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ISSN (online) 2045-6174 www.speechmag.

com
The big
breakthrough
on a small
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T
he new DynaMyte is a lightweight,
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advanced communication capabilities, and uses the same software. A built- in
remote control unit allows the user to
access computers and other household appliances, and it
portable device with powerful communication
DynaMyte is just half the size of DynaVox 2 and yet it retains all its
The DynaVox 2
features a system of alarms capable of performing a variety
augmentative
communication aid of preset tasks. A clear, easy to operate touch display
has introduced 0
provides access to the full range of DynaMyte's
new era of freedom to
communication power. Its long life battery and durable,
people of all ages who
have speech disabilities. rubberised casing guarantees easy to carry communication
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DynaMyte is a natural product extension from the
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develop a greater sense of self expression and
independence.
For full information and demonstration, contact
DYNAMIC
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ISSN (online) 2045-6174 www.speechmag.com
CO
Winter 1997
(publication date 24th November)
ISSN 1368-2105
Published by:
Avril Nicoll
Lynwood Cottage
High Street
Drumlithie
Stonehaven
AB393YZ
Tel/fax 01569 740348
e-mail avrilnicoll@rsc.co.uk
Production:
Fiona Reid
Fiona Reid Design
Straitbraes Farm
St. Cyrus
Montrose
Printing:
Manor Group Ltd
Unit 7, Edison Road
Highfield Industrial Estate
Hampden Park
Eastbourne
East Sussex BN23 6PT.
Editor:
Avril Nicoll RegMRCSLT
Subscriptions and advertising:
Tel I fax 01569 740348
Avril Nicoll 1997
Contents of Speech & Language
Therapy in Proctice reflect the views
of the individual authors and not
necessarily the views of the publish
er. Publication of advertisements is
not an endorsement of the adver
tiser or product or service offered.
Cover pictLlre:
Auditory sequential
memory by Maggie Johnson
News/
Comment
4
Activating
Potential
for
Communication
,;,---........-..,deficits have a particu
Speech and language
and occupational
therapy staff
outline the benefits
of a packaged
programme for the
elderly.
Counselling
NLP 9
Studying Neuro Linguistic
Programming has made a
significant impact on the way
Caroline Skelton works as a
speech and language therapist.
She explains how.
Special
Debbie Wilcox ,
Sarah-Jane
feature - clinical
Burns and
Anita
Mdadzean
In two reports, Ann Parker
teaching 13
who run
describes group placements early
in pre-school centres with communication
Keena Cummins, then for adults groups list the ten
with a learning disability with resources they could not
Sarah Farazmand. do without.
2
18
COVER STORY
Auditory segu.ential
memory defiCits
Memory involves all the senses, but
auditory memory
lar impact on language
development. Maggie
Johnson shares the
approach adopted at
Gap House School.
Reviews 22
Outcome measures, symbols,
neuroanatomy, phonology,
sensory motor development
and AAC.
How I manage
speech souna
difficulties 24
Three opinions on the speech
and language therapy
management of an eight year old
boy, Mark.
MyTop
Resources 30
SPEECH & lANGUAGE TH ERAPY IN PRACrJCE WI HER 1997 1
ISSN (online) 2045-6174 www.speechmag.com
N EWS & COMMENT
Forging partnerships
As therapists we want to work with people to empower them,
but many feel our training does not eqUip us adequately.
However, an imaginative partnership of tutors, Clinicians and
outside bodies has enabled groups of speech and language
therapy students at University College London to gain
valuable, real-life experience while providing direct and
indirect input to people who would otherwise not receive it.
Ann Parker at UCL would like to hear from service providers
keen to work with her on other such innovative projects.
Maggie Johnson is also keen to ensure her students -
children with specific language disorders - are equipped for
the real world. Group teaching brings particular benefits in
helping the children understand and accept their residual
auditory sequential memory deficits. Parents, teachers and
children are all advised of their part in compensating for the
difficulties these cause. This is an article bursting with practical
strategies for assessment and intervention, many applicable
to other client groups too. More specific practical suggestions
for eliciting velar plosives appear in How I manage speech
sound difficulties, but the more general process of case
management decision making can again be extrapolated.
A speech and language therapy / occupational therapy /
nursing partnership is much in evidence in the Victoria
Infirmary Trust, where the special skills each discipline can
bring to the implementation of a standardised programme,
Sonas aPc, are demonstrated. Anyone who has worked with
elderly people in continuing care knows there is often
frustration and a sense of helplessness involved. However,
Lois Brown and the team show that, when the basics of
communication through touch and other senses are
addressed in a systematic and repetitive way, real gains in
quality of life can be expected and recorded. At the other
end of the age scale, children in early communication groups
can benefit from imaginative - and often 'home-made' -
sensory stimulation given in partnership with parents, as
explained in My Top Resources.
The importance of the senses is also fundamental to Neuro
Linguistic Programming, an approach based on using specific
linguistic patterns to challenge thought processes and bring
about change. Caroline Skelton provides a practical guide to
how it can help speech and language therapists build
rapport and give clients the confidence and the means to
work out the nub of their difficulties and address them.
A book on outcome measures, co-authored by Pam Enderby,
features in Reviews. In a recent lecture on the future of the
profession, Professor Enderby's warnings included the
implications of ever-shifting demographics,
epidemiology, technology, consumer
power and political landscape. All the
authors here show their commitment to
forging partnerships and updating skills
to keep up with these changing
demands and needs.
Please give me a call if you too are
involved in interesting projects and
would be willing to share your
experience and resources with your
COlleagues through this magazine.
Avril Nicoll
Editor
Lynwood Cottage, High Street, Drumlithie
Stonehaven AB39 3YZ
tel/ ansa/ fax 01569 740348
e-mail avrilnicoll @rsc.co.uk
SP[[CI 1& LANGUAGE THERAPY IN PRACfI CE WIi'<'TER 1997
Books for
schools
In a five yea r initiative, WH
Smith is providing around half
a million free reading books to
over 400 primary schools in
the UK.
The company is working with
the Department for Education
and Employment and teachers
to ensure the bookJist is best
suited to the educational needs
of the children. The schoo ls
chosen have all already
demonstrated th eir commi t
ment to improving literacy.
Secretary of State for
Education and Empl oyment.
David Blun kett, described it as
"an excell ent example of how
this government and business
can work together to achi eve
objectives for the good of all
parts of the community and I
am con fident that it will help
fulfil the target for literacy
which we have set for 2002."
Advances in
psychiauy
All exhibiti on at the Museum
of London raises questions
about the way people with
mental health problems are
seen by soci ety.
The co ll abo rati ve venture
between the Museum and
Bethlem Royal Hospital is one
of the events cel ebrating the
750th anniversary of the hospi
tal, the world's oldest caring for
people with mental di sorders.
It runs until 15 March [988
and includes an interacti ve CD
ROM covering the latest
advances in psych iat ry.
Dewit,: MuseulIl o( London, tel.
0171 600 3699.
Fll.1ency
gams
All unforeseen benefit
or speech recognition
technology fdr people
who stammer has
been noted by IBM.
Peopl e who stammer
have often found
communication by
keyboard less
cha llenging than
speaking, but the
pausing and slower
speech ra te currelltly
nt>cessary to use
peech recognition
technology has helped
at least two users
improve their fluency.
IBM manufactures
the VoiceType speech
re ognition word
processing software.
Details: DUllcan Ross,
IBM Speech Busilless
MtJrltlgel; lei. 011256
344741.
Pre-school
project
A new project will
draw together
i nfonnation and
research on the
relalionship between
speech, language and
literacy problems,
investigate prevention
and arly intervention
and a
re ource package ,1l1d
rraining.
1 he joint pre-school
Yt.'1Uure between
,\IASIC and the
Rrili h Dysl exia
Association is being
fu nded bv Glaxo

D lails: AFASIC, tel.
01 71 236 6487.
Tuberous
Sclerosis
gene
Recent research has
uncovered the sec
ond gene involved
in Tuberous
Sclerosis, a co ndi
tion occurring in approximate-
l y 1 in 6000 new-born babies.
Alt hough the tumours it causes in many parts of the body
are usually benign, they can l ead to medica] problems
including epilepsy, learning diffi culti es and au ti sm. It is
hoped DNA test ing and reliabl e geneti c counsell ing will
now become possible.
Details: The Tuberous Sc/elosis Associaliol1 , Liule Barnsley
Farm, CatshilL, Bromsgrolle, Worceslershire B61 ONQ.
2
ISSN (online) 2045-6174 www.speechmag.com
hnsl mas catalO(lue 1997
AFASIC CHRISTMAS CA
Christmas card catalogues (" also including gift ideas), are
available from many organ! ations including:
The NatioIUlI Autistic Society ' , 393 City Road, London EC 1VINE.
'Ine Stroke Association", tel. 017l 4904773 or write to Stroke Associalion (Trading) Ltd, Stroke
House, Whitecross Street, London ECl Y 8]1.
AFASIC, teL Dl7l 236 6487
(Reu,lers ml1y uish !O note that at lrust 0111' ADA, hIlS disrontillued its Christmas card suits 115
they failed 10 raise income, the charity belieJ'es as II result of Ille market TellChing saturation.)
TJ Supplement
success
Parents are claiming a
nutritional supplement can
help children with the
symptoms of dyspraxia,
attention deficit/hyperactivity
disorder and dyslexia.
Efalex contains a combination
of thyme oil and the essential
fatty acids docosahexaenoic
acid, arachidonic acid and
gamma linolenic acid. It is
believed it acts to maintain
eye and brain function,
compensating for unusual
biochemistry, and can be
taken by children from two
years old.
One parent of a twelve year
old boy with clumsiness, a
short concentration span,
lack of focus and a tendency
to fidget said, "When Efalex
Preventing recurrent strokes
As part of Stroke Week, the fo llowing information was made ava il
able by the Stroke Association.
New research shows 14 per cent of people who have had strokes
are not taking aspirin, even though it could reduce their risk of hav
ing another stroke. The Association wants to encourage wider use
of long-term aspirin treatment and is urging GP practices to main
tain a regi ster of all their patients who have had strokes and to
assess each patient's sui tabi lity for aspirin treatment. They wou ld
also like to ensure that advice on reducing alcohol intake and cig
arette smoking is clearly given. (Report: Preventing recurrent strokes:
are opportunities being missed?)
A new leaflet to help people who have had a sLIoke reduce the
risk of having another has been produced (Keeping well after YOllr
stroke). It stresses the imporlance of understanding the type of
sLIoke and treatment and the need to take medi cines regularly, as
well as highlighting the value of regular blood pressure checks and
lifestyle changes. Details: The Stroke Association, tel. 0171 490 79999.
EWS
Business and
disability
The charity Scope and Talk
Radio have combined to survey
how businesses are ser.ving
people with disabilities since
the Disability Discrimination
Act came into force.
I! is unlawful for businesses
to refuse to serve disabled
people or, compared with
non-disabled people, to offer
goods and services with a
lower standard of service or
at less advantageous terms.
The results of the survey will
be used to educate business
es, lobby Parliament and
influence business and trade
bodies by highlighting areas
of good and poor practice.
Details: Scope / Talk Radio
Illfonllation Lille, tel. 01908
200022.
-/
SCOPE
fOR P[OPLl WITH PA LSY
Cerebral palsy
development
A new module to develop
professional skills in the
diagnosis and management
of people with cerebral palsy
is being offered as part of a
Masters degree at City
University.
Gillian Nelms (ACE Centre in
Oxford) and Nicola Grove,
speech and language therapist,
will contribute to the
programme which is receiving
funding from Scope. Topics
such as motor patterns and
health issues, social aspects of
cerebral palsy, oral motor ski.lls
and communication and MC
are included.
Details: Scope, tel. 0171 636
5020.
was launched we wondered
whether it might make a
difference. As parents
you will try virtually
anything to improve
lot of your child
and it's all too easy to
think you've spotted an
improvement where
none actually exists. In
this case, however, we
struck gold."
Efalex is available in
Boots, pharmacies,
health food stores and
leading supermarkets.
Details: Efamollllformatioll
Line, tel. 01483570248.
developments are reponed in the annual
review of Action for Dysphasic Adults (ADA).
There are now 13 affiliated self-help groups wi t.h five others in process.
CommUlliCilte workshops, which offer standardised training to a range of
care professionals, are continuing and a medical teaching pack is available
for use with medi caI students and professional s. The charity has also
become more involved in advocacy and empowerment. and held a train
ing day on the subject in February.
This year will see the publicalion of the 2nd edition of the National
Register of Language Opponuniti es, a systematic di rectory detailing all
the resources ava ilable across the country to people with dysphasia; it
will also be available on disk. ADA's regional committee has also estab
li shed a working party to study the effect of the Disability
Discrimination Act on people with dysphasia.
Action fOl Dysphasic Adults, 1 Royal Street, London SE1 7LL, tel. 0171 261 9572.
SPEECH & THERAPY IN PRACn CE W1N- I'ER 1997 3
ISSN (online) 2045-6174 www.speechmag.com
THE ELDERLY
Actlvatln Potential
Co fused, disorienla ed and
deprived elderly
peo Ie are ofle as
cfiem ups. Sonas aPc is a
ackaged programme designed
to meet their needs. Speech
and language and occupational
therapy staff of the Victoria
Infirmary nRS Trust 0 Ine Its
implementadon a benefits.
Sonas aPc was devised by Sister Mary
Threadgold, a speech and language thera
pist in Dublin. Sonas is Gaelic for 'well
being' and aPc represents 'activating poten
tial for communication'. The multisensory
packaged programme on audio tape uses
music, singing, touch, smell and taste to
Rromote interaction and a sense of well
being amongst participants.
Training in the use of the programme was
offered to a group of professions allied to
medicine (PAMs) and nursing staff in
Glasgow in 1996, in two half day work
shops run six weeks apart. The programme
provides for a group and a one-to-one
approach.
We now have groups of approximately
eight confused or socially isolated (often
dysphasic) clients attending with two facil
itators, in this case a speech and language
therapist and occupational therapist. Each
group lasts 45 minutes to 1 hour and
groups are run at least weekly in four dif
ferent care of the elderly units with the
same clients attending. Some have contin
ued for 18 months while others are recent
ly formed. Some clients were known
already to our departments having had
therapy input and others were referred by
nursing staff, family or self-referral.
Clients are invited to attend and the choice
is theirs. Twenty five per cent of patients in
most of the continuing care wards attend.
Familiarity
An audio tape takes the group smoothly
through a 45 minute session, commencing
with a signature tune and personal wel
come by the facilitator. The groups rely on
repetition, triggering memories and
encouraging interaction. A group develops
its own character as the weeks progress,
and a feeling of shared experience and
familiarity benefits therapist and client.
The same tape is used every week. We have
not found this too repetitive either for
clients or ourselves, but the second side of
the tape provides a change in songs, cued
speech and music, allowing variety when
necessary.
The programme includes:
1. gentle exercise
2. singing
3. massage based on the simple 'metamor
phic' technique taught during Sonas aPc
training. Shoulders and upper arms are
massaged gently by the facilitators moving
round the group, accompanied by music.
'The skin is our first medium of commu
nication" (Montague, in Sonas manual)
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 1997 4
ISSN (online) 2045-6174 www.speechmag.com
TJ IE ELDERlY
and touch is thera '
remark how" , " peU!lc. Clients often
nICe the ex '
notice other cli " penence is, and
4, a rh' rlhm' , entsenjoYl ng it too,
TUI Ica sect ion
5, a taste and smell secti
the tape all ows the t: .,. on, For the latter,
perfumed 0' 1' ao Hators time to rub
l
fOllowed b), ha d ,IntO each client 's hand
n exeroses and '
ment to sll1elllho ' I A' enCOurage_
cOl, t !JOl es '
very confused I' , ' a passive or
c lent WIll fli
on the propenies of ,J.- 0 er a comment
I " " uleo!/ 'Th' ,
y , It smell s Il'k I - IS IS love-
e avender" "1
me of a good soa " , t reminds
6, cued Speech _ ,
proverbs ple!lon of well- known
7, a shon p 1
' oem a lOwi ng I ' ,
!lme after more acu' , ,I mmg, llstenillo
8 \ e secUons b
, an 0pponunity for individ ' ,
9, a closing song, udl panlCJpation
MOdification
We can modify o ur a
aCCOUnt of I'n j' 'd pproach to take
(JVI lIal n d I
taped programme is i ee s a lhough the
hard of hea ring I ' Ixed, We ensure a
c lell[ IS s d
tape reCorder 'nd ,eate near the
, "provIde
wllh Easi -comms for lh some elienls
Indi vidua ls if 1/ e seSSIOn, We ask
massaged, as Iheir shoulders
touched, A blind ryone enjoys being
approoches explai ned v man has al/ the
li y sla nled and a I' erbaily as he is eas
" c lenl wah a h '
IS aSS lsled wilh P' ' emlplegia
, asslve movem C
exerCise sections Th ellIS lor the
' ose who a
b
J
/
are given lhe 0 0 ' re non-ver_
Channels of nunlty 10 use o lher
humming or rh'rlh ca li on, for example
"
h
JU lilll
t e smglng parts,
Cal lap , ,
ping dunng
Participation
As Ihe clients b
ecome
'
{; 'I '
programme 010 , am i lar with Ihe
, re POSitive "
nOled and a de ' , paIllopalion is
' crease In neo '
o
b
VIOUS, Some /' ba!lVe aspens is
c lell[s are p "
a
II
seclions ofc ' artlCJpatory ill
, ,ermg 10 '
remin isce Ol h
o
SlOg, dance and
' crs are '
but may enjoy one secti qUI!'1 and passive,
One lady is very ',on 10 pan lcular,
, , aruuous and
nlCa!l v(' Ulllil th ' lIncommu_
" e exercises \ '1 h '
'
A em ers
nother lady has her e ' ,
the early pan of th yes !lgh tl y closed for
e session b '
fi II
u y along wi lh the ta .' UI sings tune-
and will make "0 d pe In a srnall voice
O
th9nk the facill,b eye COntact. silli le and
tal
, ors at the d
A chent who is severel d en ,
stanl chatter and ,Y emenled uses con- '
ticipate in any s was malall y unable to par
ectlon Til ch '
/
essened and sh h .. e altenng has
, e as Improv d
espeCially al th ' ,e turn taking, ,
mical section, e of the rhyt h_ '
experience of tOUche 10 enjoy the
tams eye Contaa and 'I taste, She main-
ml
An ernotionally labil: es rnore often,
109 the ea rl y aCII'V't' CVA el lent cries dur
, , lies bu t co '
panlclpale and ' n!lnues to
has enjoyed the' on complet ion, says she
group,
AppendiX 2 B
t. Areod! enef/rs ro
clienr YmOde, ponobl oClllroro
rs
rime fo:r:,P ond Which c::rogromme effect;
be repeored ove::
vdUol cltenr lime ol/oWin oJ penod of
;xperience. needs, deve/oPI'g corelul mOdili .
0;': Conrlnued fa

5. Aforum for
ory
reom. ng re/orions wirh ,,.
some field. . diSCUSSion . rile
meering rh,s hos orher rheroPisrs
USint ro form on in rhe
onses wirhln rh lonol form We
VlduOI sresp ono/ observof oJroup
Appendix 1 - Benefits to clients
1. Arelaxed, Informal atmosphere to encourage freedom of
expression.
2. Time to share enjoyable experiences In asafe, empathetic
environment.
3. Freedom of choice to attend, with no expectations of performance.
4. The opportunity for group members to develop and build
relationships through tIme.
S. Freedom to use any communication channel - verbal or
non-verbal, touch, gesture, facial expression or eye contact.
6. Therapists' obsenation of the individual's preferred sensory
channel and reinforcement of Its use in activities of dally living.
7. Aroutine and predictable sequence of events allowing severely
confused clients to become familiar with the material and the other
members.
8. Reduction in tension and increase in confidence and self-esteem.
9. Acknowledgement of personal Integrity in confused people.
. ng ond for
rhe need forUor/on oVer rimeRcrtonol ossessm
o/orm ond 0 norurol observorion
10 vIgorously and 1h len s e joins
' rhythrn' en cont ributes to the
h ' n seClion B ,l-
S e appears relaxed and I _ ' , y U,e end
egroup OVer rroce on
the other group rn b lappy, smili ng at
Appendix 3 Considerations
1. Illness and disability in the group can cause inconsistent
numbers, or disruption of client mix.
2. Appropriate accommodation is important; aquiet room,
large enough to have acircle of up to 10 people, some in
wheelchairs, with facilitators moving around to assist in
exercise and perform shoulder / arm massage. One of our
clients likes to dance during the music programme and space
within the circle for this to be done safely was necessary.
3. Avoid interruptions during the group.
4. Staff shortages can interrupt continuity.
S. Time is needed to prepare and transport clients to the
Sonas room.
,
SPEECH & LANG ' , ,
VAGI: lHLRAPY IN PRA
en.F
ISSN (online) 2045-6174 www.speechmag.com
THE ELDERLY
Appendix 4 - Speech & Language Therapy record sheet
Sonas ape
name diagnosis
ward communication
mental state/mood

eye contact
smiling
vocallslng
talldn!
-
touching


rhythmlcaillovement
nonverballnitlatlol of communication
verbaflnltlatlon of co..munlcatlon
sleeping
shouting
hitting out

purposeless movement
cJosed eyes
cryln!lmoanlng
obsenatlons of posltll. partlctJation
observations 0' ne!atlve
_.
codes
participation mood/communication
o did not participate in activity P passive/little or no spontaneous communication
1 required assistance/prompting to participate in B bright/chatty
activity A agitated/verbally aggress ive
2 responded spontaneously
One-to-one
A second twenty minute audio tape is
designed for use on a one-to-one basi s
with clients. It contains timed sections of
music, song and poetry whid] lead the
faci litator through gentle massage of the
s hou lders, back of neck, hands and
head.
This individual approach is very useful
with severely dement ed or withdrawn
cli ents or those with very disruptive behav
iour who may not be able to attend group
sessions. We have used it successfully to
reduce agi tati on in a severely confused
client. Typicall y clients become visibly
more relaxed during the massage and
spontaneously cha t to the facilitator, per
ha ps prompted by familiar tunes and
memori es invoked by the music or poetry.
Outcomes
Benefi ts to clients and facilitat ors are listed
in Appendices 1 and 2. Through time,
clients demonstrate improved well-being,
self-co nfidence, self-esteem and IIUSt.
The behavioural signs of we U-being are
discussed by Kitwood (1996) and are
observable following repeat ed Sonas group
attendance:
a) demonstrating pleasure
b) bodily relaxation
c) assertiveness
d) express io n of a range of emotions
e) sensi tivity to the emotional needs of others
f) humour
g) creative self expression (such as singing
and dancing)
h) helpfulness
i) affect ion
j) self respect (such as concern about
appea rance)
k) acceptance of others who also have a
dementing illness, or other disability.
Altho ugh difficult to monitor objectively,
ca re staff and relati ves have noticed gener
all y improved alertness, happiness and
relaxa tion following the gro up in some
individual s and quality o f life is improved
at the time of the group. The progra mme
can "manage" behaviou r in some noisy,
distracted, disrupti ve or sleepy cl ien ts.
Clients have demonstrated their trust by
their continued free choice attendance over
a long period of time. Indi viduality in
responses is allowed. Dysphasic clients
have benefited from the social and com
municative aspect of the group and all
have tolerated the mixed memory abilities
and physical limitati ons of other cli ents .
SPEECH & LANGUAGETHERAPV IN PRACTICE WINTER 1997 6
ISSN (online) 2045-6174 www.speechmag.com
-- -
---
TJ IE ELDERlY
Appendix 5 - Occupational Therapy record sheet
Sonas ape
name diagnosis
ward communication
mental state/mood
elat.
1i$POIiDED-io SI6UTUII mE
-
PARTICIPATED IlIlmo SOIiG
PARTICIPATED III WICISES
)!mClPAnJ III SIIiG AlOIiG (0
J IIJOYJD MASSAGE. DIIIII
PDnCIPATlD WITH IIiSTlUfjEIiTS
AIISWERED pROVE.as
OFFEIED PARTY PIECE
III SlIIG AlOIiG
PAIIIClNnD III nOSlliG SOIiG
IISPOIiSE TO SWIOII (+VE OR - VE)
MOOD/COMUILICATlOIL
codes
QarticiQation mQod/communication
0 did not participate P passive or no spontaneous communication
1 required assistance/prompting to participate in B brighUchatty
activity A agitated/verbally aggressive
2 responded spontaneously
I
Appendix 6 - Group
record sheet
SOllAS oPc
group record sheer tor
Adaily reCord of chan '. word
communication as a interaction and
The programme's implementation has a Sonas diary, sum- Ch 0 attending 'SON
onge may occur In any ot rhe tol/ Wi AS aPe' group
highlighted potential for enjoyment marising the aims of
0 ng areas
through well-being activities for the more the group and atten
confused patients. Other such options dance details, to
I DATE
COMMEllrS
eye conroct
include privately arranged aromatherapy, involve carers and
smiling
an therapy (in two units), social activities relatives - panicu
and outings run by occupational thera- larly useful for the VOcal/sing
pists, music in hospital, relaxation, latter when they
ro/klng
Therapet service and reminiscence. can only visit in
rouchlng
the evening or at
exercises De elopments weekends. Some
We are continuing with our groups and relatives or
singing
more staff are being offered Sonas training friends, including
rhythmical movemenr
workshops to allow further groups to stan. a local minister,
The Sonas aPc training is suitable for all have sat in on a making aconrrlburlon
carers including nurses, volunteers and day group but this
using musical Instruments
Inreracrlng In rhe group
USing gesrure
complerlng proverbs
responding ro
IJ massage
2) rosre
3) smell
4) music
cued speech
centre staff. Running the groups requires has to be han
commitment and consideration died with care.
(Appendix 3) but the rewards keep us Some of the
motivated, as do interdisciplinary meet- evaluation
ings and contact with Sonas aPc trainers. forms we have
We are keen to maximise the potential for developed are
staff involvement and carryover. To this in appendices 4
end, we exchange information on clients' - 7; the speech
strengths at the end of the group, attempt ilnd language
to provide a written repon on client atten- therapy record
dance approximately every 10 weeks, dis- sheet (4) , the
playa client list in the ward with group occupational
aims boldly presenLed and disseminate therapy
information at social rounds with ward record sheet
staff. We are developing record sheets and (5, ) a group
SPEECH & LANGUAGE THERAPY IN PIMCTI CE WINTER 1997 7
ISSN (online) 2045-6174 www.speechmag.com
Appendix 7 - Performance Evaluation sheet
Sonas aPc . Performance Evaluation
nAME: WARD:

O. Too III/absent
I. Refused
2. Required encouragement
3. Passive
4. Came willingly
IOrientation/memory
O. Poor
I. With prompting
2. Good
I Interaction/relationships
O. Offered nothing
I. Spoke only to leaders
2. Interacted with one another
3. Interacted freely
4. Helped others
IContribution
O. Offered nothing
I. Disruptive
2. Contributions Inappropriate
3. Contributions appropriate
record sheet kept in case notes (6) and a
Performance Evaluation sheet (7) left in
multi-disciplinary team notes in the nurs
ing notes in the duty room.
This holistic programme is proving a wor
thy tool for use by PAMs with confused,
disorientated and socially deprived elderly
people. As therapists we feel we have skills
in observation, interaction, running
groups, communication and diagnosis
which allow us to implement it very effec
tively. For us, Sonas aPc is a quick and
effective way of creating rapport and giving
a greater insight into an individual's needs
and potential. 'it allows us to respond to
these needs and to have informed and real
istic exchanges with nursing staff, relatives
and other disciplines.
Lois Brown is a Speech and Language
Therapist, Pauline Dunsmuir and Julie
Loudon Occupational Therapists and
Rhona A1ontgomery a Speech and
Language Therapy Assistant with Victoria
Infirmary NHS Trust in Glasgow.
Iinterest/panlcipation
O. Offered nothing
I. Uncooperatlve
2. Joined In whh persuasion
3. Actively panlclpated
I Enjoyment/humour
O. Showed no signs of enjoyment
I. Occasionally showed pleasure
2. Enjoyed majority of session
3. Thoroughly enjoyed session
I level of activity
O. Persistent restlessness
I. Intermittent restlessness
2. Appeared calm and relaxed
I Concentration/tolerance
O. Poor
I. Patchy
2. Good
I Sens!dv!ty to emodonoi needs of others
O. Passive
I. Insensitive
2. Sensitive
Summary
A version of this article has been submitted
to the British Journal of Occupational
Therapy.
References
Kitwood, T. (1996) Not Them and lis
Simply Us Training Pack. Dementia
Services Development Centre, University
of Stirling, Stirling FK9 4LA, tel. 01786
467740.
Threadgold, Sister M. (1995) Sonas aPc
manual. Dublin.
Further information about Sonas aPc is avail
able from
Rosemary Hamill (MRCSLT, Dip. ACS, CMH)
Training Development Officer
Sonas aPc
Belvedere Place
Dublin 1
tel/ansa/fax 00 353 1 8366874
Sonas aPe facilitator:
Questions
What are the benefits of a Familiarity for this client group builds confidence,
repetitive programme for
MiW"IWJ.MI reduces tension, leads to pOSitive participation
elderly confused people? and triggers memories.
How is Sonas aPc improving A natural setting allows more accurate assessment
speech and language
of individual needs while therapeutic skills in
therapy provision? assessment, diagnosis and interaction enhance the
benefits of the set programme for the clients.
Are developments As well as highlighting the benefits of 'well-being'
IIIIIIIIactivities for this client group, opportunities for
taking place as a result of
the programme's involving relatives and carers are Deing followed up.
im prementation?
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 1997 8
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COUNSELLING
Neuro Linguistic
Pro ramming

Speech &
Langua e
-"'-hera i 's
Studying
Neuro Linguistic
Progranlming
has made a
significant impact
on the way
Caroline Skelton
works as a
speech and language
therapist.
In this
article she shares
its principles
and how she is
putting it
into practice.
~ u i d e
have always been interested in using counselling approach
es and psychological models within speech and language
therapy. In 1994 I took a short course in hypnosis and,
when I started in a specialist voice and fluency post in
Chesterfield later that year, sought supervision through the
psychology department. I was lucky to be offered this by a
Consultant Health Psychologist experienced not only in
using trance states but also in Neuro Linguistic
Programming (NLP). I have found NLP extremely useful and pow
erful in my work, and feel I am only just beginning to tap the huge
potential it offers for speech and language therapy.
What is NLP?
Neuro LinguistiC Programming began in the 1970s In Cali fornia. It
linked observable linguistic patterns to neural (thought) process
ing to find new ways of understanding behaviour and to pro
gramme (facilitate) change .
It was conceived by John Grinder. a linguist, and Richard Bandler,
a mathematician and psychotherapist. who were interested in
human excellence.They stud ied a number of therapists who were
outstanding in their field t o distil the crucial elements of their com
munication. Their aim was to model expert behaviour and lan
guage patterns. Bandler and Grinder's work identified interesting
patterns of language and non-linguistic communication, and al so
led to the understanding that these patterns represent the super
ficial expression of under lying thought processes. Grinder and
Bandler realised the therapists were using specific language pat
terns to challenge their clients' thought processes in order to open
up their thinking and make change possible.
As NLP developed, it focused on the processes and structure of
thi nking: how we perceive the world and how we organise our
experience, memories and learning. By studying these processes
in high achievers we can model their skills, and by understanding
faulty or ineffective processing, we can begi n to make positive
changes - for-oursel ves and others. NLP is now taught widely, and
SPEECH & LANGUAGE THERAPY IN PRACTI CE WI'lTER 1997 9
ISSN (online) 2045-6174 www.speechmag.com
COUNSELLING
the basic principles of modelling have been applied to business
and spor'ts as well as therapy and education. There is a growing
resource of NLP technology for therapeutic use, with change pat
terns designed to tackle particular types of difficulty such
dysfluency
Case 2 - CF
CF referred herself for therapy for a stammer
She presented with mild
characterised by repetitions and blocks
as phobias and weight loss. with high levels of avoidance at
Basic Principles dysarthn'a word and speech levels. She
We often interp,-et other people's "" attended for eight therapy
behaviour intuitively; a certain look . r I LN ."'" sessions, working on a
or tone of voice gives us a feel- / \..-d.::) - block-modificatIOn
ing about the person's state of LN was referred for speech and language therapy, " '\ approach. CF mC!dE
mind. IncreaSing the accur!- for mild dysarthna resulting from a brain tumour. LN s .\ good progress In
cy of our Interpretations speech had a fast rate, was larrcel
y
intelligible, but occasionally reducing
through good use of sen- I d Th fi d . h d .. 'd d
sory acuity is fundamen- S urre . I erapy ocuse on sowing t e rate an Improving avol once on
tal to the p,'actice of articulatory accuracy. LN made good progress with the Improving
NLP By improving our exercises, but still reported difficulty in slowing his . rate . . . contrc
observation of subtl e particular Situations, resulting In frustration and loss of Intelligibility. However ShE
changes in others, LN contrasted his VAKOG experience of "good" versus "bad" reported
we can make con- speech. In describing good speech attempts, LN was visually aware of continued
scious and less sub- his listener, auditoril y aware of his own voice, and aware of planning / difficulty wil
jecti ve intel-pret a- I h
tions based on an sentence construction in his mind prior to actually speaking. In the bad teep one
indi vidual's unique speech attempts, LN's visual awareness was extremely limited, he had calls at wo'
and minute varia- no auditory representation of his own voice but was acutely aware of when she
tions in behaviour. unpleasant tightness in his chest and generalised body tension. Having was require
NLP al so supports elicited VAKOG data in some detail, we "mapped across" sensory to repeat a
the premise that representations from bad to good, for example by expanding visual specific
awareness and filling in the absent auditory channel. messc:!e. She
ingful communi cation, Interestingly, during this process, LN linked his feelings of frustration blocke
and gives the therapist to similar feelings experienced as a child when, as one of uncontrollably,
additional tools to build seven children, he had had to compete for attention and and sometimes t
rapport with even the most had not been "heard" to his satisfaction. LN felt that the phone down
challenging clients. NLP IS expe- NLP therapy had been an important part of his without saying a sing
riential rather than theoreticaL but process in modifying his speech, and was word.
there are a number of basic princi- " positive about general ising the gains he We discussed in detail
pies or pre-suppositions which need to had made. He will be seen on a exactly 'vI/hot CF was
be understood. Here are a few:
I. We experience the world thmugh our review basis. visua/ising, hearing and feeling
senses, ie. vi sual, auditory, kinaesthetic. olfactol-y and each time she mode the call. It
gustatory (VAKOG). Our language and vocabulary renect became apparent that even before ShE
our sensory processing in a literal manner (eg. " I see what you started to dial the number she was "hearing
mean", "t hi s sounds interesting","1 feel sure", "that stinks", ' 'I've got herself stammering on a particular consonan
the flavour of that"). I We used on NLP swish pattern to change
2. Our learnings and memory consi st of VAKOG data. Changing this unconscious rehearsal of the stammer
t he qual iti es of our sensor y representations (size, colour. pitch, vol
ume etc.) wi ll change the quality of t he experience. into the desired smooth speech, so that eac
3. We use our experience to create our own map of the world. time CF dialled the number. she automatical,
Each of us operat es from our individual map. The "map" is not the imagined saying the words We also
same as the "terr itory". used a circle Of excellence which helped CF
4. Our behaVi our is goal -dl-iven. (athel- than simply responsive to to approach the situation in a calm state. C
stimulus. All behaviour has a positive intenti on (consci ous or filled her imaginary circle with coloured lighr
unconscious) and at any given time we make the best choice avai l- representing relaxation and confidence. By
able to us. I'
S. Most of our behaviour is carried out unconsciousl y. Our con- stepping into her circle prior to making
scious minds can process onl y a limited amounl of informati on at telephone calls or entering other stressful
any one ti me. situations, she was able to access a
6. We are limited by the choices we perceive, therefore it is help- controlled state,
ful to widen our perceptions t o increase the range of options Six months later. CF reported that she was
avai labl e t o us. able to make the phone calls with only
7. All t he resources we need al-e availabl e to us from dwect or I d d
occasiona easy soun repetitions on , mol"
indirect experience. C
importantly, with a feeling of control. F
continues to be seen on a long-term review
Principles into practice
I attended an NLP Practit ioner ( OUI'se in 1996, and hope to com
Ibasis.
plete my Master Practitioner training in January 1998. In common
10 SI'I'I' CH & LANGUAGE THLlv\l>Y IN PRACTICE WINTER 1997
ISSN (online) 2045-6174 www.speechmag.com
COU SELLlN
At 62 years old. AM suffered a severe
stroke with right-sided weakness and
mild dysphasia. This came as a serious
blow to AM and her husband who
were looking forward to retirement in
the country. She was using a wheel
chair, was dependent on ner family
and had been forced to give up a
busy social life. Nine months after the
stroke. AM had only occasional word
finding difficulties resulting in hesitancy.
but t hi s was made significantly worse
by anxiety and lack of confidence. AM
ad itted she was avoiding speaking
-it a Ions and limiting her return to
socia lsi g because of this anxiety and
lack of corfi dence in her speech.
In a li ght trance. AM identified the
resources she needed to tackle social
speaking s ations. She was able to
recall t imes In her life when she had
felt the determi nation and courage
she presently lacked. With guidance.
AM accessed these resources from
her past memories. was encouraged
to re-experience those strengths in
t he present and to picture herself
using them in identified situations in
the future. In the weeks following the
session, she did in fact tackle several
of the previously feared situations.
She reported that although her
speech had not been fully fluent. she
had a different attitude and her
confidence improved through coping
with the challenge.
LJ was referred to the speech and language therapy department with a three month hi story of severe dysphonia
following 'flu, which meant she had been unable to perform her job. She worked in personnel management in a large
company undergoing major change. Her department was short-staffed and LJ had been under a lot of pressure, but
she was reluctant to accept her persistent dysphonia might be stress-related.
LJ attended four therapy sessions to work on relaxation, deconstriction of the larynx and voice facilitation. She was
able to achieve good voice quality on single sounds within the first session, but after four weeks was still unable to
sustain voice beyond phrase level.
The fifth session was spent on an NLP reframing p,attern. This technique assumes there is a positive intention for all
behaviour. It also relies on the metaphor of "parts '. The client is asked to set up a communication with the part of
herself which is controlling the unwanted behaviour, i.e. the dysphonia. The client then asks this part what its intention
is. In a I ~ g h t trance, LJ was able to access this part. Its initial response was concerned with slowing down, which LJ
found perplexing. After further questioning, she realised the underlying intention was to look after her health. LJ
recognised thi s as a worthwhile aim. and we then talked about other options for pursuing this aim in a more adaptive
manner. LJ came up w ith new choices and negotiated w ith the part to relinquish its original strategy in favour of a
new alternative. The final step is an ecology check, to ensure the new strategies are acceptable and appropriate.
Having completed the reframing, LJ's voice started to improve rapidly, and after the following session she was put on
review.Two months later, LJ reported that her voice had been " normal" in the intervening period. She had chosen to
resume work on a part-time basis. and had been able to talk on the telephone and in Important meetings without
any difficulty. She was discharged.
SPEEC H & lANCUACE TI-iERAPV IN PRACTICE WINTER 1997 11
ISSN (online) 2045-6174 www.speechmag.com
COUNSELLING
with the best of my own learning experiences, NLP has been Caroline Skelton is a Specialist Speech and Language Therapist for
famili ar enough to support and explain what I already know, whi lst Chesterfield Royal Hospital NHS
chall enging limiting beliefs and all owing me to expand my learning Calow,
further. Derbyshire S44 5BL,
Four case histories are described (Cases I - 4) to illustrate how I tel. 01246 277271.
have begun t o use NLP in speech and language therapy. Some of
the change patterns are more effective using a trance state simi lar Further information on NLP training from:
t o deep relaxation. I always discuss thi s with the patient first and ask Centre NLP
them to sign a consent form for hypnosis. My clients are all adults PO Box 178
with acquired disorders or dysfiuency, and I have tended to use Leicester
NLP patterns where I already have a counselling role. However, LE38ZU
the use of sensory acuity and rapport ski ll s is central to all thera t el. 0 I 16 2873356.
peuti c intervention, and equally applicable to any client group.
I have been fortunate in attending the courses and receiving Recommended reading:
supervision for my work but, for anyone interested in finding out Bandler, R. and Grinder, j . ( 1979) Frogs into Princes. ISBN 1
more about NLP. there are a number of trai ning companies who 870845-03-X.
offer introductory courses and most good bookshops now sell a O'Connor. j. and Seymour. j, ( 1990) Introducing NLPThorsons.
reasonable range of titles. I look forward t o hearing other thera McDermott, I. and O'Connor, j. (1996) NLP and Health. ISBN 0
pists' experiences of N LP 7225-3288-1.
This article is the first in a short series looking at how speech and language therapists have used training in other fields
to assist their work. Personal construct psychology and family therapy will be featured in future issues.
Questions Answers
Why does NLP work? NLP observes patterns of communication, relates
them to underlying thought processes and uses
language to challenge ana open up the mind to change .
How can NLP inform
111i'MfMllinterpreting behaviour become more honed tnrough
tiIThe skills of tuning in to a client, building rapport and
speech and language '
therapy at a basic level? NLP training.
What does NLP add to NLP recognises the importance of confidence and
traditional speech and attitude in overcoming communication difficulties and
1rMU allows people to identify and prepare positively for language therapy
approaches? !II.!! difficult and stressful situations.
RESOURCE UPDATE. _.RESOURCE ..RESOURCE UPDATE..
effect of Down's Syndrome on
Dysfluency
A booklet Dysfluency, Stammering &
Down's Syndrome has been produced
by the British Stammering Association
and the Down's Syndrome
Association.
Written by Monica Bray, Leeds
Metropolitan University, the book
let explains dysfluency and the
language and fluency and uses
the demands and capacities
model to explain how people
can help (3.50 for 10 or 40p
each inc. pap).
The BSA can also supply copies
of other books, including a new general text
The Stammering Handbook, by Jenny Lewis (Vermilion) and
Coping with Stammering, a self-help book for adults, by Trudy
Stewart and Jackie Turnbull (Sheldon Press).
Details: BSA, tel. 0181 983 1003 / DSA, tel. 0181 6824001.
12 SPEECH & lANGUAGETHERt\PY IN PRACTICE WINTEH 1997
Signalong
for new
The SIGNALONG AT
motHers
WORK series continues
An updated leaflet on safety at work
with the publication of
for new and expectant mothers has
General Retail (17.50).
been issued by the Health & Safety
The vocabulary is
Executive.
aSSOCiated with super
An amendment introduced in 1994 to
markets, DIY stores,
1992 legislation means if particular
garden centres, filling
risks cannot be avoided by other
stations, dry cleaners
and hairdressers,
means, employers need to make
Changes to the working conditions or
safety, equipment,
hours of a new or expectant mother
tasks and job titles.
or offer suitable alternative work, or if
The next book in the
this is not possible, give her paid leave
series will deal with for as long as necessary to protect her
Horticulture and health and safety or that of her child.
Agriculture and The leaflet is aimed at employers,
suggestions are employees and representatives.
welcome. Details: Kay Ref The Management of Health and
Meinertzhogen, tel. Safety at Work (Amendment) Regulations
01634832469. 1994, ISBN 0-11-043021-2, 1.10.
including health and
ISSN (online) 2045-6174 www.speechmag.com
SPECIAL FEATURE
In two papers, the
Speech and Language
Therapy Service of the
Camden and Islington
NHS Trust and the
Department of Human
Communication
Science, University
College London (UCl)
report on joint
projects combining
genuine service
requirements with the
need to offer high
quality, supervised
cHnicai practice for
students.
A service
-
I.Group
p'lacements
in Under Fives
Centres
2. Group
placements
With adults with
a leaming
disability
by Ann Parker and
Keena Cummins
I. Group placements in Under Fives Centres
This project was designed to solve two well-known problems. The
first. limited staffing resources, is sometimes given as a reason for the
second, a shortage of clinical places for speech and language therapy
students, but we aimed to combine effective use of limited clinical
resources for children under five years of age with a consistent. well
supervised and high qualiry learning experience for students.

In reassess ing the available resources wi thin the Camden and


Is lingto n N HS Trust Health Centres' team, it had become increas
ingl y apparent that a policy of prioritisation was required. The
available literature outlined the importance of ea rly intervention
and its positive effect on prevention of secondary emotional disor
ders, language difficulties and ultimat e cost effect iveness (Ward
1992), and so the system for speech and language therapy within
local Health Centres had been tailored to focus on parent interac
tion using video play-back (Kelman and Schneider 1994).
However, it was felt many children continued to be missed fwm
the process, particularly in some catchment areas where failure in
attendance was still high. A development was therefore required to
address the needs of these children, without diluting service deliv
ery within Health Centres where parental involyement was a pri
mary target. and without increasing waiting lists by relocdting staff.


A review of clini c- based learning opportunities available to the
Department of Human Communcation Science, UCl, had high
lighted the value of facilitative, adult lea rn ing models (Marson
1990) in developing students' confiden e. Where students were
given a range of genuine responsibi liti es they were helped to
achieve a realisti c picture of the role of the speech and language
therapist, in terms of both work with clients and general clinical
management.
While the learning environment needed to be supportive and struc
tured, and provide a hi erarchy of learning, experience with paired
and group placements - more unusual in service settings but stan
dard practice for university-based clinics - seemed to indi ca te con
stant one-to-one supervision, while valued at many stages, was not
SPEECH & LANGUAGE THERAPY IN PRACflCE WINTER 1997 13
5
ISSN (online) 2045-6174 www.speechmag.com
SPEClAL FEATURE
necessarily the ideal for every placement. Feedback from our stu
dents matched reports from other initiatives (Grundy, 1994;
RCSLT, 1996). Placement in a group of peers seemed to offer a range
of additional opportunities, such as learning to work in a team, use
of peer support and feedback and a degree of responsibility for a real
task which supported confidence in problem-solving approaches.
Group placements in a singl e department provided a consistent
experience for the students and a greater number of placements
under the supelVision of a smaller number of clinicians. They also
offered a view of the student team as a resource, rather than a drain
on the resources of the speedl and language therapy service.
.
The underlying philosophy of the student learning process for this
particular project was that of a hierarchy of learning, making use of
a didactic language enrichment programme in association with an
introduction to the interactional model through student self-analy
sis. The Let's PIa), Language Scheme (Barnell and Fletcher (985)
was chosen because of its definition as an enrichment programme,
rather than a therapy tool, its strengths being provision of a basic
screening procedure, with identification and differentiation of chil
dren at risk of communication difficulti es, and structured group
activities provided in a specific daily programme.
The students were to take responsibility for learning through gener
al peer support, regul ar video-recording for daily peer feedback and
review and constant telephone access to supelViso rs Video equip
ment was an essential tool for the project and the key support sys
tem was a weekly tutorial, provided jointly by staff of the Camden
and Islington Speech and Language Therapy SelVice and UCL.
P
PreparatOlY work for the project included meetings and policy
decisions between the Educmion Department concerned, the
Camden and Islington team, UCL clinical tutors and the Heads of
Nurseries, as well as obtaining parental consent for both the pro
gramme and the use of video-recording. Four Under Fives Centres
were selected thmugh identification of the highest ratio of children
considered to be at risk of language delay.
1r[jatUlill il f(iJ g
[n addition to checking the students' e.,xisting knowledge of a range
of relevant formal non-verbal and communication assessment pro
cedures, their direct preparation for the project included two train
ing days during the first week of the block placement. interspersed
with two days within the placement environment. Staff members
from the Centres and UCL contributed to both training days to
emphasise and support the cooperative nature of the proj ect, but
the content was primarily devised by Camden and Islington teams .
Day one focused on orientation, aims, expectations and anxieties,
Health and Safety issues and uaining in use of the Let's Play
Language Scheme. For the second day, each student was requested
to bring one video of themselves interacting with a child and one
video of a group of children.
Day two focused on interaction and problem solving. Students
were introduced to child and adult interactional styles (Weitzman,
1992) and the parent-child interaction model as described by
Kelman and Schneider (1994) with specific relationship to parents.
,This system was then adapted for student use. Subsequent group
tutorials provided support for individual student's assessment of
their own interaaion abilities, abstraction of an adaptational aim
for the next stage of work and problem-solving focused on situa
tions which had arisen within the working environment.

Each pair of students spent the first week of the four-week place
ment screening all children within the Centres. Their second week
involved setting up a timetable, appropriately grouping the chil
dren and embarking on the programme. The third and fourth
weeks involved continuation and extension of the group activities
from the programme, adapting activities where relevant, monitor
ing development through note-keeping, re-screening and comple
tion of a summary report. All therapy was videoed and individual
video interaction sessions were carried out on a daily basis

Tutorials were held in a weekly, hair-day session and focused on:
i. Feedback and problem-solving.
ii. Feedback of each student's personal child-adult interaction,
including identification of a new individual aim.
iii. Group video: discussion of behaviour management and adap
tation of activities.
[n this way students were introduced to case presentation, and were
encouraged to discuss issues that might lead to resistances, blocks
or obstacles to learning (Boyd Webb, 1984) and thereby limit the
efficacy of their worl<.

Throughout the programme students completed a Personal
Professional Profile which included personal skills, clinical skills
and professional behaviour as demonstrated. In addition, subse
quent to the placement, they completed an assessment question
naire and were provided with personal assessment grades. There
was also a closing summary meeting in which the process was
reviewed, identifying goals which were met successfully and those
which would need to be adapted in the future.

At reassessment all the children had improved since screening.
Those children whose rate of change was reduced were recom
mended as needing to be referred to the speech and language ther
apy selVice. Feedback about the process was provided in writing
through individual forms tailored for students clnd nurseries.
The students reported they had benefited from having insight into
the working nursery environment, experience of liaison with and
support from Centre staff with in-depth knowledge of children, the
opportunity of learning about organisation and time management
in association with working with children at a range of develop
mental stages. They also appreciated the opportunity to gain expe
rience of children with and without communication difficulties,
both within groups and on an individual basis, and to give lan
guage support to children who normally might not have the chance
to attend speech and language therapy.
The nurseries reported they had benefited from being provided with
assistance in identifying or confirming children with language diffi
culties, a model of speech and language therapy, and the process of
additional language enrichment. They noted the children benefited
from structured and specific input in regular sessions, more close
contact work and an increase in confidence and general skills. The
students were also said to have provided a positive contribution to
organisation and record keeping. All Centres reported they would
like to be included in any further pilots canied out.
lE1flf@
(ffi [j[JU [JU g
Pine & Horne (cited in Boyd Webb, 1984) olltline some specific
prerequisites for effective Jearning. They sta te the learning environ
ment should
a) encourage people to be active
b) emphasise the personal nature of learning
c) accept that difference is desirabl e
d) recognise people's right to make mi stakes
e) tol erate imperfection
f) encourage openness of mind and trust in self
g) make people feel respected and accepted
h) facilit ate discovelY
i) plll emphasis on self-evaluation in co-operation and
j) permit confrontation of ideas.
Our discussion with the students indicated that group placements
with a genuine purpose, structured as a team project, can offer a
14 SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 1997
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SPECIAL FEATU RE
strong model in all of these areas, with experience that is comple
mentary to that provided by individual placements.

The students provided an additional service, augmenting existing
support for the needs of the children within the Centres, providing
an essential link and model to Centre staff and paving the way for
further training and input addressing more specific communica
If
tion difficulties. In adopting an interactional model, the therapists
were also able to learn about transference of skiJls from one care
group to another, in preparation for empowering Centre staff
through this technique. It was exciting to work with such a highly
motivated group of students who were open and prepared to take
risks with ideas and questions, and willing to learn from mistakes
in order to develop their personal sl<ills.

Liaison and continuity 0 interaction between lecturers and supervis
ing therapists were optimum. The experience obtained was con is
tent for each student, making assessment of progress easie.r and more
definable, and the mutual understanding between those irl\ h d
more explicit and detailed. A larger number f students provid
ed with a strong experiential learning environ ment an I the range of
experience and responsibil i[ enrourag d an inCIease in students'
confidence. The establ ish me.nt of a commitment to a group place
ment with joint aims means that a more consistent relationship,
with more frequent contact and discussion, can be formed between
a University-based tutor and the speech and language therapy ser
vice, to the benefit of all the panicipants in the project.
ih [J
While modifications and improvements will undoubtedly be
involved, we are continuing and developing this approach in further
under fives centres and other settings. Specific developments
include extension to other groups of students and provision of
workshops in under fives education centres by speech and language
therapy to augment understanding of the needs of children with
speech and learning difficulties through an interactional model.
At University College London, we have built into our placement
system a stronger focus on paired and group placements, with
developments such as workshops for our students to help them
make the most of opportunities to work in such teams. Other
workshops for supervising therapists and University-based tutors
enable discussion of ways to support the development of students'
skills, autonomy and confidence in such settings while providing
high quality supervision. It is hoped all our students will have the
opportunity to learn in paired and group service-based settings as
part of their clinical experience.
References
Barnett, M. and Fletcher, s. (1985) Let's Play Language. Cambridge:
LOA publications.
Boyd Webb, N. (1984) From Social Work Practice to Teaching the
Practice of Social Work. Jorll"lll1l of Educlltion for Social Work 20 (3).
Grundy, K. (October 1994) Peer placements: it's easier with two.
CSLT Bulletin.
Ke!man, E. and Schneider, C. (1994) Parent-child Interaction: an
alternative approach to the management of children's language dif
ficulties. Child l.ang1lage, Teaching and Therapy 1 (1).
Marson, S. (1990) Essentials of Management: Creating a Climate
for Learning. Nursing Times (86).
RCSLT (1996) RCSLT Forums on 7ilwring for ExpeJiential Learing:
fillal report of the RCSLT Illitiative, 1995-6. London: Royal College
of Speech and Langauge Therapists.
Ward, S. (1992) The Predictive Validity and Accuracy of a Screening
Test for Language Delay and Auditory Perceptual Disorder.
Ellropeall Joumlll of DisordeJs of Communiclltion 27.
Weitzman, E. (1992) Learnillg LlIllglwge and Loving It . Hanen
Centre Publication.
SPEECH & LANGUAGE THERAPY IN PRACTlCE WI! -ER 1997 15
ISSN (online) 2045-6174 www.speechmag.com


SPECIAL FEATURE
2. Group placements with adults with a leaming disability
This project was concerned with fulfilling a genuine service need
while offering a group placement for students in a spedalist area of
work, adult lea rning disability. The aims were to;
provide clients with an appropriate service response to their com
munication need
provide the four students concemed with an opportunity to
respo nd to a genuine referral from its onset
prepare the students for the particular nature of the placement
before starting
give an opportunity for peer support in the group and in pairs.
In addition, it was possible to avoid one difficulty therapists in this
team had experienced; this placement was specifically designed for
a group of students who had requested to work with adults with
learning difficulties and was offered in a block placement period
designated for adult work. When the focus of placements for a par
ticular year group had been work with children, students placed
with the team had viewed the placement at best as a welcome
alternative and at worst as a poor subsUtute for the unavailable core
placement.

Four third year students who had expressed an interest in working
with this client group attended a two-week group placement block
within the Speech and Language Therapy Learning Disability
Service, based in two multi-disciplinary teams. The students' main
focus was to work in pairs, following through two speech and lan
guage therapy referra Is.
In preparation for the placement, a college-based orientation ses
sion was jointly led by the therapy tea m leader and the college
placements' coordinator. This session provided an opportunity for
the students concerned to gain an overvi ew of the placement and
to discuss their previous clinical experience and current skills and
needs. The aim was to prepare the group for the nature of the place
ment and to emphasise the collaboration between the college and
the placement tea m. The responsibility and degree of student
autonomy in the programme was to be. balanced by a careful struc
ture for peer support, with group supervision by the therapy team
on a regu lar basis throughout.
week-One
otlentation to location and timetable
1. Three clients had been referred from a local day service and were
on the speech and language therapy waiting list. Key workers had
requested an assessment of their communication with the aim of
identifYing strategies to support each client with a focus on group
dynamics.
2. School pupils attending a Link Course at a local Further
Education College required a communication screen to identifY
their needs and enable therapi sts to plan their provision for the
forthcoming full-time course.

During the final feedback session the students listed the ski ll areas
in which they felt they had had an opportunity to deve lop:
1. interacti on skills with a new client group
2. observation
3. precise note taking and report writing
4. gathering and pooling of informati o n
5. developing a framework for screening and assessment
6. drawing conclusions
7. time management
8. collaboration
9. introducing self to staff and clients
10. negotiating with staff
11. fitting into a Service and team
12. independence and flexibility
13. evaluating own work and interact ions
14. problem-solving skill s for specinc situations, such as clients
absent during planned assessment time, general time constraints,
other priorities for staff and unpredictabl e events.
Each student was also asked to complete a detailed individual eval
uation of thei r experience in this placement. All four students list
ed a range of advan tages of this type of group placement, that is,
one with a specific task. From their evaluations, certain themes
emerged:
1. Peer placement offered support, shared knowledge and ideas,
reciprocal learning, a less daunting experience, "someone at your
joint visits with speech and language therapists, meeting people who have a
learning disability
assessment workshop
meeting with other professionals based within the service
development of a screening assessment to be used with clients
discussion of strategies to use with clients/carers during the placement
Week Two
visit to referral locations
presentation of draft assessment process to peers and then to therapists
completion of screening assessment
analysis of assessment results
presentation of assessment results to peers and therapists
end of placement evaluation.
16 SPEECH & I ANGUACL 11-fERAPY IN PRACfICE WINTER 1997
ISSN (online) 2045-6174 www.speechmag.com
SPECIAL FEATURE
Answers
A is required between education
8 ...establishments, speech and language therapy service
managers and clinical tutors, providers of potential host
services and students; client consent is also needed.
M ...U .,NI Adequate orientation sessions, tutorials, telephone
"1access to tutors, video equipment, time with each
.,.... other and protocols for self-assessment are required
"!'I for maximum benefit.
Group placements develop team working, peer
support and confidence as a result of responsibility
for real-life problem-solving, can provide a service in
under-resourced areas, and allow clinical supervisors
to concentrate on delegation and management.
own level ". Two students expressed a preference for peer place
ment, while the others found this "equally enjoyable" to an indi
vidual placement.
2. Group support from therapists provided useful direction, a
wider perspective, opportunity to question and helpful feedback in
a non-threatening context.
3. The single focus provided by the specific project was preferred by
three students and all felt they had the same opportunity to gain as
broad a pi ot ure of the service as in other placements.
4. Support from UCL was seen as more indirect, but available when
required.
One student commented that potentially group placements might
give a less committed student the opportunity to opt out and rely
on peers, although this had not been a problem on this occasion.
All students questioned the necessity for the pre-placement
preparatory session, and in this respect (see below) this compo
nent was more beneficial to the service than to the students.
l. The students were far more independent on a peer placement
compared with those on single placements because of the support
they were able to offer one another.
2. Support for the group from therapists was seen as time-effective
with the focus on facilitating the student team in problem-solving
and less need for didactic teaching.
3. The single focus provided by a specific project enabled an
increase in output from the service. Careful selection of referrals to
be followed through was seen as essential to the process.
4. The preparatory session, jointly led with the university depart
ment, focused the student group, gave recognition to the relevance
of the placement and accelerated the typical student adjustment
period for this area of work. Before this, the planning stage had
included a half-day workshop for the speech and language therapy
team, which renewed enthusiasm for student placements and
enabled the staff to consider strategies for supporting a group
placement.
Group placements are not a new idea. They have been operated for
many years in university-based clinics, where the advantages are
acknowledged to be different types of learning opportunity, not
only an increase in available-placements. Service-based placements
can also offer this type of learning experience, with the same range
of specific advantages for the students involved. The focus on spe
cific projects allows the students to be seen (and to perceive them
selves) as a professional resource. All four students enjoyed and
learnt from the placement, and three reported a particular interest
in working with the client group in the future. The speech and
language therapy team continue to offer peer placements and are
planning further group projects, and the UCL placements team
continue to be enthusiatic about group placements focused on a
real service need, as a basis for high quality learning opportunities
for students.
The authors
Ann Parker, Senior Lecturer in Professional Studies at the
Department of Human Communication Science, UCL wrote the
first paper with Keena Cummins, Principal Speech & Language
Therapist working in Parent/Child Interaction for Camden &
Islington Community NHS Trust and the second with Rachel
Farazmand.. Therapy Team Leader with the Camden & Islington
Speech & Language Therapy Learning Disability Team.
Acknowledgments
The authors are grateful to Al ison Ruddock (Principal Officer for
Under Fives) and her coll eagues, the Heads and Staff of the Under
Fives Centres and Further Education College and the Learning
Disability Service staff. Thanks also to our colleagues in Camden &
Islington, especially Sarah Hulme, Rob Spence, Claire Topping, and
those at UCL, Myra Kersner, Rachel Rees and Maggie Vance. We
should also like to thank the families and clients concerned and the
students themselves, now qualified speech and language therapists.
Note
UCL's Department of Human Communication Science
would be interested to hear from any Speech and
Language Therapy Service Managers who would like to
develop similar projects with groups of students. Please
contact Ann Parker, Department of Human
Communication Science, Chandler House, 2 Wakefield
Street, London WClN IPG.
SPEECf-1 & LANGUAGE THERAPY IN PRACI'lCE WINTER 1997 17
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COVER STORY
Memory involves all the
senses, but auditory
memory deficits have a
particular impact on
language development
given the transient,
sequential nature of the
spoken word.
Here, Maggie Johnson
describes the approach
adopted at Gap House
School for addressing
auditory sequential
memory deficits in
children with a
developmental speech
and language
disorder.
Lost

in a
moving
stream

audrtor.
sequen lal
de lerts
M
emory is fundamental to the process of language acqui
sition and involves:
immediate recall (shon term memory)
recall of serially presented information (sequential
memory span)
retention of information while processing and acting on it (work
ing memory)
storage of information for future use (long-term memory)
Talking to parents
It is often difficult for parents to appreciate the difference between
listening memory, which is sequential, and visual or experiential
memory. Assessment findings may seem contradictory; "But he
remembered exactly where we used to collect conkers when we
went back five years later - he's got a better memory than me! ".
It is imponant to explain these differences early on in simple terms,
for in complex language disorders residual auditory memory
deficits are likely to persist into adult life. The Generation Game
conveyor-belt analogy is a useful one which captures the now-you
see-it-now-you-don't aspect of sequential memory - images which
seemed so clear a moment ago are quickly lost in the moving
stream of casseroles and cuddly toys .... .... How much harder it
would be if you had to recaIJ those prizes in the same order as the)!
had appeared - yet in spoken language with its phonological,
morphological and syntactic sequences, that is exactly what is
required.
It is also necessary to explain the difference between rote memory
which is generally associated with a good memory span but
requires no comprehension, and verbal memory of which compre
hension is a vital component. Most people can recall no more than
18 SPEECH & LANGUAGE Til ERAPY IN PRACTICE WINTER 1997
ISSN (online) 2045-6174 www.speechmag.com
six
or seve n
words in
II. Long-term Memory
or many presentations.
(a)
Can you say that
again a bit at
a time please?
COVERSTOR
weakness (Fig.I) .
(ii) individual learning
(i) direct work on extend
ing memory span / i mprov
ing retention
(ii) classroom support
(iii) compensatory suategies.
At Gap House we tend not
to work directly on extend
ing auditory memory span
(i.e. gradually increasing
from two to three to four
items and so on) beyond
seven to eight years of age.
This is when basic auditory
memory span (as measured
by digit repetition) tends to
plateau, but verbal memory
(as measured by sentence
repetition) continues to
increase as the child's com
prehension and syn tactic
ability improves. Instead,
we concentrate on usi ng
semantic organisation, visual
imagery and cueing strate
gies to improve retention of
verbal information, and
bu ild up co mpensatory
s:tTlIlegies to prepare chil
dreJl for when they l eave
the school.
l1troughout their time at
Gap [l ouse, children are
helped to recognise and
ac ept their problems. It
can make n enonnous dif
ference to know they are
not gelling it wrong, they
simpl y ca nnot remember.
The focus is then on find
ing a way round the diffi
culty rather than feelings of
failure. All work is done in
groups so that the children
can learn from and support
each uther. As a general
rule they are discouraged
sequence if pre
sented randomly, but
they will manage 20
words perfectly, if pre
sented in meaningful
sentence-form. Children
with comprehension dis
orders do not have this
advantage and can there
fore hold very few ideas
or key-words at anyone
time. They may have a
well developed rot e
memory for vocabulary
and sentence patterns
however, leading to com
paratively fluent expres
sivelanguage.
This article will describe
the approach adopted by
therapists at Gap House
in addressing auditory
memory limitations.
The children are aged
between 5 and 11 years
and present with a range
of speciftc and complex
speech and language di s
orders. They fall within
the broadly average
range of ability overall.
Experi ence shows these
children are unlikely to
find a ' cure' for their
poor auditory sequential
memory. Our aim there
fore is to extend memory
span as far as possible
and then heir develop
compensatory tech
niques which can be car
ri ed into adult life.
Assessment
Assessment will include
both formal and infor
ni'al measures, and
involves identifying:
(i) areas of strength and
Figure 1: Assessment I Observation Checklist
Short-term auditory sequential memory - immediate recall for
spoken word.
(a) Digit Span, eg.3-5-1
(b) Word Lists. ego cup-horse-bike
(c) Sentence Repetition, eg o The dog barked at the cat.
- information is committed to memory after a few
Rote-sequences
nursery rhymes, familiar slory
days of week
seasons
months of year.
(b) Comprehension of rote-sequence
answers questions about rhyme/story
knows what day it is I what day comes after Thursday I
when goes swimming, etc.
knows which season their birthday I Christmas is, el c.
knows what month it is I whose birthday comes first , etc.
III. Working Memory - continuation of short-term memory traces
while information is processed and acted on.
(a) Digits
time-lapse, ego write down sequence of digits after 30 seconds
mental arithmetic, ego write down digit plus 2 (i.e. I say 4, you
write down 6) .
(b) Words
time lapse, ego Pass on 'shopping list' to person in next room
time lapse plus distractors, ego Hunt through box for these 3 items ...
syntactic processing, ego sentence formulation I narrative using
two to three stimulus words
semantic processing, eg - Odd-Man-Out: which word doesn't belong?
(word relationships) - Similarities and Differences: how are
'orange' and 'apple' the same, and
how are they different?
(c) Sentences
time lapse, ego "At the end of the session can you tell
Daniel it's his turn please?"
verbal absurdities, ego say why sentence doesn't
make sense: " I kept my hands in my pocket and blew
my nose."
deductions, ego What Am I? (child uses three
clues to deduce answer)
inference, i.e. Uses own knowledge to supply
missing information, ego "There was a loud
bang and glass in the road. What had
happened?"
strategi es (Fig.2). hates the story-tapes we got for the car - from guessing unl ess the adult asks them
This second aspect is parti cularly signifi there are no pictures to follow". to guess (they' ll need to do thi s during for
cant for its implications in planning inter mal c1SS oss ment, for example). They learn
vention, and helps tu explain apparent dis Intervention it is more effective to say "I forgot what you
crepancies in performance. One parent said", ask for repeti ti on or seek confirma
commented after discussi ng her child's Intervention can be thought of in three tion ("Did you say ... .7"). Conversational
;}SSE'SSment flDdings "So that's why she main strands: repair of this type plays a large part in
SPEEC [ [ & lANCUACE THERAPY [N PRACl'ICE W[NTER [ 997 19
ISSN (online) 2045-6174 www.speechmag.com
COVER STORY
Sorry, I can't
remember
all that.
oping com
pensatory strategies and
this is documented in more
detail in "Functional Language
in the Classroom" (FLIC) under
the chapt er on Active Listening (Johnson,
1996),
Figures 3 and 4 outline the main tech
niques used at Gap House,
especially the
Continued
needs to
way process
teachers
to check
standing
modify
delivery if neces
sary, and
dren prepared
to let teachers
know they are
having diffi
culty,
children will
need confi
What next?
dence to do
this howev
On leaving Gap House, the children's par
er, and this
ents and receiving schools are provided
involv e s
with an advice sheet on compensatory
more tha n
strategi es (availabl e from AFASIC, Glossary
arming
Sheet 26) . It is imperative that any resid
th e m
ual auditory me mory limitations are recog

Figure 3 : Intervention Strategies
Key Stage 1
STRATEGY
nised by all involved,
child ,
support
be a two
with
prepared
unde r-
and
their
chil
Figure 2 - L
earning S
QUESTION trategies
Has Ch' l
Idgot ;
sPok'en in' ,mmedlate
Is Child' ormation? recall far PROCESS
s memo ' A IIMPL
marginally i ry for lists of Udllory Me ICATION
t
g
, CUP-blue"troved by add7
0rds
only C mary Span
, s Immedi Ig Vs. big_ b ng meanin? omprehe '
recall impro Iue-cup g , affeCting prOblems
What t IS presente If r al memo
of ViSUal su d VISually? ViSUal me ry
C
' PPOrt i a man"
an child s mOst Pproach' T , multi-sensa
Are lest malery Out a spoken ' Slfjning, sym ' ry
,
Whl'e inslrUClnals available ,instrUCtion? ,v:rttten W0n:1 Cha
bOIS
, Pictures
s P IOns ' lOr s ' verb I ' rts '
, 9rtorrnanc , given? canning M a Compre" , COIourCOc/i
Child has e e (,) better .. ay be USin ' ension ng
Instructlon/es Shut while WOrse if (C)hunk cUe to
en/ng 10 I eXlemaJ IOn
so /m c!Jstraclors
The after tl/ne_l Out sPoke ma/en I ViSual
Can Child
carry
(ii) proved ab'l, remoVed,
of was refiant on Iy to mentallse
task and s perform POOrl WOrking I'll
Does Child apSe? n InstrUction s to
alWayS ha lJddenly 'Click,toBI start of
than Va to be d a task
emory
WOrking I'll
Can explained? emonslrated S
child h I rathe,
emory
Order to dad verbal
informat ' ef/ve fUrther ormation In
o Ian Cre meani
Oes Child a atlvely? ng I USe SemantiC I S
mformatlon . a beNer On ab prOCeSSing y,n/aCtic I Phonol '
(eg, can do preSented v aVe tasks If
P Us WOrkin 0g,caJ
but not If h dd-Man-ou ISUally?
ears WOrds) t IVlth Pictures So can C Working me
E/I/n ' g memory
inates
Of) oncentrat mary
proceSSing e
EXAMPLES / COMMENTS
Basic listening / attention skills
Left to right (L -> R) sequencing
Basic auditory sequential memory span expansion using visual
memory reinforcement, increasing from1-4 items at child's pace
Retention of sentence patterns using colour-coding as prompt
Rote-sequences / lines in play using motor-cues (finger-spelling / Cued
Articulation / signing), visual support (pictures / symbols / words) or 'chaining'
Teach awareness that messages can' t always be understood.
Following spoken instructions - adult uses various support strategies which children
learn to identify.
(i) non-fade prompts (pictures/symbols)
(ii) fade prompt (signing)
(iii) 'chunking' - use pausing to separate information into meaningful units for child
to absorb / visualise / act on before hearing next chunk
FOllowing spoken instructions - child employs various
strategies which they learn to identify.
(i) draws own pictures (need to identify key-words)
(ii) 'chunking' - pick out 3 words / ideas they have to remember
(iii) rehearsal (repeats key-words only)
(iv) rehearsal (sign and speech)
(v) rehearsal - is order important? Do they need to remember
actual sequence of words or key-words in any order?
Clarification Strategies, ego ask for repetition / ask for Signing / say ' I can' t remember'
Gather children in a circle before presenting Class Instructions to whole group:
(i) children leave circle with non-fade prompt
(ii) children tell adult what they have to do before leaving
the circle. Adult repeats as necessary.
Circle Time:
(i) Newstime - all children primed to remember another child's news; later to
remember evervone's news
(ii) Give all children a simple command, then see if they can
remember everyone else's, not their own!
Discrimination, location, selective listening,
"Good listening" from FLiC (see resources).
Provides visual framework for retaining
sequences of sounds / words.
Visual cues (to be gradually phased out):
pictures , symbols, signing.
Language Through Reading Colour Coding Scheme
(see resources)
Chaining: pictures in L -> R sequence, Cover first ,
say from memory and then ' read' rest; cover first
two pictures, say from memory and then 'read' rest , etc.
ego Go to the bottom of page / and draw a circle
around / the jar with the most sweets.
ego L - > R symbols on Flashcard
Key questions [When / Who / Where ?] to
structure narrative and aid recall. FLiC "organisation"
20 SPEECH & LANGUAGE TH ERAPY IN PRAGnCE WINTER 1997
ISSN (online) 2045-6174 www.speechmag.com
Could you write
that down
for me please?
COVER STORY
Figure 4: Intervention Strategies
Key Stage 2
Clarification Strategies - gradually become more sophisticated
ego 'Can you say the last bit again please?'
Rehearsal
(i) introduce delay before children carry'out instruction (eg. wait for buzzer/run round playground/draw a house, first)
(ii) give information which has to be retained until next day / next session / next week Combine with next two techniques
Visualisation techniques (Buzan, 1986)
(i) retaining list of items in correct order using multi-sensory ego if the first two items are 'red' and 'orange' start
imagery and thematic linking. Useful for lists such as planets in solar system. story off by imagining a ripe squashy tomato
crashing through the window and splatting you in
the face. You wash it off with ice-cold orange juice ...
(ii) retaining items from a shopping-li st I key-words from a
story / series of commands in correct order uSing ' one's-a-bun" technique
Mnemonics - let children make their own up!
Chunking - children make up own rules for learning phone numbers 312653 = 3 - my age (12) - my door number (65) -
3 again
Note-taking - children practise noting main pOints using symbols I Enquiry and Elimination games
drawings or written word to aid deductive reasoning Short Stories
Verbal Absurdities
Identikit descriptions.
Class Instruction - provide reminders and opportunity for using ego each child has personal timetable to fill in
clarification strategies with week's events. Children have to let teacher
know if they get lost.
Preparation for leaving
(a) Personal Plan for most useful learning techniques and AFASIC Glossary Sheet 26.
clarification strategies
(b) Advice sheet for parents / receiving school
Please say that
slowly while I
write it down.
strategies
adults in
their new school
Why do parents of "'lIllt can be difficult to separate out different aspects of
children with a language memory - auditory sequential, visual, experiential.
disorder often feel the MI.... verbal - and realise which a child is using.
will need to give permission for the strate
gies to be used as appropriate.
Maggie Johnson is employed by Canterbury
and Thanet Community Healthcare Trust and
leads the Thanet Paediatric Speech and
Language Therapy Teqm. She is senior therapist
Questions
child has a good memory?
When should direct
intervention stop?
How can children be
helped to understand
their difficulty?
at Gap House, an L.E.A. primary school for
children with specific speech and language dis
orders.
Acknowledgement
Grateful thanks to the Speech and
Language Therapy Team at Gap House:
Caroline Emby, Julie Gore, Ruth Watson
and Tracey Hull .
References
Buzan,T. (1986) Use Your Memory. BBC
Books, London.
Resources
AFASIC, 347 Central Markets, Smithfield,
London EC1A 9NH (0171-236-3632)
Johnson, M.(1996) Functional Language
in the Classroom. Available from
Manchester Metropolitan University
(0161-247-6394) f7.25 inc. p & p.
As auditory memory span is unlikely to expand after a
child is eight years old, any direct work should be
supported by the group teaching of compensatory
nniques and advice to teachers.
e children have to recognise and accept they are not
ng, they simply cannot remember, then be confident
and prepared to seek specific help as required.
Language Through Reading, ICAN Book
sales
Passey, J.(1993) Cued Aniculation, Stass
Publications.
Canterbury & Thanet Verbal Reasoning
Skills Assessment Pack. Available from SLT
Dept, Kent & Canterbury Hospital, tel.
01227766877, f12 inc. p&p.
SPEECIf & lANGUAGE TlIERAPY IN PRACTICE WI NTER 1997 21
ISSN (online) 2045-6174 www.speechmag.com
REVIEWS
NEUROANATOMY
Excellent illustrations, little
information
Brain Dissection and Surface
Anatomy for Communication
Sciences
Douglas B. Webster
Singular
ISBN I 56593 855 0 {I 950
Thi s manual is designed to show the
3-D organisation of the brain with
particular emphasis on communica
tion disorders. The manual is divided
into two main sections.
The first, Surface Anatomy of the
Brain, gives an overview of the main
structures of the brai n with accom
panying illustrations in the form of
labelled black and white photographs.
It describes the position of structures
of the brain in relation to other struc
tures and occasionally mentions the
functions of these structures.
The second sect ion, Dissection of
the Brain, describes how to go about
dissecting the brain to reveal it s
internal structure and organisation.
This section again contai ns many
photographs to illustrate structures
described in the text and show the
physical relationship of adjacent
structures. This part of the manual is
geared to hands-on dissection and
clearly describes the different parts
and textures of the brain and how
best to remove 01- dissect t hem to
achieve the best resu lt.
The manual does provide excellent
i llustrati ons of cerebrum, dien
cephalon, brainstem and cerebellum
but contains little or no information
about the function of these regions
of the brain or the structures con
tained within them. It makes only
fieeting reference to the structures
involved in communication and
speech and spends as much time
discussing those involved wit h vision
and smell.The manual may be a use
ful library resource for speech and
language therapy students studying
neuroanatomy but has little to offer
the practising therapist.
There are two videotapes (not avail
able for review) which go along with
this manual and are designed to show
the dissection of a human brain, with
voice-over explanations, demonstra
tions of techniques and structures and
close-up views. These may again be of
most use to the student speech and
language therapist studying neu
roanatomy to show the brai n and help
in the identification of rts structures,
Fiona Dennis is a speech & language
therapist at Dundee Royal Infirmary,
AAC
A must for every department
Handbook of Augmentative and
Alternative Communication
Sharon L. Glennon and Denise C. DeCoste
Singular
ISBNI-56593-684-1 {HOO
This new book written by Glennan and
DeCoste with contributions from other
authors provides an up to date extensive
review of the field of Augmentative and
A lternative Communication, It covers
most topics in depth starting from the his
tory of the field, service del ivery models,
assessment techniques and use of MC
with a large variety of consumer groups,
Each chapter offers the reader a wealth
of information and this reviewer found
quite a lot of food for thought in each
and every chapter, For example, the idea
of expand ing the team concept from a
multidisciplinary t eam to a truly collabo
rative team w ill help in seeking to
improve our service to our consumers.
Glennan and DeCoste coin some new
phrases such as "arena" assessments but
these are explained well. The second half
of t he book is divided into consumer
groups and accompanied by case stories.
These cases, although at times long, are
well written and convey the reality of
implementing an MC system into a con
sumer's life, Account is taken throughout
of the views of many different profession
als and fami ly members and the concept
of "fami ly centred" services is introduced,
A few chapter s and most of the appen
dix is geared for the American market
and, although interesting t o note different
types of American legislation and its
impact on the delivery of MC systems, it
really is not very valuabl e to the UK pro
fessional. However, there is a useful list of
World Wide Web sites on disability and
a few e-mail addresses of suppliers,
These will prove useful to those who
have access to t he Internet.
This book is invaluable for any profes
sional involved with Me. It is not an
introductory text and readers will need
to have some knowl edge of the fi eld
either through courses or other readings
to get the full value from it It is a must
for every department, cent re, or institu
tion which has a consumer base using
Augmentative and Al ternati ve
Communication strategies, This book is
truly a "handbook" of the field of Me.
Thi s reviewer welcomes it wholeheartedly,
Deborah Jans is Coordinator and Specialist
Speech and Language Therapist at
KEYCOMM-Lothian Communication
Technology Service, 29 Bryson Rood,
Edinburgh EH I I I DY
AAC
Practical examples undermined
Literacy through Symbols: Improving Access for
Children and Adults
Detheridge, T and Detheridge, M.
David Fulton Publishers
ISBN 1-85346-483-X {13. 99
Thi s A4 paperback is packed wit h practical exam
ples collected by people who are real enthusiasts
for symbols. The book is well laid out and sign
posted with introductions and summaries t o each
chapter. and a w ide margin cont aining headings.
There are useful addresses and li sts of materials
and resources at the back
I would be glad to have t his book because it does
contain some interesting and useful information
but I do have some reservations about it The title
makes no claim to other than literacy. yet a great
deal of the text is tackling issues which are much
more to do with communication in a wider sense.
Too many of the issues involved remain unspoken.
For a newcomer to symbols, it needs to be sup
ported by a framework w hich takes into account
individual s' differing levels of language abi lity. There
is a worrying lack of expli cit attent ion t o this fac
tor: although the authors discuss whether or not
to use word-by-word symbolisation or just to
symbolise key words, the issues they cover seem
to me to be political rather than to do with indi
vidual needs, For me, one of the most powerful
ways of helping someone take a more active part
in communication is for communicative partners
to adapt t o the person's level of understanding
why should thi s be any less Important w hen lan
guage is being communicated through symbol s?
Yet we are presented with examples of symbol
use that to me seem dogmatic in their symbol-for
every-word approach. For example, on page 9 1,
we are shown an aide-memoire for a swimming
kit, which is clearl y a list, and would be written thus
by anybody who was writing It for themselves, yet
in the examp le it is present ed as a full sentence, "In
your swimming bag you need: swimsuit, towel, tal
cum and comb," with full text and every word
symbolised: not only visual clutter but lack of
attention t o the message's real-life use.
The advantages of the authors' use of practical
examples was somewhat undermined for me by
the confusing range not only of different symbol
systems but of the different sizes, clarity and qua lity
of the images. There are some quite ghastly
Blissymbols on page 10 and I hated the room labels
on page 40 which had all sorts of unnecessary com
plications in them. I think some edit orial comment
from the authors here would have been welcome.
I reckon the book will be most seful for those
worki ng with children and youn people in educa
ti on: those working with adults may find it less use
ful, as it does not reall y tackle t he issues involved
in introduci ng symbols to he environments of
adults whose educational history and communica
tive opportunit ies m y be very diverse.
Jennifer Reid is a sp ech ond language thempist with
Fife Healthcore currently lorklng with children with
speCiol needs in mains ream and special schools.
Reviews in this issue were provided by thera
pists attending an RCSLT Scotland study day.
If you are interested in doing a review, contact
the Editor, 01569740348.
22 SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 1997
ISSN (online) 2045-6174 www.speechmag.com
REVlEWS
SENSORY MOTOR
DEVElOPMENT
Well-presented and
practical
Sensory Motor Activities
for Early Development
Chia Swee Hong. Helen Gabnel
and Cathy St John
Wms/ow
ISSN 0 86388 153 X 29.50
This is a pradical and easy t o
read non-academic spu-al
bound book wrrrten by
Occupational Therapists. tt
primaril y targets t he newly
quali fi ed therapist and Cdl-er
For t he purpose of review,
the book is divided into
three distinct sections.
Section I
Four chapters covering senso
ry and body awareness, basic
movement, hand skills and spa
t ial and early perceptual skills.
Each of these four chapters
has a small but concise intm
duction defining normal
development and the difficul
ties which childl-en can face if
t hiS area of development IS
delayed. The activities sug
gested for treatment are
practical and stimulat ing with
the materials required easily
accessible by al l.
Section 2
This contains twelve examples
of small group sessionsThe aim,
materials and development of
the sesSi ons are cl early defined
and pmvide an excellent pho
tocopiabie resource for a ther
api st implementing gmup work
lhemselves or for other pmfes
sionals / carers to run.
Section 3
This provides an alphabetical
subject resource list, eg ani
mals, clothing, shapes. Under
each of these subjects are
t he foUl ' headings (as men
tioned in Sed:Jon I ) and
methods by whiCh specific
aims can be achieved.
This book is wel l presented
both in layout and graphiCS
produci ng an Invaluable
resource for any therapi st
working wi th children who
h(lllc speci fi c diffic It ies in t he
areas Indicated above.
Aileen Il/leForlane IS Senior
Occupouonol Therapist - Child
Health, Robert Henr-yson
School, Dunrermlme. Fi re
OUTCOME MEASURES
Simple, clear, demystifying
Therapy Outcome Measures - Speech and Language
Therapy
Pam Enderby, Alex John, Manno Sloane and Brion Petherhom
Singular
ISSN I 56593-807-0 3350
Thel"apy Outcome Measures, (TOM) consists of two manuals:
the User Manual and the Technical Manual, plus laminated cards
of outcome measures for t en cl ient groups.
n)e ai l ) of the apprO<lch is to "assisl with the practical Imple
men anon of gathering outcome data on patients receiving
treatment' fOCUSing on the use of one tool to assess the
pat ient and hiS/her neecs In a holistic way.
Even fro fear die term 'outcome measure' cannot
fall t o app","clate the 5.1fT; :l"ar way the manuals are written
and to ililmediat ely see hoi 1hIS apprcach is directly applicable
to a speech clnd language tJ- eraplst's .....-ark. It IS an important
step for the speech and language theraoy profession to have a
way of evaluating what therapIsts see the " Jcb "tallfng allow
ing the clinician to evaluate the "quail 'of care to dlents,
The Technical manual covel's various measun:s (L Tently avail
able to evaluate health status and goes on 0 e plain that tra
ditionally therapists have measured change In speec ar' J lan
guage deficits only, although realising that t hel"apy should have
an impact on many other areas of a client's life, As a result
TOM uses the parameters of impairment. disability, handicap.
(fol lowing WHO International Classification) with the addlDon
of the pal ameter distress/wellbeing t o refiect the multitude of
areas therapists are Involved with. TOM is based on the behef
that the above parameters are all of equal importance in eval
uati ng therapy outcomes.
The Technical manual goes on to detai l t he development of the
outcome scales, the pilot study data collection. the reliability
and validity studies and outcome /esults. The limitations of the
study are cleal' ly stated, (eg. short time scale for data collec
tion) as are the strength s.
One hundred and thil"ty two t herapists from ei ght sit es were
involved in developing measures I'elating to impairment dis
abil ity etc, after three hours of t l'aining. Data from 1, 17 1
patients from t he eight sites was analysed and showed the
TOM approach as reliable (when basic t raining and practice is
given), val id and sensitive to change.
The ial-ge number of thel-apists involved I-esulted in a common
language for t he core rating scale; however the inclusion of a pri
mary core scale allows therapists in an area to devise specific
scales if necessary.
The core rating scales for each communi cation disordel- all ows
scoring of 0.5 points, taking the basic 6-point scale to a possi
ble I I points, allOWing a senSit ive I"ating scale.
The user manual gives conCl"et e detai ls on the procedure for
using TOM such as which pat ients to use TOM with and prac
tice needed before. beginning data collection.
As Enderby states, t rying to capture and refiect clinical Judgement
is difficult however; this approach all ows for outcome measure
ment "i a practical , rel iable. achievabl e and communicable way".
Every speech and language therapist should have access to this
invaluabl e tool whi ch demystifl es out come measures, making
what can often be a difficult procedure to approach and carry
out much easi er It gives a start ing point for each therapist or
department (if they haven't done so already) accurately to
I"ecord Int ervention.
Andrea Jones IS a Speech & Language Them 151 working WIth Adults
with Learning Disabilities In Lanarkshire Health Care NHSTrust
PHONOLOGY
Immense value
Children's Phonology
Sourcebook
Lesley Flynn and Gwen LClnCClster
Winslow
ISBN 086388 156 4 {J950
A photocopiable sourcebook of this
type is always a welcome addition to
any paediatric speech and language
therapy department where therapy
programmes and materials are con
stantly in demand. To be able to use
them as part of a parent programme
pack which enables parents to help
their own children who have phono
logical diffiCUlties, is of immense value.
The information pages within the
book encapsulate the advice given
to pal"ent s on a one to one basis in
most speech and language therapy
cl inics and as such could be used to
prOVide speech and language thelapy
service deli vel"y In different w ays, for
example as home programmes, in
ser ice t lalni ng to Nursery and
PrImary School t eachers and, as in
our paedlatic depart ment part of a
parent group programme for the
parents of children w fth phonological
dll'ficu "'tho are on the waitmg
list '01' therapy.
To support the ideas and therapy
matenals In their b...ook the authors
have gi ven a I ide ovel iew of
reseal'ch evidence dealing Wit h
phonological acqUisition at all levels of
input and :;uggest a meani ngful mini
mal CQ.1trast therapy and an auditory
input approach to Intervention.
They also underline, in chapt el' 7.
the impOl'tance of finding ways of
auditing the effectiveness of our
intervention st rat egJes and provide
a summary of studies compari ng
the efficacy of different approaches
to phonological therapy.
The theoretical component s of t hi s
book are useful but I have to say
that some of the technical ter-minoJ
ogy used (post vocali c obstruent;
canoni cal shape) was difficult to fol
low even for the IllOst recently
trained speech and language thera
pists in my department
Nevertheless, my vi ew of thiS
sourcebook is a posrtJve one and I
would recommend It as a useful and
informat ive herapy resource.
Margaret Sibbald IS 011e[ Specialise
Speech & Language Therapist
(Paedlotfl(S) In the Monklands I
Cumbernauld DiviSion o( Lonarkshire
Heolthcare NHSTrust.
Note {rom Singulor Publishing re - Articulation and Phonologlcol Disorders, by Ken Bleile, reViewed In the Aurvmn 97 Issue:
"Thi s book is a second edition and does not replace, as the reVieWE r Implies, Ken Bleile's other work. Manual ofArtlcuiatJOn and
Phonological Disorders. Rather, this second edition has been rewi/teen to (ol/ow the JI;1 onua('s format to enable users to work With both
titles.As the reviewer nghtJy surmises, thiS book o( exeroses IS designed (01 students, the tVlonual IS de51gned as a cllmcal reference
(although it is widely adopted os a student textbook)."
SPEECH & L\ N CLJi\cr TllrcRAPY IN PR;\CTICE WI , I U( 1997 23
ISSN (online) 2045-6174 www.speechmag.com
sound
difficulties
Speech and language therapists, given the case history
information opposite, set out their management of Mark.
Morag Ogilvie is a speech and language therapist
working with children in community clinics in Edinburgh.
At the time of writing, Rachel Osenton worked for
Thameslink Healthcare Services NHS Trust, but has since
become Rachel Stanbury and is a senior speech and
language therapist with Northern Devon
Healthcare NHS Trust.
Pam Williams, Juliette Corrin, Sarah J. Colebourne, Shula
Burrows and Sarah Friel are the speech and language
therapy team at the Nuffield Hearing and Speech Centre,
Royal National Throat Nose 8 Ear Hospital, london. This
specialist centre offers assessment and treatment to
children with speech, language and hearing difficulties.
24 SPEECH ... LA. UAGE TIl ERAPY IN f'RACllCE WI ITER J997
Mark
Mark is eight when he
moves to your area. The
speech anCilanguage
thera)?y transfer records
show He was late to talk
but language de'!elol?ment
was age p p r o p n a t ~ by
four years andl1eanng
difficulties have been ruled
out He was in distress at
birth with the cord round
his .1eck but general
developmenThas been
unremarkable. From
conversation and school
progress it is clear he is an
Intelligent child. His older
brother attended therapy
for a few phonolowcal .
difficulties all of wf1ich
were sorted out by the time
he was six.
Mark uses f for th and
I for r. Therapy for initial
stopping was successful but
he has persisting velar
fronting (all worll positions).
He is unable to produce
velars even in isolation. His
mother reports he
sometimes used to confuse
tlk/dlg when spellin but
no longer does so. ark is
co-operative and
motIVated to improve his
speech but is becoming
despondent.
ISSN (online) 2045-6174 www.speechmag.com
HOW I...

..

on
Tom has a tongue which can bend to show

alveolar or velar placement. \Nhen Tom says a


Morag Ogilvie chooses the Metaphon
Edlttburgh Sick Children's
back sound or a front sound for Mark to iden
approach to tackle Mark's diffirufties
tify, Mark can see exactly what Tom's tongue is
NHS Trust
and ouUines atherapy dream scenario - doing, while I express the action verbally
and the other one.
Welcome to Edinburgh, home of Metaphon , where clinics echo to
the sound of small children charging from the back to the front of
the room while blowing long/shon bla IS on \\Oh i tJ (loudl y or qui
etly), Metaphon therapy is my usual first cho ice or phonologi cal
problems, but would I use a Metaphon approach with il. l, rk - does
a child who can't say /k/ at age eight have a phonologi cal pro lem'!
Assessment
Mark and his Mum are offered a 45 minute appointment at his
local clinic. After some general chat and a history, I move on to
more formal assessment. In spite of some irritating features
we've coloured that pointy sun in yellow but they all still call it a
'star' - I find the Metaphon Screening Assessment gives a good
quick impression of a child's phonological system, I never use the
summary sheets, but do sometimes use the process specific probes,
I also do a consonant imitation test and an oral exam, Mark has
good tongue movement and no obvious abnormalities,
I'm interested in Mum's report that Mark used to spell the way he
spoke, but can now spell properly. Does this mean his phonolog
ical representations are intact, or has he learned to compensate?
I'm interested, but not enough to investigate further at this point.
I succumb to the temptation to get on and do something,
Targeting therapy
Mark has two inappropriate phonological processes operating, We
should be able to sort out /r/ -> /1/ without much trouble, which
would give Mark a feeling of achievement. However, he is more
conscious of the velar fronting, After all, he can't say his own
name, To help Mark have some control over his therapy, 1would
"Tom's tapping the top of his mouth with the
back of his tongue, He's making a back sound,"
When Mark has to take turns producing front or back phonemes,
he is still unable to produce /k/ or /g/, but I accept any 'back sound'
from his coughing/gagging repertoire,
We begin word-level activities using the pair tar/car (so the /k/ will
be facilitated by an open vowel) and Mark sees the communicative
impact of a change in word initial phonemes, Week three there is
no clinic because the therapist has a meeting, When Mark returns
in week four, Eureka! - he can produce velars, Over the two weeks
so mething has clicked and Mark is now able to raise the back of his
tongu e to command (honestly, this does happen), Now alongside
the /I..t tapho ll programme (example of game in figure 1), we play
velar-onl - games to encourage less effortful articulation, At the end
of eight weeks Mark is using velars in clinic tasks and when reading
aloud, He is put on review to be seen again in three months in the
expeoation that veJars will have transferred to his spontaneous speech,
The other scenario
In spite of our best efforts , !lark shows no signs of velars, He needs
more help so he doesn't begin to feel a failure, Time for the
Tongue Gym, I explain to "lark that just as I can' t do press-ups
(demonstration and collapse) hi s lOngue muscles need some help
to make back sounds, He gets a tongue work-out sheet and a chart
to keep a record of his practice (see Certificate of Achievement,
Figure 1), Metaphon aOivities continue, with me trying to shape
Mark's back sounds closer and closer to velar placement. By the end
of eight weeks Mark is producing an effortfu.l / k/ which he can use
in clinic tasks with a big gap (Mar - K), Mark is given a two month
break, and comes back showing little change, At this stage I would
consider targeting the
ask him which process he would prefer to tackle first.
Mark opts for the fronting, and he's offered a block of eight week
ly therapy sessions, At the end we will take stock and decide what
should happen next: Because Mark is already self-conscious about
his speech, he gets one of our precious after-school appointment
times so he is not embarrassed by being withdrawn from class, As
Mark has moved to a new school, I would want to liaise with his class
teacher so that s/he understood Mark's speech sound system and that
Mark could not be expeoed to decode reading words accurately for
sound at this stage,
To Metaphon or not?
In Mark's case there are three things
that would persuade me to go the
Metaphon way,
1. Fronting is not the only process
operating, This suggests a generally
delayed phonological system of which
fronting may be only a particularly firm
ly frozen part,
2, Mark seems a bright kid who should be
able to benefit from the opportunities
Metaphon therapy gives to reflect on his speech sound system,
3, Mark knows he "can't say" certain sounds, With Metaphon,
Mark will be able to experience success in his first few sessions of
therapy which wiII hopefully give him the confidence to persist if
things get a bit tricky,
The dream scenario
Mark enjoys the Metaphon aCUvJlles and produces a series of
/r/->/I/ process so Mark
does not get too dis
couraged, When this
had resolved, we would
return to the vel aI's for
more slow progress,
If Mark were to con-
Certificate of
w. heRb) pro_,
, Mark's Tongue
"'Jib Ibi, CcniIic.te '
IClIleY.melll of ilS
Back Sounds

""'"
Figure 2
coughing and gagging noises for ' back sounds', Because I know
communication,
Mark is going 10 have problems making velars, at Phoneme Level,
I use Tom the cardboard crocodile to feed Mark very precise artic Reference
ulatory information about how the speech sounds are produced, Howard, J. & Dean, E, (1994) Treating Phonological Disorders in
SPEECH & Li\NGUi\GETHERAPY IN PRACTICE WINTER \997 25
ISSN (online) 2045-6174 www.speechmag.com
HOWl..
NORTHERN DEVON
healthcare
_?_:w MiM !
on

Rachel Stanbury has tips
for eliciting velars and suggests
an intensive school holiday
course of therapy.
Children. Whurr. London.
Following Mark's referraL he would
first be offered an init.ial assessment
appointment. The information
gained from this would be vital in
determining the management plan
and the nature of any intervention
offered. The session would consist
basically of a case history taking
and an in-depth assessment of his
speech sound difficulties.
Given that the basic information
about Mark's early history is already
available, I would want some fur
ther details regarding his therapy
thus far such as "Which approaches
have already been employed, in
what way and with how much suc
cess?" This information might come
from either Mark's parents, his pre
vious speech and language therapist or even from Mark himself.
While taking the case history, I would take note of any regional
accent used by Mark's parents and bear this in mind along with
the accent prevalent in the area the family have recently moved
from. After alL it would nOl be appropriate to target the fjth
contrast if 'th' is not used wi thin that accent .
During the se-hi tory taking, Mark' parents' level of concern
may become apparent. 1 his is also going to be a consideratio n
when planning the form of intervention a it may affect both
thei r auendance at the clinic and the amount of support given
at home.
My assessment of Mark's speech would fOGI on 'lsped.s
of speech production. Firstly, I might administer the SfAP
( outh Tyne ide Asse.s!lmenl of Phonology; STASS Publkatlons)
10 give me an overview of his spont.1neous sp ech sound use,
albeit at tlle single word lewl. J would follow tbis by looking at
Mark's phonological awarenes with regard to the with
which he has di ffi culty. l'his could involve several different tasks
such as:
discrimillillion between the ounds leg L/r) ill iso lation
dis rimination between the sounds in word initial position
right / wrong judgements from my producti on, eg I woul d say
' Iabbit' and ask Mark is I had pronounced the word correctly
silent sorti ng, eg Mark would have d seledion of pictures
,." Aspecialist op'
beginning with T and 'r' and he would
sort them according to what he
believed the initial sound to be.
This would be an important part of the
assessment because, if there is a problem
at this leveL work on speech production
alone is not going to be effective.
Finally, I would try some elicitation of
the problem sounds. For the sound jkj for example, this could
include using his finger to hold down the front of his tongue
while he attempts the sound. Alternatively, he may be able to
produce a velar fricative from which the plosive might be elicit
ed. A third strategy would be to try and develop tbe sound from
the velar nasal which most children use even if they do not use
jk.gf. This would be by asking Mark to produce an extended 'ng'
sound holding his nose part way through to build up the intra
oral air pressure and this release an oral velar plosive.
Having completed t.he case-history taking and assessment, I
would then formulate a management plan with the parents and
Mark. It is very important at this stage that all parties are happy
with the final plan as the motivation and cooperation of every
one is needed. A number of factors would now need to be con
sidered. These include:
I. Mark's age and the fact he is at school full time.
II. The availability of parents and/or others both to bring ,"lark
to the clinic and to work with him between sessions.
III. The outcome of the assessment and elicitation.
One option which I feel might be very suitable for Mark is a
block of intensive therapy. This could be arranged within the
school holidays thus avoiding the problem of missing school. It
may also be easier to maintain Mark's motivation over the
course of one week rather than several. The block would consist
of one session every day for a week with each session lruillng 45
mi nutes to an hour and with reinforcement activiti es to be car
ried out ill home.. The aims and content of the block would be
determined by the outcome of the asses ment but I would like
to target the /k,g/ sOllnds for speerh sound production if at all
possible due 10 their high frequency. Sound discri mination and
phoneme awareneSl> work could covcr a broader range or con
trasts.
Each session would ind ude bOl h work on chscrimimllion Ol nd pro
duction and would tematic.ll ly from the single sound
level througb the word level JOlI unto SC'ntence level and generali
ati on. '[he follow-up aruvities lor each day w mid be aimed at
consolidat ing the skills achic\'ed during that day's session.
Finally, I would follow up the block with a report to Mark' s
s hool and if possible a telephone call to outl ine the input he
had received, his current presentation in U!ml S of speech and
any ways in \,' hich further progress could be encouraged in
school. Mark' s parents would also be advised on how to contin
ue some work with him at home and a review appointment
would be planned.
n
Therapists at the Nuffield use in-depth
! assessment to ensuretargeted treatment and rapid progress.
"
-;
vVe were pleased to
receive a referral for
'Mark from his GP
in his new locality. The referral was instigated by
bis current speech and language therapist who had
seen him once and, in the I ight of his transfer records, had decided
she would like an opinion from a specialist centre on Mark's CUf
26 SPEECH & LAN GUAGE TJ-JERAPY IN PRACI'JCE WINTER J997
rent presentation and future management. It was very helpful to
receive copies of speech and language therapy reports and school
progress reports.
After approximately three months on our waiting list, Mark was
offered a co-ordinated appointment, seeing one of the speech and
language therapists in the morning and the Consultant
Paediatrician in the afternoon.
ISSN (online) 2045-6174 www.speechmag.com
HOW!. ..
Assessment
The speech and language
vides visual feedback of
tongue-palate contact. It
therapist carried out a
detailed three hour diag
nostic assessment with
Mark's parents present. During the session, the therapist first took a
case history involving information from both I\ lark and his parents.
Then a detailed assessment batt erv was administered. In the light of
Mark's ongoing speech diffi culti es and hi, histo r;. of language and
spelling difficulties, it was felt appropri ate at thi s stage to rc-;mess
his language functioning, h.is reading and spelling level s ,md h is
phonological awareness skills in addition to h is speech skills. -Ihe
following formal and informal assessments wne admini stered:
1. Language Assessments
British Picture Vocabulary Scale (Dunn, Dunn, Whetton and Pint ili e)
Clinical Evaluation of Language Fundamentals I1evised (Semel, Wii g,
Secord)
Renfrew Word Finding Vocabulary Scale
2. Literacy Assessments
Schonell Graded Word Reading Test
Neale Analysis of Reading Ability Scales
Vernon Graded Spelling Test
Assessment of Phoneme/Grapheme knowledge
3. Psycholinguistic Assessment of Mark's speech difficulties, inves
tigating his processing at input, internal representation and output
levels.
a) Input tasks, ego auditory disu-imination of complex non-words
auditory non-word rhyme detection
b) Tasks involving internal representation
real-word rhyme detection
lexical decision
sound blending
syllable identification
rhyme string production
alliteration string production
spoonerisms
c) Output tasks, eg . spontaneous speech sample
NuffIeld Dyspraxia Programme Assessment,
which investigates:
oro motor movements
single sound production
single sound sequencing
naming and repetition of single
words (at ev, ev ,evev, eeve
and multisyllabic levels) and
phrases and sentences
Repetition of non-words
J
Findings
Evaluation of the assessment battery revealed Mark's primary area
of difficulty now is with speech output. Al though he may well have
experienced input difficulties in the past (which would have affect
ed the precision of his phonologi cal representations of some
sounds), evaluation of his input processing, phonological aware
ness and spelling skills suggested these diffi culti es had largely been
overcome. In terms of output, his use of I f/ for <th> was attributed
mainly to local accent and therefore did not wa rrant intervention.
However, he was unable to produce /k/, /g! and I r! sounds even in
isolation. He also appeared to have poor kinaesthetic awareness of
his lips and tongue, although he had 110 obvious oromotor dys
function and no structural or organic diftlculties.
Recommendations
In the light of Mark's speech profile, age and apparent resistance to
conventional therapy, it was felt that he would be suitable for thff
apy using electro palatography (EPC). EPG is a technique that pro-
involves the wearing of an
individually-made artificial
plate (similar to a remov
able orthodontic appliance), which has 62 electrodes embedded in
its surface. As the tongue touches the electrodes they create a two
dimensional display on a computer screen. In this way, the wearer
receives immediate visual and kinaesthetic feedback of the position
of the tongue. This technique is particularly helpful for older chil
dren, as it offers an added dimension to articulatory therapy.
It was decided to offer Mark a course of ten weekly one-hour ther
apy sessions which would include the use of EPG and other tech
niques. A report was written detailing all the assessment results and
recommendations and was sent to both his local speech and lan
guage therapist and school. His local therapist was invited to visit
lh Olre to become acquainted with the EPG approach. A dental
examinalion was arranged for Mark, which involved the taking of
denta l impr ions of th e upper and lower teeth. These plaster casts
were necessary for the manufacture of the EPG plate, which took
approxima tely ane month.
Once I\ \ark's pl ate ...."ali recejwd and fitted, a detailed speech exam
ination Llsing Ere \ -as carri ed out. This re\' ealed that Mark was
using a double arti culation for lhe production of velar sounds but
had a normal pattern for the production of alveolar sounds.
Although he incorporated ve.lar contact into his articulatory pat
tern, the release of the plosi \'e occurred in the alveolar position. He
was registering an articul atory contrast fo r /tl a nd / k/ but without
the necessary acoustic di fferences - hence he had a primary pho
netic problem with phonologica l impl ia ltjons.
ATTENTION-DEFICIT / HYPERACTIVITY
DISORDER (ADfHD)
AD/HD'98 - University of Cambridge
We arc pleased to announce ADfHD'98. a four-day residential
conferencc at the University of Cambridge. 6th - 9th April. 1998.
International key speakers inelude Prof. Russell Barkley, Dr Tom
Brown. Dr Michael Goldstein, Dr Sam Goldstein. Prof. Philip
Graham (Chair of the National Children's Bureau). Prof. Peter Hill
and Prof. Mel Levine.
Papers. symposia and posters are inyited,
An Intensive Training Day for Health and Education
Professionals on ADfHD
Speaker: Je nny Lyon, Chartered Educational Psycho logi t
(f I 00 plus VA T, including course pack / text book and buffet lunch)
University of Manchester - 7th November
Charing Cross Medical School, London - 5th December
Napier University, Edinburgh - 6th February 1998
John Moores University, Livcrpool- 2nd March
A list of audio/video recordings from ADfHD'97 (held a t Lni vcrs it\ of
Oxford. 7th - 9th April. 1997), is now available on requ t. utgether
with the official conference publication (published a t 16. in d udin"
postage, softbound - ISBN I 901906000)
Further details are available from Angela Ra ndell
IPS (International P sychoI\tg) Sen;ces)
Freepost SEA 1132 (no UK postage r equir d)
17 High Street. Hurstpi cr point, West Susse 8 !\ 6 9S
Telephone 012i3 835533 Facsimile 012 3833250
SPEECH & lANCUACE TIIERAI'Y IN PR. Cl IC[ IVtNHR 1997 27
ISSN (online) 2045-6174 www.speechmag.com
NEWS &> EVENTS
Therapy
Mark's therapy concen
trated on
1. identification and
perception of the differ
ences between the adult
model production of
aJveolar and velar
sounds, in isolation and
in word positions.
2. production of velar
sounds, in isolation and
then in word positions.
Mark's therapy was sup
ported by the use of
lhree complementaty
approaches:
(1) EPG palterns
(2) pictorial symbols
for speech sounds and
minimal pair pictures at
CV, CVC and CVCV lev
els from the Nuffteld
Dyspraxia Programme
and
(3) alphabet letters.
Once Mark was able to
produce a velar sound,
he was given 'home
work' of picture materi
als to support his thera
py in between his ses
sions.
Practical points
1. For an older child, after-school or intensive summer
holiday appointments can be offered to lessen
embarrassment about therapy attendance.
2. Work on speech production may not be enough and
assessment and therapy must identify and address any
input and internal representation problems too.
3. The opinion, age and accent of the child, frequency of a
sound and perceived ease of remediation will all influence
the decision about which sound to work on first.
4. Elicitation techniques for velar plosives include use of a
puppet to demonstrate positioning, a finger to hold down
the front of the tongue and working from strengths, eg a
velar fricative or nasal, or coughing I gagging.
5. Preferred assessment and therapy techniques include
ideas from Metaphon, Nuffield and psycholinguistic theory.
6. With an older child, the primary work will be with the
child, but parental support and an understanding class
teacher influence attendance, home practice and outcome.
7. If instrumentation is available, electropalatography can
be motivating and informative.
8. If progress is not good, referral to a specialist centre
should be considered if possible.
Mark made rapid progress
and was soon able to pro
duce Ikl as a single sound
and gradually in word posi
tions. He also soon gener
alised his new articulation to
Igj. Mark was delighted with
his own success and was
motivated to go on to work
on establishing I r/. Using
EPG, he was able to identify
his articulatory confusions
wilh III and the I rl sound was
rapidly incorporated into
simple CV and CVC words.
The remaining sessions were
spent consolidating work at
phrase and sentence level.
References
Connery, Y.M. et al (1992)
Nuffteld Centre Dyspraxia
Programme. London: Rt'lTNE
Hospital.
Hardcastle, W., Jones, W.
(1974) Electropalatography
Reading IBM System.
Stackhouse, J. and Wells, B.
(1993) Psycholinguistic
assessment of developmental
speech disorders. European
Journal of Disorders of
Communication. 28 (4).
RESOURCE UPDATE. ..RESOURCE UPDATE.. ..RESOURCE UPDATE.. .
Voice care
The Voice Care Network, a national
group of speech and language
therapists and specialist voice
teachers, continues to press for voice
awareness training in initial teacher
training. The Network provides
workshops and advice packs (see
examples below).
Roz Comins, Network coordinator,
welcomes information from
DynaMyte
speech and language
A small augmentative
therapists on numbers of
communication device suitable
teachers on their
for ambulant users is now available
caseload (new from Dynamic Abilities.
referrals, current The DynaMyte, a smaller version of the
treatment, review). DynaVox 2/ 2(, is suitable for.all ages.
.voice and the Software includes a concept associated
Teacher pack, 12.00 42000 word prediction and search capability,
(payable to Voice reinforced by 2600 visual symbols. Both
Care network) can be personalised and messages can be
printed. A long life battery, protective
with a Warm-up on
screen cover and a rubberised case
Audio Cassette, 5.50
Keep in Good Voice
with shoulder strap and handle are
(payable to Roz Comins).
provided. Details / demonstrations:
Dynamic Abilities, tel.
Details and full publications list:
07202487878.
Roz Comins, Voice Care Network,
29 Southbank Road,
Kenilworth ev8 7LA,
tel. 07926852933.
28 SPEECH & LANGUAGE TH ERAPY IN PRACfI CE ~ V l N T E R 1997
Led"amb,ml"ity' gt ' ,
lsa lrammg
AforU1coming training pack is
aimed at helping staff working
with people with learning dis
abilities on parenting.
First Steps to Parenthood
(55.00) includes strudured
interview sessions to help staff
assess the knowledge and
requirements Of their clients at
different stages Of parenting.
Details of this and other
training resources fram:
Pavilion Publishing, tel. 07273
623222, W'NWpavpub.com.
Nursery Projects
A new bi-monthly magaZine
dedicated to under fives educa
tion has been launched by
Scholastic.
Nursery Projects includes
adion rhyme and role play
ideas, photocopiable adivity
sheets, advice on planning
themes and information on the
latest nursery resources.
Details: Scholastic Magazines,
tel. 07926876250.
ISSN (online) 2045-6174 www.speechmag.com
EVENTS
University of East Anglia
Postgraduate Courses
January
Aphasia Therapy - A State of
the Art
Tutors: various Fee : 95
February
The Lidcombe Programme
of Early Stuttering
Intervention
5 days - details on request
9-10 March
Communication in Children
with a Severe Visual
Impairment
Tutor: Ian Bell Fee: 95
Venue: University of East
Anglia, Norwich
Details: Sally Wynne, Course
Co-ordinator, Continuing
Vocational Education Office,
The Registry, University of
East Anglia, FREEPOST,
Norwich NR4 7BR.
SPRING '98 published
23 Feb 1998
IN FlffiJRE ISSUES
working with parents
integration
family therapy
Retfs Syndrome
aphasia group therapy
working with carers (AID)
A Singular offer with your
clinical companion ... until
31 / 1/ 98, new subscribers to
Speech & language Therapy
in Practice are entitled to a
10 voucher towards their
next purchase from Singular
Publishing. Singular has
kindly extended this offer to
existing subscribers.
VOUChers are available
following application to:
Avril Nicoll,
Publisher,
Speech & language
Therapy in Practice,
FREEPOST S(02255
STONEHAVEN
AB393ZL
tel / fax 01569 740348,
e-mail avrilnicoll@rsc.co.uk.
ISSN (online) 2045-6174 www.speechmag.com
6. Photographs
Although there are man
benefited greatly from .. commercially available h
t group
',"od,a0'1' ,'cd; " ,'d",', pho,o, h". b . wo '"p'" of ,,'h phoro . "'0 ,ook
games, I.e . hello songs. een used every session in were mounted on
2. Blanket
Children love thO ..
IS activity Th
encouraged to r . e child is
adults lift the eled on the blanket, and two
'd n sand ge I .
Sl e to side. Thl' nt y sWing from
. . s encourages ' .
antiCipation and . 10lnt attention
. communlca . T '
tlcularly useful ' . tlon. his is par-
I ren who are d'ffj I 109 non-verbal
ch
'ld lor motlvat'
d I ICU t to en
oun this activity gage. We have
and non-verbal co both verbal
I
mmunlcat' .
to ready steady gol and Id
lon
In response
are keen to signal I I d own/. Children
again/! go an lagain, again .....
/ gluck
Ulerapists ce from
activities A,we have
sk'ills ong With encou these I
....... It gives h' raging PI" I
:"7 to partie' c Ildren th e- io
... nlch som Ipate in ta e PPOrru
tendy e children ' ctile activo -
aVoid Ch ' In the gr 'ties
Ildren are oups coosls_
SO th s play if th encouraged
emselves ey are not k to
foam ' . een to
t IS spray d
ray. Gluck . e Onto a
consists of IS made in a sh IItable or
to Corntlo a ow r.-
a smooth b ur and cold -..,.
set in th Ut solid water
up will e tray, but wh paste. It w/f
Th
seem t" en mo-'"
is is oft 0 melt" . ....
of ou en used i and ue,co,'nA.,.
r .... -- r faVOUrite str n nurseries and
S:ch as plastic relievers!
re prOvide utlery and
for " d. Thes .
child as w:" gIVe
I shaving (. IS reluctant t as
..r oam to b ' 0 touch
egm exploring
5. See h ......
A
t rougih
vai/ab/e play balls / ..
". b _OH<' """d " """ p',ddp,b"' I" <h. "o,p. C"'" ," '"'",....d '" ........ die

__of chei' ,,,'"',. "d '""",b,I", Imm.
dl
," CO ,h. wk. "'" won!, ... """"".....
..-'" "'e dlon< ,co,p ,nd """,1" wl,h ,p,,\fi, .mph"" 0' ,ho," won!, , ,,,d" homO,
,,!uP, bo1d Ion<"" "Iett.
d
"d ,'n,l. won!,,.d ph"'" we" p,I,,,d, m",meed and Jom\IWOI'II
Oft <ani, Th<oe wo,d, w." ,ho"n pO' "b"",.d ,Iott.d Inco d..' pi""' pod<.u on AS ",,,s.
Th'" we" pl".d on ." w,\I b, ",h ,ttl,l" '0' "f."'" by "'-.u.. on4
repetition of these key words was enc:ouraaed
Debbie Wilcox and S
are speech and I arah-Jane Burns
Anita Mcfadze anguage therapists and
an a spee h
therapy assistant with language
Children's NHS lim urgh Sick
rust.
These resources are in r
out-patient clinic at the Regular use in an
Ch ildren in Edinbur h h oyal Hospital Jor Sick
weekly basis. The g w ere groups are run on a
d
groups are staffi d by
an language thera . e two speech
assista nt. Althou h plSts and a multi-talented
different levels run groups JOT children at
r. ,resources ar d'
JOT early communicat ' e use pnmarily
IOn groups k'
carers and their ch'ld WOT Ing with
These children are at a I ren
their development and m:e- lzngu lstlc stage In
children present h ny are non-verbal Th e
d ffi wit varying d
1 lCUItY, autISm spe f I egrees oj learning
d I ,Cl l C angu d
eve opmental dela )1 S age lSorder and
d' . orne have b
WgnOSIS and reqUIre not een gIVen a
Carers attend WIth the ch
a
penod oj assessment.
actwitles TherapIsts Ihldren and work through
are t ere to d
reqUIred. Groups b a VIse / model If
I d egln and e d . h
e acttVl tt es, eg, hello son n WI t therapISt
We hope you Jind some oj mde game/ Singing.
have as much Jun ese Ideas useful and
as we do uSing them.
during activities.
bubbles
pop
again
(name's turn)
ready, steady, go.
stop
9. MUsical ta
The ins . pe for bod
com fo yawareness
merclally r the
It was too 10 available LOA tape Was fro
to make ng for our c/' tape. Whilst m the
. Our 0 lent excell
enJoyabl Wn. The . group and ent.
The a e and with d fjmusl
c
had to b We deCided
and r SSIstant chose efjm/te rhythms e very simple
ecorded Ive si' .
lng the ins these played mple pieces of
each piece trumental and a keyboard
We ch . r ythmieal ffi' c ang
rock the followin e ects for
sw. ogether g movement .
109 arm s.
b s move fj
ru hand Ingers
Th
s tog th stam '
e childr e er p leet.
to c en Were
a opy or obser encOUraged b
Ifproximate/y the actions. T{ their ca rers
you can't play mmutes. IS tape lasted
teer. If no Yourself e .
available is a willing vo/u
to the th / tape. 1m 0 fantastic m
marching ;;:e music rocking
Stripes" _ I a band play' The Piano" y
et your ' Ing "Th or
Imagination e Stars and
go!
Ji(t,alIab\e from Nottingham Rehab, ref L II I, . I 05.
version was just under 20. Firstly you must decide on the largest s\J.e SW_'
.... child... and ",. '1"" In ,h. dlnl', S"I. 0", .'".,' ,,,on!'ngiy. Fo' 0", dink
the triangular template to cut out 12 separate sections. We used cheap lining m:I.tIll'\al.. bllit.1
': ,G...... was 3 metres.
quor., "",."'1 will ,,,,,d 'P co mo'" w"" "d "" .Th.lOO, ,;d" on ,\11, '
......... ,".,.,",,,,,,h Seam" fo, ,,,,,n,,,,.Th. m,,,n,1 " <h. """" of ....
Tradin rom Step B Jingling pIa
320 g Estate Yo y Step Ltd L y ball
200, ref pp' ate, Bristol ' avenham Rd
This large i 5098, I 3 95 Bs 17 5QX Beeches
for a small c e.ar ball (50' ex VAT. ' tel. 0/454
P
child cm /20" d
arent PVC to lie acros' iameter .
gle When thO It contains fo s) IS made from - big enough
_ ..... _"' heavy, so cut out a small circle in the centre of
the parachute about 15 cm in diameter and replace
vftth twO larger circles of material sewn on either
side.Tum under edges and hem.This can be as easy or
c.ornpIlcated as you like, using many colours, fewer sec
tIonS or adding handles to the outside edges.
parachute is well used and loved by the children.
children's art: is moveu:. metal trans
particularly (. ntlon and is us d
hiS
IS great fo which iin
ttJm-takin or respond' e regularly ' : attracting
g. Ing to nam 10 Circle ga
e, eye co mes
ntact and
VtIe use a variety of circle games, ego running under in
response to name I bouncing small sponge balls on
the parachute- We target skills such as turn-taking,
waiting for Igol,anticipation and joint attentio
n
.
The
photograph shoWS one we made earlier!
ISSN (online) 2045-6174 www.speechmag.com

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