I Yo" ,.. was A PENNY FOR THEM? 'A penny for your thoughts' is a phrase which presents problems for those with speech difficulties, to convey. DynaVox 3100 and the lighter DynaMyte 3100 communication aids are the perfect solution for helping both adults and children to be able to express their thoughts and their needs more fully. EASY TO USE DYNAVOX 3100 AND DYNAMYTE 3100 INCLUDE THESE FACILITIES: Over a hundred ready to use communication pages and vocabulary sets. Dynamic touch screen display &scanning options. Fast processing speeds, communication and page creation. Infrared environmental control feature including PC access. Available with DynaSyms or PCS from Mayer Johnson. The smaller and lighter DynaMyte 3100 has the same communication capabilities and gives greater freedom to the more active user. DYNAVOX 3100 & DYNAMYTE 3100 The Great COfnmUVlicators For full information, Clnd for a demonstration, call FREEPHONE 0800 243006 or contact SUNRISE Sunrise Medical Limited (AAC) Dept ST11 , FREEPOST (00348), High Street, Wollaston, Stourbridge, West Midlands DY8 4BR Fax: 01384 44 67 99 ISSN (online) 2045-6174 www.speechmag.com Contents 1999 * www.speechmag.com WINTER 1999 (publication date 29th November) ISSN 1368-2105 Published by: Avril Nicoll 33 Kinnear Square Laurencekirk AB30 1UL Tel/fax 01561377415 e-mail: avrilnicoll@speechmag .com Production: Fiona Reid Fiona Reid Design Straitbraes Farm St. Cyrus ontrose Printing: Manor Group Ltd Unit 7, Ed ison Road Highfield Industrial Estate Hampden Park Eastbourne East Sussex BN23 6PT Editor: Avril Nicoll RegMRCSLT Subscriptions and advertising: - el /fax 01561377415 >4vril Nicoll 1999 Contents of Speech & Language Th erapy in Practice reflect the views of the individual authors and not necessarily the views of the publish er. Publication of advertisements is not an endorsement of the adver tiser or product or service offered. Any contributions may also appear on the magazine's Internet site. Cover picture: Carers' workshop see page 2 News I Comment 17 Ethics "... there is potential for conflict between parents and professionals when the parents wish their child to 4 Life stories receive more treatment. The parents may feel that "Both professionals were able to monitor and support this should be part of the child's rights, and withhold each other within the group. Speech and language ing such therapy is contrary to the just needs of the therapists may inadvertently come across emotional child. The therapist, in disagreeing, does not see this issues with clients which they are unprepared I not as an issue of justice but of clinical need. " trained to address, particularly in such a group where Jois Stansfield and Christine Hobden find out if issues from the past may come up. Therefore, it was an ethical perspective can help resolve disagreements important to have a clinical psychologist present who about intervention. was trained to take on a counselling role. " Lucie Hamilton, speech and language therapist, and Karen McKenzie, clinical psychologist, share their 20 Reviews thoughts on the advantages and limitations of life Head and neck, assessment, parental needs, visual story work with adults with learning disabilities. perception, dementia, dysphagia, brain injury, aphasia, autism. 8 Conference report 22 In my experience "Always test what was best about a conference by the things that are still going round in your head" "". to be able to continue to deliver useful support to (Beryl Kellow). the patients, the inner motivation to help The Association of Speech & Language Therapy must be channelled through the medium Managers' conference, Countdown 2000. of respect." 10 COVER STORY Working with carers "We were able to develop some unique and sensitive measures to aid us in our attempts to evaluate the day These and similar measures may be useful for others engaged in providing support and counselling days for people with communication disorders and their carers." Chris Code reports on an Action for Dysphasic Adults (ADA) pilot day for carers of people with aphasia. bilingual community are explored. 13 Further Reading Psychiatry, staff attitudes, phonology, hearing impairment, stammering. 30 My Top Resources "Do you know the names of the members of 'Steps'? What is 14 Assessments assessed Britney Spears' latest single? What happened this week on 'Home and rigorous evaluation by practising therapists. Find out what Published assessments and programmes are again given a Away' and 'Eastenders'? Who did they really think of the Work Readiness Profile, Dysphagia Man Utd play this week?" Evaluation Protocol, Assessing and Teaching Phonological Audrey Richardson gives the low Knowledge, the Burns Brief Inventory of Communication down on working with and Cognition and the Test of Pretend Play. adolescents. IN FUTURE ISSUES dysphagia more assessments assessed autism more ethics cleft palate head and neck cancer voice transitions Speech 8r. Language Therapy in Pradice has moved. All correspondence should now be sent to: Avril Nicoll, Speech & Language Therapy in Practice, 33 Kinnear SquarE. laurencekirk. Abedeenshire, AB30 1UL tel/fax 01561 377415. For subscribers in the UK, the FREEPOST IS noYt Avril Nicoll. Speech & Language Therapy in Practice. FREEP05T 5C02255. LAURENCEKIRK. Aberdeenshire. AB30 1ZL The magazine's complementary intemet site, speechmag, has also moved to http://www.5pI!echmag.com e-maij (Mail is being re-directed from the old address and callers to the old telephone number will hear a recorded message ...,m rhe fJ >'o ' numbed Apologies for any inconvenience caused by these changes. SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 1999 Jan Roach reflects on her work in the mental health field. 24 How I manage biUnguaUsm Assessment of pre-school minority ethnic children, creative partnerships to bring benefits for adult clients and speech and language therapy in a truly ISSN (online) 2045-6174 www.speechmag.com ____________________~ ~ e ~ Working together Research aimed at improving sup port for children with speech and language difficulties has been joint ly funded by the government's edu cation and health departments. Recognising the difficulties caused by the local health and education authorities' different legal and funding responsibilities, and the variation in services across England and Wales, the researchers are clar ifying current provision. Therapy commissioners and providers, past and present users and parents and teachers will then contribute through interviews and meetings to a plan for better services. The team, led by Dr James Law, comprises researchers from City Un iversity, the Institute of Education and Warwick University. A web site is under development: www.city.ac.uk.css. Common sense for cerebral palsy Follow up care for children with cerebral palsy once they the specific advice on standards for speech and language are discharged from paediatric services is criticised in a therapists drawn largely from Communicating Quality 2 expert report. (Royal College of Speech & Language Therapists, 1996). The recommendations for minimum standards of health The panel recommends referral to speech and language care in children with cerebral palsy state that, without therapy should take place as soon as potential communi further clearly organised provision for their care, a criti cation difficulties are identified, and that therapists cal period in their physical and social development can be should take into account "how much time the family has, missed. Lack of continuity of care is a general problem or is expecting, to provide to help their child. This .. . can for parents of children with cerebral palsy which can be be the main variable when planning treatment." helped by the involvement of 'senior professionals'. The Supervision and specialist training should be available to importance of a seamless, team approach and working in therapists working with this client group. partnership with parents and the voluntary sector is The report, which aims to improve equity of service, was emphasised. compiled based on the best available evidence from ran The expert panel who made up the report . included domised, controlled trials, consensus among appropriate research psychologist Dr Carole Yude who has a 25 year experts and "the often forgotten factor in assessing pro old son with a hemilegia and is chair of the voluntary fessional opinion - common sense." organisation Hemi-Help. Speech and language therapist Available from: Bell Pottinger Healthcare, tel. 01932 Debbie Onslow provided additional information, with 350005, e-mail enquiries@bell-pottinger.co.uk New network An innovative plan for an independent, charitable network of therapy, research and educational services for people living with communication disability is to go ahead. A 2.5 million grant has been secured by the CONNECT - Communication Disability Network - initiative from the Dunhill Medical Trust, who will provide a building for the first Centre in London. This Centre will draw upon the expertise of the City Dysphasic Group and will ini tially focus on providing services to peo ple living with aphasia following stroke. In future, a network of regional centres will be formed across the UK, funded in whole or part by CONNECT, with the remit extended to include a wider spec trum of communication disabilities. The first Internet global disability conference has highlighted the growing use A key concept of CONNECT is working in of the Internet as an information source for parents and clients. partnership with individuals, their families At the time of going to press, the autism99 site had been visited by more par and friends, communities, volunteers and ents than medical, social services and education professionals put together. students, health and social care decision Updated information on this will be available in the Spring 2000 issue. makers and providers of public services. Running from 2 - 23 November, the conference emphasis was on the practical Professor Sally Byng, Carole Pound and issues surrounding autistic spectrum disorder, with new research and thera Dr Susie Parr, who are lead pies highlighted. ing the initiative, are keen Papers,included David Holmes discussing how the needs of adults with autism to hear from people inter are both similar to and different from their needs as children and adolescents. ested in forming partner The success of the Picture Exchange Communication System was described by ships with CONNECT to Andrew Bondy and Lori Frost. Peter Vermeulen, who has produced 'I'm develop regional Centres (c/o Special', a method and workbook for introducing children, adolescents and Department of Language and young adults to their autistic spectrum disorder, says the "content and design Communication Science, City are compatible with an autistic style of reading, understanding and think University, Northampton ing." Partnership with parents was considered in Paul Bartolo's paper on Square, London EC1V OHB, tel. delivering a diagnosis. 0171 477 8290, e-mail Autism 99 was co-sponsored by The Shirley Foundation and The National s.c.byng@city.ac.uk) Autistic Society (tel. 020 7833 2299, http://www.nas.org.uk). www.autism99.org SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 1999 2 ISSN (online) 2045-6174 www.speechmag.com
In better voice Voice therapy is included in an extended specialist service aimed at getting performing artists back to work more quickly. The British Performing Arts Medicine Trust provides free clinics in London and Manchester for performance related injury and illness. Osteopathy, the Alexander Technique and counselling are also available. Details: tel. 020 7240 3331, e-mail bpampt@dial.pipex.com Training expanded The national educational charity for children with speech and language difficulties is expanding its training programme. I CAN hopes its training centre's move to a London base combined with provision of courses in more locations in England will make its courses more widely accessible to a range of health and education professionals. To support this, speech and language therapist Fiona McMahon has been appointed as Training and Information Manager. New courses include detection and treatment of oragmatic language impairment and the role of speech and language therapy in multiprofessional assessment and special educational needs tribunals. Meanwhile, I CAN's Dawn House School has been praised in an Ofsted inspection, with the successful ' eamwork between teachers, classroom support assistants and speech and language therapists get ting special mention. Details: I CAN tel. 08700107088. Advocaqt volunteers SIGNALONG is looking for volunteers to help with t he testing stage of its self advocacy project. With initial funding through a Department of Health grant, the group aims to cover signs for body awareness, emotional developmental, self advocacy and citizenship, coping with bereavement, coping with violence and crime and possibly general health. Details: 01634 832469. Child stroke A study is to investigate the number of children in t he UK who suffer strokes. The year long Stroke Association funded project will also determine how the children are investigated and managed and the problems faced by survivors. The Association has welcomed the development of a communication system for Sarah Chandler, unable to speak after two severe strokes at the age of six and seven . BT worked with the Oxford ACE Centre to bring together a variety of components including t he Laureate speech synthesiser, an Internet service and a high speed network link. The technology has been licensed to her school and could therefore be developed for use by others. The Stroke Association, tel. 0171 5660300. Avril Nicoll, Editor 33 Kinnear Square Laurencekirk AB30 1 UL tel/ansa/fax 01561 377415 e-mail avnlnicoll@speechmag.com ... comment. .. Respect . costs nothing A simple dictionary definition of respect is 'treat with consideraton'_ Jan Roach's experience leads her to ask what sort of models for gooo communication are we if we can't start our relationships with cl ient; a position of respect? We know this is far from easy, as people and their experiences are so diverse.. Two elements of the Ethical Grid, cited by Jois Stansfield and Christine Hobden, specify respect - 'respect persons equally' and 'respect autonomy. Using an approach grounded in ethics gives an added perspective to decisi o making. Not only can it increase your confidence in what you are doing and guide you in making it explicit, it can help identify opportunities for compromise and working together with parents, carers and other disciplines with whom you may have little in common. Respect means recognising and responding to different needs. Chris Code and colleagues found out what the participants in a carers' day hoped to gain, planned the day accordingly and measured how far it had met expectations. We need to be in the habit of routinely checking what people want from us at least then we can be open with them about what we can actually provide. We have to make an effort to get on the same wavelength as the people we work with; as Audrey Richardson says, 'street cred' matters when it comes te communicating with her adolescent groups. Fear of the new or challenging puts up barriers to respect . In sharing their experience of working with bilingual clients and families, Jane Stokes, Rita Thakaria and Christine MacLeod inspire readers to approach such clients { an open mind and honesty. Although resource constraints make a nonsense of 'equity of service', we can at least offer equity of respect. Like adults with learning disabilities, many of our clients have huge gaps . their understanding of self now, self in the past and future self. For speech and language therapists wary of venturing too far into potentially 'emotional' territory, Lucie Hamilton and Karen McKenzie's life story " serves to remind us of the support offered by multidisciplinary starts from a position of respect. Lack of funding for equipment and service development is a real challenge. While addressing this, we mustn' t forget the most ',,..,,.,..-= resources such as respect cost nothing and have a high ra:e of re, IL SPEECH & LANGUAGE THERAPY IN PRACT1C.E ER 99'l 3 ISSN (online) 2045-6174 www.speechmag.com
II Life story work offers individuals with a learning disability the opportunity to review both the positive and negative aspects of their lives, in a format that allows them to take control over those aspects which they wish to share, reflect upon and discuss. Following a joint group, Lucie Hamilton, speech and language therapist, and Karen McKenzie, clinical psychologist, share their thoughts on the advantages and limitations of this approach. t has been suggested that the need to review one's life is universal and required to help the person reach a sense of completeness about what has been achieved (Butler, 1963). A number of techniques have been used to try and meet these needs in different client groups, including reminiscent work and life reviews with older adults (Butler, )963) and life story work. The latter arose from work with chil dren who had been in long-term or foster care, with the aim of helping them make sense of their disrupted past (Hussain & Raczka, 1997). More recently, life story work has been introduced to individuals with a learning disability. Previous researchers have reported on the use of this approach with individuals who live in hospital who are in transition from institutions to commu nity residential homes (Hussain & Raczka, 1997; Hewitt et ai, 1997). This work notes that most of the information available about clients from these settings arises from clinical reports in casenotes and may be sparse or irrelevant. As many clients with a learning disability have communication dif ficulties (Department of Health, 1995) and cogni tive impairments which may lead to difficulties with memory and sequencing, it may be hard for them both to link their past to the present and to communicate it to others. These communication difficulties impact on a number of levels. There has been increasing recognition that individuals with learning disabil ities may have greater difficulties than non dis abled people in recognising and identifying emo tional states in themselves and others (Moffat et SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 1999 4 ISSN (online) 2045-6174 www.speechmag.com team working ai, 1995; Rojahn et ai, 1995). The recognition and professionals and group members involved. expression of feelings associated with past events Each professional had different roles within the may pose additional group. The clinical psy chologist's was to ensure , .. individuals with the group was emotion events outwith the ally therapeutic and to " here and now" may learning disabilities may monitor the emotional also present problems impact on the individu (Bradshaw, 199B). Such als within the group. have greater difficulties than difficulties have been The speech and lan linked with the expres guage therapist's role sion of challenging was to ensure each non disabled people in behaviours (Moffat et group member could ai, 1995). There has understand and respond recognising and therefore been an to what was being dis increasing recognition cussed and to graphical of the importance of identifying emotional states ly record discussions. the emotional aspect of Both professionals were the lives of individuals in themselves and others able to monitor and sup with a learning disabili ty (Gardner, 1997). Stories have been identified as offering a thera peutic medium to explore emotional themes (Dwivedi, 1997) as well as a way for individuals to make sense of their history (Hewitt et ai, 1997). Life story work therefore offers a means of allow ;ng clients to make sense of their past to record information which is personally relevant to them and explore feelings that this brings (Atkinson & Williams, 1990). Filling the gaps Our life story work with clients who live in com munity settings arose from the realisation that these people had the same difficulty of making sense of their past as has been reported about individuals who have lived in hospitals (Hewitt et ai, 1997). The aims for the group were to allow the participants to explore issues relating to their past in a safe environment, to record their experi ences in a form that would enable them to com municate them to others and to provide an oppor :unity for group members to look at the similari ties and differences in their life experiences. In addition, it was also hoped to identify if individu als had gaps in their memory or information about periods in their life and, if so, that these could be at least acknowledged and hopefully filled. The group was run weekly by a speech and lan guage therapist and a clinical psychologist. Working jointly was beneficial for both of the professionals involved and the group members. We hear we should be working with other pro fessionals but rarely how people go about doing it. Our starting point for this group was to acknowledge each other's different backgrounds and training and to identify areas of different knowledge / skills and of overlap. We had regu lar planning and review meetings for the group; initially for long-term planning and then short term deciding what to do before each session and "how it went" after each session . These meet ings were extremely important to ensure there was continuity and development for both the port each other within the group. Speech and language therapists may inadvertently come across emotional issues with clients which they are unprepared / not trained to address, particu larly in such a group where issues from the past may come up. Therefore, it was important to have a clinical psychologist present who was trained to take on a counselling role. From the clinical psychologist's point of view, the speech and language therapist was important to ensure that the members understood what was being said and were able to express themselves, partic ularly to communicate their feelings - a require ment for any "emotional therapy" . Predictable and safe Each session was run for one hour and had a sim ilar structure with the aim of creating a pre dictable and safe environment (Hussain & Raczka, 1997). The members were welcomed and the ini tial group rules were developed. These included confidentiality, listening to others and turn-tak ing. The group members were reminded of these rules at subsequent sessions. They were then asked to mark how they were feeling on a visual analogue scale which ranged from "good" through "OK" to "bad". This was repeated at the end of each session to give a crude measure of the impact of the group on the members. The group were reminded of the last session's topic to help aid memory and to enable continu ity of the work before the current topic was intro duced. Individuals could either work on their own with support or in the group setting, but everyone would return to the main group to dis cuss the results of their work and compare their own experiences. All the individuals had communication and mem ory difficulties and, as a result, each aspect of the group work was supplemented with symbols, drawings, photographs, pictures chosen from magazines or anything that helped put the indi vidual's story in context for them. Each new topic was introduced, initially in the form of a question, for example, "What sort of things did you 0 as a child?" Such questions usually produced ve Ii e response so it was necessary to introduce pictu es / objects for discussion to help prompt responses. All responses were recorded. Each individual vas asked to try to draw / wri te down their re5pO/lSe'S with support from the group leaders. One of e group leaders also graphically recorded the main themes of the group disC1.J ssion. Once disrus - os about a particular topic had finished, e " d ual and group records were combined and a e more formal using symbols and t individual an overall record of the gro p_ the record 'formal ' made it possi c group member to share informa 'on J ( cate about what had happened in e 9 gave what they had talked about more stE others (see figure 1). Initially, each piece of work was placed 0 a . _ line. This consisted of a long piece of pc anchored at one end with a photo of - me as a baby" and at the other with a picture of -me now". The group members, however, appea ed to find the presentation of so much information a: one time confusing. The time line was t herefore replaced by a life story book, with a ne age being added at each session and placed in the co' rect sequence to represent that individual's life. Life changes The group covered a variety of topics similar t o those outlined by Hussain and Raczka (199n, However, an emphasis was placed on he life changes associated with the transition from child to being an adult. The themes broadly ranged from birth to childhood, school and family t o ado lescence, friendships and places we have lived and our current life. Group members were a so offered the opportunity to discuss how they lei about each period of their life. While previous authors have acknowledged so -= of the potential disadvantages of life story r including the disruption to the individual's e ' ing concept of their life (Hewitt et ai, 1997), has been little discussion of the problems i ere in this work which result from the individ cognitive and communication difficulti es. A number of themes and difficulties arose d - the life story work, and the ways in hich hE: __ _ ics were approached had to be adapted Of carded to meet the needs of the client5. ticular, it became apparent that t he grot: some difficulty with abstract concepts the concept of time itself. For examp G such as "what did you look like as a became irrelevant until the group ...erE difference between a baby, a child All discussions had to be related to a or picture to make them more meM' keep the participants' attention 'oc Continuous process Some group members also had their memory of their h'st I'f .. SPEECH & LANGUAGE THERAPY IN PRACTICE 5 ISSN (online) 2045-6174 www.speechmag.com team working "* Figure 1 - Examples from a Life Story Book. (Written information has been made less s Things that I did I had as a child ...eacn aspect 01 the group work was supplemented wi th symbols, drawings, photographs, pictures chosen from magazines or anything that helped put the individual's story in context for them. 5 0 + 5 :; 14' , ~ , ~ ~ \:::Y iT<9 . f""
fIT\/1 ~ ~ 19J : ~ : C3 cff ~ Played in the park. I liked the swings best. I once feU Off the roundabout. , Liked going horse riding when I was at school. Used to bake cakes with my mum. Did computers at school. Played the guitar with my mum. Had a pet dog called ___ who was brown. Played cards with my mum. .... of information they'd been given about it. As a result, it was necessary to obtain additional back ground information from family members, key workers and support staff to help fill in these gaps. This information was then brought to the group, discussed and recorded in a form that made it accessible to the participants, that is, a life story book. This also allowed them to view their life as a continuous process, rather than a series of unconnected discrete events. In common with many individuals with a learning disability (Moffat et ai, 1995) the recognition and expression of emotions posed some difficulties for the group members. It was however of interest that sessions felt by the therapist to have been difficult or painful for the group tended to be First went to school in ____, then went to ____ School. My teachers at ____ school were called ____ and . I really liked them. I was a quiet baby and ate loads. Cried a lot and didn't eat much. Liked doing jigsaws and dancing. rated as such by the majority of group members on the analogue scale. Two main themes arose from the group. The first was the need to produce a document that sum marised the individual's life so far and which could be used to link the past with the next stage in the individual's development. This document was therefore not static, but continued to be added to after the group ended. The second theme was of the emotional need of participants. Life story work offered an opportu nity to focus on a particular period of life and explore how it felt at that time. The life story book also offered a way to develop existing rela tionships with others. It gave people a quick and easy way of relating to the participants, as infor mation was laid out in a way that was accessible. The participants could also control how much of this information they wished to share with others, for example only the factual parts about where they lived as a child, or also how they felt about this. The success of the life story work described above did however rely on four main factors: The use of concrete visual examples and reminders of all the topics discussed, that is, every thing was illustrated with a picture, photo, draw ing or symbol the necessity of obtaining detailed information from others to help fill in the gaps in the person's history an awareness that some concepts central to life SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 1999 6 ISSN (online) 2045-6174 www.speechmag.com work..::i'-"ng "-____ ecific to protect identities.) Things I have done I do I would like to do. now. as a grown up... Do the housework at home. I r this year ego dishes. making my bed. I( 11 Watch vldeos. ego Hary Ploy tennis .and squash with : Popplns. Lion King. ;;::=:;:;;;:;::::=:-:-:t1l Aintstones. If :::::::::J. eo! CJ 0 Made a vase. Don1 go fishing. Dressed up as a witch. I wore a pointy hat and a black Sometimes wash staff coat. members' cars. () Don1 do computers. bul Go swimming in ____ .: :: : would like to. or ________ Get my hair cut In with my mum. Do some gardening at home. J.. Go shopping for clothes, music and food. Don't like sometimes take _____'s shopping If It's busy. dogs for a walk. eece Went to hospital when I broke going on trips In the cor. ecce my leg.
story work may be unclear to clients and require clar of Learning Disabilities 26, 6266. from hospital to community based se " . ification or teaching as life story work progresses Butler, R.N. (1963) The Life Review: an interpreta' Journal of Learning Disabilities for Nun = time to obtain information before the group, tion of reminiscences in the aged. Psychiatry 26, Health & Social Care 1(3), 105109. for the group itself, and to help the individuals 368378. Hussain, F. & Raczka, R. (1997) Life Story put the resulting information in a format which is Department of Health (1995) The Health of the People with Learning Disabilities. Bri tish useful \lnd meaningful to them. Nation a strategy for people with learning dis of Learning Disabilities 25, 7376. abilities. HMSO, London. Moffat, c.w., Hanley, M. & Donnell an. Lucie Hamilton is a speech and language therapist Dwivedi, K.N. (Ed) (1997) The Therapeutic Use of Discrimination of Emotion, Affective en and Karen McKenzie a clinical psychologist at Stories. Routledge, London. Taking & Empathy in Individual s \ ' Roodlands Hospital, 9 Hospital Road, Haddington. Gardner, A. (1997) How Do We Stop Doing and Retardation. Education and train ' Start Listening: responding to the emotional retardation and developmental disa References needs of people with learning disabilities. British 7685. Atkinson, D. & Williams, F. (1990) Know Me As I Journal of Learning Disabilities 25, 2629. Am. Hodder & Stoughton, London. Hewitt, c., Branton, J., Dunn, J. & Wil lcocks, A. Bradshaw, J. (1998) Assessing and Intervening in (1997) Life Story Work: issues and applications for the Communication Environment. British Journal learning disabled people undergoing transition SPEECH & LANGUAGE THERAPY IN PRACTICE ';o?S ISSN (online) 2045-6174 www.speechmag.com ' , con ference report
Avril Nicoll went.to fil Information technolo work, provides the data needed to make purse strings listen 8ill Mutch bli eves an aspect of cl inica I governance is managers \ taking stock and defining ) V l a culture which is patient focused and values staff. "The world Is moving very fast and there is an anxiety to 'get it all together'. There are so many problems in work practice - Jane Richardson and others talked about the importance of taking time to reflect and take stock instead of having constant knee jerk reactions. " Jan Roach \ Training - 'a culture of enquiry' He advocates investment in training and enabling access to information to develop staff to their full potential and adopting a 'no blame' approach which lets everyone learn lessons when things don't work out. Gill Edelman points out that there are always gaps in learning, and always new things to find out. The bigger picture Managers are charged with interpret ing and implementing government policy. They need to be aware of 'the bigger picture' . The conference began with discussion of the implications of devolution, and delegates and speak ers were from all over the United Kingdom. The value of the networking opportu nities of a conference are inestimable a chance to step back from everyday work and exchange ideas about man agement with people working to the same agenda but in very different set tings and circumstances. We need to be aware of the influence of developments such as the Internet on the awareness of the general public and make sure we keep working to make our message heard. Pat Oakley offered delegates a strategic view, recognising speech and language therapy as a small service in a period of extreme change. She challenged delegates to take time to reflect and focus on what we are actually trying to do with the profession. "We have to think about how we avoId \ '. \ tokenism in \ staff and I professional development For example, how does a / j study day actually change practice?" Joe Reynolds Kate Malcomess finds 1\ clinicians can identify their own training ) needs when they have / access to a suitable IT system. "We need to work with others and cross barriers - an interchange of ideas. We are enthusiastic about this and would like to do more of it, and are now being actively encouraged to do so by government policy. R Jenny Wood Bill Mutch says we need a massive investmen IT systems. The system in use by Irene Morris' hours of input time wasted and no useful feE van der Gaag slammed the waste of money i However, as Kate Malcomess points out, peol say you cannot measure what you are doing. must be seen as valid and robust by clinicians produce data for change. Her Trust's system ~ clinicians on a daily basis which helps them rE practice, and this bottom-up, continuous refll continuous change, A system t hat recognises that caseload is nc workload, and that there is much complexi Partnership < I CAN, Afasic and the Royal College of Speech & Language Therapists are working on a partnership to offer a one-stop shop infor mation service. Gill Edelman believes partnership is the way forward as exemplified by I CAN's collaboration with many different agencies. SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 1999 8 ISSN (online) 2045-6174 www.speechmag.com conferen ce repoft enee What re evance would the erapy managers' conference have to therapis d out. Acknowledgement Thanks to delegates Lesley Culling, Liz Duff, Hil ary Hood, Beryl Kellow, Joe Reynolds, Jan Roach, Kirsteen Shilson and Jenny Wood for their insig hts. collection systems managers and direct feedback to to find out more about the care aims and care partnerships between patients and carers they engender as I am very enthused by what she said." Lesley Cu lling User involvement Bill Mutch on clinical governance again reminds us about humanity and humility and that self-regulation is a privilege not a right. He asks, are we listening to patients and carers? Sally Byng concurs: if th e user perspective is not included, any 'evidence' is scien t ifically flawed. Her qualitative research found peop e with aphasia suffered from a lack of respect in attitudes of professionals. They ended up disempowered and passivi sed, typified by the statement from one client, " After a time he Ithe therapist) found I was doing alright ." The research also highlighted the need for clients to be given information over and over again about their condition and therapy to make sure they get the opportu nity to hear it at the time they are ready. "/ shared this with all my staff, as it has a wider releva nce than stroke. We have to think, how am I explaining myself, what is th is person's perception of me, have I made myself clear? People felt humiliated by their speech and language therapy experience, which is an awful indictment." Kirsteen Shilson - Irene Morris' group have adopted user involvement to the extent that patients and carers are now an integral part of the selection process for key staff posts. meaningful 11m has been axed lack received. Anna . as 'iniquitous'. don't trust you if you "/t hill taken Kate Ma/eomess five years 'heart and soul' to her system. / want Delegates at the ( dinner were enfi? . Maire-Louise harp and sing; Kirsteen 5hils Do you know your area and Power and Secondment is its culture - the populati0n a useful influence and the economy? Do you approach to "Irene Morris heads up a know who has the power, asks partnership consortia of small services like Irene Morris? Who needs to working and speech and language therapy. be cultivated? Who can help can help bring This is pertinent for me because you effect change? Transitions about the we have just merged with anoth need work. What partners do necessary er Trust and we - speech and you need to be collaborating understanding, language therapy and other with - social work, education, collaboration housing, user groups, volun small services - are working hard and ta ry sector, GPs, private sector, on influencing our new board. " compromise. the public, another Trust? Beryl Kellow SPEECH & LANGUAGE THERAPY IN PRACTICE :: ' :::; 9 ISSN (online) 2045-6174 www.speechmag.com
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ex e a Ions A pilot support scheme in the aphasia field has applications for therapists working with carers of people with any communication difficulty. Chris Code reports. esearch over the years has highlighted the situation of relatives of aphasic people. Every student is familiar with the cliche ' aphasia is a family problem', but we are nevertheless very aware of its truth. There is now clear evidence that carers and relatives of aphasic people can experience significant difficulties with psychologi cal and social adjustment. (For more details, recent accessible reviews of the research literature can be found in Taylor Sarno (1995), Elman and Bernstein Ellis (1999) and Johannsen-Horbach et ai, 1999.) In acknowledgment of this, Action for Dysphasic Adults (ADA) has been concerned to improve and increase the provision of support for the partners, relatives and carers of aphasic people. There is now a useful body of literature on providing various kinds of support groups for the relatives and carers of aphasic people, for example Rice et ai, 1987; Wahrborg & Borenstein, 1989; Hoen et ai, 1997. ADA has developed an approach to provide one-off support days for relatives and carers, with a pilot carers' day taking place in Exeter in February 1999. Framework The support day was designed so it might easily be used as a model or framework around the country by the Regional Development Advisers (RDAs) who make up the professional regional arm of ADA, and other professionals engaged in running carers' support days. We were able to develop some unique and sensitive measures to aid us in our attempts to evaluate the day. These and similar measures may be useful for others engaged in providing support and counselling days for people with communication disorders and their carers. Eight employees of ADA, including five Regional Development Advisers, made up a two-day brain storming workshop at City University, London, facilitated by Carole Pound. Here the group dis cussed and developed the topics and issues they considered should be covered in a day for relatives and carers. This resulted in the development of a range of ideas and materials to incorporate into a resource that could be utilised by facilitators plan ning to run a Carers' day. The workshop partici pants identified the main domains of concern as: i. provision of information; ii. communication I conversation training; iii. emotional support; iv. practical coping strategies. The resulting resource manual, Conversation & Coping, is split into a trainer's manual and a par ticipant's manual, with overhead transparencies and handout masters. It also includes the basic structure and content for three sample days for carers and relatives with a variety of aims: 1. developing confidence in conversation; 2. developing confidence in coping and managing disability; 3. developing confidence in coping with emotion al issues. The manual is also a flexible resource of ideas and materials. ADA decided to run a pilot carers'/rela tives' day before introducing the model more widely, and Exeter was chosen for this. There are a number of ways to decide what to put into a support day of this kind. We could have decided on the basis of our past experience or by reference to published reports on carers' support days. However, although this was to be a 'group' support day, we decided we would attempt to find out what the individual participants felt was impor tant to cover, rather than us professionals deciding the complete contents. We started with our past experience, the ideas we had generated at our workshop and our knowledge of the published materials available, so the broad domains of the day were pre-determined and planned from the perspective of our professional knowledge base. Maximising time Having established the broad topics to cover, an important constraint is the limited time in a work ing day. How could we maximise the four hours or so available to us? We decided to ask the partici 10 SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 1999 ISSN (online) 2045-6174 www.speechmag.com ~ cover story Table 1. Planning questionnaire Table 2. The seven topic areas and the overall percentage that the participants requested the day should cover. Your name: Date: ____ Approximate date of my partner's stroke ___-----,- Topic Percentage Please read the statements on the following page carefully. Coping with Emotions 14.5 Under each statement is aline with the words AGREE and DISAGREE The Nature of Aphasia/Stroke 9.5 at each end. Please place an 'X' on the line nearest the end which Services for My Aphasic Relative 18 you agree with. Community SUpport for Carers 17 For instance, for the statement, "I would like to spend time on the Developing My Own Personal Support 14.5 Carers' Day talking about community support for carers of aphasic Coping 8. Problem Solving 17 people" you might agree just a little and therefore place the 'X' New Roles 8. Responsibilities 9.5 towards the DISAGREE end. On the other hand, you might agree Table 3 . Programme for Exeter Carers' Day with the statement quite a lot You would therefore place your 'X' towards the AGREE end, like this: lOam Introductions DISAGREE__________ --"- X___ .AGREE 10JOam Outline of the Day Stroke and Aphasia and Your Relative. (PARTICIPANTS' CONTRIBUTIONS What is your partner's aphasia Now please read through the statements first and then make your like? The differences between the spouses' aphasia. What happened when he/she had his/her stroke? choices. Effects of brain damage.) llam Identifying Services and Support 1) I would like to spend time on the Carers' Day discussing feelings (PARTICIPANTS IDENTIFYING Services for People with Stroke and Aphasia; Stroke Association I of depression, anger, stress and other emotions, and how to cope Dysphasia Support / Family Support, ADA, Community Groups; Community Help.) with them. 11.45am Identifying Emotions DISAGREE_ ________ _____ ,AGREE (ACTIVITY Feelings' analysis, dealing with anger.) 2) I would like to spend time on the Carers' Day trying to 12 noon Lunch understand more about the nature of aphasia and stroke. l2.4Spm Personal Support DISAGREE,______________,AGREE (ACTIVITIES to identify sources of personal support.) 1.4Spm Identifying and Solving Problems 3) I would like to spend time on the Carers' Day trying to (PARTICIPANTS' ACTIVITY) understand more about the services available for my aphasic partner. 2.1Spm Tea DISAGREE AGREE 2JOpm Partner's Roles and Responsibilities 4) I would like to spend time on the Carers' Day on community (PARTICIPANTS Identifying roles before and after.) support for carers of aphasic people. 3JOpm Close Educate the community OISAGREE_ _____________ ,AGREE (Advocacy, assertiveness, mutual.) 145pm Close 5) I would like to spend time on the Carers' Day on ways to develop my own personal support. DISAGREE _____ ___ ______,AGREE We decided we would attempt to find out what the 6) I would like to spend time on the Carers' Day discussing ways to develop skills in coping and solving problems. DISAGREE_ ____ ________ _ ,AGREE individual participants felt was important to cover, rather 7) I would like to spend time on the Carers' Day discussing than us professionals deciding the complete contents. responsibilities I have taken on which used to be my partner's. DISAGREE AGREE pants how much time they wanted to devote to between the amount of time individuals felt they difficult, if practically possible at all. However, we dJferent topics and devised a questionnaire to would like to spend on a topic, and how impor can directly assess whether we have met the par help us (Table 1). It asked participants to rate, on tant or relevant that topic is to them. The pro ticipants' expectations. Given that we had asked a semantic differential scale, the degree to which gramme planned for the day (Table 3) was based them to contribute to the planning, we devised t hey agreed or disagreed with seven statements very closely on the participants' averaged ratings. another questionnaire, completed at the end of '[Overing a range of topics. Thus, about 17 per cent was devoted to coping the carers' day, to measure if the contents had Potential participants were contacted by letter and problem solving and about 9.5 per cent to met with their expectations. and by phone to establish if they would like to background information on the nature of stroke For the evaluation questionnaire we asked partici attend. A comfortable room was provided free by and aphasia. pants to rate the same seven questions as before, but ~ a m a l o t pic, the operators of The National The day had a main facilitator (Chris Code), a this time each statement was prefaced "From my l ottery, which had parking and easy access. Stroke Counsellor (Jackie Byrne) and two more point of view, we spent enough of the day.. ," thus: ?articipants were nine spouses (seven females and 'neutral' observers. The observers' role was to help 1. From my point of view, we spent enough of the t ,vo males) living in or near Exeter in Devon us evaluate the usefulness of the day. One was day discussing feelings of depression, anger, stress whose aphasic partners ranged from very severe Regional Development Adviser Margaret Conan, a and other emotions, and how to cope with them. Iy to mildly impaired and disabled. Most aphasic speech and language therapist with experience The mean responses for the group are shown in partners had been aphasic for several years with working with Carers National Association, and the Table 4. The overall mean score was 8.3 out of 10, the most recent being 12 months post-onset. other was retired Chief Speech and Language suggesting that overall the day met 83 per cent of We summed the questionnaire responses and Ther apist Janet Howitt, with extensive experience the group's expectations. The lowest mean score t urned them into percentages. We then sectioned of aphasia. They did not sit outside the group, but (7.25 out of 10) was for 'ways to develop my own t he 4 hours 15 minutes available and planned participated in the activities. personal support'. Although this was he lowest. activities that directly reflected their requests it still seems we met 72 per cent of expect ations able 2). This indicates that, for the participants, Success) for this topic. The highest mean was 9.25 for 'dis services for aphasia, community support for carers We wanted to assess the usefulness of the day so cussing feelings of depression, anger, stress and and problem solving were their main concerns. we could improve things for similar days that ADA other emotions, and how to cope with t hem'. Coping with emotions and developing personal or others would run in the future in different Interestingly, despite the fact that \ e actually support were next in importance, ' followed by parts of the country. Deciding if such a day was spent a large proportion of the day discussing Knowledge of the nature of aphasia and stroke 'successful' depends on what the aims were. personal support, and li ttle t ime discussing emo and taking on new roles and responsibilities. Establishing the difference it might have on the tions and how to cope wit h them, it was the par e reasoned there should be a close relationship everyday lives of the participants would be very ticipants' group perception that we did enough ~ SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 1999 11 ISSN (online) 2045-6174 www.speechmag.com cover story .... on the latter but less than enough on the former. (The development of personal support refers to such things as phoning a friend when things get bad, talking t o neighbours / doctor / vicar / family, enjoying 'treats' such as wine or chocolate cake and involvement with a support group.) Agreement Two facili tator/observers independently complet ed the same questionnaire within a couple of days. Their overall averages were very close (7.71 and 7.57) suggesting excellent agreement that the day had been between 76 and 77 per cent suc cessful in meeting their expectations. Both scored 'developing my own personal support' and 'dis cussing ways to develop skills in coping and solv ing problems' as being covered the least satisfac torily. This agrees well with the relatives. What have we learnt for future days of this kind? 1. Participants appeared to get a great deal from the day. Despite the fact that many had husbands and wives who had been aphasic for many years, the day met some of their needs. 2. We provided a great deal of 'paper' informa tion in the way of leaflets, addresses and names and phone numbers of organisations, agencies and individuals who might be useful to them. While we were under no illusions that all or even much of this material would be Re ections: 1. Do I consider read, participants were working in encouraged to keep partnership with the information some where accessible as a the voluntary and resource. private sectors 3. We were struck by when providing the amount of help available in the com services? munity to support car 2. Do I recognise ers and how little some carers' needs for participants knew about the sources of long-term support. We were support? equally impressed by the amount of infor 3. Do I find out mation some partici what people pants already had and want from me were able to share with other group and then check members. that what I 4. We decided before provided met hand on seven impor tant domains that their expectations? could be covered ade quately and usefully in one day. Clearly, a different group, at a different time and in a different place, might have come up with different topics. We would have found it harder to meet expectations if we had decided how much of what to include without consulta ti on wi t h participants. 5. Our method of evaluating the day provided us Table 4: Participant's ratings on how they perceived the content of the day had met their expectations. Topic Percentage Score (Out of to) Coping with Emotions 9.25 The Nature of Aphasia I Stroke 9.12 Services for My Aphasic Relative 8.25 Community Support for Carers 8.0 Developing My Own Personal Support 7.25 Coping & Problem Solving 8.12 New Roles & Responsibilities 8.12 Total 58.1117 =Mean 8.30 (83%) ... despite the fact that we actually spent a large proportion of the day discussing personal support, and little time discussing emotions and how to cope with them, it was the participants' group perception that we did enough on the latter but less than enough on the former. Action for Dysphasic Adults (ADA) is the only British charity concerned solely with improv ing awareness and services for people with aphasia and their partners, relatives and car ers. ADA has been concerned in recent years to increase the number of self-help groups for aphasic people around England, and cur rently there are over 20 such groups with more in the pipeline. There are now six Regional Development Advisers employed on a part-time basis to provide support on a regional basis, covering all of England, as well as parts of South and West Wales. There is also a completely independent ADA in Northern Ireland with similar aims. ADA 1 Royal Street London SEl 7LL tel. 0171 261 9572 http://www.ada-uk.org with some clear information. If we had properly reflected the participants' wishes for the amount of time spent on each topic, we would expect high agreement that the day had met expecta tions. The day appeared to meet 83 per cent of the group's overall expectations. 6. Predetermining the areas to cover reduces the time involved in planning. An alternative and more time consuming procedure would be to ask potential participants to provide topic areas that can be narrowed down into a range which could be included in a day and could involve individual consultation and interview. 7. We felt it was useful to tap not only the rela tives' perceptions on the day but also the p o f ~ sionals' to give us a broader view of its impact. There was a very high level of agreement. 8. Given that the amount of time spent on deve oping personal support fell short byabout 17 cent of participant's expectations, there may 'i . be an unmet need for the development of pr sonal support for the relatives and carers of apha sic people in the group. This is despite the faa that we spent as much time on the topic as the participants appeared to request. Of courSt because we spent time on the topic does no mean we spent quality time on it. The issues mao not have been covered adequately. The mismatc between the participants' ratings suggests per haps we did not. 9. We know that measuring people's perceptions and expectations is a tricky process (CampbeJ 1976), whether we are using interviews or stan. dardised questionnaires. For future relatives' a carers' days of this kind we need to consider carE fully possible mismatches between participants perceptions and expectations. Chris Code is the Research Officer with Action for Dysphasic Adults (ADA). The address for corre spondence is Professor Chris Code, School o Psychology, University of Exeter, Exeter EX4 4QG, tel. 0136383900, e-mail c.f.s.code@exeter.ac.uk. Acknowledgement The initial two day workshop, and the develop ment of the resulting resource manual. Conversation and Coping, was supported by tile Prudential Carer's Initiative. References Conversation & Coping (1999) London: Acti on fOI Dysphasic Adults. Campbell, A. (1976) Subjective measures of we' being. American Psychologist 31, 117-124. Elman, R. & Bernstein-Ellis, M.A. (1999 Psychosocial aspects of group communication treatment: preliminary findings. Seminars in Speech & Language 20, 65-72. Hoen, B., Thelander, M. & Worsley, J. (1997) Improvements in psychological wellbeing of peo ple with aphasia and their families: evaluation of a community based programme. Aphasiology 681-691. Johannsen-Horbach, H., Crone, M. & Wallesch, ( . W. (1999) Group therapy for spouses of aphasic patients. Seminars in Speech & Language 20,73 83. Rice, B., Pauli, A. & Muller, D.J. (1987) An eva lua tion of a social support group for spouses and aphasic adults. Aphasiology 1, 247-256. Taylor Sarno, M. (Ed.) (1995) Aphasia Recovery: Family-Consumer Issues. Special Issue of Topics In Stroke Rehabilitation 2,3, 1-87. Wahrborg, P. and Borenstein, P. (1989) Famil therapy in families with an aphasic member. Aphasiology 3, 93-98. 0 ISSN (online) 2045-6174 www.speechmag.com further readi n g This regular feature aims to provide information about articles in other journals which may be of interest to readers. urther readin The Editor has selected these summaries from a Speech & Language Database compiled by Biomedical Research Indexing. Every article in over rl
thirty journals is abstracted for this database, supplemented by a monthly scan of Medline to pick out relevant articles from others. --,- To subscribe to the Index to Recent Literature on Speech & Language contact Chr istopher Norris, Downe, Baldersby, Thirsk, North Yorkshire 1) Y07 4PP, tel. 01765 640283, fax 01765 640556. Annual rates are Disks (for Windows 95): Institution .90 Individual 60 Printed version: Institution 60 Individual 45. Cheques are payable to Biomedical Research Index; g. S"",MMERING PHONOLOGY Hancock, K., Craig, A., McCready, c., McCaul, A., Costello, D., Campbell, K. and Gilmore, G. Rvachew, S., Rafaat. S. and Martin, M. (1998) (1999) Stimulability, speech perception Two to sixyear controlledtrial stuttering outcomes for children and adolescents. J Speech skills, and the treatment of phonological Lang Hear Res 41(6)124252. disorders. Am J Speech Lang Pathol 8 (1) This research is a long-term follow-up of a previously published, controlled trial on the effectiveness of 3343. three stuttering treatments (intensive smooth speech. parent-home smooth speech, and intensive elec The relationship between stimulability, speech tromyography feedback) for children and adolescents aged 11 to 18 years, who stutter. The previous perception ability, and phonolog ical learning controlled trial showed all three treatments to be effective compared to nontreatment after 12 months. was examined in two descriptive studies. In This paper reports on the treatment effect iveness after an average of four years post -treatment. Results Study 1, the children received nine group demonstrate that treatment gains were maintained in the long term, with rates of stuttering similar to treatment sessions targeting three phonologi the one-year postoutcomes. There were no signifi cal processes using the cycles approach. cant differences among the three treatments in Treatment progress was not observed for long-term effectiveness. This controlled study sub STAFF ATTITUDES sounds that were unstimulable before treat stantiates the claim that the treatments investigat Upton, D. (1999) Clinical effectiveness ment. Given stimulability, treatment progress ed will more than likely have substantiallong-ter and EBP 2: attitudes of healthcare pro was greater for sounds that were well per benefits for the fluency and personality of children fessionals. elin Linguist Phonet 13 (1) 26 ceived before treatment in contrast with who stutter. 30. treatment. In Study 2, the cycles approach was sounds that were poorly perceived before The concepts of evidence-based practice (EBP) modified so that each child received three and clinical effectiveness have become more brief, individual treatment sessions followed important within the NHS in recent years. In by si x group treatment sessions. Each individ order to enable suitable initiatives to be PSYCHIATRY developed and for future policy to be shaped ual session targeted stimulability of target Hoffman, R.E. (1999) New methods and evaluated, it is important that the current sounds. using phonetic placement, and per for studying hallucinated 'voices' in level of attitudes towards and knowledge of ception of target sounds, using the Speech schizophrenia. Acta Psychiatr Scand these concepts are ascertained. This survey Assessment and Interactive Learning System Suppl 395, 8994. recorded the level of knowledge of EBP and (SAILS). In Study 2, good progress was The mechanism of hallucinated speech or clinical effectiveness and examined the atti observed for most target phonemes, including 'voices', a symptom commonly reported by tudes of a sample of 207 podiatrists, speech those that were unstimulable or poorly per schizophrenic patients, is poorly understood. and language therapists, occupational thera ceived before treatment. We have undertaken two types of study -0 pists and physiotherapists towards these con explore the hypothesis that th is symptom aris cepts. Results showed that the participants es from pathologically altered speech percep rated their level of knowledge of evidence HEARING tion networks. The first consists of neural net based practice/clinical effectiveness as poor, work computer simulations of narrati e although they expressed a positive attitude IMPAIRMENT speech perception. We have shown hat " towards the concepts. In part icular, profes these networ ks are partially disconnected Miyamoto, R.T., Kirk, K.I., Svirsky, M.A. and sionals considered themselves to have poor undergo a 'monamine' neuromodul a ory y Sehgal, S.T. (1999) Communication skills in research and information technology skills turbance, ' hallucinated speech' (speech pediatric cochlear implant recipients. Acta and lacked an ability to undertake computer cepts occurring in the absence of p on ::::': Otolaryngol (Stockh) 119 (2) 21924. literature searches. input) are simulated as well as specj c Detailed longitudinal stud ies of speech percep perception impairments. The latta' tion, speech production and language acquisition prompted us to conduct parall el have justified a significant change in the demographics of congenitally and prelingually deaf children actual schizophrenic patients using a who receive cochlear implants. A trend toward earlier cochlear implantation has been justified by speech tracking' (MST) task. 5f r6: 0, improvements in measures assessi ng these areas. To assess the influence of age at implantation on jects to track narrative speec age five years was used as a benchmark. Thirty-one children who received a Nucleus clarity of wh ich is reduced cochlear implant and use the SPEAK speech processing strategy and two children who received a multispeaker 'babble.' Ha Clarion cochlear implant and use the CIS strategy served as subjects. The subjects were divided into strated speech percep -Oli three groups based on age at implantation. The groups comprised children implanted before the age experimentally indlKed 1=- =J of 3 years (n = 14), children implanted between 3 years and 3 years 11 months (n = 11) and those which clearly differe. u2: '!--:1 imp lanted between 4 years and 5 years 3 months (n = 8). The children were further divided according hallucinators a d to whether they used oral or total communication. The earlier-implanted groups demonstrated sta support the h tistical ly significant improvements on measures of speech perception. Improvements in speech intelli ous products gibility as a function of age at implant were seen but did not reach statistical significance. The results networks. of the present study demonstrate that ear ly implantation promotes the acquisition of speaking and listening skills. SPE.ECH & LA.NGUAGE l1fERAPY 13 ISSN (online) 2045-6174 www.speechmag.com assessments assesse Speech &Language Therapy in Practice readers continue to find out if the marketing speak for published assessments and programmes matches the reality. Helpful teaching activities Assessing and Teaching Phonological Knowledge John Munro Australian Council for Educational Research $89.00 (Aust) If you work in an educational setting and have an interest in literacy, Helen Cheal suggests you check out this package. The introduction to this assessment proposes to serve two main purposes: 1) to check children's readiness for particular aspects of reading teaching 2) to understand and diagnose a child's reading difficulty. The author suggests it is applicable for use with children in their first three years of schooling but also for older children to assess the extent of their phonological knowledge. A profile is compiled for each child based on their assessment results, which highlights any areas of difficulty and the manual recommends specific teaching activities to target these. The author states this assessment / teaching package is suitable for teachers and / or 'educational diagnosticians'. It is not therefore designed specifically for use by speech and language therapists. The assessment does not claim to be a definitive test of a child's phonological knowledge and the author recom mends using it alongside other tests of reading abil ity, vocabulary knowledge and language function. The involvement of speech and language thera pists in literacy assessment / teaching is somewhat controversial and depends largely on the policy of individual departments and / or work settings. However, recent research (for example, Stackhouse and Wells, 1997) emphasises the importance of phonological skills for both oral communication and literacy development. When I agreed to pilot this assessment I was work ing in the Junior Department of a Language Unit in addition to a community clinic with a paediatric case load. I decided to use the assessment and teaching activities in the language unit setting as many of the children there had literacy difficulties and I was, therefore, more involved in this area than with most of my community clinic caseload. CASE EXAMPLE: H (chronological age 8;11years) H presents with a phonological disorder with large ly age appropriate language skills. His reading and spelling were approximately at a 6;6 year level. Before I began any assessment with H, I complet ed the accompanying Screening Checklist with his teacher which looks broadly at four areas: oral communication, pronunciation of words, reading aloud and spelling. It was useful to complete this jointly and helped clarify H's strengths and weak nesses. However, some of the questions were rather vague, for example, 'Does the child express ideas in the appropriate way?' There is also a par ent questionnaire which explores factors such as early language development and family history which could be used to accompany a speech and language therapy case history. Difficult to keep attention The actual assessment is divided into five main tasks and includes activities such as the identifica tion of rhyme, alliteration, segmentation of words and manipulation of sounds in words. These are said 'to cover the span of phonological development relevant to early literacy develop ment'. I found the assessment quite time con suming and it was difficult to keep H's interest, even though he has good attention skills and is used to doing therapy / assessment activities. The tasks involve a mixture of auditory and visual stimuli with line drawings and printed letters, words and non-words. All the pictures are verbally labelled by the tester which is just as well, as many are quite obscure, for example, plank, tramp, twist. However, this means it is not possible to assess the full extent of the child's own phonological repre sentations as the tester is always giving the labels. The assessment was useful for highlighting some deficiencies in H's rhyming skills, which I had not been aware of during therapy activities. Although H could detect rhyme easily and produce rhyming words in isolation, he had difficulty generating rhyming words in prose. The teaching section in the manual provided some helpful ideas which I utilised during therapy and discussed with his teacher to incorporate during literacy activities. I also discovered that H's production difficulties with consonant clusters / blends was reflected in his ability to segment words with clusters / blends and read non-words containing them . This did not come as a particular surprise but confirmed my therapy aim to focus on these in more details. H could manipulate words with three sounds quite well, for example, deleting sounds, substituting sounds and blending them, but he began to fail when another sound was added. This was encouraging as we had focused on blending three sound words in therapy for a long period and it appeared to have been successful. It also highlighted that it was now appropriate to move on to four sound words. Although I feel the assessment did provide some useful information, much of this could also have been gained informally. It does not cater fully for a child with a speech sound difficulty as many of the tasks rely on the child producing words / sounds and there are no clear guidelines to testers about how to score the child's speech if it deviates because of an articulatory and / or phonological difficulty. It may be useful to use the assessment alongside the psycholinguistic framework developed by Stackhouse and Wells (1997) to gain a deeper understanding of the child's level of functioning. I am no longer working in the language unit and doubt I will have time to use the assessment in the community clinic. However, I may select some of the assessment tasks and adapt them to my work ing practice. The teaching activities are helpful and I will be able to refer to these for school pro grammes and therapy planning. I would recom mend the package to therapists who work in an intensive educational setting who have a particu lar interest in literacy, but do not feel it is a vital tool for community clinic work. Helen Cheal is a speech and language therapist with Sandwell Healthcare Trust in the West Midlands. 14 SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 1999 ISSN (online) 2045-6174 www.speechmag.com assessments Easy to complete Work Readiness Profile Helga A. H. Rowe Australian Council for Educational Research $70.00 (Aust.) Despite some reservations, Sue Harris recommends this profile designed for use with older adolescents and adults with disabilities. I work in a college of further education with stu dents who have special educational needs (both physical and learning disabilities). Although I am a speech and language therapist, I am employed as a teacher, my speciality being communication. like most people in this field, I am always looking for effective assessments for this cl ient group. The profile comes neatly packaged in a folder and contains a set of answer booklets, individual record forms, group record forms and an instruc ti on manual. Unlike some instruction manuals, this one is not enormous and was easy and quick to read. The information in the first chapter is useful as background to the assessment. The notes on administration were clear and my col leagues - less experienced than myself in the administration of test material - found them sim ple to follow. The administration of the test itself takes only 10 15 minutes. Despite the fact that the author claims it can be self-administered, there were no students at my college who had the reading abil ity needed. However, this assessment is also designed for clients who have physical disabilities where self-administration would be appropriate. My teaching colleagues found it easy to complete on behalf of those students whom they were hop ing to place in work experience. Following com pletion of the answer booklet, the scores are then transferred to an individual record form and an average score for physical and personal effective ness is obtained. Again, this took just a few min utes to carry out. The record form shows an indi vidual's strengths and weaknesses and also those areas which need support and further training . We did not use the group record form as we were looking at students' individual abilities. We found a number of drawbacks: 1. A high level of reading competency is needed for clients to complete the forms themselves. Makes you think The Test of Pretend Play Vicky Lewis and Jill Boucher The Psychological Corporation 312.63 Given the strengths and limitations of this test, Alison Webb believes a checklist of skills with suggestions for suitable materials would have been more useful. The Test of Pretend Play (ToPP) is designed to test th ree different types of symbolic play: substituting' up to four items to represent some thing else attributing an imagined property to an object or person reference to an absent object, person or sub stance . "'herefore it assesses types of play not tackled by other tests. For example, the Test of Symbolic Play lowe and Costello) on Iy tests functional (repre sentational) play. as both a verbal and non-verbal section, plus a useful structured observation sheet. The verbal test, although recommended for three years and over, places heavy demand on comprehension and I would only use it with older children. For example, it asks the child to "make the dolly go down the hill in a sledge into the snow." Bored I had expected the materials to provide a rich lan guage sample. They in fact had the opposite effect, and the children became bored with the materials. They have to interact with the doll for five sub-tests and with the teddy for four. The teddy does not have jointed arms or legs, which made interpreting the distinct movements for scripted play difficult. The section where the child is expected to pretend to be a tree, or cold, made them very self conscious and it would probably be better to assess those skills informally. A five year old autistic boy refused to participate in any of the test, as he dislikes dolls and teddies. The test confirmed my clinical judgement on both the three year olds I used it with: case 1 - three years old, language delay, mainly expressive - ToPP revealed age appropriate play case 2 - three years, four months old with possi ble general developmental delay in addition to 2. It can be difficult to come to conclusions about individuals exhibiting patchy performances; how ever, this would also prove the case when other assessments are used. 3. Given the client group which the assessment is aimed at (learning disabled clients, those who have "other" disabilities and those with multiple disabilities) there is a distinct bias towards those skills suited to manual types of work. At times the instructions mention physically disabled clients without taking into account that their intelli gence is often unaffected and therefore they may be capable of more complex work. 4. The sections relating to physical abil ity have some discrepancies, for example, in the same sec tion picking up a matchbox is equated w ith usi ng modified computer systems. One of the main strengths of the assessment is that it is easy to administer and score. The results usually corresponded with the observations we had made about clients. The assessment can be used to monitor progress. This could be a useful tool when assessing prospective students for entry to college courses. Despite some reservations, I would recommend this as a useful addition to our repertoire. Sue Harris, a speech and language therapist, works as a teacher at Oxford College of Further Education. language delay - ToPP revealed a delay of around one year in pretend play. Would I recommend it' It certainly assesses areas not covered by other tests in a clear, structured way, and the observation sheets are very useful . It made me think about areas of play I normally ignore. It would be useful to clinicians who work with developmentally delayed children, where structured play targets are part of the therapy programme. However, I looked at it with a col league, both of us experienced in work with chil dren, and there are aspects we found difficult ourselves and which we would find hard to explain to a parent or carer. For example, you are required to elicit four 'substitutions', that is, four different things representing other things, yet today so many of the representational toys around are very detailed and do not require the same level of pretence . A checklist of skills with examples of equipment you could use would be more beneficial, as it felt very artificial to try and elicit some of the beha '0 rs. Alison Webb is an independent speech and lan guage therapist in Peterborough. She Ylon the Test of Pretend Play in the Reader Offer of the Spring 99 issue of Speech & Language Therapy in Practice. SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 1999 15 ISSN (online) 2045-6174 www.speechmag.com assessments Thorough, but layout is poor Dysphagia Evaluation Protocol W Avery-Smith, A.B. Rosen, and D. M. Dellarosa From The Psychological Corporation 56.00 While Elsje Prins found this protocol thorough and consistent, existing assessments may be as useful to experienced cltnicians. How many times have we asked fellow clinicians, "What do you use as a bedside assessment? Have you got a formal I informal assessment - and can we borrow it?" Most frequently the answer is "well, we have sort of devised our own." 50, it was quite a novelty to be given the task of reviewing this protocol, consisting of a 43 page manual, a spiral bound pocket manual , and a four-page record form. The authors are all occu pational therapists, thereby reflecting that the assessment, diagnosis, and treatment of dyspha gia is not the sole province of speech and lan guage therapists. The manual consists of four distinct areas: admin istering the protocol; guidelines for initiating, continu ing and halting a dysphagia evaluation; alternative administration of the protocol for confused or non-communicat ive patients; and a section on validity and reliability which includes two case studies comparing the protocol with videofluoroscopy. The pocket manual provides guidelines for bedside assessment. My first criticism is that this American product has not been adapted for use in the UK. American terminology such as 'NPO/PO' or 'manual muscle testing' is used. Weight is measured in pounds rather than kilograms. Squashed My main concern is not so much the content of the protocol but the way the record form is designed. The layout is confusing with little room for recording information. Important informa tion gets squashed together with little room to record additional comments. There is no space Try before you buy , Burns Brief Inventory of Communication and Cognition Martha S. Burns The Psychological Corporation 137.00 Lynne Couzens finds this assessment quick and portable but of limited use. If you are looking for a screening assessment for adults with acquired disorders which is broad ranging and quick to administer, then this may be just what you are looking for. It covers a wide range' of functional skills associated with: left hemisphere (relating to aphasia); right hemi sphere (abstract language, visuo-spatial skills, prosody) and complex neuropathology (memory and attention). It is highly portable, containing everything you need other than pens, paper and a tape recorder. The three inventories can be used independently to determine clients' intervention needs in particular areas. Some sub-sections have 'predictor tasks' - success on these eliminates the need to administer the whole section, very useful when pressed for time. Treatment grids classify skills deficits as severe, moderate (and most likely targets for intervention), and mild. Whilst the author acknowledges that there is no substitute for "knowledge and know how" she provides an excellent rationale for each task and a very useful "goal bank" to be used as a guide, if needed, when setting functional goals. What is it like to admini ster? Just as it claims, it is 'brief'. The stimulus pictures and words are clear ly drawn in black and white and you won't be searching for mislaid objects as you don't require any. The scoring system is simple, there are sepa rate record booklets for each inventory, each with a very clear treatment grid. The addition of sub tests for memory, attention and visuo-perception extends the appropriateness of the assessment to those clients presenting with closed head injury or early dementing disease processes. Disappointing On the negative side, those looking for a cogni tive neuropsychological approach will not find it here. The language sub-tests on the left hemi sphere inventory are disappointing. Some of the sub-tests require customising for use in this coun try and will therefore lose validity (unless of course your clients eat 'grits' for breakfast or reg ularly visit the 'movies' - particularly if starring Lucille Ball) . Some may find the 'functional goal for a medical history or information on the results of procedures such as a or MRI scans. Having canvassed some colleagues and invited them to try out the protocol, their replies were similar to my own views: good to see that cervical auscultation is used, but the jury is still out on its effectiveness . useful for a thorough examination with space for a summary and advice that can be passed on in written form . .. useful for clinicians new to dysphagia. helpful for training purposes. usefu l for the private sector as it provides con sistent documentation. pity about the forms. The protocol does have a positive value in that it is thorough and will remind the clinician to be consistent in the assessment of dysphagia. As a training tool, it can have a role to play. It is a pity that not more thought has gone into the design of a user-friendly record form. I am not sure that an experienced clinician on acute wards will find the protocol any more useful than the one s/he has already designed or pinched from colleagues. Elsje Prins is a speech and language therapist at Harrogate District Hospital. bank' useful; others may feel the inventories sim ply direct more in-depth assessment. Would we buy this assessment? We tried it with clients in long-stay rehabilitation following trau matic brain injury - the complex neuropathology inventory is standardised for thi s client group and did not find it particularly useful in this set ting. However, those new to this area or working in more acute settings may find it useful. Colleagues working with adults with early dementing diseases such as Alzheimers were very interested in trying out the inventories, particu larly those who had limited access to psychologi cal reports. Our recommendation 7 1t is well worth looking at, but borrow it if you can before you think about buying it. Lynne Couzens is a speech and language therapist at the National Centre for Brain Injury Rehabilitation at St Andrew's Hospital in Northampton. Orders for The Psychological Corporation on tel. 0181 308 5750 and the Australian Council for Educational Research at http://www.acer.edu.au. tel. (03) 9277 5651. Under the spotlight in the future issues are the Hearing Attitudes in Rehabilitation Questionnaire, PETAL, Phonological Abilities Test, Clicker 3 and Earobics. 16 SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 1999 ISSN (online) 2045-6174 www.speechmag.com ethics
ose I 0'5 ri t? thics is concerned with the funda mental principles, norms or val ues which lie behind particular moral judgements (Campbell and Higgs, 1982). Four major princi ples of health ethics are outlined by Beauchamp and Childress (1994): autonomy: deliberated self-rule, or the ability of the individual to make choices; beneficence: working for the benefit of th e individual; non-maleficence: doing no harm; justice: a moral obligation to act on a fair adjudication between conflicting claims. The Code of Ethics presented by the Royal College of Speech and Language Therapists (RCSLT) in Communicating Quality 2 (1996) i s based in social conventions about accept able behaviour and what conduct is claimed to be good or bad, right or wrong, in accor dance with the principles of health care ethics as shown above. There is, however, f requently a tension between these basic principles when they come to be applied in practice and a number of authors have developed protocols to help health care pro f essionals consider all aspects of their ethical decision-making in clinical situations. One of the best known of these is the Ethical (5eedhouse) Grid (Seed house and Lovett, 1992). The grid divides decision-making into four levels: health care principles (inner, blue, level), the duties of the health worker (second, red, level) the nature of the outcome to be achieved (third, green, level) relevant practical features (outer, black, level). Into these levels are embedded boxes which draw attention to particular areas for consideration (see figure 1). The aim of using the grid is to select the box or boxes which best solve the problem at hand. The use of the grid is exemplified in consid ering work with Jack, a child with cerebral palsy. Great deal of therapy Jad< is a 10-year-old boy with spastic quadripleg tao He attends a special school in Scotland and his Jack is a 10 year old boy with cerebral palsy. His parents and his speech and language therapist have very different opinions on how his therapy should be delivered, as does Jack himself. Can an ethical perspective help them come to an agreement? Jois Stansfield and Christine Hobden find out. Record of Needs specifies physiotherapy, occupa tional therapy and speech and language therapy as being required . Jack's speech is severely dysarthric and his language comprehension varies depending upon his physical health, the commu nicative environment and the assessment used, but it is estimated to be around a si x year level. Jack has had a great deal of therapy over the years and has been provided with a TouchTalker, although he is not keen to use this, preferring to use vocal communication. Jack's parents are very anxious that he receives daily individual speech and language therapy input from the therapist, and the school is purchasing sufficient time for this to be a possibility. Jack himself is uncoopera tive in individual therapy sessions and his speech and language therapist believes he requires a complete break from regular direct work, fol lowed by a period of group work to encour age functional use of the TouchTalker. In considering her actions from an ethical per spective, Jack's speech and language therapist found the following elements of t he Seedhouse Ethical grid helpful: 1. Blue: respect autonomy 2. Red : do most positive good 3. Green : most positive outcome for self 4. B lack: wishes of others 1. Principle: autonomy Jack's ability to chose freely what he wants to do is compromised by his physical disability and his limited cognition and communicative skills. Competence can be seen as the ability to understand information, make a jUdgement, intend a certain outcome and communicate the wish (Beauchamp and Childress, 1994). Jack is restricted in the ability to communicate his wishes, but may not anyway be competent to make informed decisions. Parental consent would normally be required for therapy, so autonomy needs to be balanced against the child's best interest (Lefton-Greif and Arvedson, 1997). As a child with a cognitive impairment, Jack himself has not ever been asked to give con sent for therapy, so his autonomy has not been taken into account formally, although his par ents are not only giving consent but requesting a particular form of intervention. He is clearly with drawing cooperation, although he has not got the physical ability to carry out his wish to avoid therapy as he is non-ambulant and cannot physi cally refuse to attend. Assuming that therapy which parents request is available and appropri ate, difficulties arise when the child refuses to cooperate in therapy. 2. Principle: beneficence The best way to enable Jack to develop his co munication skills is in dispute. Beneficence is the principle of enhanc' 9 e \ el fare of the child by doing good. I Jack' s case, 'good' is seen by his parents as t e provision of a particular style and amount of int erventi on. Parents often have to invest a great deal of energy ~ SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 1999 17 ISSN (online) 2045-6174 www.speechmag.com ethics .... before they get t he services they want to( their children, often feeling that ' all is not well' long before any profes sional is concerned. A Record (or Stat ement) of Needs, once established, I ~ the mi nimum standard against parents can measure service provision and they are unsurprisingly ery protective of its contents. The speech and language therapist's j udgement is that Jack will not cur rentl y benefit from the type of inter vention requested by parents. At some points, intervention with a child with learning difficulties can involve their environment being made more conducive to communica tion and there being support from carers, rather than direct work. Dilemmas occur when there is con flict between the parent's choice and professional judgement, and the speech and language therapist has to make decisions about how to address the parents' concerns while maintain ing a principled decision about intervention which does most positive good, in addition achieving the best personal outcome as seen in the grid. 3. Principle: nonmaleficence Jack himself is making it clear by his behaviour Re ections: 1. Do I make use of ethical models and clinical guidelines when reaching decisions on client management? 2. Do I seek to balance profeSSi onal judgement and parental I client choice? 3. Do I have an awareness of my own moral values and the influence they have on clinical decisions and outcomes? that the current type of speech and lan guage therapy input is not to his liking. In itself this is not a rea son for curtailing therapy: changes in the style of input could enable the therapist to continue individual work. However, it may in fact be counter-pro ductive to force a par ticular style of inter vention upon the child in these circum stances. There may be a discrepancy between the thera pist's or parents' judgement of benefi cence and non-malef icence. Should Jack become completely resistant to speech and language thera py, his attitude to speech and language therapy and to com munication in general could become nega tive, thus producing a red level green level blue level Assuming that therapy which parents request is available and appropriate, difficulties arise when the child refuses to cooperate in therapy. harmful outcome. On the other hand, Jack's par ents are considering the therapist's advice as being potentially harmful to Jack and thus in itself unethical. 4. Principle: justice In moral reasoning we should serve the needs of the client before the wants. Consideration of the availability of resources occurs in the last level of the Grid. Resources can affect who is taken on for therapy and when children are discharged. At times the intervention programme that a therapist wishes to use may create conflict because the resources are not available to do what the therapist sees as 'best' for the child. The RCSLT Bulletin (1999) sug gests that services to pupils with special education needs are being skewed towards the children of articulate or influential parents. Sometimes it is easier to cite lack of resources than to risk con frontation by saying that intensive intervention is, from the speech and language therapist's point of view, clinically undesirable. It is, however, impor tant for the speech and language therapist to tell the truth as she sees it and be prepared to justify that decision. Potential for conflict In this case, there is sufficient funding to allow for the best type of input to meet Jack's needs, but his parents and his speech and language therapist have dif ferent perceptions of what the best type of intervention is. Here, therefore, there is potential for conflict between parents and professionals when the parents wish their child to receive more treat ment. The parents may feel that this should be part of the child's rights, and withholding such therapy is contrary to the just needs of the child. The thera pist, in disagreeing, does not see this as an issue of j ustice but of clinical need. Once she had addressed the various ethical issues brought to the surface by the parents' request for daily individual intervention, the therapist turned to the RCSLT code of ethics. Here her actions were guided by recommenda tions on professional conduct and responsibility towards clients. a. Professional conduct: abstain from unnecessary therapy She decided that she should abstain from unnec essary therapy, but that, to do so, she had to jus tify clearly why she considered individual daily therapy to be unnecessary and what was a desir able alternative. She was able to use the Communicating Quality guidelines on working with cerebral palsy (RCSLT, 1996 ppI00-105) to demonstrate that indirect classroom based work could be valuable and effective in promoting communication and, in fulfilling the requirements of the Record of Needs, could still be considered to be speech and language therapy intervention. b. Responsibility towards clients: respect the needs and opinions of the client ensure wellbeing of the client keep clients informed The speech and language therapist found this a rather more difficult area to address. It was hard to decide whether Jack was resisting speech and lan guage therapy input because he was frustrated, dis tressed, afraid of failure, bored, unhappy about leaving his class, or for some other reason. He clear ly still had a communication disability and there was no question that he had a long term need for inter vention. While Jack's parents were not actually the clients, their needs and opinions are also very much part of what the therapist needed to consider. Eventually, she decided to video her work with Jack in individual sessions and the direct and indi rect work on communication skills in the class room as a focus for discussion with the parents. She sent the videos home and then arranged a date to view and discuss them with Jack's parents in his home. Jack's parents suggested a number of reasons for his resistance, in particular the thera pist's pacing of sessions and the noise outside the room. They, in turn, were able to appreciate the 18 SPHCH & LANGUAGE THERAPY IN PRACTICE WINTER 1999 ISSN (online) 2045-6174 www.speechmag.com .'f ethics value of the classroom based work being carried out by the teacher and classroom assistant to pro mote Jack's abilities to communicate with chil dren and adults within the school. Agreement The outcome of this case was that Jack's parents accepted the need for group work rather than individual during the coming school term, but requested that he be seen at home over the sum mer holidays so they could be more involved in his therapy and contribute to the therapist's aware ness of Jack's strengths as well as his needs. It was agreed that the therapist would visit once weekly for five weeks. They also requested that individ ual therapy in school would be reintroduced after the summer. It was agreed that, in the new school year, Jack would have a term of once weekly indi vidual therapy, followed by two terms of group work, with clearly defined objectives which corre sponded with his individual education plan. After seeing the classroom videos Jack's parents also initiated an after-school link with the local primary and secondary schools, in collaboration with the school and other parents, to encourage communi cation with children from the local community. This has met once a week throughout the summer term. Different dilemmas Applying ethical principles is not easy even when using guidance from the Ethical grid or the RCSLT code of ethics. In discussing ethical issues it is important to note that Jack's case may present different ethical dilemmas for different thera pists. Each of us has a value system which is influ enced by personal life experiences, education, religion and / or culture. Moral values underpin all ethical decision-making and the ethical decisi ons made will influence the outcome of each case. Jois Stansfield is a senior lecturer and Christine Hobden a recent graduate from the Department of Speech and Language Sciences, Queen Margaret University College, Edinburgh. References Beauchamp, T.L. and Childress, J.F. (1994) Principles of Biomedical Ethics. Oxford: Oxford University Press. Campbell, A.v. and Higgs, R. (1982) In That Case. Medical Ethics in Everyday Practice. London: Darton, Longman and Todd. Lefton-Greif, MA and Arvedson, J.e. (1997) Ethical Considerations in Paediatric Dysphagia. Seminars tn Speech and Language 18(1), 79-87. Seed house, D. & Lovett, L. (1992) Practical medical ethics. Chichester: John Wiley. RCSLT (1996) Communicating Quality 2. London: The Royal College of Speech and Language Therapists. RCSLT (1999) SEN tribunal appeals rise. RCSLT Bulletin 565, 1-2. Resources The TouchTalker is available from Liberator Ltd, Whitegates, Swinstead, NG33 4PA. D r-------------------------------- - and cus e-mail avrilnicoll @speem -, Macintosh PI 5 Cambridge Adaptive Communication, Do Win Boardmaker Do you need quick and easy access to a wide range of picture material? Then this offer is for you! Speech & Language Therapy in Practice has a copy of Boardmaker software to give away FREE to a lucky subscriber. courtesy of the Mayer-Johnson Co. Boardmaker is a graphics database containing over 3000 Picture Communication Symbols. you to make communication boards - with or without text accompanying the symbol tomised therapy worksheets. You control the size, shape, content and layout. It normally ret ail s at 239 and the package includes a manual and an explanatory video. To enter, simply send your name and subscriber number / address marked 'Board maker' to Avril Nicoll, 33 Kinnear Square, Laurencekirk AB30 1UL, tel. 01561 377415, mag.com by 15th January, 2000. The winner will be drawn randomly from all valid entries and be required to review Boardmaker for Speech & Language Therapy in Practice. Boardmaker is available in Windows (3.1. or above) or Mac (System 7 and greater) format. You will need 4megs of RAM and 14 (22 for Mac) megs of hard disk space. The Mayer-Johnson company produces a range of augmentative communication products (PO Box 1579, Solana Beach, CA 92075-7579, USA, e-mail mayerj@mayer-johnson.com, http://www.mayer johnson. com). Software distributors in the UK are Johnston Special Needs Ltd, Inclusive Technology and SEMERC. Competition rules: 1. Entrants must subscribe personally or as one of a department to Speech & Language Therapy in Practice, and only one entry per subscriber number is allowed. 2. Entries must be received by the editor on or before 15th January, 2000. 3. The winner will be randomly selected from all valid entries. 4. The winner will be notified by 22nd January, 2000. 5. The winner will provide a review of Boardmaker rM by a date agreed with the editor. 6. The winner will have access at work to suitable computer hardware. r - ~ - - - - - - - - - - - - - - - - ~ - - ~ ~ - - - - ~ - - - - I Winslow winners I The winner of the Autumn 99 reader offer of 400 worth of Winslow resources for work I ing with the elderly is Corinne Garvie in Cambridge - happy reading! : Barbara Birrane and Patricia Gillivan-Murphy each win runners up prizes of 5 vouchen for use against any product In the Winslow catalogue. http://www.speechm See the 'open f orum Jean McGowan's repa O(l her voice talk to soeech a language therapist> Cyprus. "My comment5 o ~ :re" patient Jiving a /OrTE experiencing VOIC!" P " ? fol/owmg periods c- ~ ~ , = ".it - .: = SPEECH & LANGUAGE THERAPY CT1CE ISSN (online) 2045-6174 www.speechmag.com an f o Promoting Mobility for People with Dementia Rosemary Oddy Age Concern ISBN 0-86242-242-6 The focus of this book's Unfortunately nowhere does it mention speech and language therapists, although it does address certain communication issues and there are many snippets of advice of value to speech and language therapists. approach to problems. For example why might someone who is normally co-oper ative become aggressive) She lists possible reasons, obvious when you read them, reviews eVlews but not reIevant_ _ 1 Tracheotomy - Airway management, Communication and Swallowing to students
Myers, Johnson, Murry
Singular remlnuer I Assessment in Speech and ISBN 1-56593-990-5 57.50 language Pathology Care for Caring Parents - A This book takes a strong medical/surgical approach to tracheotomy management, (course book and CD ROM) program for parents of and contains only two chapters relating to communication and swallowing. These Kenneth G. Shipley and children with special needs are well written by experienced cl inicians and usefully illustrated by case studies. Julie G. McAfee leader's manual - parent's book and Although it contains interesting chapters on specialist client groups such as sleep Singular Cynthia and Noel Schultz apnoea, HIV, burns and paediatrics, it does not address issues relevant to head and ISBN 1-56593-870-4 34.00 Australian Council for neck cancer in any detail and provides very little information on different methods of respiratory support . The book is relatively easy to read, but several chapters may This is a full and comprehensive not be relevant to the everyday clinical situation. It is suitable for therapists begin account of assessment of Educational Research ning to practise in this field and as such provides a good source of background ISBN 0 86431 2202 I language, phonology, fluency, voice information. However, considering the cost, therapists may be better directed to 0864312199 and resonance, neurologically other texts that have a more clinical focus. $16.95 1$75.00 (Aust) based disorders, Annette Zuydam is a speech and language therapist at the University Hospital, Th is nine session group dysphagia, AAC, laryngectomy Aintree. programme addresses the and hearing. It gives detailed emotional needs of families chapters on evaluation of clinical .J parenting a child with a information and report writing. disability. ar;lY,sn ppets It is good value for money and The Leader's manual contains is most suited to students or a aavlce theory, including their library. Assessment sheets can "model for living" - based on be photocopied. Pre-assessment affective-cog n itive-behaviou ra I information is well described theory within a family systems 14.99 and includes medical conditions orientation practical examples and exercises is on mobility. and syndromes associated with group principles and leader communication disorders. The qualities book is easy to read and all outlines of each session. The author has a common sense medical terms are explained. The Parent's companion book References are both to texts contains and to the internet. There is and suggests appropriate action . a summary of issues covered an accompanying CD-ROM . If It is clearly presented, each chapter having key points and training exercises. It is exercises to apply the theory. you are stuck on a desert easy and quick to read and reference, providing much which can be applied to The books are very easy to island and need a text book, both hospital and community settings by therapists, nurses and carers of all sorts, read and enjoyable. The focus this is the one to take as it is with varying levels of experience. is on the parent, not the child so detailed. Although not essential reading for speech and language therapists, it is a very prac or disability. Reading them Ann Gosman is a speech and tical book which should be available to every appropriate multi-disciplinary team . was an evocative reminder of language therapist with Mrs SJ Stevens is head of speech and language therapy at Hammersmith Hospital the context in which speech in London. Orkney Health Board. and language therapists and other agencies provide input. The skills and theoretical VISUAL PERCEPTION Easily photocopied knowledge required by the leaders and the premise Early Visual Skills Diana Williams Winslow behind the programme make it most likely to be run by a ISBN 0 86388 1874 33.45 "counsellor or psychologist. As in the style of other books in the "Early" developmental skills series, Diana Williams has produced a practical However, a suitably manual of use to both student and experienced clinician . experienced and skilled Each section is prefaced with a very brief theoretical introduction ranging from early visual attention through per speech and language ception and visual memory to visual skills in the school curriculum, but the focus of the manual provides a wide therapist may want to lead or range of practical and fun activities. co-lead it. The final section concludes with an excellent quick reference of visual resources. Although initially appearing visu Fiona Soutar is a specialist ally less attractive and robust than the previous books in the series, the paperback volume is easier to photocopy speech and language and the black and white pages can be reproduced to a high quality for parents or carers. therapist for the Islington A useful addition to the clinic, children's centre or school. Child Development Team. Catherine Porter is a paediatric special needs speech and language therapist with York NHS Trust. 20 SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 1999 ISSN (online) 2045-6174 www.speechmag.com reviews reviews Comprehensive Management of Swallowing Disorders State of the art More;l- I t--J ease. Manual of Dysphagia Assessment Carrau & 1. Murray in Adults Singular Joseph Murray ISBN 1565939557 99.00 5ingular The diversity of topics in these 55 chapters by expert clinicians is a reflection of ISBN 1565938712 the complex web that is dysphagia. Assessment and diagnostic procedures are discussed by seven disciplines from each perspective and, while this may cause some overlap, it shows dysphagia is best man aged within a truly interdisciplinary team. Much needed documentation on such topics as the effects of medication, radio- and chemotherapy, tracheotomy and intubation, laryngectomy, cervical spine surgery and 5 ull base surgery is provided. Non-surgical treatments such as diet modifi cation, ther apeutic strategies, dental prosthetics, and tracheostomy related dysphagia disorders are discussed as are surgical interventions. Specific populations such as paediatrics, the elderly, the critically-ill patient and management of the terminally ill patient are covered, closing with patients with Each topic is covered in detail chronic aspiration pneumonia. with evaluation as well as descrip Each chapter comes fully referenced and provides a starting point for tion of techniques where appropri research . An invaluable resource for clinicians new to the field and ate. The text is easy to read although experienced clinicians who want to update their knowledge, as an undergraduate I would have refresh their memory, or consult the current state of the art. struggled with some of the terminology. Elsje Prins is a speech and language therapist at There is a good index and excellent use of Harrogate District Hospital. .1Q=M"" -- A struggle for the non-expert Linguistic Levels in Aphasia Ed. VischBrink and Bastiaanse Singular ISBN 1-56593-8607 54.00 The 25 international contributors, "some of the finest minds in neurolinguistics", attempt to explain the unknown in apha sia. This is a study of brain and language behaviour and the conditions that arise from brain and nervous system damage that can affect human cognition and com munication functions . Looking at aphasia from the point of view of linguistic, psycholinguistic and neu rolinguistic research, there are three main areas of focus: semantics, phonology and syntax. Based on previous research, the studies look at some new aspects of breakdown in information processing. It would be most valuable reading for the expert but a bit of a struggle for the rest. However, there are some therapy sugges tions to stir the innovative mind and pro vide a challenging experience. Because of the elevated price, it should perhaps be purchased by departments, especially those with neuro rehabilitation units. Anais Nassar is a speech and language therapist (acute adult neurosciences) in East London. illustrations. The author only deals briefly with dysphagia assess ment of tracheostomised patients and those with degenera tive disorders. I would be interested to read more of his writing on these topics. The book is reasonably priced and a valuable resource for every adult clinic. The chapters on taking a history and the clinical swal lowing exam will be parti cularly useful to therapists starting their post basic training in dysphagia. I look forward to reading other books in this series. Lisa Cox is a speech and language therapist (adult neurology) at Brighton General Hospital. .____ An invaluable tool Autism A social skills approach for children and adolescents (practical sourcebook) Maureen Aarons and Tessa Gittens Winslow 1998 ISBN 0863882021 27.50 For both experienced and new clini cians working with young peo ple who have autism this will be an invaluable tool. The introduc tion gives an clear overview as to the current understanding of the disorder. The manual then takes one through assessment, setting the scene for intervention at the pre-school, infant, junior and adolescent levels. Each chapter is full of well explained age appropriate activities, resource ideas and guidelines for the running of groups. A useful checklist at the end of each chapter summarises what is required to develop an efficient service. The appendices comprise useful photocopiable letters, record sheets and parent handouts that can be used when running a social skills group. Theresa M. Drake MA reg.MRCSLT is a specialist speech and lan guage therapist with South Buckinghamshire NHS Trust. 35.00 Part of the Dysphagia series edited by John Rosenbek, si x chapters cover case history clinical swallowing exam videofluroscopic exam FEES reporting final thoughts. at BlftII'I"!'Mi bedti me reading Collaborative Brain Injury Intervention Positive Everyday Routines Mark Ylvisaker and Timothy J. Feeney Singular ISBN 1 S6593 . 733 . 3 39.95 This provides comprehensive theoretical and practical guide lines for the assessment and management of cognitive, behavioural, executive system and communication problems following traumatic brain injury in children and adults. The purpose is to provide an approach that is "functional and practical yet consistent with current theory". It contains detail of the epide mology and pathophysiology of traumatic brain injury. The theoretical discussion of cogni1jve. behavioural, executive system and communication problems following brain injury is well presented and would make cl ear reading for students or professionals new to this area. Practical management ide.as were of little value, mainly because the book is aimed at a American audience and e book's illustrative ca se histories have a paediatric bias . Not bedtime reading. it has 0 be read from cover to CD'EJ" as many chapters are i.rrter-re Whilst being intere. I find it heavy going al Would I buy it ? borrow a c.opy. Amanda Forrester is a ... speech and Bamsley. SPEECH & LANGUAGE THERAPY PRAcncE 2 ISSN (online) 2045-6174 www.speechmag.com
Reflecting on her experience in the mental health field, Jan Roach finds everything begins with respect. am lucky to be working in a setting where quality and not quantity is still the key word. The work is exhausting and frustrat ing, and self fulfilment is not easily achieved. But I'm still here and continue to be very interested in the work I do. Venturing into the world of Mental Health was a leap into the dark. It took place eight years ago following a decision to "specialise" and yet hav ing no clear idea what I meant by this. A chance phone call led me to St. Andrew's Hospital, a char itable, medium-secure, psychiatric hospital. So much for being in charge of one's destiny. It is indeed a humbling experience. One of the first outcomes for me was that, at the very least, I could show some respect. I have been questioned on var ious occasio ns how I could possibly respect some one who might have battered a fellow member of staff, or carried out some other atrocious or malev olent deed. Perhaps if I had been the recipient of the battering I might not be delivering this sancti monious message; I am sure it would redirect one's feelings for a considerable time. However, to be able to continue to deliver useful support to the patients, the inner motivation to help must be channelled through the medium of respect. This has been different from all the other speech and language therapy jobs I've had. I have had to learn about what life can really be like for fellow human beings. Such things as aggression directed not only at others, which is bad enough, but also self-directed. The list of self-abuses is endless. One thinks of one's own children when reading case notes about other people's kids who have been abused and humiliated, and scarred physically and mentally for life. Some life, eh? Consistent Our business is communication. What sort of mod els are we if we belittle or ignore vulnerable peo ple? To get beyond the endless effing and blind ing, you have to show a consistent readiness to lis ten, and grab opportunities to move away from the paranoid ramblings. I wonder what it is like to hear voices in your head? Is it anything like listen ing to our inner thoughts? At least they have a semblance of logic and balance to them. Imagine them taking you over. Delivering messages with all sorts of instructions, some of which are decid edly evil. It just gives me a different perspective, and I am aware that I am sometimes competing with these voices during my sessions. So, we begin with 'showing respect. ' I am very conscious that many of the patients have little or no awareness of my approach . Its effect is proba bly shown by the trust that they gradually impart towards me. Sometimes you just run out of ideas. It doesn't matter how many times you share your kind words about self-monitoring - it isn't going to happen. What a complete and utter failure you are. Outcome statistics indicate a nil return. Why should any purchaser pay anything towards your continued presence in this hospital? The only thing is that when they see you, they now smile and acknowledge you and indicate that they are looking forward to their next session with you. They weren't offhand and they weren't inappro priate. That felt good. Do you think they felt some empathy with their fellow (wo)man? But there are as many who do not respond as those that do. If I have achieved at least one thing for each per son I see, that has improved their quality of life, then I don't feel so useless. Respect demands that you listen, something all speech and language therapists do. But I remem ber being told by a young girl that a lot of her problems were caused because no one listened to her description of her problem. She found it diffi cult to understand what people said to her because they seemed to be speaking too quickly. Some training from this department, with sugges tions to her carers, made a radical difference to her behaviour, and she was eventually able to function in a normal environment, knowing how to help herself. Respect needs time and space. I give people time, in an environment that is quiet, comfortable and hopefully relaxing. The wards are frenetic, noisy and often smoky. It isn't always possible to find peace and quiet in their own rooms. When you have serious mental health problems it must be very difficult at times to live with others who have similar problems. Many of the patients are ego centric and are unable to give empathic support . Respect requires confidence - in yourself, your col leagues and your patients. 'Thank you' is very sel 22 SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 1999 ISSN (online) 2045-6174 www.speechmag.com In mJ! experience I dom heard. You will however hear immediately if you have done something wrong. This is the sort of job where you really do need the backup from other members of staff. The multidisciplinary team is often required to help you through fallow periods. All the patients have such complex needs. Not one of us has all the answers. One also has to acknowledge that even if the answers are appar ent, the patients may not wish to avail themselves of the help on offer. For the most part we do the best we can and learn fairly soon on to live with the limitations the various illnesses impose. Safer Danger must be respected. No one can work in this field without paying heed to risk assessment. Any psychiatric patient is potentially dangerous. We organise our clinical environments with the aim of reducing these risks to a minimum. However, my general experience is that, if the patient arrives (that is, the nursing carers consider the patient is at a low risk for unstable outbursts), the tone of a speech and language therapy ses sion is sufficiently positive for the patient to enjoy and hopefully benefit from the activities. When analysed, this mode of consideration of risk to oneself seems a long way from lectures at the Oldrey-Fleming School of Speech Therapy! Media stories suggest that safety is now an issue for many speech and Re ections: language therapists. In a strange way we may be safer in a psychiatric environment where all staff are taught mea sures of self-survival. Respect leads to hon esty and partnership. I always try to give the patient an awareness of their communica tion problem and how this might affect inter actions with other peo ple. Similarly, it helps carers and other mem bers of the multidisci plinary team if they have an awareness of how a communication problem affects some one's life, and how they can change their mode of approach to make communication as effective as possible. The effect of not having to battle so hard to communicate with others can sometimes improve self esteem, which in turn can reduce aggressive outbursts. I look forward to the day when all people who have mental health problems have access to our services if required. After all, it's a matter of respect. Jan Roach is head of speech and language therapy at St. Andrew's Psychiatric Hospital, Northampton. RSOURCES...RSOURCES...RSOURCES...RESOURCES... Health on the Games for small groups Internet Speech and language therapist Judith Thomas has produced A new Internet search a practical language and listening resource book for use . engine aims to classify sites sma II grou ps. containing only 'authorita Targeting a range of non-verbal and verbal communica ' 00 tive' medical information. It skills, the games are suitable for nursery and infant children is intended to help health and for short 'circle time' activities. Judith has also found e professionals keeping up book a useful training tool for helping people create an i IJ with new research and sive environment for children with communication difficu ' 6. patients looking for reliable Language and Listening Games for Small Groups, D.50 i _ medical information. p+p from Devon Learning Resources, 12 Old Mill http://www.medisearch.co.uk Torquay, South Devon TQ2 6AU, tel. 01803605531. (Fu information is on http://www.speechmag.com) Deaf directory Encephalitis An up-to-date directory of Deaf organi An new information pack is aimed at adults sations and services in the UK is aimed affected by encephalitis and their families a at anybody with a personal or profes carers and includes fact sheets on all aspects o sional interest in deafness. the condition. The British Deaf Association consulted Improvements in drug therapy and intensive ca <? with professionals and users of previous treatments have resulted in more people su directories to ensure it is as comprehen ing this illness. Often they are left with 'hidde sive and easy to use as possible. behavioural, cognitive and emotional difficulties_ From: Forest Bookshop, tel. 01594833858, The Encephalitis Support Group is calling for email: more research. dea fbooks@forestbk.demon.co.uk Information pack - 7 from the Encephalitis (22.50 individuals, 35 organisations.) Support Group, tel. 01653699599. MND Information Aphasia handbook The first Library and Information Centre on motor A handbook of information and neurone disease has opened in Scotland. advice for people with aphas'" The service is available to patients and families, and includes issues around rehabilit.r to health and social care professionals. It is run by the tion, social services, employment Scottish Motor Neurone Disease Association from and benefits. their headquarters at 76 Firhill Road, Glasgow G20 The Aphasia Handbook by Susie Pan; 7BA. Carole Pound, Sally Byng and Details: Sandra Wilson, Information Officer/Librarian, Bridget Long is available from tel 0141 945 1077, fax 0141 945 2578, e-mail Ecodistribution, tel. 01509 890068 info@scotmnd.sol.co.uk, www.scotmnd.org.uk for 12.75 including p&p. Tuberous Sclerosis Waste An idea shared A new information leaflet guidelines Registered users of Clicker 3 cor for nurses covers treatment New guidance on com access a growing bank of rea advice, diagnosis and prog plying with environ to-use Clicker grids free a nosis for Tuberous Sclerosis. mental as well as company's Internet site. Symptoms of this genetic dis health and safety legis Ann Crick who will be manag order can include epilepsy lation relating to the Clicker Grids for Learning says and autism, and the leaflet handling, storage, "Many teachers are p odu - ", suggests referral to speech transport and disposal wonderful Clicker res.ou ES :;:: and language and other of clinical waste has use in their classroo therapies may be necessary. been published by the vice will spread good From: Tuberous Sclerosis Health & Safety enable the sharing 0 . . Association, tel. 01527871898, Commission. wi II save teachers .2::. ? e-mail secretary@tuberous' From: HSE Books, tel. time." sclerosis.org 01787881165, 10.50. Details: http://o.vwll _ . SPEECH & LANGUAGE THERAPY IN PRACTIC.E 23 ISSN (online) 2045-6174 www.speechmag.com how I Jane Stokes works as clinical manager speech and language therapy (preschool & community) for Greenwich Healthcare Trust. Rita Thakaria joined the adult speech and language therapy service of Redbridge Health Care I\IHS Trust in the north east of london in 1 996. She is senior specialist at King George Hospital, Essex. Christine Macleod is a generalist speech and language therapist in lewis and Harris, one of only two Gaelic speaking speech and language therapists there. .. manage bilingualism The social, linguistic and cognitive advantages of bilingualism are well documented. Respect for diverse cultures and languages has been growing and in recent years we have witnessed a revival of indigenous languages in the UK. What does this mean for people with communication disorders who have been or are being raised bilingually and for their speech and language therapists? Professional guidelines are unequivocal but still incomplete, and the meaning of 'bilingualism' seems increasingly hard to define. Our management of it must be responsive to individual circumstances and an evolving society. Three contributors share their up-to date experience. Assessment of pre-school minority ethnic children, creative partnerships to bring benefits for adult clients and speech and language therapy in a truly bilingual community are explored. 24 SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 1999 ISSN (online) 2045-6174 www.speechmag.com I approach the assessment of a pre-school bilingual child with enthusiasm and enjoyment. I could not work anywhere where I did not meet people who speak different languages and have different cultural backgrounds to mine. So I count myself lucky to have worked in London's East End, in China and Hong Kong and now in Greenwich with families and profes sionals from a range of linguistic and cultural backgrounds. I feel privileged to have worked with speech and language ther apists in the national and London Special Interest Groups on bilingualism, and to have had contact with nursery staff, health visitors, teachers, bilingual support workers, educational psy chologists and voluntary community organisations. When a potentially bilingual child comes for me to assess, I am helped and guided by people I have worked with over the years. And like any speech and language therapist I am constantly review ing my approaches to assessment. Assessing a bilingual pre-school child is not so different to assess ing a monolingual one. Of course, it is vital to have access to a bilingual co-worker or interpreter, preferably trained, and if possible to develop a relationship with someone you can turn to with questions about language and culture. While this may be difficult in places where there are relatively small numbers of bilingual children on the caseload, every effort must be made to find local community resources or support staff within educa tion. Otherwise we are not offering linguistic minority groups equal access to our service. If we only assess a bilingual child in English using assessments standardised on English populations, then we must acknowledge the limitations of the assessment and should be questioning the validity of the results. Opportunity to learn Therapists may feel apprehensive about 'getting it wrong' because they know nothing about the language or cultural background of the family. But if the assessment process is viewed as an opportunity to learn about and become involved in the communication of the child, the therapist need not be constrained by the fact that s/he knows nothing about the way the child's home language is structured, or the family's reli gious beliefs. Working in the UK, there are over 100 languages we may come into contact with and we cannot expect to have an encyclopaedic knowledge of them. We are experts in com munication, so we can draw on our skills of observation and informal assessment, and use our abilities to listen to what the family is telling us, non-verbally as well as verbally. There are significant cultural differences in how children are spoken to, expected to behave and encouraged to develop. Colleagues sometimes ask me for information on, for exam ple, whether a particular ethnic or linguistic group play with dolls, or what eye contact means in different societies. We all know this can be very different but beware the racial and cultural stereotyping this way of thinking can lead to. Think how people might typically describe the British cultural group ('They have a roast dinner every Sunday' or 'They always have their babies in hospital' ... ) When working with families from different linguistic and cul tural backgrounds I am forced to abandon the 'I'm the expert' approach. I learn so much: one day that Vietnamese is a tonal language and the next day that birthday cakes do not feature in the life of a Jehovah Witness. With an open approach to the case-history taking and a curiosity about the child's communicative competence we can learn so much more than if we are held back by thoughts such as 'I must remember to ask .. .' or 'I must be careful not to.. ' In assessing a pre-school bilingual child, the areas of investi gation are common to the assessment of any child. The London Special Interest Group on bilingualism has produced a checklist for assessing the communication of young bilin gual children and some of the key points are listed: 1. Listening and attention: Expectations about whether a child should sit and attend will vary and this may be reflected in the child's actual attention and listening abilities. The child may have greater difficulties listening to an unfamiliar language. The name given as the child's 'official' name may not be the name s/he is called by, so the child may not respond when called. It is important to check what the child is called in the family and what the child is to be called at school. 2. Auditory comprehension Always check the familiarity of the vocabulary and the cultur al appropriacy of the objects and pictures used in assessment. If you are not sure, ask the family or bilingual colleague you are working with . When working with an interpreter consid er whether the questions you might typically ask in English can readily be translated. For example, 'Which one do we drink from?', that old favourite of speech and language ther apists, is almost impossible to translate word for word in any language. Consider in advance how you can make your lan guage easy to understand and discuss with the interpreter or bilingual colleague how best to translate certain key phrases. 3. Expression In some languages a short sentence may be equivalent to a much longer one in English so, again, that seemingly inno cent question 'How many words does your child put togeth er?' may not be very useful. The sentence 'I don't want to eat any rice' (seven words in English) can be expressed in two or three words in Bengali or Cantonese. 4. Phonology The phonotactic structures of different languages and the influence of tones make it almost impossible to do a detailed analysis of phonology without a trained native speaker. We do know that processes such as fronting and stopping occur across languages, and that clusters are not a feature of many languages. Without access to developmental norms and phonological data, the therapist needs to rely on reports of intelligibility and work with this. 5. Interaction and Behaviour Consider how appropriate it is in other cultures for a child to initiate interaction with an adult. This may influence how the child behaves in the clinical setting. Observation in the home is invaluable. In school or nursery, learners of English as an additional language may have a 'silent' period of at least six months before embarking on the daunting challenge of speaking in another language. 6. Play Again, think about cultural variations in the attitudes to play and observe the child in different contexts. Do not be afraid to ask the family or a bilingual colleague and don't make any hasty or unsubstantiated judgements. I still hear colleagues in health and education say 'But they don't play.. .' In the words of an Irish song 'There's a thousand things to do So let's start here with me and you Gonna take a little time Let's see what we can find Walk with me, talk with me Tell me your stories I'll do my best to understand you' (Flesh and Blood, by Shane Howard, from Mary Black's album 'The Holy Ground'.) how I A roast dinner everY Sunday? Jane Stokes finds an open approach to the assessment of pre-school bilingual children reaps rewards. Ed Hooke with Jane Stokes SPECH & LArtGlJAGE THERAPY IN I'ttACTlCE WINTER 1999 25 ISSN (online) 2045-6174 www.speechmag.com .00 howl * .... Recommended reading Duncan, D.M. (ed) (1989) Working with bilingual language Miller, N. (ed) 1984 Bilingualism and Language Disability. disability. Chapman & Hall, London. Croom Helm Ltd, UK. Baker, C. (1995) A Parents' and Teachers' Guide to Abudarham, S. (ed) (1987) Bilingualism and the bilingual. Bilingualism. Multilingual Matters Ltd, UK. NFER-Nelson. The Special Interest Group on bilingualism exists as a forum for promoting professional development for speech and language therapists and seeks to promote awareness of the issues related to bilingualism in the profession. It is one of many special interest groups supported and linked by the Royal College of Speech and Language Therapists. It was founded in May 1985 and the current chairperson is Dr. Deirdre Martin, School of Education, University of Birmingham, UK. The London SIG on bilingualism is a local group with similar aims. Its current chair person is Ed Hooke, Speech and Language Therapy, Newham Community Health Services NHS Trust. Strp_nger IInKS, sigrificant cnange Rita Thakaria demonstrates how creative partnerships can lead to a more equitable service for minority ethnic clients. A Pproximately one in five of the population served by my Trust is from an ethnic minority, half of these from the Indian sub-continent. The Health of the Nation White Paper (1993) states services must be sensitive and respond to the unique and diverse needs of different ethnic groups. When developing culturally sensitive services four priority areas are: Communication; Information provision; Diet; Religious and cultural needs (Mciver, 1994). I work closely with my team, senior Bilingual Specialist and the Clinical Audit department, and take an active role in the London SIG (special interest group) Bilingualism. Achieving equal care for all patients can be considered a major challenge in the present economic and political cli mate. However, as the following projects demonstrate, devel oping stronger links within and across the professions, the health service, charities and our training establishments can bring about small but significant changes. 1. The Bilingual Speech & Language Therapy Student Register Our service does not currently have co-workers or trained interpreters. To develop improved service access, an audit was conducted over one month on the 'Adequacy of initial assess ments with bilingual inpatients'. It revealed: 7 out of 37 new patients were from an ethnic minority group a diversity of languages, ego Punjabi, Urdu, Gujarati, Turkish, Spanish only 1 of the 7 patients was fluent in English 85 per cent of initial dysphagia assessments with bilingual clients were considered adequate 50 per cent of initial speech and language assessments with bilingual clients were considered adequate there was ad hoc information gathering by nursing and med ical staff regarding the first language and knowledge of English. Strategies employed with bilingual clients which allowed for adequate initial assessments were: assessments conducted by a bilingual speech and language therapist member of ward staff 1 family used as a communication link and interpreter in-depth discussions with relat ives and ward staff. The audit concluded there was a need to have a more stan dardised approach and access to speakers of a diversity of lan guages who have knowledge of speech and language therapy, with the ideal being trained speech and language therapists. The outcome was the implementation of a new referral proce dure and the introduction of the Bilingual Student Register. The new referral procedure allows for a more systematic response to bilingual patient referrals. A new referral card for the wards includes first language and family 1carer contact number. On being informed of the referral, the therapists gather information from staff on the spoken language and the availability of informal interpreters in addition to med ical, communication and swallowing information. The Bilingual Student Register is a measure towards accessing speakers with competence in a range of languages and basic knowledge of speech and language therapy. Created in part nership with the London colleges, it is updated each academ ic year and contains a list of speech and language therapy students who feel competent in other languages as well as English. This unique partnership equally benefits clients, stu dents and therapists. Opportunity to participate The register has been in operation for a year. To access it, the therapist identifies her client's spoken language by liaising with the referrer, client or family. The therapist is then given a list of students from the register who are speakers of the given language. The therapist contacts the student and invites them to the clinic for a session or whole day. During the appointment with the bilingual client, the student is responsible for interpreting and being the communication link between the client and the therapist. In return, for the remainder of that session or day, they are given the opportu nity to participate in the clinic caseload. The level of participation is dependent upon their clinical knowledge and familiarity with the service. Training is pro vided and confidentiality is discussed. The register currently holds speakers with Urdu, Punjabi, Gujarati, Mandarin, Greek, Italian, French, Spanish, Malay, German, Arabic, Chinese dialects, Portuguese, Shona, Chewa and Swahili . Due to logistical issues such as exams, holidays and commit ments to ongoing clinic placement, the register has been most useful for outpatient clinics and home visits. We have received positive feedback from the training establishments involved. Suzanne Beeke and Ann Parker from the Clinical Placements Team of University College London are keen that placements should reflect the reality of speech and language therapy, including work with bilingual clients. They plan to audit the experiences of the students volunteering for the 1999/2000 register so they can further develop their support for the initiative. Marie Gascoigne, Clinical Coordinator at City University believes a more formal arrangement would help fill in gaps. If the speech and language therapy service could predict, based on retrospective figures, the frequency and volume of referrals needing certain languages, placements could be arranged to include a regular translation session. Clients and staff of this service have also been extremely encouraging and the paediatric service now accesses the reg ister. However, to ensure effectiveness of the register and its development, further research in liaison with the training establishments is necessary. More demographic studies are also needed to gain a better understanding of our resident population. Furthermore, as the value of working with speech and language therapy co-workers has been well established, it would be beneficial to compare this with working with a bilingual student. 26 SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 1999 ISSN (online) 2045-6174 www.speechmag.com ~ h O W I _______________________ 2. Stroke and dysphasia information booklet The London SIG Bilingualism has representation from mono lingual and some bilingual speech and language therapists who are specialists in bilingualism and from bilingual co w orkers. With such a wide spectrum of individuals it is an ideal opportunity for identifying and addressing needs which are shared across London and the South East of England. One planned outcome has been the publication of an information booklet on stroke and dysphasia. 'The incidence of stroke in men from the Indian sub-continent is igh... People born in the Indian sub-continent and the African Commonwealth also experience significantly higher mortality from stroke' (Balarajan and Raleigh, 1993). It can be expected that the incidence of dysphasia is also high. In striving to provide an equal service, we were concerned to provide an explanation of stroke and dysphasia to people who do not speak English. Little meaning The adult sub-group of the SIG together with the co-workers evaluated available translated material and established that the majority contained literal translations which held little mean ing, and were too lengthy. This was further compounded by the knowledge that often people may not read the language they speak (Mciver 1994). One successful format was the Action for Dysphasic Adults (ADA) Stroke and Dysphasia information booklet - "Drawing the picture together". This is presented as simple line drawings accompanied by short simple text. We approached ADA to see if they were interested in collaborating to produce a new booklet based around the original format. Using pictures to aid understanding in three community lan guages - Bengali, Punjabi and Urdu - the booklet has been designed as a tool for speech and language therapists to facil itate the client and carers' understanding of communication disability following stroke. In a simple format, it covers the cause of stroke, how a stroke can cause language difficulties and the role of the rehabilitation team. Bilingual co-workers are an integral part of the project. They have translated the written material and added their knowledge of common cultural beliefs. Together with the bilingual thera pist, they have been able to combine their knowledge of the medical and social consequences of stroke and communication difficulties with knowledge of different cultural backgrounds. The information in the booklet has been redesigned to take account of and confront these issues, such as the common mis conception of there being medication to 'cure' the stroke and restore function and the frequent tendency for clients from this culture to see themselves as the passive recipient of care from the rehabilitation team and their family. By bridging the lan guage barrier, the new booklet offers a starting point towards culturally sensitive rehabilitation of bilingual clients. References Balarajan, Prof. R. and Raleigh, Dr. S. (1993) The Health of the Nation: Ethnicity and Health - A guide for the NHS. NHS Executive. Mciver, S (1994) Obtaining the views of Black Users of Health Services. Kings Fund Centre. It is anticipated the' Bilingual Stroke and Dysphasia information booklet' will be available from March 2000. .0 S cottish Gaelic is a Celtic language spoken by 68 per cent of the population of the Western Isles of Scotland. However, Gaelic monolingualism is now vestigial, being a feature of pre-school age children. Code-switching between languages is not infrequent among bilinguals, and in our community is quite common. Is this because ours is a truly bilingual community, both Gaelic and English having co-existed over the last hundred years (figure 1)7 Though once the nation al language of Scotland, Gaelic was gradually overtaken by Scots and in the 19th Century its use was actively discouraged. Educational policy has changed over the past 40 years with a subsequent shift in attitude towards the language. Two gener ations ago it was mostly English that was used in the schools. The next generation, taught in English, had a choice on enter ing Secondary education and taking a two-language course, of French and Latin, or French and Gaelic. However, those brought up in the Stornoway town area and thus not thought to be fluent Gaelic speakers were not allowed to take Gaelic. Nowadays, we have another picture altogether. Gaelic medi um education began in Breasclete School (Lewis) in 1985, w ith nine pupils. By 1994, there were 545 pupils in 18 schools th roughout the country. Gaelic-medium education is on the i ncrease, with units springing up all over Scotland. There are likewise numerous Gaelic pre-school playgroups interspersed hroughout the country. These were initiated by CNSA (Comhairle nan Sgoiltean Araich) and are a common feature of our culture, catering for native speakers and English incomers alike. It is now compulsory for all pupils entering 5econdary education in the Western Isles to take Gaelic for the fi rst two years. The education department supports Gaelic medium educa ti on in recognition of Gaelic's importance in the life and cul lure of the Highlands, and endeavours to take into account the wishes of parents and individual needs when considering entry to it. It is however policy that certain children, for example those with severe language difficulties (case 1). should not enter Gaelic medium education unless Gaelic is their first or only language, because the demands on them would be too great. "If it is probable that a pupil can devel op basic competence in only one language, then efforts should be directed to the development of communication in the language which will be most important and widely useful throughout the pupil's life" (Iliffe and Macleod, 1994). Gaelic medium education is mostly available in mainstream settings and the main problem at the moment is lack of funds for its advancement. No research A research project with three to five year old children in the Western Isles (Donaldson, et ai, 1997) suggested age, lan guage input from parents and the child's own language pref erence all influenced children's mastery of Gaelic grammar. It needs to be made clear to parents that no research has been carried out in the learning difficulties field in Gaelic, and there is insufficient support. Specialised provision is only available in English (case 2). There are no Gaelic resources for learning difficulties. Only now is a commercially produced reading scheme being devised for mainstream education. Previously, teachers have been putting material together themselves. The same is true for speech and language therapy. I have produced a Gaelic phonology assessment, and adapted some language assess ments, as no standardised ones are available. Assessments cannot be translated from English, since the structures of the two languages differ so much. There are very few Gaelic speaking therapists and more are needed to address the needs of Gaelic speaking children and adults. For most older clients, Gaelic is an oral language. Often they prefer to communicate with professionals in English, as they may not have learned Gaelic literacy skills (case 3). With bilin guals, it is sometimes difficult to know which language to use, but usually I let them set the pace and adapt accordingly. ~ Adapting to change Christine MacLeod shares her unique experience of living and working in a bilingual community. SPEECH & LANGUAGE THERAPY IN PRAOICE WINTER 1999 27 ISSN (online) 2045-6174 www.speechmag.com
how 1 Practical points 1 . To enable equity of service, ways of bridging language and cultural divides between therapists and clients must be identified and funded. 2. Openness to leaming about different cultures and individuals is an opportunity for personal and professional development. 3. Speech and language therapy management will necessarily be influenced by client I parental wishes, the environment and, for children, educational policy and resources. 4. Special interest groups are a useful medium for identifying need and bringing about change. 5. When working together, partners should consider how they can pool resources and bring benefit to both. 6. Literacy levels should always be taken into account when planning information leaflets and therapy. References Donaldson, M.L., Gillies, w., Reid, J. and Macleod, C. (1997) Children's acquisition of Scottish Gaelic grammar: a preliminary investigation. ESRC Final Report. Project number R000221466. IIiffe, S. and Macleod, D.J. (1994) Gaelic Medium Education: Pupils with Special Educational Council Education Department. Mackinnon, K. (1986) Scottish Highlands. Accents of English 2. Needs. Highland Regional Gaelic and English in the Cambridge University Press. Figure 1 - The progress of Gaelic In 1891, Gaelic was spoken by over 75 per cent of the population of the area of Scotland stretching north from Islay, across through South Argyle, the Grampian and Perth regions up to Inverness and most of Ross shire and Sutherlandshire along with the Western Islands. By 1981, the region where over 75 per cent of the population spoke the language was restricted to the Western Isles, (apart from Benbecula and the town of Stornoway - areas of adventitious incomer settlement), the northern tip of Skye and the small island of Canna (Mackinnon, 1986). The 1981 Census showed 82,620 people in Scotland able to speak, read or write Gaelic. Case 1 P is a nine year old with a specific language disorder. He was first referred by his GP at 4.04 years when he mimed a lot. Only Gaelic was used at home. He watched both Gaelic and English programmes on television, and mixed the two languages frequently when he entered a Gaelic medium unit. P had much difficulty receptively and expressively in both languages, and preferred his own company. He echoed a lot and was fastidious about placing his writing materials back in the same position each time he used them. Therapy was initially given in Gaelic, his first and preferred language. In accordance with policy, the first two school years were spent working entirely in the Gaelic language. By primary 3, Pwas reading English fluently but developing dysfluent speech. Was it the introduction of the functional use of English in school that had caused the problem? Was he undergoing some emotional trauma? Was he becoming more aware of his inability to understand and be understood? He also became confused with mutations and lenitions within Gaelic and argued these were wrongly spelt. With Gaelic the basic order of words is verb-subject-object as opposed to the more usual form of subject verb-object. Should P have gone into Gaelic-medium edu cation? In the end it is the parents' preroga tive, and there are very sensitive issues involved, but probably not. P has now trans ferred to English based education and is mak ing good progress. Case 2 R, who has Down's syndrome, is a child of English-speaking parents, who was in a special school for two years. The par ents decided to send him into Gaelic-medium education, hoping it would be successful, although they had no knowl edge of any precedent. Both R's Gaelic and English were dif ficult to understand largely because of phonological diffi culties. At age seven, his language level was such that he was able to put two to three English words together. These were difficult to understand because of his poor sound system. After three to four months in the Gaelic Unit he could speak a few Gaelic words and produce one typically Gaelic vowel. Our opinion was that perhaps this parent was being too ambitious, and the child's most realistic chance of achieving his potential would have been in a special class. However, he is now progressing well, speak ing some Gaelic and beginning to read and write it, beyond the school's expectations. Policy has now become more relaxed. Case 3 M is a 77 year old lady referred two weeks after suffering a second stroke. She was assessed informally and with the Whurr Aphasia Screening Test for comprehension and expression, using her first lan guage, Gaelic, then English. Her comprehension skills were poor, and expressive language consisted of "yes" and "no". She attempted spelling out words though these were almost invariably wrong. She could not copy shapes, letters or fig ures. Automatic speech was possible. English was her preferred language in counting, though she could also count in Gaelic. In picture-naming, code-switching and association were used frequently, ego the Gaelic 'Iitir' (letter) was used for 'letter-box' without the letter picture cue. Gradually, she learned to address members of her residential home appropriately. Two to three years post-stroke, her communication skills in both languages have markedly improved, giving her a better quality of life. M's pre-morbid situation was such that she would have spoken mostly Gaelic, living in a Gaelic-speaking environment, which is still the case. Although her conversational speech is mostly in Gaelic, she likes to use English when attempting any set work. r--------------------------------------------------, Free translated stammering tapes " Speech and Language Therapy in Practice has five audio taped translations of .. "c;>,oes Your Young Child Stammer?" courtesy of the British Stammering Association to 5t ~ ~ ~ I ~ I ~ ~ n 9 give away FREE to a lucky reader. Association The Association's popular leaflet has been produced in Urdu, Punjabi, Somali, Gujarati and Bengali to meet the information needs of a variety of minority ethnic groups. To enter the prize draw, send your name and subscriber number (or address) marked 'BSA tapes' to Avril Nicoll, 33 Kinnear Square, Laurencekirk, Aberdeenshire AB30 1UL or e-mail avrilnicoll@speechmag_com. The closing date is 15 January, 2000 and the winner, drawn randomly from valid entries, will be notified by 22 January. The British Stammering Association is at 15 Old Ford Road, London E2 9PJ, tel. 0181 983 1003. L __________________________________________________ 28 SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 1999 ISSN (online) 2045-6174 www.speechmag.com EVENTS BETT . The Educational Technology Show 12-15 January, 2000 Exhibitors and a seminar programme. A special needs zone is included. Details: http://www.education -net.co.uk. Ticket Hotline, tel. 01203 426458. The Education Show 23-25 March, 2000 NEC Birmingham More than 600 exhibitors and a seminar programme. Includes special needs and early years focus areas. Details: http://www.education-net.co.uk. For free tickets and pre-booked seminar tickets (chargeable) tel. 01203426549. 4th European Parkinson's Disease Association Conference 9-12 November, 2000 Hotel Inter-Continental Vienna Details: Martlet, Blenheim House, 120 Church Street, Brighton BNI IWH, tel 01273 686889, e-mail debbie@mart/et.co.uk Contributions to Speech & Language Therapy in Practice: Contact the Editor for more information and / or to discuss your plans. 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. .. Special offer for personal subscribers - Introduce a col/eague* to Speech &Language Therapy in Practice and you both get an extra issue - free! The new subscriber fills up their details on the form and puts your name in the 'recommended by'space. Once their payment has been received, they will get 5 copies for the price of 4 in their first year's sub scription, and you will be notified that your subscription period has been moved on by three months. So, tell all your friends the advantages of a personal subscription to Speech & Language Therapy in Practice. Remember - you will get an extra issue for every new subscriber you bring in. 'Must be a NEW subscriber to the magazine. POSTCODE: POSTCODE . . Speech &Language Therapy in Practice has moved. PLEASE SEE CONTENTS PAGE FOR DETAILS ISSN (online) 2045-6174 www.speechmag.com 1. Talkabout . A social communications skills paCkage by l e x t<elly, Wlnslow 32.50 This practical manual provides a framework for the development of social skills, It has six levels, each concerned with a particular aspect of communication, starting with self awareness and awareness of others, moving through general communication skills within a group, body language, talking and conver sation skills and assertiveness, Each level has photocopiable worksheets which are very appealing to young people, help to promote thought and discussion and can be kept by the client as a record. It is a well organised, invaluable guide to planning stimulating programmes for groups - I use the work sheets as a base and supplement them with other practical activities, 2. The social skills game by Yvanne Searle & Isabelle Sireng, from Wfegames (approx no). pUb Jessica Kingsley. 116 Pentonvl!le Rd, London NI 9JB A therapeutic board game to help children and adolescents who experience difficulties with relationships, Intended for group work, it focuses on a positive and fun group expe rience and can be adapted for older or younger children. It aims to improve self awareness, interpersonal relationships ,ver bal and non verbal communication and assertiveness, and to facilitate discussion of emotional and behavioural issues, It includes cards which promote thought / discussion, as well as social games and role play activities designed to target eye contact, concentration, group interaction, listening and confidence, I play this with a group of autistic children (12-14 years) and we have a good time as well as improving our social skills, 3. Knowledge Of teenage culture A definite advantage, Do you know the names of the members of 'Steps'? What is Britney Spears' latest single? What happened this week on 'Home and Away' and 'Eastenders'? Who did Man Utd play this week? This stimulates group discussion and gives you an advantage when planning turn tak ing games, for example guessing the famous person or TV programme from description or playing '20 questions', It gives you 'street cred' and helps your popular ity with the group as well as motivating them. 4, Social skills Training Sue Spence, NFER-Nelson 100 A comprehensive package for assessing and enhancing social skills with children and ado lescents. It includes useful theory on the nature of social competence, and a comprehensive assessment procedure in the form of questionnaires and checklists for parents, teachers and clients, Basic social skills assessment charts give the client a rating before and after social skills therapy and so measure outcomes, After assessment, the package gives practical guidelines for improving social competence as well as detailed session plans and home task sheets on topics such as feelings, saying 'no', dealing with teasing and bullying and giving compliments, This can be easily adapted to suit a variety of client groups but is particularly useful for more able children with good basic language skills, 5. Wnlteboord I used to go through vast quantities of large sheets of paper to record ideas my groups had during brainstorming sessions, so I invested in a portable whiteboard (approx, 18" x 24"), It is used for many other activities too - making charts of likes and dislikes, playing games such as variations of 'hangman' and making a com munication board by sticking on pictures, sym bols or photographs with blue-tac. The children enjoy writing on the board themselves and this can be used as a reward, 6 ,A,5slstan Is A speech and language therapy assistant works with me and runs some of the groups, She .is well qualified having masses of expe rience and being a church youth leader as well as having three teenagers. She has some excellent practical ideas and provides me with endless photocopies of useful material, Some of the children have learning support assistants who accompany them to the groups, They give me information about the child, help to control any behaviour problems, and participate in role play activities, They also carry on ideas from the group into the child's everyday social and educational programmes, 7 Colarcords Winslow I use many of the sets but the most useful are the Color Libraries, particularly Food, Animals and Birds, Sport and Leisure and Occupations as the pictures are suitable and appealing to ado lescents, They are used endlessly for social games such as '20 questions', 'what am I describing?' and memory games, as well as providing visual stimulation for discussion of likes and dislikes. The sport and leisure cards are useful when dis cussing 'What I am good at' or 'What would like to try'. A selection can help clients remem ber what they have done during that week and so share experiences with the rest of the group. When discussing personality types, occupation cards provide a cue to thinking of the person al characteristics required for various jobs. Emotion cards are also well used, They can illustrate body language and promote dis cussion on 'feelings', oJ is a speech and language therapist with East Cheshire NHS trust who works in a mainstream secondary school which has special provision for children with learning difficulties. Groups Of adolescents work on communication skills and social use of language. The groups usually have five or six members matched as far as possible for age. ability and level of social skills. Skills targeted vary from basic communication skills such as listening, turn taking and eye contact with the younger or less able groups. to feelings and emotions, friendship, bullying, social appropriateness and moral issues with the more able and autistic groups. .--__"" 8. 'Guess who?' MB Games This great game is fun for everyone. It is meant for two players but can be adapted for group use. There are boards with male and female faces bearing different characteristics (hair colour, eye colour, glasses, etc.) Someone chooses a card which matches a face on the board and the other players must determine who was chosen by asking questions like "does (s)he have blue eyes?" Apart from reinforcing language structures such as question forms, the game is invalu able when working on 'describing people' during the awareness part of the social use of language programme. There is also the bonus of turn taking skills and discussion forming part of the activity. 9. What would yau do' L D ~ !O 95 These cards depict eight social situations, each with five possible outcomes, The situations include vandalism, bullying and robbery. The children discuss them and give their own opinions as to how they would respond, The five outcome cards can give further ideas and they can rate each one as a good or bad response, Moral aspects of the action choices can be discussed. The cards help increase the children's awareness of the effect their actions may have on other people. They also help reasoning skills (what would happen if ...) and decision making, Useful when addressing such topics as friend ship, or feelings, I find these cards particular ly valuable when working with a group of autistic children. 10 Party fOod At the end of term and when one of the group has a birthday, we have a relaxed ses sion and bring in some popular party snacks such as crisps, chocolate biscuits, mince pies (at Christmas), and drinks. The 'party' session is useful for encouraging such social skills as turn taking, sharing and good manners, Likes and dislikes can be discussed as well as such issues as dietary constraints or food presentation, The relaxed nature of the sessions gives rise to much informal conversation and is excel lent as a group gel activity, I can often sit back while the conversation flows and observe the progress being made in social communication skills, The celebration of someone's birthday helps to develop awareness of others and, for the birthday person, an increase in self-esteem, as their friends make them feel important. ISSN (online) 2045-6174 www.speechmag.com
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