
To enter, simply send your name and address marked Speech &
Language Therapy in Practice - SW offer to Su Underhill, Speechmark,
Telford Road, Bicester, OX26 4LQ. The closing date for receipt of
entries is 25th April and the winners will be notified by 1st May.
Semantic Workbooks are available, along with a free catalogue,
from Speechmark, tel. 01869 244644.
The lucky winners of the two reader offers in the Winter 02 issue
are Nicola Robinson and Angela Abell (Black Sheep Press narrative
packs) and Tracy Hull, Jane Oates and Mrs K. Phillips (Scallys World
of Verbs from Topologika). Congratulations to you all.
Spring 03 speechmag
Just wanted to say that I think the website is
excellent. We have a returner to practice starting
with us, and I was able to use the index of
articles to point her in the right direction.
(e-mail from chief speech and language therapist Christine Mills)
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 a copy of a back article online.
Plus
The editor has selected the previous articles you might
particularly want to look at if you liked the articles in
the Spring 03 issue of Speech & Language Therapy
in Practice. If you dont have previous issues of the
magazine, check out the abstracts on this website and
take advantage of our new article ordering service.
If you liked...
Jois Stansfield & Pia Taylor, try (161) McGrane, H. &
Stansfield, J. (Autumn 2001) Strength in compromise.
Sue Dobson, see (047) Dumble, M. (Winter 1998)
Identifying eating and drinking difficulties.
Panna Chavda & Laura Helsby, look at (082) Spooner,
L. & Hewison, S. (Autumn 1999) Autism - making
therapy work.
Becky Shanks, what about (066) Popple, J. &
Wellington, W. (Summer 1999) Rhyme Time.
Rebecca Howarths My Top Resources, try (129)
Strudwick, S.: Consistency of advice, (130) Marks, J.:
From vicious to virtuous circle, (131) Russell, S.:
Changing the pattern. All from Autumn 2000, How I
manage early feeding difficulties.
Prime & Predigest, see (046) Coley, J. (Autumn 1998)
My Top Resource.
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!
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lnsde cover Sprng o speechmag
Reader oers
Win Bungalow software (Propeller Multimedia), Semantic
Workbooks (Speechmark) and Speaking & Listening
Through Narrative (2nd ed) (Black Sheep Press) (p.13).
News / omment
8 lrom reacton
to acton
...referrals needing an
urgent response were not
spaced but tended to
come in clusters. As the
number of speech and
language therapists
employed is limited, and
only certain of them may
have the expertise to
assess swallowing within
such a learning disability
service, this became a
management issue.
Sue Dobson and colleagues describe their move to a
preventative approach for adults with profound and
complex needs and eating and drinking difficulties.
+o Ony a story'
...the answer to the question, Why is narrative so
important?, is that it could offer clinicians a way to
work with language impaired children to build on their
narrative skills and, in so doing, offer them an increased
chance of participation in classroom learning.
Once upon a time, a fairy godmother weaved her magic
on children in Stockport schools. The children were
never short of a story again, and they all lived more
happily ever after. But, for Becky Shanks, this foray
into narrative therapy was just the beginning...
+( Sensbe soutons or dat deas: a
search or answers
Mr Anderson has a social disability which he has so far
appeared to manage in the manner best suited to his own
perceived needs. He did however request help in this
instance and, as this was so unusual, the GP agreed to a
referral to speech and language therapy to develop
strategies to overcome his difficulties. We used an ethical
framework to identify what - if any - role we would have
to play.
Ethical principles need to be interpreted rather than
just applied in our work. To the golden rules of ethics -
beneficence, non-malificence, autonomy, justice - Pia Taylor
and Jois Stansfield now add another: communication need.
+; lurther readng
Turners syndrome, ageing, aphasia, selective mutism,
dysphonia.
SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2003 +
+8 vorkng wth bnguasm: the am
o our care
The children needed to feel they could use their home
language outside the home setting to help with their
communication. This approach increased their confidence
and self-esteem and enabled them to use both their
languages in a positive and valuable manner.
Panna Chavda and
Laura Helsby find
that running bilingual
groups not only has
benefits for the children
concerned, but brings
parents and other staff
on board too.
+ Socoogca
perspectves on
nequaty seres
()
Barbe and Ken:
an unequa
reatonshp
Some studies have highlighted considerable differences
in the way in which health professionals manage male
and female clients, suggesting that gender can be an
important factor both in the assessment of symptoms
and in the choice of treatment.
When you see a little boy who cant sit still, when you
are referred a middle-aged female with dysphonia,
when you visit your GP - do you question whether gender
might be influencing the treatment you give and
receive? Sarah Earle gets us thinking.
Revews
Language development, deafness, early years,
dementia, AAC and dysphagia.
( How l am negotatng care pathways
I would be interested to explore ways of achieving slow
release of the therapists expertise over the long haul of
the patient getting on with their life. (Cecilia Yardley)
Too often, speech and language therapy and other services
are difficult for clients to access and negotiate, and
therapists themselves are not always clear which way
to turn. Neil Smith and Cecilia Yardley believe care
pathways offer a way ahead.
Back cover Ny Top Resources
There is no better way to learn about normal feeding
development than by having your own personal research
project in front of you day to day. (NB: This may seem a
drastic measure... the dysphagia courses at Manchester
Metropolitan University are an acceptable alternative.)
Rebecca Howarth works in a specialist acute childrens
hospital and provides a community service to preschool
children with feeding and swallowing difficulties as
part of a multidisciplinary team.
SPRING 2003
(publication date 24th February)
ISSN 1368-2105
Published by:
Avril Nicoll
33 Kinnear Square
Laurencekirk
AB30 1UL
Tel/fax 01561 377415
e-mail: avrilnicoll@speechmag.com
Design & Production:
Fiona Reid
Fiona Reid Design
Straitbraes Farm
St. Cyrus
Montrose
Website design and maintenance:
Nick Bowles
Webcraft UK Ltd
www.webcraft.co.uk
Printing:
Manor Creative
7 & 8, Edison Road
Eastbourne
East Sussex
BN23 6PT
Editor:
Avril Nicoll RegMRCSLT
Subscriptions and advertising:
Tel / fax 01561 377415
Avril Nicoll 2003
Contents of Speech & Language
Therapy in Practice reflect the views
of the individual authors and not
necessarily the views of the publisher.
Publication of advertisements is not
an endorsement of the advertiser
or product or service offered.
Any contributions may also appear
on the magazines internet site.
Cover picture by Paul Reid (posed by
model). See p.4
IN FUTURE ISSUES
DYSPHAGIA USER INVOLVEMENT INTENSIVE INTERACTION SOCIOLOGY
PROGRESSIVE NEURO APHASIA PECS
CONTENTS SPRING 2003
www.speechmag.com
Prme and Predgest
My fingers, said Elizabeth, do not move over this
instrument in the masterly manner which I see so many
womens do. They have not the same force or rapidity,
and do not produce the same expression. But then I have
always supposed it to be my own fault - because I would
not take the trouble of practising. It is not that I do not
believe my fingers as capable as any other womans of
superior execution. (Jane Austen, Pride and Prejudice)
It is a truth universally acknowledged that a speech and
language therapist in possession of a good idea must be
in want of a publisher. Avril Nicoll asks, what are you
waiting for?
( OVER STORY
news
SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2003
Scope welcomes report
The national disability organisation whose focus is people with cerebral palsy has
welcomed an audit commission report on children with special educational needs.
The report found that national targets and performance tables fail to reflect the achievements
of many children with special educational needs, so inclusive schools may appear to perform
badly. In addition, a lack of systematic monitoring by schools and local education authorities
makes it difficult to recognise good or to challenge poor practice. Scopes research and
public policy officer said, Scope particularly welcomes the way the report highlights the
tension that exists in the Governments agenda. It is promoting the policy of inclusion at
the same time as failing to value anything other than the achievement of academic targets.
Until such time as there are some real incentives for doing well at inclusion, disabled children
will continue to have a less than equal opportunity in education.
The audit commissions report also pointed out that children with special educational
needs remain a low profile group in spite of the significant numbers involved and, while
early intervention can make a difference, it is yet to become the norm. They note that
parents of children with special educational needs often have difficulty with school
admissions, and that schools must increase their accessibility in the broadest terms but
also need to be supported in seeking to meet a wider range of needs.
The audit commission is an independent body responsible for ensuring that public money
is spent economically, efficiently and effectively, to achieve high-quality local and national
services for the public.
Special educational needs: a mainstream issue is on www.audit-commission.gov.uk.
www.scope.org.uk
Student mental health
The latest annual survey of counselling services in further and higher
education suggests mental health support for students is being
neglected while the need for it is increasing.
The Association for University and College Counselling division of
the British Association for Counselling and Psychotherapy survey
found that university counselling has lost over 10 per cent of its real
budget since the mid-90s. Two thirds of counsellors in new universities
and further and higher education colleges, and half the counsellors
in the old universities, felt that the proportion of seriously dis-
turbed clients had increased over the past year. Fifteen per cent of
all counselling clients in further and higher education presented an
issue linked to suicide, a significant recent increase.
Members of the association believe reasons for the increase may
include student debt coupled with rapid expansion of colleges and
campuses placing pressure on the system. They are calling for
greater appreciation of the role of embedded student counselling
services in supporting students and improving student retention.
British Association for Counselling and Psychotherapy www.bac.co.uk
Timing in motor neurone disease
Timing, multidisciplinary community teams and maintaining involve-
ment throughout the progression of the illness are vital elements of
a palliative care service for people with motor neurone disease.
In a keynote session at the 13th International Symposium of the Motor
Neurone Disease Association in Australia, Dr Susan Mathers urged del-
egates to make use of the knowledge they have. The Melbourne
medical director of neurology said, Patients want a rough time-
frame of their illness. The clinician has a responsibility to anticipate
the patients needs and to work towards a timely addressing of
those needs.
Emphasising the importance of multidisciplinary care in the community
for people with motor neurone disease, Dr Mathers stressed that
clinicians should remain in touch with clients throughout the illness.
As well as providing a better service, this encourages people to
become more involved in their own care.
The annual three day international symposium, hosted by a different
country each year, brings together leading scientists, researchers and
clinicians as well as people with motor neurone disease. Other pre-
sentations included talks on quality of life, cognitive and psycholog-
ical effects, advances in genetics and enhancing quality of care.
MNDA, tel. 01604 250505, www.mndassociation.org.
Sure start for all
A cross departmental unit intends to
deliver a joined up approach to childcare,
early years education and family and
health support.
The new Sure Start unit will support all
families in England from pregnancy until
children are 14 years old, or 16 years for
those with disabilities and special educa-
tional needs. It will encourage local
authorities, communities, voluntary and
private sector organisations to work
together to provide more single points of
contact and integrated services. Sure Start
for all children is building on the work of
the local Sure Start programmes for chil-
dren living in disadvantaged areas.
The government is also committed to
establishing new childrens centres to pro-
vide childcare, family support and health
services in one centre, for up to 650,000
children in disadvantaged areas of
England by 2006.
The inter-departmental Childcare Review:
Delivering for Children and Families, see
www.strategy.gov.uk.
Queens award for
Queen Margarets
A prestigious award has been presented to a university department
in recognition of its pioneering work in the clinical application of
speech science.
Queen Margaret University College in Edinburgh received a Queens
Anniversary Prize following a decade of internationally renowned
work by its department of speech and language sciences. Uniquely
in the field of education, these prizes sit within the national honours
system, and the process involves fierce competition from higher and
further education institutions throughout the UK.
A spokesperson from the Royal Anniversary Trust, which presents the
prizes, commented that the portfolio of
innovative procedures has significantly
enhanced diagnosis and therapy for people
with speech disabilities. In pioneering new
techniques, the University College has
forged strong links with health service pro-
fessionals and with researchers around the
world and has gained an international rep-
utation for it specialised undergraduate
and postgraduate training. Head of
department Jois Stansfield (see p.14)
praised her staff for their teamwork and
welcomed the importance the award places
on research which has real value to clients.
http://sls.qmuc.ac.uk
Helen Gowland (right), of Tayside
Speakeasy, chats to television presenter
Lorraine Kelly after receiving the Women
Who Mean Business Award 2002. The
award is designed to celebrate women in
the Dundee and Angus area whose
achievements and efforts in their business,
career and personal lives have been innov-
ative, inspirational to others or have been
set against a challenging background.
Short videos of the nominees were
shown at the awards ceremony. There
was silence as Helen, who was a research
physiotherapist prior to her brain haem-
orrhage, described the effects of her
aphasia and demonstrated the many
strategies she uses to communicate.
Helens video also showed her running
an exercise class at an Age Concern Club,
describing her involvement in the Dundee
Expression art project and listing her various
hobbies including belly dancing.
Also in the picture is Helens friend Jan
Wilson (a paediatric speech and lan-
guage therapist in Dundee) who nomi-
nated her for the award.
The Women Who Mean Business Award is
organised by the Women Ahead network
of which Lorraine Kelly is patron. Helen
Gowland was interviewed in the Winter
01 issue of Speech & Language Therapy in
Practice.
www.womenahead.co.uk
Speech & language
therapist uses
electropalatography
with a child
The Articulograph facility is the only one of its type in the UK. This equipment
tracks the movement of small copper coils attached to the lips, jaw, tongue and
soft palate. This improves our understanding of normal speech production.
http://sls.qmuc.ac.uk
SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2003
news 8 comment
Nurturng taent
As Rebecca Howarth observes (back page), in paediatric speech and language
therapy you can have no better teaching tool than your own children.
Watching my preschool sons and their girl friend this week acting out stories
in turn with the same lego characters, I was struck by the gender differences.
The boys stories involved lots of fighting, noise and destruction, while their
friend had a beautiful princess dancing with her prince and a dragon putting
on hairspray. Amusing enough, but does this early stereotypical behaviour
have implications for their future? In the second of her sociological
perspectives on inequality series, Sarah Earle (p.21) has some ideas to make us
think about how gender affects us and our interactions with others.
One of the fascinating things about young childrens stories is the wonderful
tangents sparked off by an unexpected sound or event interrupting their
train of thought. As we grow into adulthood we become more constrained
by what is right and expected, and need reminding that it is possible to do
things differently. Sue Dobson (p.8) and colleagues have gathered and
analysed information on eating and drinking difficulties in adults with
learning disabilities to plan a shift in service management towards prevention
of dysphagia. Pia Taylor and Jois Stansfield (p.14) used an ethical framework
to help an elderly client decide to make some changes in his life, thus opening
up his communication opportunities. Neil Smith and Cecilia Yardley (p.24)
both perceive the need for such organised and evidence based approaches to
therapy that are nonetheless highly flexible and responsive to individuals.
Perceptiveness is a talent which Jane Austen used to devastating effect in her
stories. That they have as much relevance to todays society as they did to the
time in which they were written is evident to me. With any luck after reading
Prime and Predigest (p.4), this will be evident to you too, and inspire you to
get writing. Speech & Language Therapy in Practice awaits your call!
Jane Austens talent for storytelling was encouraged and nurtured by her
family as she grew up. Part of our role, where needed, is to enable parents
and carers to value every form of communication. Panna Chavda and Laura
Helsby (p.18) used groups to give bilingual children and their parents and
teachers a sense of pride in their ability to promote language development
through two languages.
As proud of my boys as any mother, I have to say in their favour that both their
lego stories finished with a very important sounding The End, and the older
one even had a witch writing it on a piece of paper. But, as Im sure they could
do with more structure to their plots of death and destruction, Im off to try
out some of Becky Shanks suggestions (p.10) for improving their narrative...
...comment...
Avr Nco,
Edtor
Knnear Square
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Autism research
A newly formed research trust aims to raise and
distribute funds to research interventions in autism,
evaluating their effectiveness against agreed national
or international criteria.
The Autism Research Trust has been set up as a separate
associated charity of the National Autistic Society. A
collaborative venture sponsored by Cambridge
University, the Board of Trustees includes Dr Lorna
Wing. Richard Mills, director of research at the
National Autistic Society, said the new trust will be
listening to parents and professional carers to ensure
a strategy and priorities that will lead to treatment,
help and comprehensive advice that is relevant to
their needs and of the highest quality.
www.nas.org.uk
New post at I CAN
I CAN, the national educational charity for children
with speech and language difficulties, has appointed
a widely experienced teacher and inspector to a new
post of director of services to children and families.
Linda Redford is a member of the Care Standards,
SEN and Disability Tribunals as well as the Council for
Disabled Children and ACE Council (Advisory Centre
for Education). I CAN says she will play a leading role in
completing its national network of early years centres
and developing plans for the evolution of I CANs
special schools into regional specialist centres.
Stammering updates
The European Commission is joining forces with the
European League of Stuttering Associations to raise
awareness of stammering as part of the European
Year of People with Disabilities.
To receive monthly news updates e-mail
elsa.Europe@telia.com and type EYPD Subscribe.
Tapestry work
An independent applied psychologist has set up the
Tapestry Life Centre to continue her work on atten-
tion deficit hyperactivity disorder, autism, Asperger
syndrome and related disorders.
Lisa Blakemore-Browns centre is based at the Brunel
Science Park, opened by her alma mater Brunel University
to provide tenants with the opportunity to undertake
scientific and technical work in a university environment.
The centre takes its name from Lisa Blakemore-
Browns book, Reweaving the Autistic Tapestry.
www.brunel.ac.uk
Brain injury therapist
Speech and language therapist Judith Mitchell has joined
the committee of HIRE (Head Injury Re-education).
The charity works to increase awareness of the
educational needs of children, young people and
adults with an acquired brain injury, work for
improved education provision, provide a comprehensive
source of information and encourage and promote
research. Judith, an independent speech and language
therapist who is committed to interdisciplinary
working, joins a solicitor, researcher, social worker,
mother and two teachers on the committee.
HIRE, tel. 01869 324339, forthcoming website:
www.headinjuryreeducation.org
cover story: n my experence
SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2003 (
It is a truth universally
acknowledged that a
speech and language
therapist in possession of
a good idea must be in
want of a publisher, as
Jane Austen might have
said. Avril Nicoll suggests
that getting your work
on paper requires the
single-mindedness of a
Mrs Bennet, the
determination of a Mr
Darcy and preferably the
liveliness of a Lizzy - but,
thankfully, not the skill of
the Pride and Prejudice
author.
1
prime v.tr. equip (a person) with information etc.
2
predigest v.tr. make (reading matter) easier to
read or understand.
(Definitions from the Concise Oxford Dictionary, 8th ed.)
Prime and P
1
My first and very short-lived
venture into publishing was as
a 10 year old pupil at Eastern
Primary School, co-producing
the aptly named Eastern
Express on a banda machine.
As a teenager I recall labori-
ously typing, cutting and pasting circulars then, as
a young therapist, collaborating in the production
of Backchat, a staff newsletter doomed because
we took it a bit too far.
A recent perusal of my School days...Treasure
Album found the word journalist cropping up
over several years as my ideal career choice. Not
until my final year at school does speech thera-
pist appear, so it is perhaps appropriate that the
two areas are now combined in the editing and
publishing of Speech & Language Therapy in
Practice. A crucial part of this is inspiring other
people to write up the work they are doing.
Naturally, I turn to one of my own sources of
inspiration, Jane Austen, for assistance.
My fingers, said Elizabeth, do not move
over this instrument in the masterly manner
which I see so many womens do. They have not
the same force or rapidity, and do not produce
the same expression. But then I have always
supposed it to be my own fault - because I
would not take the trouble of practising. It is
not that I do not believe my fingers as capable
as any other womans of superior execution.
As we do in speech and language therapy, I am
constantly learning and improving on my editing
skills. But is it possible that some people are simply
not suited to writing? Ferguson & Mortensen
(2002) point out that we would not be in the
business of therapy if we thought that language
skills could not be developed, learned or enhanced.
We often fail to recognise that we can shape our
own language skills, as much as we can shape those
of our clients. Time, confidence and practice are
essential and inter-dependent elements of writing.
As research is not done until it has appeared in
writing (Ferguson & Mortensen, 2002), accept
that setting aside time for writing up your work is
not only valid but crucial for the future of a pro-
fession working to increase its evidence base and
avoid re-invention of the wheel. With a perceived
lack of encouragement in the NHS to write up suc-
cessful and unsuccessful projects - both equally
important - clinicians have to be prepared to
motivate themselves. Draw confidence from the
writing you already do; look at case notes, reports
SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2003
cover story: n my experence
you have good therapy deas
want to ncrease our
evdence base
need nspraton to put pen
to paper (or mouse to mat)
Read ths
and user information and notice how you adapt
the style to meet the needs of the different audi-
ences. And practise, practise, practise: write a let-
ter to a newspaper or the professional press, do a
book or product review, or produce a newsletter
for clients (Marsh & Brookes, 2002, item 4). If writing
from scratch fills you with dread, get a colleague
to interview you on tape about your project or
case and use that as the basis of an article.
Listing the requirements of an accomplished
woman:
...and to all she must yet add something more
substantial in the improvement of her mind by
extensive reading.
What professional publications do you read?
Who else is reading them, and are they people
you are trying to influence for funding or to
change practice? What level of evidence or opinion
and clinical experience is needed? Are they
focused on a certain client group or for general
consumption? Why would you want a particular
article to appear in one rather than the other?
When you are planning to write up your work,
producing the article before looking for some-
where to get it published is a bit like putting the
cart before the horse. Every publication is operating
in the market and depends on the uniqueness of
its style and content for survival. Although you
know your subject best, the editor knows what
makes the readers come back for more and how
the different aspects of the publication work
together to make it what it is. Just before I started
editing Speech & Language Therapy in Practice I
was asked by the editor of another magazine to
write an article. Her evident disappointment
when I had written the article I thought her read-
ers would want rather than what she had asked
me to do was a salutary lesson.
While this magazine is not above good-natured
ribbing of the style of more august journals
(Irvine, 2002), we should value the diversity of
reading material available to our profession and
make use of it to reach different audiences.
Although you must observe the protocol that an
article is not submitted to more than one journal
without the express permission of the editors
involved, it is acceptable to write up different
aspects of the same piece of work to appeal to the
different sectors.
When Lydia went away she promised to write
very often and very minutely to her mother and
Kitty; but her letters were always long
expected, and always very short.
All publications have guidelines for authors which
are essential reading before you write an article or
do a book review (contact the relevant editor or see
websites associated with the publication for a
copy). Following the guidelines and being familiar
with the style and content of a particular publication
will greatly increase the chances of your article
being accepted. The degree to which authors and
editors work in partnership varies between publi-
cations. Speech & Language Therapy in Practice
has a flexible approach depending on the experi-
ence and wishes of the writer, and I am always
happy to talk things through with potential
authors at any stage. Make every effort to meet
deadlines and do what has been agreed with the
editor, but accept that the editor is coordinating
the whole picture and may not be able to get
back to you as quickly as you would like.
Elizabeths spirits soon rising to playfulness
again, she wanted Mr Darcy to account for his
having ever fallen in love with her. How could
you begin? said she. I can comprehend your
going on charmingly when you had once made
a beginning; but what could set you off in the
first place?
Getting started, keeping going and finishing an
article all have their challenges. Lack of time is an
obvious problem but may be an excuse for deeper
fears we are reluctant to voice. What if it gets
rejected? What if people think its rubbish? What
if the readers say theyve being doing this for
years and its nothing new? What if I get hate
mail? What if I get sued?
Well, what if we turn this on its head? The chal-
lenge of having an article accepted. The thrill of
seeing your work in print. The congratulations
from colleagues and even from therapists you
dont know. The satisfaction of confirming the
worth of standard practice, of inspiring therapists
with new ideas, of motivating people to try some-
thing different. If we can look on publishing as a
positive step and be supportive of those who have
the courage to do it, how many more people will
be willing to try their hand?
There are many ways to get started, so think
about what will work for you. I was told recently
that writers block is as credible as speech and lan-
guage therapists block, and that it can be avoided
by the discipline of setting aside time for writing
on a daily basis. Getting something down on
paper or on screen - what I refer to as scribbling -
certainly works for me, always knowing that it is
likely to change completely before it is finished.
Predigest

2
SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2003
cover story: n my experence
Eighteenth century poet Edward Young reckoned,
Procrastination is the thief of time, but
Winkworth (2002) sees it in a much more positive
light, saying we should accept the initial dither-
ing as part of the process of nailing down what
we mean. In an entertaining and insightful arti-
cle she extols the virtues of talking aloud at every
stage of the research process, even if there is no-
one there to listen. Having discovered this at an
early stage in my editing career I can vouch for its
effectiveness, even if it raises a few eyebrows.
His letter was soon dispatched; for though
dilatory in undertaking business, he was quick
in its execution.
As well as talking it through, sleeping on an idea
is often very productive. A recent interview with
Newsnight presenter Kirsty Wark (Good
Housekeeping, October 2002) revealed she is reliant
on lists and even keeps a notebook beside her bed.
Having deadlines - either real or self-imposed - help
many people to keep going, and some people like
to give themselves strict timetables. Experienced
writers suggest a highly organised, bottom-up
approach, starting with a skeleton and gradually
padding it out. Another tells me she keeps her
notes and observations in a file as she goes through
her research, uses mind maps a lot and develops
chapters and themes from them as the data begins
to make some kind of sense. My preference is to
have an idea, get as much down as possible, and
then to edit ruthlessly both for content and order. I
am therefore completely reliant on my computer
for word processing and can only wonder at Jane
Austens tenacity with paper and pen.
It is a truth universally acknowledged that a
single man in possession of a good fortune must
be in want of a wife.
Jane Austen could hardly have guessed that the
opening paragraph of Pride and Prejudice would
become one of the best known in English literature.
Speech and language therapists often write in the
style of an academic essay as this has been their
experience at undergraduate level. However, this
means the best bits of an article are left until the
end, which is pointless if the beginning is so unin-
teresting that people dont even start to read it.
Be prepared for the editors intervention to
spice up your introduction and, while writing your
article, give thought to potentially memorable
openings. These could be a question, a quote, a
case example, an anomalous assertion, or a state-
ment to make your readers think. In contrast, a
punchy ending is unnecessary, particularly if it
simply offers a summary of what has gone before.
Charles writes in the most careless way
imaginable. He leaves out half his words, and
blots the rest.
My ideas flow so rapidly that I have not time
to express them; by which means my letters
sometimes convey no ideas at all to my
correspondents.
First Impressions was the original title of Pride and
Prejudice. It may seem obvious but sloppy references,
clear outline of methodology and
results, and a discussion which
relates these results to the existing
literature in the field. She reads
the paper and annotates heavily,
re-reads it and collates the com-
ments into coherent and construc-
tive criticism. She suggests the first
one or two attempts to publish in
reviewed journals might be best
associated with an experienced researcher who can
receive the review without being put off publishing,
and can challenge any unfair comments. (And
remember, even a manuscript such as Pride and
Prejudice was originally turned down.)
Tell your sister I am delighted to hear of her
improvement on the harp, and pray let her
know that I am quite in raptures with her
beautiful little design for a table, and I think it
infinitely superior to Miss Grantleys.
Will you give me leave to defer your raptures
till I write again? At present I have not room to
do them justice.
It is important to see comments and feedback
from an editor in a positive light rather than taking
them personally. I once wrote an article for a GP
magazine and was quite insulted when the proofs
came back with some of my words changed. It now
said something I didnt mean but, if I had expressed
it clearly enough in the first place, I would not have
been misinterpreted. An editor can spot things you
have missed, can ask the questions readers will
inevitably ask, and can see opportunities to tighten
up an article to make it more readable. Think of it
as the relationship between a therapist and a
client - the client knows most about themselves,
while the therapist brings theoretical knowledge
and experience with similar clients.
Now I have got some news for you, said Lydia,
as they sat down to table. What do you think?
It is excellent news, capital news, and about a
certain person that we all like.
Jane and Elizabeth looked at each other, and the
waiter was told that he need not stay. Lydia
laughed, and said, -
Ay, that is just like your formality and
discretion. You thought the waiter must not
hear; as if he cared! I daresay he often hears
worse things said than I am going to say. But
he is an ugly fellow! I am glad he is gone. I
never saw such a long chin in my life.
The ethical side of publishing where clients are
involved is something of a minefield, yet case
examples are absolutely vital in bringing articles
alive and making them meaningful to readers. It
is very important that authors anonymise case
information so that the clients cannot be identi-
fied from the article, at the same time keeping
the information which will allow readers to
decide whether or not to use the ideas with any
of their own clients. Simply changing a name is
not enough. For the avoidance of doubt, I would
urge authors to discuss proposed articles with
clients and ask for their consent.
spelling mistakes and
frequent repetition
give a poor impression
of the value of the
content. It is vital to
focus on what you
want to achieve and
give attention to
detail. A dictionary,
thesaurus and book of
quotations should never be far away and sources
should be fully acknowledged (Bowen, 2002a).
When she read and re-read, with the closest
attention,...again she was forced to hesitate.
*****
...Widely different was the effect of a second perusal.
Ferguson & Mortensen (2002) explain the nature of
the six drafts they believe are needed for a quality
written product. Very roughly, these encompass:
ideas and diagrams; logical sequencing; reworking
and questioning; reading aloud; reading by some-
one else; and checking against style guidelines.
...I have always seen a great similarity in the
turn of our minds. We are each of an unsocial,
taciturn disposition, unwilling to speak, unless
we expect to say something that will amaze the
whole room, and be handed down to posterity
with all the clat of a proverb.
Produce as good an article as you can, but focus
on correction rather than the impossible goal of
perfection.
But really, and upon my honour, I will try to
do what I think to be wisest; and now I hope
you are satisfied.
Her aunt assured her that she was; and Elizabeth
having thanked her for the kindness of her hints,
they parted - a wonderful instance of advice being
given on such a point without being resented.
Develop a network of people who will comment
on drafts of articles for you. I rely on family if I am
unsure about a title for an article or usage of a
word. Experienced writers find friendly but honest
colleagues indispensable while drafting articles.
Joint writing, either through taking responsibility
for different sections, or having turns a draft at a
time, is favoured by some. There are often local
courses on writing for publication for NHS workers,
and university lecturers and managers may also
be willing to help you out with advice. For self-
directed study, start with the online version of
Bowen (2002b) and its useful links.
Speech & Language Therapy in Practice is not a
peer reviewed publication. This formal process
used in academic journals involves recognised
experts in a field giving feedback on an article
confidentially and anonymously via an editor.
Comments from experienced writers suggest peer
review can be a bit of a necessary evil. Be prepared
for a slow process and try not to get demoralised
if the feedback is not as constructive as you hoped.
A peer reviewer tells me she is looking for some-
thing which adds to the knowledge base in some
form, has a clear rationale, concise introduction, a
+. see wrtng or
pubcaton as an
essenta eement
o your work
. amarse yourse
wth potenta
pubcatons
. oow gudenes
and meet deadnes
(.deveop a network
o peope to assst
you
. get started, keep
gong, nsh - then
start a over agan.

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SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2003 ;

cover story: n my experence
Happy for all her maternal feelings was the day
on which Mrs Bennet got rid of her two most
deserving daughters.
Getting that article e-mailed off (or posted if this
is not possible) brings feelings of huge relief but,
if people were happy that that was the end of it,
we wouldnt have seen two sequels to Pride and
Prejudice. Be prepared to answer questions, find
out more information, do some re-working and
finally, after it is published, to deal with follow-up
phone calls and the expectation of future tomes.
Shall you ever have the courage to announce
to Lady Catherine what is to befall her?
I am more likely to want time than courage,
Elizabeth. But it ought to be done; and if you
will give me a sheet of paper, it shall be done
directly.
So, what are you waiting for?
Avril Nicoll, speech and language therapist, is pub-
lisher and editor of Speech & Language Therapy in
Practice magazine, www.speechmag.com, tel.
01561 377415, e-mail avrilnicoll@speechmag.com.
References
Bowen, C. (2002a) A few words about PLAGIA-
RISM, [Web Page] http://members.tripod.com/
Caroline_Bowen/plagiarists.htm. Date accessed:
January 5, 2003.
Bowen, C. (2002b) WEBWORDS 10 Clinicians who
do research: Hands-on scientists. [Web Page]
http://members.tripod.com/Caroline_Bowen/web-
words10.htm. Date accessed: January 5, 2003. Also
in ACQ 4 (1), 49. Speech Pathology Australia.
Ferguson, A. & Mortensen, L. (2002) Writing for
Research. ACQ4 (1), 54-56. Speech Pathology Australia.
Irvine, C. (2002) Preliminary findings of an infor-
mal longitudinal study into the research / practice
interface: noting the influence of extra trees in
the wood rather than throwing the baby out with
the bath-water. Speech & Language Therapy in
Practice. Spring, 16-17.
Marsh, T. & Brooks, C. (2002) My Top Resources.
Speech & Language Therapy in Practice. Summer.
Winkworth, A. (2002) Can I run an idea past
you? Brainstorming: The process of refining
ideas by critical discussion. ACQ 4 (1), 6-7. Speech
Pathology Australia.
Acknowledgements
This article is based on Publish or be damned, a
presentation to the Northern Research SIG in
Newcastle on 3 December, 2002. Thanks to
organisers Paula Leslie and Pauline Meek and
those who attended for their enthusiasm and
insights which are reflected throughout.
Thanks to Elinor Harbridge of Hexagon Publishing;
to Jenny Sheridan of the Royal College of Speech
& Language Therapists Bulletin; and to the four
authors who took time to brief me on publishing
from a writer and peer reviewers perspective.
Again, their comments have been subsumed into
this article.
Quotations from Pride and Prejudice by Jane Austen -
my copy published by T. Nelson & Sons, Ltd.
Don Johnston
Products making their first appearance in the
2003 Don Johnston sourcebook include the
FEAT (Functional Evaluation of Assistive
Technology) for use with pupils with learning
difficulties, and individual phonics instruction
from Simon S.I.O.
Don Johnston aims to design interventions that
use technology to help build skills, provide
scaffolds, support the curriculum and make
options available for computer access.
www.donjohnston.com
Home Editions
Schools software publisher Topologika is making
its products available to parents at a reduced
rate of 19.99 or 24.99 inc. VAT. For further
information on Home Editions including
Scallys World of Verbs, Speaking for Myself
and Freddy Teddy Bumper Pack, ask for a
catalogue.
Topologika Software, tel. 01326 377771,
www.topologika.com.
Aphasiahelp
London Connect staff and service users have
been involved in the development of a website
designed to be both accessible and informative
to people with aphasia. Comments are
welcome.
View the prototype at www.aphasiahelp.org.uk
and send feedback to beckymoss@ukconnect.org.
Have you Bookstarted yet?
A revamped Bookstart website contains general
information and advice for parents, and
information on best practice, research and
resources for professionals.
The Bookstarters bi-monthly newsletter, available
by e-mail, contains many snippets of use to
speech and language therapists working with
children. The Nov/Dec issue included an update
on Bookstarts penetration in the UK, feedback
on projects in libraries in Los Angeles and a
report of a new link with Mantra, a dual
language childrens publisher.
www.bookstart.co.uk / www.booktrust.org.uk
Pulse oximetry
A stand-alone pulse oximeter with a battery
life of 15 hours and a data memory capacity
of 160 hours is aiming to offer flexibility of
use in hospital and in homes.
OxyTrend, see www.draeger-medical.com
Diabetes and stroke
A free pack provides information on recognising
the symptoms of diabetes, as the link between
diabetes and stroke makes it crucial it is
properly diagnosed and controlled. The pack
also provides information on how to reduce
your risk of a stroke if you have diabetes.
Diabetes is common and on the increase, and
can double or triple your risk of suffering a
stroke.
Free from The Stroke Association, tel. 020 7566
0317, www.stroke.org.uk.
Experiences of autism
The National Autistic Society has published a
book containing a collection of poems, pictures,
stories, photographs, drawings and paintings by
people with autistic spectrum disorders and
their families, friends and professionals as part
of its 40th anniversary celebrations.
Autism. The problem is understanding (ISBN 1
899280 38 3), tel. 01268 522872.
Intervoice
An internet site for the international
exchange of information in the voice therapy
field has had a re-vamp.
Intervoice is accessible in English, Spanish and
German and includes updates on new tech-
nology, job and work experience adverts and
a discussion forum.
www.intervoice.de
..resources...resources...
HIV news
A weekly HIV e-news service is now available
for people living with HIV or interested in
the latest HIV news and treatment information.
The service is provided by the website World
Aids Day Gay.com and HIV publication
Positive Nation.
To subscribe, go to http://uk.gay.com/newsletter/
Staff discount
NHS staff can access discounts through an
exclusive and free online service.
NHS Discounts has arrangements with high
street names such as the Halifax, Currys,
Dixons, WH Smith and PC World. The service
does not cost the NHS any money and the
organisers hope it will encourage recruitment
and retention of staff.
www.nhsdiscounts.com
Keep signalonging
New manuals from Signalong are The
Multisensory Room (12.50) and Sounds
(12.50) from the Learning Through Sensory
Experience series, and two topic books,
Were Going to the Zoo (15.50) and What
Shall I Wear Today? (12.50).
www.signalong.org.uk
services of which conditions are likely to present
with deteriorating swallowing skills.
people with cerebral palsy who have attended
Further Education college may have had well
managed feeding programmes, and their difficulties
as they settle into adult day services are seen as one
of transition, rather than the onset of progressive
feeding difficulties after the age of 25 years.
high staff turnover in residential and daycare
services means that continuity of staff training
about feeding is difficult to maintain.
The referrals received are then often too late to
offer successful environmental management of
the swallowing difficulty. The problem has
become one of dysphagia and the person is either
too ill to respond to environmental management
procedures, has already been admitted to hospi-
tal, or the problem is about to be managed by
non-oral feeding methods.
Our locality identified these difficulties four
years ago and responded by
i. setting up a multidisciplinary feeding clinic
ii. identifying everyone in the district who needs
to be fed by staff
iii. auditing the feeding standards in all day services
iv. ensuring that everyone who is fed has feeding
guidelines in place
v. getting the level of risk of everyone who is fed
recorded and monitored
vi. establishing a rolling programme of on-site
unit training
vii. introducing joint speech and language therapy,
dietetic and physiotherapy assessments within
the units
viii making video recording and pulse oximetry
standard procedures in every assessment
ix. standardising recording of assessments
x. cooperating with a Downs Syndrome and
Dementia screening programme for those
people over the age of 35 years
xi. instituting links with hospital radiology services.
However, despite these procedures being main-
tained and monitored, it became clear that too
many emergency referrals were still being
received at certain times of the year. These refer-
rals needing an urgent response were not spaced
but tended to come in clusters. As the number of
speech and language therapists employed is limited,
and only certain of them may have the expertise
to assess swallowing within such a learning dis-
ability service, this became a management issue.
There are now more people aged over 50 years
in adult learning disability services. However,
these requests for an urgent response were not
particularly associated with the onset of dyspha-
gia in dementia, cerebrovascular accident or
other neurological disorders such as those associ-
ated with increased ageing, although there were
occasional ones.
A proactive approach
The speech and language therapists, physiotherapists,
occupational therapists and dietitian form the
basis of the feeding clinic staffing, complemented
management
SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2003 8
he work of speech and language
therapists with people with dyspha-
gia is the most reactive of any of the
other specialisms. It exists as one of
the few speech and language thera-
py emergencies. Royal College of
Speech & Language Therapists
guidelines suggest a 48 hour response time. The
person referred - usually following a stroke or
other neurological event - is likely to be unknown
to the service, with no relevant previous records.
In services for adults with learning disabilities
the situation is different. People are likely to have
feeding and drinking difficulties rather than dys-
phagia and the services response times are there-
fore usually within two weeks of referral. The
people referred are often known to the speech
and language therapy service. They will possibly
have received episodes of intervention to support
their social skills or establish alternative and aug-
mentative system communication.
The management of the problem is different too,
in that there are considerable numbers of people
who have to be fed and are unable to manage
their own nutrition. The speech and language
therapists covering this specialism also receive
urgent referrals when adults with learning dis-
abilities have an eating and/or drinking crisis. The
person has probably always been known to be
difficult to support while being given food or
drink, but
staff are used to the eating and drinking problems
they and the service user experience at mealtimes
and see nothing unusual in the difficulties.
staff get used to the person coughing during and
after meals and do not recognise it as cue for
referral.
the loss of skills the person exhibits is so slow that the
staff are not immediately alerted to the difficulty.
many people with particular syndromes are living
longer and there is little knowledge within the
T
If referrals for feeding and
drinking difficulties in adults
with profound and complex
needs are made too late or in
too great a number for the
speech and language therapy
service to respond
immediately, the problem
becomes one of dysphagia
and is much more difficult to
manage. Sue Dobson and
colleagues describe their
move to a preventative
approach.
you are enterng unknown
terrtory
need to work wth other
dscpnes
want to take the ntatve
Read ths
From
reaction
to action
by other clinical teams within the locality. A
health centre within the same learning disabilities
directorate provides specialist clinics and each spe-
cial care day service is staffed by one of the health
surveillance nurses team. The feeding team there-
fore negotiated a joint audit with these two other
teams to try and develop a proactive approach for
people with swallowing difficulties. The aim was
to identify the most common contributory factors
in the problems of people who are fed.
The teams chose to focus on the largest special
care unit where, out of the 45 people attending
on a weekly basis, 32 are fed. People who are fed
are known to be at a higher risk of swallowing
difficulties than people who can feed themselves;
indeed, being fed is in itself a risk factor.
A questionnaire was jointly designed with the
participants to include any factors which might
impact on health issues which result from feeding
difficulties, for example lack of lateral jaw move-
ment during chewing and resultant problems
with impacted earwax, or the link between dental
caries and bacteria associated with aspiration
pneumonia. Completed questionnaires from the
dentist, audiologist, orthoptist and health surveil-
lance nurse were collated with those produced by
the physiotherapists, occupational therapists and
a dietitian. The speech and language therapists
then undertook detailed observations of each
individual over a lunch-time period. These obser-
vations were then compared
with the records of those people
who had been referred to the
feeding team over the last year.
The results were then subjected
to a statistical analysis using prin-
cipal component analysis.
Key factors
The initial analysis of the data
led to the identification of 24
commonly reported factors.
However, those service users who
displayed more of these factors
only shared 16 of them (see table
1) and they were considered to
be key clinical factors in terms of
risk to people who are fed.
The six key factors which
occurred most frequently were:
1. guidelines recommend altered food texture
and/or thickness
2. guidelines recommend thickened drinks
3. a marked slow rate of eating (more than 20
minutes)
4. frequent or excessive coughing during meals
5. distress during or after meals
6. episodes of food or drink refusal for more that
2-3 days.
There was a further set of five factors which par-
ticularly focused on more general physical issues
which were of interest - but their significance in
terms of triggering eating and drinking referrals
were not clear. These were:
SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2003 ,
management
7. low resting oxygen saturation levels
8. sitting positions
9. fatigue during meals
10. being underweight
11. very occasional choking.
The statistical analysis of the initially identified
24 factors, showed that the two highest ranking
clusters of factors (when exclud-
ing crisis factors of fever or chest
infection) were as follows:
a) First order factors which
accounted for 18.5 per
cent of the total:
change in texture management
weak cough
food refusal
coughing during meals
b) Second order factors accounting
for 14.1 per cent of the
remaining ones:
constipation
oral infections.
It was considered interesting that
several of these factors could be
linked to inadequate or inefficient
liquid intake. This is often the rea-
son for recommending thickening drinks for service
users with learning disabilities rather than any iden-
tified dysphagia or acquired neurological disorder.
We therefore proposed that regular three monthly
monitoring of any service user who had three or
more of the 11 key factors for people who are fed
should be undertaken by the speech and language
therapist in the unit participating in the original
audit and two other units feeding people with
complex needs. The health surveillance nurses
agreed to monitor change in other service users
who have one or two of any of the key factors. Any
increase in the number of risk factors by either
method of data collection would trigger a full feed-
ing and drinking assessment by the clinical team.
New questions
This audit has led to us changing our approach
and clinical focus, which raises several new ques-
tions we need to explore. For example, we need
to try to determine the interaction of the other
general factors identified in relation to the identi-
fied first and second order factors; speech and lan-
guage therapists do not usually focus on bowel
function and oral infections as clinical indicators.
We will also have to evaluate the effectiveness
of this type of proactive monitoring. The differ-
ence in feeding and drinking referrals received by
the team will have to be monitored and compared
with those over the previous 12 months. This work
will also need to compare the variation in terms of
frequency, urgency of the referral and outcome of
the recommendations implemented.
Susan Dobson is Specialist Speech and Language
Therapist with the Clinical Liaison Team for
Bradford District Care Trust.
Recommended reading
Dumble, M. & Tuson, W. (1998) Identifying eating
and drinking difficulties. Speech & Language
Therapy in Practice Winter, 4-6.
Hickman, J. (1997) ALD and dysphagia: issues and
practice. Speech & Language Therapy in Practice
Autumn, 8-11.
Rawlin, C.A., Coupland, J. & Trueman, I.W. (2001)
Effective mouth care for seriously ill patients.
Professional Nurse 16 (4) 1025-1027.
RCSLT (1998) Clinical Guidelines by Consensus for
Speech and Language Therapists. Royal College of
Speech & Language Therapists.
RCSLT (1996) Communicating Quality 2. Royal
College of Speech & Language Therapists.
Tamura, F., Shishikura, J., Makai, Y. & Kaneko, Y.
(1999) Arterial oxygen saturation in severely disabled
people: effect of oral feeding in sitting position.
Dysphagia 14, 204 -211.
we need to try to
determine the
interaction of the
other general factors
identified in relation
to the identified first
and second order
factors; speech and
language therapists
do not usually focus
on bowel function
and oral infections
as clinical indicators.
A questionnaire was
jointly designed with
the participants to
include any factors
which might impact
on health issues
which result from
feeding difficulties
Do we understand the natura
hstory o syndromes and dseases
and nterpret symptoms accordngy'
Do we pan servces where we can
to avod crss management'
Do we work wth other teams to
share workoad sensby'
Reectons
Table 1 Sixteen risk factors of those referred
narratve
SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2003 +o
THE PLOT
Narrative has been described as the way in which
we as human beings render actions and events
meaningful (Lyle, 2000). Whether we are at home,
at work, in the shops or at play, the events of
everyday life are woven together by the stories
we tell each other. It is therefore an essential skill
that children need to master to be able to under-
stand and talk about their world.
At the same time, speech and language therapists
are increasingly being encouraged to link therapy
targets to the educational curriculum. With a
steady move towards inclusion, the classroom is
more commonly the place where therapy is deliv-
ered and reinforced. This means that therapists
are having to become more flexible in adapting
therapy ideas to fit in with methods of classroom
teaching and working together with teachers to
meet the needs of language impaired children in
the classroom. Narrative therapy is gaining in
popularity with speech and language therapists,
who are keen to find out more about the impact
it could have on our daily practice and the provi-
sion of speech and language therapy to children
in mainstream schools.
THE SCENE
There is now a great deal of information about
the way in which young, normally developing
children acquire narrative skills (Bamberg &
Damrad-Frye, 1991; Botting, 2002). This shows us
that even reception aged children, given the right
context, are able to convey adequate informa-
tion, taking into account the listeners knowledge
and organising the content of what they say to
demonstrate that they have some knowledge of
story structure. There is also widespread agree-
ment on the emergence of childrens narrative
skills according to agreed developmental stages
(figure 1). One of the benefits of having this nor-
mative data is that it has enabled us, as clinicians,
to compare the narratives of normally developing
children to their language impaired counterparts.
We know that the narratives of language
impaired children are shorter, include fewer
causal and temporal relationships to tie events in
the story together, and lack the same degree of
structure (Roth & Spekman, 1986).
This information becomes important to speech
and language therapists and teachers when we
consider the close links between narrative ability
and later academic success. Botting (2002) sug-
gests that, oral narratives may serve to inform
clinicians about the risk of literacy problems and
Reynolds (1998) reports that childrens narrative
ability is of vital importance in determining later
academic and social outcomes. Therefore, the
answer to the question, Why is narrative so
important?, is that it could offer clinicians a way
to work with language impaired children to build
on their narrative skills and, in so doing, offer
them an increased chance of participation in class-
room learning.
There is a growing amount of information in the
Only a
story?
Note:
In this article, the educational
stages referred to roughly cover
children of the following ages:
Foundation level includes
Nursery (3-4 years) and
Reception (4-5 years)
Key Stage 1 includes
Year 1 (5-6 years) and
Year 2 (6-7 years)
you woud be ost wthout
stores, taes, yarns, gossp,
ttte-tatte, news and
anecdotes
want more structure to
your therapy
beeve everyone has
stores n them
Read ths
Once upon a time, a fairy godmother
(in her day job as a speech and
language therapist called Becky
Shanks) weaved her magic on children
in Stockport schools. From that day
(actually, eight weeks) on, the children
were never short of a story again, and
they all lived more happily ever after.
So is this the end, or just the
beginning? Dear reader, you decide...
SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2003 ++
narratve
literature that highlights the different ways that
narrative can be assessed and then analysed.
Many studies focus on the story grammar
approach developed by Stein & Glenn (1979)
(Dimino et al, 1995; Hayward & Schneider, 2000;
Botting, 2002). This approach provides the overall
thematic organisation of a story in terms of causal
and temporal relationships (figure 2).
Children from the age of four years can be seen
to demonstrate some understanding and use of
the structures in figure 2. Between the ages of
five and six, childrens stories typically consist of
abbreviated episodes (an initiating event,
attempt and consequence); and by eight years of
age children are beginning to produce complete
episodes including internal goals, motivations and
reactions that are largely absent in stories pro-
duced by younger children. Hughes et al (1997)
report that 16 per cent of four year olds stories
consist of complete episodes compared to 60 per
cent of stories typically told by eight year olds.
Research based around using the story grammar
approach as an effective intervention has tended
to focus on older children (seven and above) with
the main aim being to improve their written nar-
ratives (Dimino et al, 1995). Fewer studies have
targeted their intervention at improving the oral
narratives of younger children with the exception
of Hayward & Schneider (2000) who reported that
the language impaired children included in their
study clearly benefited from narrative interven-
tion using the story grammar approach.
THE CHARACTERS
Speech and language therapists in Stockport have
been piloting the use of narrative therapy in pri-
mary schools as a way of developing childrens
oral language skills within the classroom (Shanks,
2000). In collaboration with the local education
authority, six schools took part in the original
pilot between September 1999 and July 2001.
The intervention was primarily aimed at schools
situated in areas of considerable social depriva-
tion. Teachers in these schools were becoming
increasingly concerned regarding the numbers of
children both in the foundation stage and key
stage 1 who were experiencing receptive and
expressive language difficulties, but who were
not receiving speech and language therapy.
Typical comments from teachers were, She just
rolls around on the floor at carpet time; He can
never tell me what he did at the weekend; She
rarely contributes to class discussions. Teachers
concerns varied widely from poor attention and
listening, restricted vocabulary and inability to
follow instructions to limited skills in recount-
ing/describing. The task for the speech and lan-
guage therapist was to devise an approach that
encompassed all of the teachers concerns whilst,
at the same time, complementing activities
already taking place in the classroom as part of
the speaking and listening curriculum.
Each school was offered an eight week block of
intervention from the speech and language ther-
Figure 1 Developmental sequence for storytelling (adapted from Hughes et al, 1997)
Level Type/Age Description
1 heap Unconnected components.
2 years
2 sequence Action sequences are described, sometimes following the order in which
2-3 years they occur. Events are centred around a particular character, topic or setting.
3 primitive Cause and effect emerges and sequences of events are causally linked.
narrative Individual components are related to a central character or theme in a
3-4 years way that indicates why events occur in a particular way.
4 focused Include a central character and true sequence of events but lack a true plot
chain due to limited understanding of character motivation and goal. As a
narrative result the ending of the story may be unrelated to events set up at the
4-5 years beginning of the story. Story structures emerge - an initiation event,
attempts, consequences, although episodic structure may be incomplete.
5 true Emergence of true plot and events connected around central character and
narrative theme. Understanding of the need to provide explanations for events and
5-7 years behaviour and so the plot results from the motivations and goals of the
main characters. Consequently the end of the story is related to its
beginning. Episodic structure develops to include intentions and internal
responses of the characters.
Figure 2 Story grammar components (derived from Stein & Glenn, 1979)
Setting Introduces the main character and describes the context of the story (Who,
Where, When).
Initiating Event The beginning of a goal based episode in the story that causes the main
(Problem) character to respond.
Internal Response Describes the main characters thoughts, intentions or emotional responses
to the initiating events.
Internal Plan Statements referring to the main characters strategy for reaching a the goal.
Attempts The main characters overt action towards resolving the situation or
(To solve problem) achieving the goal.
Consequences Represents the outcome of the attempts and indicates the attainment
(Outcome) or non-attainment of the characters goal.
Reactions Descriptions of how the character feels about the attainment or non-
attainment of the goal.
apist and the local education authority funded
four hours of learning support assistant time per
school. The school selected six children from
either reception, year 1 or year 2 (in some cases a
split year 1 / 2 group), whom they felt were strug-
gling to access the curriculum as a result of poor
receptive and expressive language skills.
The speech and language therapist met with the
special educational needs co-ordinator and the
class teacher(s) before the intervention began, to
agree on the appropriacy of the children selected,
the form that the intervention would take and
the level of collaboration required from both par-
ties for the children and school to gain maximum
benefit. The time taken to plan at this stage was
later found to be crucial to the success of the
intervention as it allowed both school and the
speech and language therapist to agree on time
needed for liaison between the learning support
assistant, class teacher and speech and language
therapist, and for the class teacher to plan an
observation of at least one of the therapy sessions.
Parental consent had to be gained for most of
the children taking part as in the majority of cases
the children were not already receiving speech
and language therapy. Parents were also invited
to meet the therapist to discuss their child and to
allow the therapist to share ideas and activities
that could be reinforced at home should the par-
ents be interested.
THE ACTION
Baseline measurements were taken by the speech
and language therapist using the Renfrew Action
Picture Test and The Renfrew Bus Story. The chil-
dren were then reassessed post-intervention and
the information shared with school and parents.
Having four hours learning support assistant
time per week for the eight weeks meant that the
children could receive an intensive block of therapy:
narratve
SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2003 +
the therapist carrying out one session a week and
then the learning support assistant reinforcing
the therapy ideas and activities at two other times
in the week. With each group session lasting for
approximately 45 minutes, it left ample time for
the learning support assistant and speech and lan-
guage therapist to plan the further two sessions
in the week and ensure that the school had all the
necessary resources with which to do this.
Narrative therapy offers an approach that is
highly structured yet easily adaptable for differ-
ing levels of ability. Based on meaningful activities
that are commonplace in every classroom, the
narrative approach addresses receptive and
expressive language difficulties in a way that com-
plements literacy hour activities. More detailed
information regarding therapy ideas, sample ses-
sion plans and carryover ideas for the classroom
are available in a published resource pack (Shanks
& Rippon, 2003). Children are taught first to
understand and then to use a story framework
through the use of colour coding, symbol and
sign. Coloured cue cards and symbols are used to
represent each element of the story.
Corresponding signs are also used to reinforce the
multisensory approach:
orange red green yellow blue
The focus of the therapy changes each week,
working on the story components individually at
first, then gradually developing the childrens
skills at retelling familiar stories and eventually
giving them the confidence to generate ideas for
stories of their own. The first few
weeks aim to develop active listening
skills as well as the childrens under-
standing of the concepts of who,
where and when. Games include
identifying deliberate errors in familiar
stories, identifying who, where and
when in books, quiz games, and sorting
pictures according to who, where
and when. As the weeks progress,
the children are encouraged to think
about why events happen in stories
and make their own predictions
about what they think might happen
next. Familiar classroom texts, nursery
rhymes and tales are used to see if the children
can devise their own endings. Puppets, the tape
recorder and role-play are important in developing
childrens confidence at retelling and, together with
the cue cards, act as prompts to enable children to
use the narrative framework for themselves. The
children are able to use their position of being the
special children chosen to attend the weekly
group to show the other children from their class
the colours and signs associated with the story
framework and in doing so increase their confi-
dence in their own abilities. This also aids the
transfer of the approach from the small group to
the whole class.
THE DENOUEMENT
Thirty children took part in the pilot study and the
results were striking (see case example in figure
3). When re-tested following a three month period
of intervention, the changes recorded using the
Renfrew Action Picture Test and the Bus Story
proved to be highly statistically significant. A
detailed account of the measures used and the
specific methods of analysis can be found in
Davies et al (2002). Qualitatively, teachers
observed marked improvements in the childrens
confidence and ability to participate in classroom
activities. The therapy session that the class teach-
ers observed provided the opportunity for them
to see how the children functioned in a different
environment and how the therapy ideas could
carry over into the classroom. The fact that the
teachers were able to see the therapy in practice
increased their chances of incorporating the therapy
ideas into their teaching. The learning support
assistants and teachers involved in the pilot
reported that they had a greater understanding
of the role of a speech and language therapist
and felt more confident in using the structured
narrative approach in the classroom to support
other children with speech and language difficulties.
As well as the benefit to the six children involved,
each school had a learning support assistant
trained in using the narrative approach with
other children. Two of the schools were so
impressed they decided to use the narrative
approach across the whole of key stage 1.
Following the success of the pilot study, the local
education authority agreed to fund two sessions a
week for the speech and language therapist
to continue the narrative approach as
long as schools were prepared to fund the
four hours learning support assistant time
from their own budgets. Far from putting
people off, schools have been volunteering
readily and there is now a waiting list for
interested schools. A further three schools
have received the intervention over the
past year with similar results. The main-
stream support service is now bidding for
further sessions to allow the approach to
become part of the speech and language
therapy service offered to mainstream pri-
mary schools in Stockport. Further funding
from the local education authority targeting early
years has enabled another speech and language
therapist from the department to adapt the current
narrative pack for use with children at the foun-
dation stage (Broughton et al, 2002), and early
analysis of that data suggests equally good results.
THE SEQUEL
Narrative therapy has proved itself to be an effective
intervention, with far-reaching benefits not only
WHAT
WHO WHERE WHEN HAPPENED THE END
therapists are
having to
become more
flexible in
adapting
therapy ideas
to fit in with
methods of
classroom
teaching
Figure 3 Case example
This boy in year 2 had recently moved to the school and had English as an additional language. His
class teacher felt that he was an able child but very lacking in confidence and reluctant to contribute
verbally within the classroom. These are the two narratives he generated unsupported using the text-
less book Two Friends by L. Miller.
Pre-intervention (chronological age 6;8y)
Once upon a time there were two friends. They played along together. Then they thought theyd
have a race. The cat won.
Then he was running on another race but then the dog get lost so he was thinking where was the
cat so he ran away.
He thought he was....it was that way in the hills. In the hills he saw a dragon and then he ran the
other way and there was a dinosaur. Then he got up and from the roof then above him was a lot of
water so he went over it. He swam down. The water was going after him. Then he ranned and
ranned really far away. Then he ranned. He saw his best friend.
Analysis
Linking ideas sequentially through time. Providing setting information and initiating event but not
developing a goal based episode. Lots of action based sequences without causal links. Probably at
primitive narrative stage.
Post-intervention (chronological age 6;11y)
Once upon a time there was a cat and a dog and they were talking each other. The cat said I will
scare you away with my meow and the dog said I will scare you away with my woof. So they
both made funny noises, woof woof, meow meow. But the cat stopped meowing cos he was
too tired so they decided to have a race. The cat was winning because he was forwards but the dog
lost him on the hills. He said woof woof. So he thought it was down the hills, quickly speeded
down the hills and under the hills he met a dragon and he said to him Have you seen the cat? I
want to play with him. But he didnt know where he was. Then he met a dinosaur Have you seen
the cat? I want to play with him. No I havent seen him anywhere. When he got up he saw a river
going really fast. He went following the river. When he got onto the end of it, he saw a tail and he
saw the cat and when he met the cat he at last got back into the finishing line and then they had
another race down the hill and they did that again and again.
Analysis
Linking ideas temporally and causally. Goal based episode consisting of setting,
initiation events, attempts and consequences. Ending relates to initial problem in the
story. Uses dialogue and more formal story language. Good example of a true narrative.

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2003 +

narratve
Hot o the press!
vn Speakng 8 lstenng Through Narratve (
nd
ed.)
Becky Shanks article appears just as the second edition of her highly acclaimed
Speaking & Listening Through Narrative is published. To mark the occasion, Black
Sheep Press is offering CD ROM copies to FOUR lucky Speech & Language Therapy
in Practice readers - absolutely FREE (normal price 45)!
For your chance to win, send your name and address to Speech & Language Therapy
in Practice - SLTN offer, Alan Henson, Black Sheep Press, 67 Middleton, Cowling,
Keighley, W. Yorks BD22 0DQ by 25th April. The winners will be notified by 1st May,
and are asked to let Black Sheep Press know what they think of the resource.
Speaking & Listening Through Narrative consists of 125 photocopiable pages
including instructions and sample lesson plans, illustrated worksheets, games
and exercises and carryover ideas for the classroom. It is available from Black
Sheep Press, see www.blacksheep-epress.com, or telephone 01535 631346 for a
free catalogue. Other narrative resources are Language Through Listening
(14), Nursery Narrative Pack (45) and Reception Narrative Pack (45).
for the children involved, but also for the
wider school population including teachers
and support staff. Future studies would
need to focus on collecting more longitudi-
nal data to look at the long-term benefits of
the intervention and possibly the implica-
tions for childrens written narratives.
Within our own profession, this study
highlights the need for more sensitive
assessment tools if narrative therapy is to
become part and parcel of speech and lan-
guage therapy intervention with language
impaired children.
The proven links between oral narrative ability
and future academic success only go to support
the view that speech and language therapy is best
delivered as part of the curriculum with teachers
and therapists working together to meet the
needs of language impaired children.
THE END - but only of the beginning.
References
Bamberg, M. & Damrad-Frye, R. (1991) On the
ability to provide evaluative comments: further
explorations of childrens narrative competencies.
Journal of Child Language 18, 689-710.
Botting, N. (2002) Narrative as a tool for the assess-
ment of linguistic and pragmatic impairments.
Child Language Teaching and Therapy 18 (1) 1-21.
Broughton, H., Carey, J., Shanks, B. & Rippon, H.
(2002) Nursery Narrative. Black Sheep Press. Yorkshire.
Davies, K., Davies, P. & Shanks, B. (2002) Improving
narrative skills in young children with delayed
language development. Paper presented at The
American Educational Research Association Annual
Conference. April 2-5, New Orleans (available from
Peter Davies at p.i.davies@staffs.ac.uk).
Dimino, J., Taylor, R. & Gersten, R. (1995) Synthesis
of the research on story grammar as a means to
increase comprehension. Reading and Writing
Quarterly. 11, 53-72.
Hayward, D. & Schneider, P. (2000) Effectiveness of
teaching story grammar knowledge to pre-school
children with language impairment. Child
Language Teaching and Therapy 16 (3) 255-284.
Hughes, D., McGillivray, L. &
Schmidek, M. (1997) Guide to
Narrative Language: Procedures for
Assessment. Eau Claire, WI.
Lyle, S. (2000) Narrative Understanding:
developing a theoretical context for
understanding how children make
meaning in classroom settings. Journal
of Curriculum Studies 32, 45-63.
Reynolds, D. (1998) Schooling for
Literacy: a review of research on
teacher effectiveness and its implica-
tions for contemporary educational
policies. Educational Review 50, 147-162.
Roth, F. & Spekman, N. (1986) Narrative Discourse:
Spontaneously generated stories of learning dis-
abled and normally achieving students. Journal of
Hearing and Speech Disorders 51, 8-23.
Shanks, B. (2000) Telling Tales. Bulletin of the Royal
College of Speech & Language Therapists 583.
Shanks, B. & Rippon, R. (2003) Speaking and
Listening through Narrative: a pack of activities
and ideas. 2
nd
ed. Black Sheep Press. Yorkshire.
Stein, N. & Glenn, C. (1979) An analysis of story
comprehension in elementary school children in:
Freedle, R. (ed) New Directions in Discourse
Processing. Norwood, NJ.
Resources
The Renfrew Action Picture Test and The Renfrew
Bus Story by Catherine Renfrew are available
through Speechmark or Taskmaster.
Becky Shanks is a speech and language therapist at
the Childrens Therapy Centre, St. Thomas Hospital,
Shaw Heath, Stockport SK3 8BL, tel. 0161 419 4301,
e-mail becky.shanks@stockport-tr.nwest.nhs.uk.
The first few
weeks aim to
develop
active
listening skills
as well as the
childrens
understanding
of the
concepts of
who, where
and when
Do we take the tme needed to pan
to reach our goa - ke the ox wth
the Gngerbread Nan'
Do we, ke the od woman wth the
Nagc Porrdge Pot, eed n enough
to our cents'
Do we ensure ndereas get to the
ba'
Reectons
news extra...news extra...
Funding for useful technology
The government is planning to make more funding
available to allied health professionals researching
the provision of useful technology for clients.
Previous funding has focused on medical staff, and
a Department of Health seminar will provide the
opportunity for allied health professionals to suggest
ways of opening up this support. Fiona MacAulay
(author of Communication - an inalienable right
in the Winter 2002 issue of Speech & Language
Therapy in Practice) is to represent the Royal
College of Speech & Language Therapists at the
seminar. Fiona is a clinician at Ninewells Hospital,
Dundee, and part of a multidisciplinary research
team from the department of applied computing
at the University of Dundee. The team won a
medal from the British Computing Society at their
annual IT awards for the development of ICU-Talk,
a system designed for intubated patients in an
intensive care unit.
www.computing.dundee.ac.uk/projects/icutalk
www1.bcs.org.uk
One solution to recruitment
difficulties?
When you draw up your equal opportunities policy,
do you give thought to the needs of left-handers?
The results of a non-scientific study on the left-handers
day website suggests left-handers may have to be par-
ticularly tenacious when pursuing jobs in education
and health, as physical environments are geared to the
majority right-handed population. Challenges faced
include documentation layout, computer equipment,
phone handsets, scissors, rulers and even black and
whiteboards.
The left-handers club is calling for the perceived
link between career choice and left-handedness to
be studied more scientifically. Left-handers Day for
2003 is on August 13.
www.left-handersday.com
For left-handed products see www.anythingleft-
handed.co.uk.
Cooperation needed
The government has been warned that its plans to push
through new measures to tackle delayed discharges
risk undermining existing care for elderly people.
The Community Care (Delayed Discharges) Bill has
prompted a joint response from the Local
Government Association, the Association of Directors
of Social Services and the NHS Confederation. In it,
they emphasise their shared commitment to ending
the misery caused by delayed discharge from hospital
and recognise that more needs to be done to provide
integrated health and social care services. However,
they feel the governments plan to charge local
councils for delayed discharges is likely to introduce
adversarial rather than cooperative relationships, and
that the timescale of six months for implementation
is unrealistic. The group believes that the key to tackling
delayed discharges lies in an incentives regime which
spans all local agencies, with joint targets and a
shared performance management framework that
ensures local cooperation and more integrated care,
delivering the services that older people need.
ethcs
SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2003 +(
Ethical principles need to be
interpreted rather than just
applied in our work. When a 73
year old man uncharacteristically
asked for assistance with his
communication, Pia Taylor and
Jois Stansfield used an ethical
framework to identify what the
speech and language therapy
role should be. To the golden
rules of ethics - beneficence,
non-malificence, autonomy,
justice - they now add another:
communication need.
r Anderson is an independent,
73 year old man (see figure 1).
He is close to his golden wed-
ding, but this event is worry-
ing him because of a combi-
nation of health and personal
issues. He is also increasingly
frustrated at his inability to communicate easily, espe-
cially with his grandchildren by telephone.
His GP states that Mr Anderson has a social dis-
ability which he has so far appeared to manage in
the manner best suited to his own perceived
needs. He did however request help in this
instance and, as this was so unusual, the GP
agreed to a referral to speech and language thera-
py to develop strategies to overcome his difficulties.
We used an ethical framework to identify what -
if any - role we would have to play.
In any situation where the task is to work for
the health of a person, a clinician must draw on
both clinical and ethical theory and use them in
tandem (Seedhouse & Lovett, 1992), but this is
not always as straightforward as it may at first
appear. The four major principles of health care
the following levels and boxes:
1. Blue: create autonomy, respect autonomy;
2. Red: do most positive good, minimise harm;
3. Green: most beneficial outcome for the patient;
4. Black: resources available.
1. Blue: health care principles. Create autonomy;
respect autonomy.
Seedhouse & Lovett (1992) see the fundamental
inspiration of medical care as the will to create
autonomy, the desire to give a person height-
ened control over his life (p.26). Mr Anderson is
actively seeking intervention to increase
his autonomy in communication. Since the
motivation to create autonomy is funda-
mental, it follows that in areas of their
lives where people have some autonomy
it ought to be respected (Seedhouse &
Lovett, 1992) and, as health professionals,
we have some obligation to contribute
actively to this desire.
Respecting autonomy in healthcare has
many prima facie implications such as
telling the truth, respecting privacy, confi-
dentiality and informed consent (Gillon,
1994). As Mr Anderson is the one seeking
intervention, informed consent is
assumed from the outset; indeed, as he is
usually self-sufficient and independent,
his GP saw this as an unusual situation,
demanding a referral. Mr Anderson may not,
however, be entirely au fait with the work of
speech and language therapists and may expect
direct rather than indirect approaches to his iden-
tified problems. Mr Anderson will need to be
seen as competent, adequately informed and vol-
untary in his deliberations regarding this and any
future therapy (Department of Health, 2002).
2. Red: duties of the health worker. Do most positive
good, minimise harm.
3. Green: general nature of the outcome to be
achieved. Most beneficial outcome for the patient.
Beauchamp & Childress (1994) believe morality
requires not only that we respect persons auton-
omy, but that we refrain from harming them and
actively contribute to their welfare. The ideal is to
provide net benefit to patients with minimal
harm - beneficence in the context of non-malifi-
cence (Gillon, 1994; Beauchamp & Childress,
1994). Mr Anderson requests intervention to
relieve distress, and increase his quality of life.
Initial consultation and assessment deemed Mr
Anderson as an appropriate candidate for a brief
block of therapy, therefore we were in a unique
position to do good for him personally. However,
ethics are beneficence (do the most positive
good), non-malificence (do no harm), justice (fair-
ness, or equity), and autonomy (enabling the indi-
vidual to make decisions). These principles are not
absolutes, but prima facie, indicating that the
principle is binding unless overridden or out-
weighed by competing moral principles
(Beauchamp & Childress, 1994). As a result, the
principles need to be interpreted, rather than sim-
ply applied in our work.
Canons or Codes of Ethics establish guidelines
and standards for the ethical principles and prac-
tices of a group of professionals. In
speech and language therapy, west-
ern professional bodies such as the
Canadian Association of Speech-
Language Pathologists and
Audiologists (1992), Royal College of
Speech and Language Therapists
(1996), Speech Pathology Australia
(2000) and the American Speech-
Language Hearing Association (2001)
may differ in the specificity of their val-
ues and rules, but they reflect very sim-
ilar beliefs and philosophies regarding
their particular standards of integrity.
They espouse the four prima facie prin-
ciples of autonomy, beneficence, non-
malificence and justice, either explicit-
ly (Speech Pathology Australia) or
implicitly (Royal College of Speech & Language
Therapists) through their professional ethical
codes. These codes are useful in providing guid-
ance on how one can achieve fair, open and
respectful relationships with those one serves,
however, as Pannbacker et al (1996) recognise,
they cannot give us solutions: we must in the
end search for the answers on our own (p.ix).
In Mr Andersons case, we applied The Ethical
Grid (Seedhouse & Lovett, 1992) to help to clarify
the decision making process. This Grid (see figure
2) is based on the idea that health professionals
need to take into consideration various areas in
decision making:
health care principles (inner, blue level)
the duties of the health worker (second, red level)
the general nature of the outcome to be
achieved (third, green level)
pertinent practical features (outer, black level).
A reminder
The Grid is essentially a reminder that there are at
least four separate levels at which to think, and
that within these levels there are several different
ways of deciding on strategy. To address Mr
Andersons communication needs, we focused on
N
In any
situation
where the task
is to work for
the health of a
person, a
clinician must
draw on both
clinical and
ethical theory
and use them
in tandem
Sensible solutions or
a search for
you want to
have ar open and respectu
reatonshps
appy ethca decson makng
prortse cents on the bass
o need
Read ths
Jois Stansfield Pia Taylor
SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2003 +
ethcs
we were also aware that he suffers from concur-
rent disabilities including severe headaches, and
breathlessness which is exacerbated by doing
too much. In addition he has recently had
queried (though unconfirmed) transient
ischaemic attacks, which may be indicative of
deteriorating health status. Intervention must
aim to not aggravate such conditions. Hence, a
principled decision had to be made by the speech
and language therapist regarding the appropri-
ateness and manner of delivery which did the
most positive good, achieving the best personal
outcome for Mr Anderson, whilst minimising
harm, as seen in the Ethical Grid.
4. Black: practical issues. Resources available.
Gillon (1994) claims that equality is at the heart of
justice (p.xxv) and may be summarised as the moral
obligation to act on the basis of fair adjudication
between competing claims (p.xxv). At times a
therapist may feel anxious or guilty because the
resources are not available to carry out the interven-
tion programme they see as best for the individual
client. In Mr Andersons case, for example, we
considered onward referral to a Hearing Therapist
who may have been of considerable value in helping
him compensate for his hearing loss. However,
with only four hearing therapists in Scotland, this
resource is very limited and Mr Anderson was
unlikely to be a priority case. Similarly, we too had
limited resources and were unable to see Mr
Anderson as a priority, partly because of the Trusts
guidelines on clients of this age and the apparent
insignificance of his communication needs.
Age alone is, however, insufficient ethical
grounds for not offering intervention, indeed the
NHS Research & Development Strategic Review
(Department of Health, 1999) sees widespread
ageism in society as a violation of the principle of
justice. This Review suggests that professionals
often make inappropriate assumptions that older
people cannot benefit from health care or suffer
too many side effects or complications. Equally,
while in this case it was a management rather
than a professional imperative which reduced our
capacity to act, Mr Andersons difficulties were
not insignificant to him, a fact emphasised by his
GP in making clear how rare it was for Mr
Anderson to seek help in any area of his health
care. We fully accept the necessity to be able to
consider individual need, regardless of artificial
barriers. When priorities have to be decided in
healthcare, we also agree with Seedhouse &
Lovett (1992) that it is the most needy clients who
should be helped first; it is that definition of need
which gives rise to difficulties in interpretation.
Figure 1 Background (from discussion with Mr and
Mrs Anderson)
Medical history: high blood pressure; series of
heart attacks in 1972-5 and subsequently, most
recent 1990. Controlled by drug therapy. Three
possible transient ischaemic attacks in March 2002.
Concomitant disabilities: severe headaches
(helped in past by acupuncture); severe breath-
lessness (wife says exacerbated by even mild
physical activity or doing too much); age
related hearing impairment (hearing deteriorating,
has tried NHS aids and recently spent 600 on
private aids which he finds of limited value);
wears dentures (ill-fitting despite a number of
attempts to improve fit).
Education: left school at 16 (unusual in his social
group, where most left at 14).
Employment: worked for an animal feed company
all his working life except when drafted into
army for National Service. Retired through ill
health in 1975.
Social: Mrs Anderson (74) is extremely involved
in local church and other community social
activities. Mr Anderson declines to join her on
her frequent social outings, although will visit
relatives for quiet lunches/teas. Never been a
gregarious individual, but increasingly isolated
by hearing loss and difficulty in accommodating
multiple sources of noise.
Family: At onset of health problems children
were 10, 9, 2. Children now adults, scattered
around UK. Family communication is by weekly
phone calls and e-mail, rarely involving Mr
Anderson who refuses to attempt to use e-mail.
Mr Anderson is especially distressed at inability
to communicate with grandchildren. Rarely
writes letters although would always respond
to letters from others. Regular visits from each
of children and their families.
Interests: Family; gardening; reading; stock-market
especially as available via teletext.
Reported communication difficulties:
Mild comprehension difficulties especially in
noisy surroundings;
Articulation difficulties - as a result of ill-fitting
dentures/hearing/transient ischaemic
attacks/other?
Cannot understand grandchildren (ages 18, 15
Scottish; 13, 10, 5 Welsh) on the phone.
Reason for referral:
Forthcoming golden wedding and the need to
make a short speech.
Personal distress.
Figure 2 Ethical Grid
daft ideas:
answers

Professional conduct
Having considered the four prima facie principles
of healthcare through the Ethical Grid and relat-
ed these to Mr Anderson, we also turned to the
Royal College of Speech & Language Therapists
Code of Ethics. Professional conduct guidance
requires speech and language therapists to
refrain from discrimination on the basis of race,
religion, gender or any other consideration
(1996, p.18). This emphasises again the principle
of justice: Mr Andersons age alone should not
mean he is less of a priority. We have a duty to
respect the needs and opinions of the clients to
whom a duty of care is owed (RCSLT, 1996, p.18).
Mr Anderson is seeking therapy to relieve distress
and, if he is an appropriate candidate for therapy,
this need ought to be respected and acted upon.
We also looked at the Royal College of Speech &
Language Therapists guidelines on working with the
elderly population client group. These recommend an
in-depth assessment of (his) communicative envi-
ronment (as) necessary ...to identify any fac-
tors...which may be adversely affecting (his) com-
munication skills (1996, p.115). It may be that
advice on minimising background noise in Mr
Andersons home in addition to assistive listening
devices (Doyle, 1998) would be of value. Referral
to other agencies/professionals may be considered
particularly in relation to: vision, dentition, hearing
(RCSLT, 1996, p.116). Referral to a hearing therapist
has already been discussed as a possibility. Mr
Andersons poor fitting dentures will require
attention as they may be impeding adequate
articulation. However, we are aware that his den-
tures are ill-fitting despite a number of attempts to
improve fit and, if we are to respect his autonomy
and he declines further dental intervention, thera-
py may instead have to be conducted around this.
For adults such as Mr Anderson who fall into the
deafness / hearing impairment client group, inter-
vention may involve individual or group therapy
aimed at improving communication (RCSLT, 1996,
p.113). Specific therapy may require focus on com-
munication skills and strategies,...speech intelligi-
bility,...and other issues in relation to social skills
(RCSLT, 1996, p.113). Mr Andersons acquired deaf-
ness means therapy needs to address adjustment
to (his) new hearing status (RCSLT, 1996, p.113).
Series of suggestions
So, what did we do? Mr Anderson had two com-
munication needs, one short-term and one requir-
ing rather longer-term strategies. We were able
to offer Mr Anderson two speech and language
therapy sessions. The first, before the golden
Figure 3 Therapy sessions
ethcs
SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2003 +
experience of speech and language therapy and he
appreciated the fact that this had been possible
despite the limited resource made available. An ethi-
cal framework can therefore help to address the com-
munication needs of individuals by consideration of
the four prima facie principles through a tool such as
The Ethical Grid and also with more specific clinical
guidelines such as those outlined in appropriate pro-
fessional codes of ethics and good practice guidelines.
It is not always a straightforward process to use an
ethical framework to address the communication
needs of clients. However, this appears to be the very
nature of ethics itself. As Beauchamp & Childress
(1994) state, we all recognise that morality would be
a cold and uninspiring practice without various traits
of character, emotional responses, and ideals that
reach beyond principles and rules (p.462). Ethical
decision making comes to life through its application.
Pia Taylor is a speech pathology student at LaTrobe
University who was an exchange student at Queen
Margaret University College. Jois Stansfield is Head
of Speech and Language Sciences at QMUC.
References
American Speech-Language-Hearing Association
(2001) Code of Ethics. ASHA Leader 6 (23) 2-4.
Beauchamp, T.M. & Childress, J.F (1994) Principles of
Biomedical Ethics. Oxford: Oxford University Press.
Canadian Association of Speech-Language
Pathologists and Audiologists (1992) Canon of
Ethics. Journal of Speech-Language Pathology
and Audiology 16 (4) 257-258.
Department of Health (1999) Topic Working
Group Ageing and Age-Associated Disease and
wedding celebration, explored the range of his
communication difficulties and resulted in a series
of suggestions for him to consider (figure 3). The
second was a follow-up, at which Mr and Mrs
Anderson both reported that his communication
opportunities had expanded and improved.
The short-term need was by far the easier to
address. After a discussion in the speech and lan-
guage therapy session, followed by a private fam-
ily consultation, Mr Anderson decided to break
with his original view of family tradition and ask
his eldest grandson to speak at the Golden
Wedding. This was successful on two counts.
Firstly, as Mr Anderson reported at his appoint-
ment two weeks after the event:
he spoke slowly and clearly, and for the first
time in years I understood every word he said!
And he was far better received that I would have
been ... he had even done his homework and
found and used some of my original speech notes
from our wedding, which was a pretty good one,
though I say so myself.
Secondly, Mr Anderson had only needed to
thank everyone for attending the event.
For the longer-term a number of potential
strategies were suggested, some of which were
more successful than others. It is possible that Mr
Anderson will ask for a further referral at some
point in the future but, in the meantime, he was
happy to accept or reject advice according to his
current perceived needs.
Mr Anderson reported that he felt that his autono-
my had been respected, he had been able to make his
own decisions, overall he had benefited from the
Do l use cnca and ethca theory
n tandem'
Do l try to avod makng
napproprate assumptons about
peope'
Do l respect reasons gven by
cents or acceptng or rejectng
my suggestons'
Reectons
Communication
need: immediate
Forthcoming
golden wedding
and the need to
make a short
speech.
Communication
need: longer term
Personal distress:
cannot understand
family, especially
grandchildren
(ages 18, 15
Scottish; 13, 10, 5
Welsh) on the
phone.

Outcome
Rejected: They will think there is something wrong and worry about me.
Rejected: What a daft idea, they will think I am dead!
Accepted in conjunction with 4) below.
Accepted after discussion with family and enthusiastic agreement by eldest grandson.
Easily identified accent, speed of childrens speech, inability to hear properly and hard to
listen when they started to talk fast. Suggested that parents discuss this with children
so they try to speak slowly and clearly when talking to grandpa. Limited success.
Eventually also identified that they often called at the end of a day when Mr Anderson
was tired and this increased the difficulties. Suggested Saturday and Sunday lunchtimes
for regular weekly phone calls. Big improvement in understanding younger grand-
children. Older ones not keen to be committed to a regular time of day.
Telephone was very old and had no modern facilities. Investigating buying a new phone
which could accommodate new technology. Ongoing.
Older children were happy to address e-mail messages direct to Mr Anderson, which Mrs
Anderson would print off and he would respond to by letter. This led to a major
increase in correspondence.
Encourage face to face orientation before commencing a conversation. Some success. Both
Mr and Mrs Anderson are attempting to do this, though both find it difficult to maintain.
Reducing noise sources. Limited success. Mr Anderson liked to watch teletext with the
sound off the TV but Mrs Anderson wanted to listen to TV programmes. In the absence
of a second TV in the house this continues to be a source of frustration for each.
Try again to have dentures fitted correctly. Rejected. This has been a long running and
painful problem and Mr Anderson did not consider it anything to do with the speech
and language therapist.
Suggested, with the proviso that these individuals are rare in Scotland. Not accepted by
Mr Anderson who considered it unnecessary at present.
Suggested solutions
1) Indicate to guests beforehand that
there would be no speeches.
2) Pre-record a speech to be played by
audio- or video tape at the ceremony.
3) Say only thank you for coming.
4) Ask another family member to speak.
1) Identify causes of the problem.
2) Develop strategies to maximise
communication
3) Onward referral to hearing therapist or
private speech and language therapist.
Disability NHS R & D Strategic Review.
www.doh.gov.uk/research/documents/rd3/age-
ing_final_report.pdf Retrieved April 11, 2002.
Department of Health (2002) Consent - Reference
Guide to Consent for Examination or Treatment.
www. doh. gov. uk/ cons ent / r ef gui de. ht m.
Retrieved April 11, 2002.
Doyle, J. (1998) Practical Audiology for Speech-
Language Therapists. London: Whurr Publishers Ltd.
Gillon, R. (1994) Preface: Medical Ethics and the Four
Principles in Gillon, R (Ed) (1994) Principles of Health
Care Ethics. West Sussex: John Wiley & Sons pp. xxi-xxxi.
Pannbacker, M., Middleton, G.F., & Vekovius, G.T.
(1996) Ethical Practices in Speech-Language
Pathology and Audiology: Case Studies. San
Diego: Singular Publishing Group Inc.
Royal College of Speech and Language Therapists
(1996) Communicating Quality 2. London: RCSLT.
Seedhouse, D & Lovett, L. (1992) Practical Medical
Ethics. Chichester: John Wiley & Sons.
Speech Pathology Australia (2000) Code of Ethics.
www.speechpathologyaustralia.org.au/pages/cod
e%20of%20ethics/codeofethics.html Retrieved
April 11, 2002.
SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2003 +;
urther readng
APHASlA
Thommessen, B., Thoresen, G.E., Bautz-Holter, E. & Laake, K.
(2002) Validity of the aphasia item from the Scandinavian
Stroke Scale. Cerebrovasc Dis 13 (3) 184-6.
The validity of the aphasia item of the widely used Scandinavian
Stroke Scale (SSS) in discriminating between aphasia and normal
language function in 33 stroke patients of an acute stroke unit was
studied. The patients were assessed by a nurse using the aphasia
item from the SSS and by a speech and language therapist carrying
out a full evaluation of the language function, which served as the
gold standard. There was good agreement between the nurses
and the speech and language therapists scoring (weighted kappa
= 0.74, 95% CI 0.51-0.97), and the sensitivity and specificity of the
SSS aphasia item were also satisfactory. However, the predictive
value of a positive test was as low as 0.55 (95% CI 0.23-0.83),
demonstrating that nearly every second positive was false positive.
The results indicate that using the aphasia score of the SSS as a
diagnostic aid for aphasia after stroke gives a high rate of false pos-
itives and inflates the prevalence figures for aphasia in epidemio-
logical studies of stroke.
AGElNG
Laasonen, M., Lahti-Nuuttila, P. & Virsu, V. (2002)
Developmentally impaired processing speed decreases more
than normally with age. Neuroreport 13 (9) 1111-3.
Several studies show that although function may recover after
brain damage the insult can nevertheless cause accelerated deterio-
ration in old age. This has been interpreted as indicating reduced
neuronal capacity to counteract age-related decline with plastic
changes. Psychosocial and compensatory factors obscure the neu-
ronal explanation. Since the speed of processing sequential temporal
information is impaired in developmental dyslexia, we investigated its
dependence on age (20-59 years) in psychosocially comparable groups
of dyslexic and fluent readers using six tasks. Processing speed was
impaired in dyslexia and decreased with age. The decrement was
faster in dyslexic than normal readers in processing periodic stimuli.
No exacerbation occurred in reading and other experiential factors.
Our results, therefore, support the neuronal explanation.
lURTHER
READlNG
Ths reguar eature
ams to provde
normaton about
artces n other
journas whch
may be o nterest
to readers.
The Edtor has
seected these
summares rom a
Speech 8 language
Database comped
by Bomedca
Research lndexng.
Every artce n
over thrty journas
s abstracted or
ths database,
suppemented by a
monthy scan o
Medline to pck
out reevant
artces rom others.
To subscrbe to the
Index to Recent
Literature on
Speech & Language
contact
hrstopher Norrs,
Downe, Badersby,
Thrsk, North
Yorkshre YO; (PP,
te. o+; (o8,
ax o+; (o.
Annua rates are
Ds (or vndows
,):
lnsttuton L,o
lndvdua L;o
Prnted verson:
lnsttuton L;
lndvdua Lo.
heques are
payabe to
Biomedical
Research
Indexing.

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SElETlVE NUTlSN
Bergman, R.L., Piacentini, J. & McCracken, J.T. (2002) Prevalence
and description of selective mutism in a school-based sample.
J Am Acad Child Adolesc Psychiatry 41 (8) 938-46.
OBJECTIVE: To examine the prevalence of selective mutism (SM) in
a public school sample and compare the functioning and symptoms
of children with SM to age- and gender-matched unaffected chil-
dren. METHOD: Kindergarten, first, and second grade teachers in
a large district were asked to identify pupils who met DSM-IV cri-
teria for SM and to complete ratings of speaking behavior, social
anxiety, other internalizing and externalizing symptoms, and over-
all functioning for these and comparison youngsters. Teachers
completed the same ratings on the SM children 6 months later.
RESULTS: A participation rate of 94% (125 of 133 teachers) was
obtained, and the prevalence of SM was .71% (16/2,256). Measures
were completed for 12 (75%) of 16 identified children. Compared
with peers, children with SM were more symptomatic on measures
of frequency of speech, social anxiety, and other internalizing
symptoms. As a group, children with SM had improved 6 months
later but remained impaired and symptomatic when compared
with the comparison group. CONCLUSIONS: SM may not be as rare
as previously thought. The functioning of children with SM is
impaired, and although there is some improvement over time,
notable impairment remains, suggesting that intervention is
preferable to waiting for SM to remit spontaneously.
TURNERS SYNDRONE
Temple, C.M. (2002) Oral fluency and narrative pro-
duction in children with Turners syndrome.
Neuropsychologia 40 (8) 1419-27.
Despite good verbal skills, children with Turners syndrome
(TS) have been found to perform poorly on oral fluency
tasks. Explanations for this impairment were explored in a
study of 9-12-year-old children with TS. The children with
TS were found, as expected, to have impaired levels of
retrieval on initial letter fluency tasks, in comparison to their
peers. Children with TS were also found to have receptive
vocabularies which were significantly better than controls,
indicating that the weak performance on oral fluency cannot
be attributed to lower vocabulary levels. Naming skills were
normal for children with TS, indicating that oral fluency
scores cannot be attributed to generalised problems with
lexical access. Analysis of the content of fluency perfor-
mance indicated clusters of words within sub-categories
which were of normal size but there were fewer switches
between clusters than for controls and fewer returns to pre-
viously successful clusters. Additionally, a significantly larger
proportion of the words generated were of low frequency
(e.g. Assyrian, antediluvian) and the children with TS did
not thereby show a normal frequency effect in word
retrieval. One explanation is that these reflect abnormal
action of executive language retrieval processes. Within
narrative production, picture description was normal.
However, in relation to narrative tasks, hypothesised to
place greater executive demands, there was impairment
which was significantly greater for narratives of yesterday
than narratives of organising a party. This impairment with-
in the narrative generation tasks could be attributable to a
selective impairment within executive retrieval skills, or
could represent an impairment in episodic memory or the
executive processes involved in its retrieval.
DYSPHONlA
Casper, J.K., Clark, W.R., Kelley, R.T. & Colton, R.H.
(2002) Laryngeal and phonatory status after
burn/inhalation injury: a long term follow-up study. J
Burn Care Rehabil 23 (4) 235-43.
Although persistent hoarseness has been recognized in
patients who have sustained burn and/or smoke inhalation
injuries, there is little documentation to support this obser-
vation. Furthermore, there is no quantification of either
the pervasiveness of the problem or the severity of the dys-
phonia resulting. It was the intent of this study to examine
the laryngeal condition and voice production of a group of
patients who were long-term survivors of burns and inhalation
injuries. Only 10 patients (8 male and 2 female) of a larger
cohort were willing to return for this examination. They
were ambulatory and did not require respiratory assistance,
and it had been 16 to 25 years since their initial traumas.
Videostrobolaryngoscopic examinations were performed
and analyzed, measures of various acoustic and aerodynamic
parameters were made, and severity of dysphonia was
judged. Seven of the 10 subjects were rated by experienced
listeners as having some degree of dysphonia. All subjects
had some abnormality of the laryngeal mucosa.
Stroboscopic examination was found to be helpful in iden-
tifying laryngeal abnormalities in at least half of the subjects.
Early attention to these problems, many of which are treat-
able surgically or behaviorally or both could lead to an
improved voice for the patient and for this reason an
improved quality of life.
groups
SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2003 +8
t has been well documented that group
therapy for children is an effective way of
working (Brigman et al, 1992). It allows par-
ents to see their child in relation to other
children and gain a different perspective so
that, instead of solely focusing on their
childs difficulties, they can begin to appreciate
their strengths. However, when working in a busy
community clinic, it is very easy to select children
for group therapy on the basis of high caseload
numbers, rather then looking carefully at individ-
ual needs. This is particularly problematic for
bilingual children and their families as, when
selecting them for group therapy, their overall
language competencies may not be taken into
account. When a childs full abilities are not
acknowledged, parents are automatically margin-
alised and unable to participate fully in the group
therapy experience.
l
The advantages of
bilingualism are such that
a speakers overall
language competency
may be more than a sum
of parts. Panna Chavda
and Laura Helsby find that
recognising and facilitating
this in group therapy not
only has benefits for the
children concerned, but
brings parents and other
staff on board too. Here,
they tell us what they did
and why they did it.
you are pannng
therapy groups
have bngua
cents
want to measure
eectveness
Read ths
The vibrant, multicultural City of Leicester has
many minority ethnic groups represented, and a very
high bilingual speaking community. We find bilin-
gual children can be included in general groups with
monolingual children where the aim is to improve
areas such as social skills, attention and listening.
However, we wanted to offer more targeted groups
with a focus on the specific needs of bilingual chil-
dren with language development difficulties.
When planning our groups for a busy inner city
clinic, we used the Malcomess (1999) decision-
making loop (figure 1) to identify the clinical
need, in other words the why of therapy. When
we ask why we do things with clients - as well as
what we do and how we do it - it enables us to focus
on a more functional model of service delivery
rather than just a diagnostic, medical model. It
allows us to tailor care to individuals and to begin to
look at the outcome of intervention. We then arrive
at a care aim which leads to goal setting, interven-
tion and review with a measure of effectiveness.
We grouped individuals according to their care
aims then identified care aims for the overall
group. Our level of input included the planning
phase (two weeks), running the groups (six
weeks), and the post-group report writing, review
and contact with schools (two weeks).
We ran two language groups for children chosen
on criteria of age, language difficulties, parental
commitment and support. All came from a bilingual
background with English and Gujarati spoken at
home. The first group had seven boys aged 5-8 years,
presenting with mainly moderate language difficulties
across both languages. The second group also had
seven boys, this time aged 7-10 years, with higher level
language difficulties across both languages.
Insight
At the start of the groups the parents completed a
questionnaire (adapted with permission from
Hulme et al, 2001). We wanted to look at parents
expectations of the language group and to gain
insight into their understanding of language issues.
The questionnaires were discussed with parents
in Gujarati and, if needed, in English. Several
themes emerged:
1. Many children with language 100% disagreed
problems are simply lazy.
All of the parents felt the difficulties their children
experienced with language were genuine.
Working with
bilingualism:
Panna Chavda Laura Helsby
SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2003 +,
groups

2. Playing with your child is 100% agreed

important in learning language.
3. Parents play a vital role in the 100% agreed
treatment of language disorder.
While all agreed that parents as well as other mem-
bers of the family play an important part in the
treatment of language difficulties, some found it
difficult to fully support therapy due to time
restraints, lack of ideas and language barriers.
4. Language disorder is a 40% agreed,
new type of a problem; it 40% disagreed,
was not around years ago. 20% did not know
Although some parents knew about language dis-
order, over half did not know it existed.
5. Gujarati children have 70% disagreed,
language problems because 30% agreed
they have to learn to use or were unsure
more than one language.
Most parents related this question to their child.
A small number felt that learning Gujarati and
another language can initially cause confusion,
and that a child may find it difficult. The majori-
ty saw that the difficulties their child experienced
were not due to learning Gujarati and another
language. Comments included, It is the parents
attitude that causes the problem not the lan-
guage. Some parents reported that they had
been advised to speak in English to their child,
which gave them the impression that this would
resolve the language difficulties.
6. Learning to speak more 70% disagreed,
than one language causes 10% agreed and
language problems. 20% were unsure
Similarly, the majority felt that learning to speak
more than one language generally causes no
problem, and cited their own successful experi-
ences. They acknowledged that it may initially
take some children longer to learn two languages
but in the long-term there are more advantages
associated with it. They also noted the importance
of learning the home language for bonding with
the family members and for cultural identity.
7. Children with language 50% agreed,
difficulties often have 40% disagreed and
problems with their behaviour. 10% were unsure
The majority who agreed with this related it to
the children being unable to express themselves,
leading to frustration.
8. Children with language 95% disagreed and
disorder are stupid and will 5% agreed about
have problems getting a the difficulty in
good job when they grow up. getting a job
The majority disagreed. They felt that, with enough
help, their childrens language difficulties should
not hinder them in the future, and they were opti-
mistic about the children doing well. They felt the
attitude of other people such as teachers, parents
and employers would be important.
9. Attending the group 50% agreed and 50%
will cure my childs felt it would help the
language problem. language difficulty but
not cure it.
Half of the parents were hoping that attending
the group would cure the language problem.
Half did not feel the group would provide a cure
but that it would help the child to learn and give
ideas to parents on how to deal with the lan-
guage problem and think differently.
10. Speech and language 100% disagreed and
therapy does not work. felt it helped their child
The majority were very confident that speech and
language therapy
to date had made
a big difference
in the childrens
learning. A
number felt that
school had a vital
role to play and
that getting the
right help at
school was
i m p o r t a n t .
Parents said that
they had more
ideas on how to
work with their
childs language. They felt early detection of the
problem was important.
The questionnaire gave qualitative information
about the parents perception of their childs lan-
guage difficulty. Discussion with them during the
completion of the questionnaire gave insight into
the understanding of our role as speech and lan-
guage therapists, and meant we could reinforce cer-
tain perceptions and change others through the
group.
Closer bond
The groups ran in a local clinic for 45 minutes once
a week over a six week block with two bilingual
English / Gujarati speech and language therapists.
The group children who are statemented have
school-based language support assistants.
Holding the group over the school term from
January to March enabled these assistants to
attend without the burden of a larger time com-
mitment. They observed the group dynamics and
activities and got involved where appropriate.
They were an extremely useful resource and
helped to develop a very important closer bond
between schools and the speech and language
therapy service. In turn, the assistants reported
how beneficial it was to have time to reflect and
to practise the activities during the week.
After the six weeks the remainder of the term
time was given over to re-running the group tasks
in school at the discretion of the language support
assistants.
The groups had a structure each week:
A gelling game to encourage group cohesion
(for example, (a) fruit salad - objects or pictures
were given to each child, two items were called
out, and the children with those items swapped
places; (b) passing a ball with a verbal activity).
Activities to develop attention and listening
skills in a group setting via Sounds of the World
listening tape (UNICEF, no longer available).
The core of the sessions consisted of tasks based
on themes. Examples of themes were advertising
(for older children), countries and languages spo-
ken, food and drink, animals, transport, shapes,
Figure 1 Clinical Decision-Making Loop (Episode of care)
Identify Clinical Needs
Intervene
Review
goals and
measure
effectiveness
Set goals for
intervention
Kate Malcomess, 1999
the aim of our care
and training given so we take advantage of the
rich possibilities offered by bilingualism and
ensure that the children receive therapy appropri-
ate to their clinical needs.
Panna Chavda is Clinical Lead Speech and Language
Therapist (Bilingualism) and Laura Helsby Chief
Speech and Language Therapist with Leicester City
West NHS Primary Care Trust. Address for correspon-
dence: Childrens Speech and Language Therapy
Service, Prince Philip House, St Matthews Health and
Community Centre, Leicester LE1 2NZ.
References
Asian Book of Nursery Rhymes. Mantra
Publishing. (ISBN 1852697016).
Brigman, G., Lane, D. & Switzer, D. (1992)
Teaching Children Success Skills.
Journal of Educational Research 92
(6) 232- 329.
Cummins, J. (1984) Bilingualism and
Special Education: Issues in
Assessment and Pedagogy.
Multilingual Matters, Clevedon.
Hulme, S., Rahman Jennings, Z. &
Thomas, D. (2001) Alternative
Methods. Bulletin of the Royal
College of Speech & Language
Therapists August, 10-12.
Malcomess, K. (1999) Measuring
Effectiveness. Workshop. (See
Malcomess, K. (2001) The reason for
care. Bulletin of the Royal College of
Speech & Language Therapists
November, 12-14.)
Masidlover, M. & Knowles, W. (1979)
Derbyshire Language Scheme.
Derbyshire County Council.
Sage, R. (2000) Class Talk. Stafford Network
Education Press.
Useful Resources
* The Bilingual Family Newsletter is written by and
for parents. See www.multilingual-matters.com,
e-mail marjukka@multilingual-matters.com or
write to Multilingual Matters, Frankfurt Lodge,
Clevedon Hall, Victoria Road, Clevedon, England
BS21 7HH.
Online catalogue: www.bilingual-supplies.co.uk.
SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2003 o
groups
words from one language are used in a sentence in
another language. So we said, I like baath for din-
ner for I like rice for dinner.
Positive and valuable
The children needed to feel they could use their
home language outside the home setting to help
with their communication. This approach increased
their confidence and self-esteem and enabled
them to use both their languages in a positive and
valuable manner. In addition, the language support
assistants and parents saw first-hand, or through
feedback in the homework discussion, how suc-
cessfully both languages could be used to help
bilingual children with language difficulties.
Having parents taking part in the groups with
feedback given in their home
language ensured the positive
aspects of bilingualism were
conveyed, and allowed code
switching and other normal fea-
tures of bilingual communication
to be reinforced.The language
support assistants were able to
understand the importance of
using the childs overall commu-
nicative abilities and to value the
learning of the home.
During each session, we kept a
record our observations of the
childrens language and interac-
tion while completing the tasks.
This information was used when
we completed a communication
skills rating questionnaire
adapted from The
Communication Opportunity Group Scheme
(COGS) (Sage, 2000), which is used in
Leicester to promote effective communica-
tion in schools. We found it a very useful
tool to measure baseline performance for
bilingual children, and will be using it as an
ongoing measure of change and as a basis
for discussion with parents and teachers.
The rating scale has four main areas: general
skills, formal conversation, formal presentation
(speech/writing) and non-verbal communi-
cation. It is rated from high competency to
no evidence of the skill on a scale of 1-5.
The communication skills rating alongside
conventional assessment provides a much
more holistic picture of the childrens lan-
guage strengths, weaknesses and progress,
allowing the mapping of skills over time
across both languages and along different
parameters.
Where there are fewer bilingual children
it can be problematic to have bilingual groups for
their specific languages but, for effective therapy,
it is better to include children who have the same
home language and English, rather than children
of many different languages. In areas where there
are no bilingual speech and language therapists,
co-workers and interpreters should be accessed
Do we seect cents or groups on
the bass o ther need - or our
need to get through our caseoad'
Do we oer a servce whch
takes account o the strengths
o a cents background'
Do we promote code swtchng,
exca borrowng and namng
n two anguages wth our
bngua cents'
Reectons

colours. We also had activities to develop giving

and receiving requests based on the Derbyshire
Language Scheme (Masidlover & Knowles, 1979)
and time sequences related to simple stories.
Maps of the world, cross cultural food items (pic-
tures and false foods) and advertisements from
local community and high street shops were useful
resources.
Gujarati nursery rhymes (adapted from Mantras
book of Asian Nursery Rhymes).
Although we had the structure and themes to
follow, there was flexibility for the pupils to intro-
duce and lead a topic of their choice.
Homework was given at the end of each session.
This was translated in Gujarati and discussed with
parents. This formed one of the most valuable
aspects of the intervention as it allowed the par-
ents to understand the what and why of the
groups. Parents who were present during the
group sessions benefited most from watching the
strategies the speech and language therapist
employed during the group, as they were able to
try these out at home. The aims of the group and
the homework set were, as a result, more thor-
oughly understood, and compliance on complet-
ing the homework was high.
Cummins (1984) discusses the idea of a common
underlying proficiency model in bilingualism. We
know there is more than enough room inside our
thinking quarters for two or more languages, and
research also suggests there is transfer between
languages. For example, a child taught multiplication
and subtraction in one language does not need to
have those concepts re-taught in the second lan-
guage, only the vocabulary to reproduce it. We
aimed not to do the tasks in one language then
another, but to use the
natural discourse of a
bilingual speaker accord-
ing to the situation to
facilitate vocabulary
and word finding. The
session reflected the
childrens natural bilin-
gual use of language
where code switching
and lexical borrowing is
a normal feature. All
the tasks were therefore
done in English and
Gujarati, led by the
bilingual Gujarati speak-
ing therapists.
In vocabulary work,
for example with our
food theme, we encour-
aged the children to
access and name items in both languages to build
up semantic links and facilitate word recall. Code
switching (for example, I have been to India, hu
rikshawma beto meaning I have been to India,
I sat in a Rikshaw) was used naturally through-
out. Names of food items were used in conversa-
tion as an example of lexical borrowing, where
We aimed not to do
the tasks in one
language then
another, but to use
the natural
discourse of a
bilingual speaker
according to the
situation to facilitate
vocabulary and
word finding.
Homework was
translated in Gujarati
and discussed with
parents. This formed
one of the most
valuable aspects of
the intervention as it
allowed the parents
to understand the
what and why of
the groups.
you
have mae and/or emae cents
work wth both men and women
beeve that gender s mportant
Read ths
SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2003 +
nequaty seres ()
ex and gender are two commonly used
terms that are often used interchange-
ably. However, the term sex refers to the
different biological and physiological
characteristics of men and women
whereas gender refers to the characteristics that
are socially ascribed. Thus, sex is generally per-
ceived as permanent and unchanging, whereas
gender is perceived to be socially constructed.
Gender inequalities are, therefore, inequalities
that arise from the socially constructed differ-
ences between men and women; consequently,
gender inequalities are themselves seen to be
socially produced, rather than immutable.
Some theorists believe that gender differences,
and hence gender inequalities, are an
inevitable consequence of male and female
biology. However, the vast majority of sociol-
ogists would agree that gender inequality is
produced and sustained by the societies in
which people live.
Gender inequalities are pervasive in rela-
tion to health, illness and healthcare. Over
the last few decades life expectancy has risen
globally. However, since the early 1960s, life
expectancy for women has exceeded that of
men (Annandale, 1998); on average, women
in the UK now live five years longer than
men (ONS, 2002). The only exception to this
general trend can be found in some parts of
the developing world, most notably in areas of
Southern Asia, for example in Bangladesh and
Nepal (Nettleton, 1995).
Although women live longer than men, on aver-
age they have higher rates of morbidity. These
rates are usually calculated according to service
use, and records show that women are more like-
ly than men to visit their GP. They are also more
likely than men to suffer from chronic conditions
and to be diagnosed and admitted for psychoses,
neuroses and depressive disorders (Nettleton,
1995). Men, on the other hand, are more likely to
experience ill health and earlier death as a conse-
quence of heart disease, lung cancer and motor
accidents (Godfrey, 1993).
S
When you see a
little boy who cant
sit still, when you
are referred a
middle-aged female
with dysphonia,
when you visit your
GP - do you question
whether gender
might be influencing
the treatment you
give and receive? In
the second of four
sociological
perspectives on
inequality, Sarah
Earle again gets us
thinking.
Some studies have highlighted considerable dif-
ferences in the way in which health professionals
manage male and female clients, suggesting that
gender can be an important factor both in the
assessment of symptoms and in the choice of
treatment. Goudsmit (1994), for example, sug-
gests that GPs often psychologise womens illness;
that is, they emphasise psychological rather than
physical factors. A study by Ayanian & Epstein
(1991) also showed that women are perceived as
emotional and prone to exaggeration, hence they
are less likely to undergo diagnostic and therapeu-
tic procedures. Research on patient compliance
also shows gender to be an important factor. For
example, in a study of patients with hypertension,
women were more likely
than men to comply with
lifestyle recommenda-
tions, medication and
attendance requirements
(Kyngas & Lahdenpera,
1999).
Distinct patterns
Sociologists question the
extent to which gender
inequalities in health and
illness are real. There are
two main sociological
explanations for differ-
ences in morbidity and life expectancy between
men and women: artefact, and social causation.
Artefact explanations refer to how our knowl-
edge of health and illness is influenced by the way
in which data are collected. So, for example, we
could explain the higher rates of morbidity
amongst women by arguing that women are simply
more attuned to their health and more likely to
admit to being ill than men (Nettleton, 1995).
Explanations of social causation, however, high-
light the fact that the lives of men and women are
very different, thereby leading to distinct patterns
of illness and disease. For example, women are
more likely to engage in multiple social roles, the
nature of which may be detrimental to their
The problem
of boys
underperformance
has vexed those
who are
interested in
explaining gender
inequalities in
education and
schooling.

Barbie & Ken:

an unequal
relationship
The pattern of gender inequalities is complex and
subject to flux. Every therapist seeks to provide client
care on an individualised basis according to need, and
yet it must be recognised that gender inequalities are
pervasive and expansive. An awareness of gender
inequalities is essential for speech and language ther-
apists since gender relations can, arguably, affect all
aspects of the therapeutic relationship, in both a pos-
itive and negative manner (see figure 4).
Dr Sarah Earle is Senior Lecturer in Health Studies at
University College Northampton. Address for correspon-
dence: Centre for Healthcare Education, Broughton Green
Road, Northampton NN2 7AL, tel. 01604 735500, e-mail
sarah.earle@northampton.ac.uk.
References
Annandale, E. (1998) The Sociology of Health &
Medicine: A Critical Introduction. Cambridge: Polity.
Ayanian, J.Z. & Epstein, A.M. (1991) Differences in the
use of procedures between women and men hospi-
talised for coronary heart disease. New England
Journal of Medicine 325, 221-225.
Department for Education and Skills (2002) National
Curriculum Assessments Of 7 And 11 Year Olds In
England, 2002 [provisional]. London: DfES.
http://www.dfes.gov.uk/statistics/DB/SFR/ [accessed 8
October 2002].
Department of Health (2002) Speech and Language Therapy
Summary Information for 2000-2001 England. London:
HMSO. http://www.doh.gov.uk/public/kt290001/index.htm
[accessed 10 October 2002].
Godfrey, C. (1993) Is Prevention Better than Cure? In: M.
Drummond & A. Maynard (eds) Purchasing and Providing
Cost-Effective Health Care. London: Churchill Livingstone.
Goudsmit, E.M. (1994) All in Her Mind! Stereotypic Views
and the Psychologisation of Womens Illness, pp. 7-12. In:
S. Wilkinson & C. Kitzinger (eds). Women and Health:
Feminist Perspectives. London: Taylor and Francis.
HESA (2002) Qualifications obtained by and examina-
tion results of higher education students at higher
education institutions in the united kingdom for the
academic year 2000/01. HESA SFR 53
http://www.hesa.ac.uk [accessed 8 October 2002].
Hoff Sommers, C. (1995) Who Stole Feminism? How
Women Have Betrayed Women. Touchstone Books.
Jackson, C. (2002) Laddishness as a Self-worth Protection
Strategy. Gender and Education 14 (1), 37-50.
Kimmel, M.S. (2000) The Gendered Society. Oxford:
Oxford University Press.
Kyngas, H. & Lahdenpera, T. (1999) Compliance of
patients with hypertension and associated factors.
Journal of Advanced Nursing 29 (4), 832-839.
Nettleton, S. (1995) The Sociology of Health & Illness.
Cambridge: Polity.
Office for National Statistics (2002) Mortality Statistics
[general]: Review of the Registrar General on Deaths
in England & Wales, 2000 [DH1 No: 33] http://www.sta-
tistics.gov.uk [accessed 8 October 2002].
Pollard, N. & Walsh, S. (2000) Occupational therapy,
gender and mental health: an inclusive perspective?
British Journal of Occupational Therapy 63(9), 425-31.
Popay, J. (1992) My health is all right, but Im just tired
all the time: Womens experience of ill health, 99-120.
In: H. Roberts (ed.) Womens Health Matters. London:
Routledge.
Sadker, M. & Sadker, D. (1995) Failing Fairness: How
our Schools Cheat Girls. Touchstone Books.
nequaty seres ()
SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2003
health, rendering them vulnerable to chronic, rather
than fatal, diseases (Popay, 1992). Figure 1 highlights
some points to consider with respect to gender, health
and healthcare.
Considerable discrepancies
Gender inequalities in education do not mimic those
associated with class (or ethnicity). In terms of general
academic performance, girls do better than boys at all
educational levels, but there are still considerable dis-
crepancies according to subject, with boys being dis-
proportionately represented, and doing better, in tra-
ditionally male subjects. For example, at key stage 1
the percentage of girls achieving level 2 or above is
greater than that of boys in all four subjects, with the
widest gap, at ten percentage points, being in spelling
(DfES, 2002). However, at key stage 2, boys do better
than girls in mathematics and science (DfES, 2002).
Within higher education, women also tend to do better
than men. For example, in 2001, 56 per cent of women
achieved a first or upper second class degree, com-
pared to only 49 per cent of men. However, there are
considerable differences in qualifications obtained
according to subject (see figure 2). Boys are also more
likely to have special educational needs and are there-
fore over-represented in referral rates for speech and
language therapy (DoH, 2002).
The problem of boys underperformance has vexed
those who are interested in explaining gender inequalities
in education and schooling. Recent thinking has focused
on the problem of hegemonic, or traditional, mas-
culinity and commentators have argued that it is this
which discourages boys (and men) from doing well
academically (Kimmel, 2000). Jackson (2002), for
example, argues that doing well at school is perceived
as feminine and that a culture of laddishness has
developed which is at odds with the achievement of
academic success. As a consequence, though, boys
tend to receive more attention from teachers. In an
American study conducted by Sadker & Sadker (1995), a
teacher was asked why boys were given more attention
and said, Because boys need it more ... Boys have trou-
ble reading, writing, doing math. They cant even sit still.
This has led some sociologists to argue that contemporary
education pathologises boyhood; as Hoff Summers
(1995) controversially suggests, schools for the most part
are run by women for girls. This may, in part, explain
why boys with special educational needs outnumber girls
so disproportionately. Figure 3 highlights some points to
consider with respect to gender, education and schooling.
Shapes the profession
The allied health professions are characterised by one
factor - they are overwhelmingly dominated by
women, particularly within the lower echelons. It is
worth considering the extent to which this shapes the
nature of the profession and how this might influence
client care. Writing specifically about occupational
therapy, Pollard & Walsh (2000) suggest that the early,
mainly female and middle-class origins of this profession
has caused a struggle to define its status and role to fit
structures determined by the medical profession;
arguably, similar struggles exist for speech and lan-
guage therapy. However, they also suggest that with-
in a principally female dominated profession the fem-
inine principles of caring, connectedness and the
importance of relationships should be harnessed to
produce an inclusive and reflective practice.
Do l recognse that varaton
between maes and emaes
goes beyond boogy'
Do l know what assumptons l
make based on gender'
Do l harness the postve and
neutrase the negatve aspects
o gender derences'
Reectons

Figure 1 Gender health and healthcare:

thinking points
could gender influence your
assessment of a clients symptoms?
could gender ever influence your
choice of treatment for a client?
do you think that therapists may
psychologise womens illnesses?
how could gender influence
compliance within speech and
language therapy?
Figure 2 First Degree obtained according to
subject and gender (2001)
Subject Female Male
Biological Sciences 11.9 6.6
Computer Sciences 2.7 9.8
Engineering & Technology 3.1 16.7
Languages 12.1 4.5
Mathematical Sciences 1.7 2.5
Medicine & dentistry 1.7 2.8
Physical Sciences 5.2 7.9
Social, Economic & Political
Sciences 13.4 8.6
Subjects Allied to Medicine 15.5 3.9
Adapted from: Table 3: Qualifications
Obtained by Students on Higher
Education Courses by Level of Course,
Gender and Subject Area 1996/97 to
2000/01(1), HESA (2002).
Figure 4 How can gender influence the
therapeutic relationship?
it influences morbidity and mortality;
it may affect the relationship between
client and therapist;
it may impact on assessment and
referral;
it may impact on choice of treatment;
it may influence compliance to treatment;
it may influence the relationship
between therapists and other
professionals.
Figure 3 Gender, education and
schooling: thinking points
does speech and language
therapy contribute to the
pathologisation of boyhood?
to what extent is speech and
language therapy run by women,
and yet suitable for males?
how can therapists encourage
males to succeed in education?
SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2003
revews
DYSPHAGIA
DEFINITELY A PRACTICAL
REFERENCE
Feeding and Swallowing Disorders
in Dementia
Jaqueline Kindell
Speechmark
ISBN 0-86388-312-5 34.95
The book covers classification of dementia, case
history taking, assessment of feeding and swal-
lowing disorders and management strategies in
a step-by-step format. It combines research
based information with clear practical ideas, and
has assessment forms in detailed and checklist
formats.
Case studies demonstrate practical applications
of the theory whilst highlighting the need to
treat each person as an individual. The book is
aimed at people with little or no experience of
dysphagia and dementia but also provides ref-
erences for more experienced therapists. It is
reassuring to have discussions on treatment
issues supported by medical/legal documents.
The management strategies may have more
application for therapists working in the com-
munity as it is often difficult to vary environ-
mental conditions within the hospital setting.
The layout is clear and concise, it provides good
value for money and is definitely a practical ref-
erence, making dementia less daunting for ther-
apists at all levels.
Pippa Hales, Suzanne Webb and Sarah West are
speech and language therapists at
Addenbrookes Hospital in Cambridge.
REVlEvS
LANGUAGE DEVELOPMENT
AN EXCELLENT IDEA
Scallys World of Verbs
Topologika Software
39.95+VAT (5, 10, 15 user and site
licences available) (special price 19.99
inc. VAT for parents)
Verbs are vital elements of early language
development and animated resources are an
excellent idea.
Scallys World of Verbs links the animated antics
of Scally the alien to spoken and written lan-
guage work. Scally is accessible and attractive,
with options to set up child-specific work par-
ticularly valuable.
There are however some serious flaws. The
verbs are frequently presented in an ambiguous
manner - for example, Scally hated or Scally
can know gives unclear information to young
language learners. The item Scally went uses
only a toilet sequence and Scally can be is
accompanied by a bee symbol(!)
I had trouble loading and accessing this soft-
ware but finally succeeded after advice from
helpline staff. Therapists should be aware that,
to use this type of resource, it is essential to
have an up-to-date multimedia PC.
If you are VERY selective this can be a useful
and motivating resource for follow-up work.
Andrew Burnett is a chief speech and language
therapist (education) with Plymouth Primary
Care Trust.
DEAFNESS
WORTH THE EFFORT
Hearing Rehabilitation for Deafened
Adults: A Psychosocial Approach
Anthony Hogan
Whurr
ISBN 1 86156 215 2 25.00
This book is a long, hard read but well worth the
effort especially for anyone new to working with
deafened adults.
Anthony Hogan believes that deafened people
must face up to their hearing loss by learning how
to use technology and communication strategies:
We strive to do more than just give people an
experience of sound, but to enable deafened people
to get on with their lives in a positive way.
He dispels the myth of cochlear implants being a
quick fix saying these patients need a dynamic
programme of rehabilitation.
His programme, and his assessments, are in the
book for us all to use.
Susan Howden is a senior specialist speech and
language therapist with NHS Tayside.
AAC
HAVE TO START SOMEWHERE
The Augmentative Communication
Assessment Profile (ACAP)
Helena Goldman
Speechmark
ISBN 0 86388 286 2 24.95
This book sets out to provide professionals with a
means of identifying the communication system of
most benefit to the non-verbal child with an autistic
spectrum disorder. In my view it is a practical resource
for therapists working in schools or other day care
settings who do not have a high level of experience
working with children on the autistic spectrum.
Contrary to the authors view, I would not expect
more specialised practitioners to adopt a wait and
see attitude or be reliant on instinct since there
are many protocols available to assess augmentative
communication strategies for individuals whatever
their level of autism or associated learning difficulties.
This book is easy to read and does give clear guide-
lines for assessing skills and planning therapy. I
liked the holistic approach and focus on multidis-
ciplinary work in functional settings. This will be
particularly helpful to less experienced staff but it
lacks a problem solving section. The contents do
not put sufficient emphasis on the pre-requisite
skills for success in establishing effective use of AAC
with autistic children such as identification of the
childs strengths, interests, potential motivators
and the establishment of joint attention skills.
Overall, while the book is readable and may be a
useful resource for some, it will not meet the
needs of more specialist therapists - but there
again we all have to start somewhere.
Heather Crawford is speech and language therapy
manager with Down Lisburn Health and Social
Services Trust.
EARLY YEARS
EASILY ACCESSIBLE
Communication Counts (Speech and
language difficulties in the early
years)
Fleur Griffiths and collaborators
David Fulton Publishers
ISBN 1 85346 797 9 15.00
As we all know, Communication Counts and
this book provides a comprehensive information
structure relevant to all working therapists. The
ideas for collaborative practice and detailed
examples are useful, as they highlight the impor-
tance of adapting our own clinical skills to
include all aspects of a childs developmental
needs.
The chapters are not drawn out and generally
easy to read. The highlighted texts provide help-
ful reference points and the photographs make
it real.
Overall this book is good value for money and
easily accessible. It encourages you to question
and evaluate your therapy techniques, always a
good thing.
Alison McCarthy is a locum paediatric speech
and language therapist in north London.
DEMENTIA
EXTREMELY USEFUL
Food, Drink and Dementia (How to
help people with dementia eat and
drink well)
Helen Crawley
Dementia Services Development Centre,
University of Stirling
ISBN 1 85769 154 7 9.00 inc. p+p
This excellent resource book written by a dietitian
is aimed primarily at nursing home care staff.
It provides a wealth of practical information in an
easily readable, interesting format and covers a
broad range of aspects which relate to eating and
drinking, from physical through to emotional,
cultural and religious considerations.
The book contains lots of exercises designed to
promote thoughts about the quality, as well as
the quantity, of food and it also includes practical
ideas on how to manage feeding difficulties.
Extremely useful for both the experienced and
the inexperienced clinician working to advise
and train staff in elderly care settings.
Tracy Broadley-Jackson is a speech and language
therapist at Stone Rehabilitation Service, a
multidisciplinary community rehabilitation team
(South Western Staffordshire Primary Care Trust/
Cannock Chase Primary Care Trust).
1. work from what clients want and what evidence suggests you should provide
2. be aware that the same route to an end place doesnt suit everyone
3. build in opportunities to stop over, divert and revisit as needed
4. act in partnership with voluntary agencies and other professionals
5. aim for equity and consistency through shared standards
6. increase confidence through being organised and transparent
7. ensure adequate induction and updates for staff in new procedures
8. think about the benefits of generic groups for clients
9. make specialist opinions accessible.
Practical points: care pathways
l am negotatng
care pathways
Too oten, speech and anguage therapy
and other servces are dcut or cents
to access and negotate, and therapsts them-
seves are not aways cear whch way to
turn. Do care pathways oer a way ahead'
are pathways are becomng amar to us as
a way o descrbng, pannng and mappng a
cents journey va derent routes rom
reerra to dscharge. Dependng on the
nature o the cents needs ths journey may
be through speech and anguage therapy
ony, or nvove a range o heath and
assocated servces workng together wth the
cent and amy.
But how do we know ths snt yet another
ad' Are there practca benets or cents
and servces' Do care pathways hep us to
acheve evdence based practce' And how do
we ensure that a care pathway oers easy
access or a, and snt a euphemsm or
passabe wth care'
Our two contrbutors descrbe how care
pathways can be a transport network
worthy o our nvestment.
Neil Smith is a specialist speech
and language therapist with
Portsmouth City NHS Primary
Care Trust at Rowner Health
Centre, Gosport, Hants,
tel. 023 92 511500,
e-mail smuff70@hotmail.com.
Cecilia Yardley is Director of
Services for Speakability, 1 Royal
Street, London SE1 7LL,
tel. 080 8808 9572,
e-mail
speakability@speakability.org.uk.
The charity Speakability exists to
reduce the barriers faced by
people with aphasia.
you
need to spread your
expertse more wdey
want to pass more power
to servce users
ke to be organsed n your
approach
Read ths
how l...
SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2003 (
Therapists had highlighted that writing reports for children with fluency
problems was difficult, therefore a fluency report format identifying areas
which should be commented on was introduced.
Equity of service
By this time joint assessment clinics were being used successfully within
the department but there was a lot of information I wanted to share
with staff, and I had to find a way to present it. In the end we decided
that, to ensure equity of service, all therapists should have access to
what is now called a fluency pack when assessing children who present
with dysfluency (figure 2). It is designed to be in line with current
research and flexible in that, if new or updated information becomes
available, it can be adapted quickly.
All new staff to the trust spend a session with me as part of their induction
to provide an overview of the service for dysfluent children. This time is also
used to discuss the fluency pack and standards. All community clinics now
have a fluency pack and specific training is arranged regularly - approxi-
mately every three months - for new staff to attend and for any other staff
members who have not previously attended or would like a refresher.
Alongside this course I recommend therapists attend another training
package, an overview of therapy approaches. This looks at the assess-
ment procedure and appropriate management for dysfluent children and
teaches intervention techniques and strategies the therapists can actu-
ally use (slow speech, modification, interaction therapy) as well as
informing them of approaches such as Lidcombe, McGuire and Starfish
which can be used by other people. This is so they have a minimum level
of awareness and understanding of several approaches and can refer on
if need be or if specifically questioned by parents. Therapists are advised
to contact me in the first instance if parents request further information.
SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2003
how l
y appointment three years
ago as a specialist in stam-
mering was a new venture for
me. Dysfluent children make
up a small percentage of a community ther-
apists caseload, adults with a stammer even
less, therefore specialist training in dysfluency
is not a priority. Yet our knowledge of stammering and how to manage
it is constantly growing and we know that timely, appropriate interven-
tion for children works (Christie, 1999). I had a daunting task in only
three sessions a week, but the job description gave endless opportunity
as it stated that I should ...develop the service for dysfluent children....
My first priority was to devise short and longer-term aims for the service
(figure 1). Initially, I distributed newsletters to help share stammering
related issues and to keep fluency at the forefront of therapists minds.
The newsletters informed staff of times I would be available for discussion
and highlighted small projects I was working on such as collating clinic
resources and equipment lists. They also included resources that I had
available and information on current theory.
Allowing therapists access to my specialist time was at first difficult to
achieve as colleagues had children they wanted to discuss urgently or see
jointly. In the beginning I used my fluency sessions to see children with their
community therapist to help with the backlog of such cases. However it soon
became apparent that this was very time-consuming, involved extensive
travelling across the trust and was erratic with regard to service delivery.
To deal with this, I subsequently developed joint assessment clinics.
Portsmouth City NHS Trust is split into three wide geographical areas. I
devised a rolling joint assessment programme so that one day per month
was arranged whereby if therapists had any particular problems with any
child they would refer them via a standard form to the clinic where we
would see them together (January - division 1, February - division 2 and so on).
These sessions gave therapists specific and structured access to my spe-
cialist time. Joint assessment clinics gave therapists working in the com-
munity time to discuss cases in greater depth with me in order to develop
a structured management plan. In effect, they became practical training
sessions giving staff confidence in working with this client group and
information which could be applied to other cases in the future.
To address longer-term aims, trust-wide standards were developed to
ensure consistency and equity of service across the department. These
were in line with current evidence based practice. Standards were pre-
sented in a flowchart format to give therapists visual guidance to help
the assessment procedure.
The standards include diagnostic criteria of beginning, borderline,
intermediate and advanced (Guitar, 1998) and a profile of risk (amend-
ed from Cook & Botterill, 1999). The parental interview and language
based assessments were deemed compulsory.
N
Unbockng
the pathway
How do you deveop a specast servce or chdren who
stammer n three sessons a week' Ne Smths work on a
care pathway or dysuent chdren n Portsmouth coud
be equay apped to other communcaton dcutes
whch have a ow ncdence n communty caseoads but
need targeted and tmey nterventon.
Figure 1 Short and longer-term aims
short-term aims:
1. to increase awareness of stammering related issues within
the department
2. to develop therapists confidence in working with this client
group
3. to give therapists access to specialists time (informal and formal).
longer-term aims:
1. to develop equity of service
2. to encourage skill mix and ongoing confidence
3. to provide a service which is in line with current practice and
research
4. to provide appropriate training packages to staff.
Figure 2 Contents of fluency pack
- procedures when working with dysfluent children
- pre-assessment telephone discussion
- parental interview
- child interview
- school aged screening assessment
- profile of risk (prognosis tool to be used with all new referrals)
- child assessment summary sheet
- guidelines for writing fluency reports
- venues / dates for forthcoming joint assessment clinics
- joint assessment referral forms
- stammering newsletters
- information / leaflets (based on those produced by the British Stammering
Association):
how parents can help young children who are non-fluent
information for referral agents
information for teachers
information for parents of children under five
what is stuttering?
stuttering prevention
ways to reduce demands on at risk children
- appendix 1 (the development of stuttering - diagnostic criteria)
- space at the back where therapists can keep copies of any information they
have seen or read which they feel is relevant and for any further information
distributed by the specialist.

A typical care pathway for a stammering child in Portsmouth City NHS

Primary Care Trust is summarised in figure 3. Our speech and language
therapy service offers an open referral system and the guideline is to see
all new referrals within six weeks. However, to be in line with current
research (Christie, 1999), we aim to see children who are referred with
fluency problems as close to the referral date as possible.
Pre-assessment telephone contact is optional and is designed to give
parents broad advice without going too far into wider issues, to offer
immediate strategies for use at home and to gain an impression of levels
of fluency and concern. Parents are sent a leaflet about stammering
with their initial appointment.
Every family attending initial assessment will receive a parental question-
naire (based on Rustin, 1987), and observations will be made on the nature
of the childs stutter, secondary features, social skills, anxiety and avoidance.
Preschool children receive language assessments as appropriate. School-
aged children receive formal language assessments on their vocabulary
development and their receptive and expressive language levels.
Therapists then develop a profile of risk (Cook & Botterill, 1999) and
make a diagnosis. Diagnostic criteria are borderline, beginning, inter-
mediate and advanced (Guitar, 1998).
Therapists have a list of therapy approaches and techniques which cor-
respond to the diagnosis made (beginning stutterer = general advice,
Lidcombe approach, shaping; intermediate stutterer = general advice,
social skills, brief therapy; and so on). These are used as a guideline to
suggest possible strategies or techniques suitable for children presenting
at a particular level. The timing of therapy is obviously important and
factors including age, anxiety levels, parental concern and willingness to
participate and change are all considered.
Several review options are available including routine three or six
month review. The preferred method is to encourage parents to contact
the department after approximately four weeks for a progress report
and to discuss any further issues which may have arisen since the last
appointment. This allows the therapist to gauge whether or not any further
intervention is required at that time.
We suggest that parents contact the service immediately if they need
any further advice, information or another appointment. This open
review system places the onus on the parents and, if we do not hear
from them within six months, they are discharged. This is clearly
explained to them in the session and in their report.
Secondary and tertiary levels of service are also available. Therapists
can refer for a joint assessment with the specialist within the trust and
there is always the possibility of referral to the Michael Palin Centre for
Stammering Children in London.
At discharge the child / parents are told about re-referral procedures
and are given advice on relapse and what to do if further concerns arise.
So, were my original aims for the service (figure 1) met?
Newsletters raised awareness of stammering issues within the department
initially, and now any new information, advice or articles of particular inter-
est or relevance are circulated to ensure that every therapist has access.
More confident
A recent drop in requests for joint assessment appointments suggests
that therapists are more confident to deal with stammering children
autonomously. Also, recent questionnaire findings showed increased
levels of confidence and reduced anxiety when working in this field.
Therapists still use informal telephone contact to discuss cases and often
this is now all that is required. The fact that colleagues are making less
use of specifically allocated specialist time has been viewed as a very
positive step within the department.
As the standard fluency pack is now being used across Portsmouth and
South East Hampshire, this has ensured equity in that all children
referred receive the same assessment procedure and general advice.
Any new research or theoretical frameworks for practice are shared as
appropriate and are added to the pack in place of old information to
ensure the whole system is fully up-to-date. All staff working in com-
munity clinics will have received both the introductory and overview
training packages in the near future and both packages are soon to be
regarded as compulsory elements in our in-service training.
SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2003
how l
Figure 3 Care pathway for dysfluent children
Italics = COMPULSORY ELEMENTS
PARENTAL INTERVIEW
PRESCHOOL CHILD
LANGUAGE ASSESSMENTS
- Renfrew Action Picture
Test
- British Picture
Vocabulary Scales
- Comprehension
- Test of Word Finding
- Test of Word Knowledge
GENERAL OBSERVATION
- secondary features: eye-blinking, tics.
- social skills, eye-contact
- avoidance
- fear, frustration, embarrassment
- type of stutter (prolongations / repetitions)
Administer appropriate type(s) of
therapy (relate to diagnosis).
Examples include
- fluency shaping 2 3
- stuttering modification 2 3
- interaction therapy 1 2 3 4
- brief therapy / client centred 2 3 4
- cognitive-behavioural therapy 3 4
- breathing and relaxation 3 4
- Lidcombe approach 1 2
- group therapy (where
applicable)
- social communication skills
approach 2 3 4
- general advice 1 2 3 4
REVIEW
- open review
system (telephone
review?)
- to contact us after
1 month for a
progress report
and re-evaluation
- formal review
periodically (3
month / 6 month)
JOINT
ASSESSMENT
CLINICS
- refer to joint
assessment
clinic if no real
progress has
been made or
if there is a
high level of
concern
- complete
referral form
FLUENCY
REPORT
fluency
format, plus
liaison with
relevant
parties THERAPY
referral to
specialist
centre via GP
DISCHARGE
- discuss relapse
- discuss re-referral procedures
DIAGNOSIS / PROFILE OF RISK
- complete profile of risk and share with
parents, discussing prognosis
- diagnosis:
1. BORDERLINE
2. BEGINNING
3. INTERMEDIATE
4. ADVANCED
contact parents prior
to assessment for
telephone discussion
to gather broad
information and to
reinforce advice;
possibly ask them to
tape the child
(see appendix 1)
}
- LANGUAGE ASSESSMENTS
- SCREENING ASSESSMENTS
(if appropriate)
CHILD ASSESSMENT
SCHOOL AGED CHILD
SCHOOL AGED SCREENING
ASSESSMENT
referral to the speech and language therapy service
send out initial appointment with standard
dysfluency leaflet
to
be seen within
6 weeks (as soon
as possible)

treatment - 2nd Ed. Lippincott, Williams & Wilkins.

Rustin, L. (1987) Assessment and Therapy programme for Dysfluent
Children. Windsor: NFER-Nelson.
Rustin, L., Botterill, W. & Kelman, E. (1996) Assessment and Therapy for
Young Dysfluent Children: Family Interaction. London: Whurr Publishers.
Resources
Renfrew Action Picture Test by Catherine Renfrew is available through
Speechmark or Taskmaster.
British Picture Vocabulary Scales, see www.nfer-nelson.co.uk
Germans Test of Word Finding and Wiig & Secords Test of Word Knowledge
from the Psychological Corporation (www.tpc-international.com).
For further information
Michael Palin Centre for Stammering Children www.stammeringcentre.org
British Stammering Association www.stammering.org
Lidcombe www3.fhs.usyd.edu.au/asrcwww/
McGuire www.mcguire-freedomsroad.com
Starfish www.starfishproject.freeserve.co.uk
The pack has been in community clinics for approximately one year. I now
need to look at its widespread use and effectiveness and whether or not
the speech and language therapy department is meeting its standards. The
pack is being audited to assess the appropriateness of the standards and to
ensure that they remain workable. The packs availability and use may also
be extended to therapists in the special needs team and not just commu-
nity clinic therapists. I will continue to monitor the information in the pack
to ensure that it remains in line with current theories and practice.
Overall, I am pleased with our progress over the last three years, and
look forward to continuing to develop the service for young children in the
Portsmouth area. From my recent work, I would strongly recommend a care
pathway approach when developing services.
References
Christie, E. (1999) Parental Awareness Campaign. British Stammering
Association.
Cook, F. & Botterill, W. (1999) A profile of risk for generalist therapists.
Paper presented at the Oxford Dysfluency Conference.
Guitar, B. (1998) Stuttering- an integrated approach to its Nature and
SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2003 ;
how l
was familiar with the care path-
way approach from a previous
incarnation working for a bowel
cancer charity. There, I saw how
developing a common understanding of a framework and pathway for
treatment could bring real benefits in terms of service planning, sharing
good practice and making it easier for patients, carers and the voluntary
sector groups that supported them to shape service delivery.
My first brush with care pathways for aphasia came when I saw an item
by Lisa Hirst in the British Aphasiology Society newsletter (2001). Reading
Lisas article and examining the care pathway she had developed, some-
thing clicked.
At Speakability, my work involves a balance between the macro view
of monitoring and influencing changes in policy at a national level, and
taking the most extremely micro view in talking with people whose lives
have been turned upside down by aphasia. These are usually the children
or partners of people with aphasia who call the Speakability information
service. The onset of aphasia may have been very recent, sometimes
within the last week, or a long time ago, even ten years or more, and it
may have been due to a brain tumour, head injury or other neurological
damage, not only stroke. Sometimes my interaction is with people with
aphasia themselves, such as those confident enough to call the information
service or to take part in Speakability events, local groups, regional net-
work meetings, or one of the working parties that inform Speakabilitys
work. I am, for example, facilitating a working party to develop a
Patients Passport, a conversation support tool to enable people with
communication difficulties to maximise their consultations with their
healthcare team.
I could see a real synergy between what Speakability was doing and what
Lisa was working on. Her outline care pathway charted the integration of
many different agents for change that take part in the aphasia journey.
Here, I could see the role of voluntary organisations like Speakability,
Headway, the Stroke Association, Connect and the independent local
groups that exist around the country. A care pathway approach could
make it easier for all of us to contribute to the person with aphasias recov-
ery, long-term rehabilitation and growth. So, I invited Lisa to speak at the
2002 Mary Law Lecture, and am delighted that she accepted.
The lecture is an annual event hosted by Speakability in London and outside
the capital. In 2002 we also held the lecture in Manchester and Edinburgh.
Named after the mother of Diana Law (the founder of Action for Dysphasic
Adults, the organisation that grew into Speakability), the lectures have
come to be a litmus test for the driving issues within the charity at a given
point in time. So, in 2000, the year Speakability relaunched under its new
name, we had a visionary presentation from Professor Steven Small of the
Department of Neurology, University of Chicago entitled The Future of
Aphasia Therapy - is it just a dream? The 2001 lecture was given by
Professor David Howard of the University of Newcastle-upon-Tyne. Under
the title The Role Of Randomised Controlled Trials In Aphasia, David argued
very convincingly that to get the resources for aphasia therapy services we
have to be able to engage critics (who often hold the purse-strings) as well
as supporters of therapy. He tackled some of the ground that underpins the
care pathway: does aphasia therapy work?; what sort of interventions
work with whom?
For Speakability, these questions about the efficacy of any particular
form of treatment, therapy or intervention are absolutely critical. The
organisation has no vested interest other than to see that people affected
by aphasia - principally the person with the condition, but also their families
as their main supporters - get the best deal. We take a broad, holistic
approach, as outlined in our campaign document, Joined Up Talking,
Joined Up Working. We are obviously concerned with speech and lan-
guage therapy, but also with earning potential, leisure activities, wider
healthcare, education and personal relationships - in fact the whole
gamut of things that keeps a person with aphasia human - not just a
patient or a tragic victim.
Space to transfer skills
As a campaigning organisation attempting to influence policy-makers and
service providers, we have to identify and understand what it is that delivers
benefit. Clearly, the overwhelming feedback we receive from people with
aphasia is that their speech and language therapy sessions were pivotal to

l
vhch way now'
Dssatsacton wth the tme, resources and evdence avaabe
or therapy or peope wth aphasa s wdespread. Reectng on
Speakabtys oo Nary law lecture, eca Yardey argues
that, when speced wthn a care pathway, communcaton
dcutes such as aphasa become measurabe and can thereore
attract resources and provde consumers wth ammunton to
press or mproved servces.
their recovery of a sense of self and their ability to rebuild communication.
But with the shortage of therapists, we need to identify components of the
therapy experience that can be replicated by family members, friends or
paid workers who are not speech and language therapy specialists. As part
of an aphasia care pathway, Speakability would press for assessment,
review and monitoring to be undertaken by speech and language therapists,
who would also consistently have space in their schedules to pass on their
approaches and transfer skills to family members. The family could then
maximise the many hours outside the therapy session and feel confident to
disseminate effective communication strategies throughout the person
with aphasias wider environment.
The audience discussions at the 2002 lectures reconfirmed what we hear
from people with aphasia and their carers, how language problems can be
sidelined and subsumed by wider issues of stroke care. Stroke care path-
ways can be quite massive, and aphasia may only get a very small mention;
and then, of course, aphasia is caused by other conditions too. But without
getting demoralised, I think that care pathways offer an opportunity to
concretise the needs of people with aphasia. Within a care pathway, aphasia
becomes something to be measured. What is measured can attract
resources. What is unmentioned lacks attention.
Many of the calls my colleagues and I take on the Speakability helpline
are about how to access speech and language therapy services. We often
hear the client end of the problem expressed so frequently by therapists -
no time, no resources. In some cases, we explain to callers how to use the
health authoritys complaints procedure in their area, to draw attention to
the lack of provision. Explicit mentions of aphasia in care pathways could
be ammunition for the would-be service user, enabling them to apply con-
sumer pressure for more resources.
The publication of the long anticipated Royal College of Speech &
Language Therapists aphasia guidelines will also help very much in this
way. Speakability will be taking part in discussions to frame the new guide-
lines, and we look forward to feeding into the process the many comments
elicited from the lecture audiences during the post-talk discussion and
post-it exercise. For this, we stuck up three large sheets with identical
generic care pathway grids divided into the phases acute, inpatient, first
few months after onset, first year after onset, long-term. The three sheets
were labelled: What do you do now? What is your ideal service? and What
stops you delivering your ideal service? The audience responded by sticking
post-its with their comments onto the grids.
There were no real surprises in response to What stops you delivering
your ideal service? Time, lack of financial and human resources and the
conflict with dysphagia work all featured very heavily. This is, of course,
grist to Speakabilitys campaigning mill, and we will take forward these
and other points raised to the Royal College of Speech & Language
Therapists guideline development discussion and to a parliamentary event
scheduled for June as part of Speak About Aphasia Month.
Thriving generic group
One of the questions raised in the discussion in Edinburgh is whether ther-
apists need to start thinking more about the generic problems raised by
language loss. A member of our Scottish audience described a thriving
generic communication problems support group. This approach has also
been successful elsewhere. Where numbers of people with any particular
condition are low, and many of their problems are shared with people with
other medical labels, this approach seems to make sense. Certainly,
Speakability is aware of a great deal of common ground between people
affected by communication difficulties whatever their cause. As a friend of
mine who has had a laryngectomy commented, Being on the edge of a
conversation is the loneliest place in the world. The people with aphasia
whom I meet seem to back that up.
One of the central points for Speakability to arise from the lecture dis-
cussion is the role of the person with aphasia in developing a care pathway.
Several participants pointed out that the whole concept of a care pathway
is alien to many patients and their carers. They commented that the way
we frame care pathways may not match the key beneficiaries ways of
viewing things at all. Interventions may not be what the person wanted at
a given time - or ever - but we tend to offer what we are able to provide
(not necessarily what, in our professional judgement, the client really
SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2003 8
how l
needs) and to design tick box services, perhaps more to show how active
we have been than to respond to the clients individual needs.
Various members of the audience suggested that the care pathway concept
for aphasia needed to be less prescriptively linear, and more iterative and
organic. It should be designed to allow a person to return as necessary to
earlier types of intervention, and the stages should not be delineated in
terms of passing time but according to stages of psychological readiness.
Certainly, it seemed that many of the audience felt that the main push for
language therapy sessions should often be delayed for several months
longer than is currently the standard until the person with aphasia has had
enough opportunity to adjust to their new life and reach a state of readi-
ness and receptiveness for therapy. Clearly, there is pressure from relatives
in some cases - I hear it on the Speakability helpline - for therapy to start as
soon as possible so that no time is lost and as much is salvaged as pos-
sible. But if experience in many cases shows that it is more efficacious to
wait a while, perhaps six months post-onset, why not do it that way?
And the issue about the shape of the care pathway - whether it is best
modelled as a timeline or as a more iterative structure, such as a waterfall
with opportunities to return to earlier steps - also forces us to think about
the entry points to the process. Speakabilitys caseload includes people at
all times and phases along their aphasia journey. Some people contact
Speakability within days of their relative entering hospital, others some
years after discharge or if their loved one has never been in the system.
The post-it exercise revealed that, after the flurry of activity in the first few
months, the involvement of therapists trailed off significantly. I would be
interested to explore ways of achieving slow release of the therapists
expertise over the long haul of the patient getting on with their life.
Certainly one way in which this would be possible, as many of the audience
noted, would be for the care pathway to incorporate more opportunities for
speech and language therapists to share and exchange skills with other
professionals including members of the multidisciplinary team and adult
educationalists, with whom a person with aphasia might have long-term contact.
One approach to therapy that may be particularly attractive from the
patients perspective was the practice described by some members of the
audience who offer their clients a menu of therapy options to pick from,
so that their personal care pathway is negotiated with them and cus-
tomised (as much as possible) to their specific situation. As a lay person, not
a speech and language therapist, I listened with interest. What I would
take forward from that discussion is the need to research, establish and
implement what works in the issue of timing, content and mode of deliv-
ery of therapy. In my work for the Speakability information service, I would
aim to put power back into the hands of people with aphasia and their
families by adding this angle to the briefing we provide (through literature
and over the phone) about the sorts of questions they can ask about ther-
apy options. I would use aphasia care pathways on both the macro level -
to press for more resources to be devoted to interventions that work - and
on the micro level, to discuss with people what options they have for getting
the best out of the system that they can actively shape.
I think the advantage of going through a formal process of developing a
care pathway is the opportunity to have some protected time to think
about and discuss how best to provide services for people with aphasia that
match their needs and priorities. I am delighted that Lisa Hirsts example
pathway showed voluntary sector groups as partners alongside therapists.
That is how we think of ourselves at Speakability. If you would like to
explore ways in which we can work together, please give us a call!
References
Hirst, L. (2001) Pathway of care for aphasia? British Aphasiology Society
Newsletter. May.
Useful websites
Speakability (includes how to get hold of reports from the annual Mary
Law Lecture and Joined up talking, joined up working)
www.speakability.org.uk
Royal College of Speech & Language Therapists www.rcslt.org
Connect www.ukconnect.org
Headway www.headway.org.uk
Stroke Association www.stroke.org.uk
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EVENTS
5 April, 2003
NAPLIC
(National Association of Professionals concerned with
Language Impairment in Children)
Improving self esteem for communication and learning
London Voluntary Sector Resource Centre
Speakers:Ann Locke, Ruth Paradice, Bill Harpe, Denise Ford
Members 55 Non-members 75
Details: Lucy Myers, 33a Sherington Road, London SE7 7JW.
www.naplic.org.uk
May 2003
H.I.R.E. (Head Injury Re-Education)
From Paper into Practice.
Assessment: How do you make it work?
Coventry University Technology Park
Details: Mary Boullin, tel. 01869 324339, e-mail
hire_office@yahoo.co.uk
14-15 May 2003 (1
1
/2 days)
CONNECT team including Carole Pound
Working with people with severe aphasia
Working with groups
Aberdeen 130
e-mail Nan.McBeath@arh.grampian.scot.nhs.uk
1-30 June, 2003
Speak About Aphasia month
Details: Speakability, tel. 080 8808 9572
www.speakability.org.uk
8-10 September, 2003
British Aphasiology Society
Biennial International Conference
University of Newcastle
Speakers include Shelagh Brumfitt and Lyndsey Nickels
125
Details: www.bas.org.uk.
13-14 September, 2003
British Stammering Association
Silver Jubilee Conference
Trinity & All Saints College, Leeds
BSA, tel. 020 8983 1003, www.stammering.org
25-27 September, 2003
Education Show London
Incorporating Special Needs London
National Hall, Olympia
www.education-net.co.uk
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EUROZONE RATES
IBAN NUMBER: IBAN GB44 BOFS 8020 0608 3990 01 SWIFT BIC: BOFSGBSIEUG
Rebecca Howarth
s a senor
specast speech
and anguage
therapst n
Nanchester. She
works both n a
specast acute
hdrens
Hospta as we
as provdng a
communty
servce to
preschoo
chdren wth
eedng and
swaowng
dcutes as
part o a
mutdscpnary
team. Rebecca
has specased n
paedatrc
dysphaga or
the ast sx years.
5. Skips/Quavers/Wotsits
No paediatric dysphagia therapist is complete without a
pocketful of crisps both as a bribery tool and also as an
assessment tool for examining biting and chewing safely.
(I also like these crisps myself so theres no chance of
any waste.)
MY TOP RESOURCES
1. Stethoscope
Although cervical auscultation (listening to swallowing
sounds) is not an independent diagnostic tool it is a
cheap, quick and non-invasive method of augmenting
existing dysphagia assessments. Subtle difficulties with
initiation of swallowing, effectiveness of swallow and
coordination with respiration can - with practice - be
identified. There are numerous courses now run (see the
Royal College of Speech & Language Therapists
Bulletin) but I would encourage therapists to practise
listening to normal swallows as much as possible and
then trial on abnormal swallows until your confidence
increases.
Litmann paediatric stethoscopes can be purchased for
around 55-60.
Austin, J. (Royal College of Speech & Language
Therapists Bulletin, August 2000) has devised a useful
checklist for speech and language therapists who are
new to using auscultation.
Zenner, P. (1995) The use of cervical auscultation in the
clinical dysphagia examination in long term care.
Dysphagia 10, 27-31.
2. Feeding and Nutrition for the Child
with Special Needs
This collection of handouts on feeding and nutrition
includes topics such as
cup drinking
oral-motor strategies
family mealtime interactions
desensitisation.
All handouts are photocopiable but can also be cus-
tomised by adding specific advice in the special instruc-
tions section. The ring bound version of this book is
more practical and more likely to withstand the rigours
of photocopying.
By Marsha Dunn Klein and Tracy A. Delaney, 98 from
The Psychological Corporation,
www.tpc-international.com.
3. Doidy cup / Kapi cups
These specially designed cups enable fluids to be
presented at a slower rate and reduce the amount of
neck extension required.
I order them in bulk and then sell on to families as this
works out cheaper than the family buying them individ-
ually. Their only drawback is the narrow handles that
are difficult for physically disabled children to use.
Doidy cups are available from Bikkipegs at 3.50 each
(01224 790626)
Kapi cups from Kapitex Healthcare at 13.50 for a set of
5 (01937 580211).
4. My own child!
There is no better way to learn about normal feeding
development than by having your own personal
research project in front of you day to day.
Watching a baby progress from a bundle of reflexes
into an independent and sophisticated feeder is truly
fascinating. It also gives you an appreciation of some of
the everyday issues that parents are often faced with.
(NB: This may seem a drastic measure to take to learn
about feeding development so, if this is not for you, the
dysphagia courses at Manchester Metropolitan
University are an acceptable alternative. Contact
Manchester Metropolitan University on 0161-247-2535.)
10. The care of children with long term
tracheostomies
This useful and easy to read book gives a sound
introduction to both assessment and implications of
tracheostomy, as well as the basics of ventilation, and
should be foundation reading for therapists who are
managing children with tracheostomies.
There is a particularly useful glossary of terms (although
you have to cope with the Americanisms) if you should
come across any unfamiliar jargon.
The contents of the book include feeding difficulties,
behavioural issues, social support, and training.
By K. Bleile (1994), ISBN 1565930940, Singular, 37.
6. Other professionals
I am very fortunate in that I have good access to
physiotherapy, occupational therapy, dietetics and
psychology but I appreciate most therapists are not as
fortunate.
Joint assessment with a physiotherapist is invaluable
when working with children with neurological
impairment as optimal position can be achieved prior
to trial swallows.
Occupational therapists have a wealth of experience on
how best to seat a child and what utensils are
appropriate if independent feeding is being encouraged.
Working with a dietitian when weaning a child off
enteral feeding means oral feeding is more likely to
be achieved.
And where would I be without a psychologist who
provides the objective view of mealtime behaviors
that, as a parent, it is easy to lose sight of?
7. Blue food dye
As I am often asked to assess swallowing in children with
tracheostomies I will usually begin with a blue dye test.
This is a quick, non-invasive bedside assessment which
can detect aspiration. Although I am aware of the con-
cerns of some therapists as to the reliability of this test I
personally find it very useful as a starting point from
which to plan further assessment (including
videofluoroscopy if a negative result is obtained).
Thompson-Henry, S. & Braddock, B. (1995) The modified
Evans blue dye procedure fails to detect aspiration.
Dysphagia 10 (3), 172-174.
Leder, S.B. (1995) Comment on Thompson-Henry &
Braddock. Dysphagia 11 (1), 80-81.
8. Feeding and swallowing disorders in
infancy: Assessment and Management
Although this book can be heavy going at times it
covers everything from anatomy/physiology to assess-
ment and is also a framework for problem solving. It is
probably not ideal as a starting point but is worth a
read/dip into once you have developed some
knowledge and experience.
By Lynn S. Wolf and Robin P. Glass, 62 from The
Psychological Corporation,
www.tpc-international.com.
9. Bottles and teats
Having a selection of these available for parents/nurses to
try is always useful and it is amazing in some cases what
impact a different teat or bottle can make.
My personal favorites are NUK products as they have a good
range of sizes as well as teats and dummies for premature
babies and products for youngsters with cleft lip and palate.
Available from selected branches of Boots or direct from
MM distributors (01438-351341).