+.

lnvest tme n deveopng good reatonshps wth generast coeagues and

other proessonas.
. Treat the cent, not an underyng or assocated condton.
. Use eary nterventon when t has a preventatve uncton.
(. Provde an acoustc envronment whch w not dsadvantage your cent.
. Be prepared or the ong-term commtment and hard work nvoved n most
speech and anguage therapy.
. Recognse when speca achevements have been made.
;. Nake assessment and therapy unctona by nvovng other peope.
8. Empower yourse and others through recognsng sks and needs.
,. Remember that askng or carcaton or repetton s dcut or anyone,
especay our cents.
+o. Beng deberatey un-communcaton aware s a useu therapy too.
P
r
a
c
t
i
c
a
l

p
o
i
n
t
s
SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2002 25
how I
l manage deaness
n chdren and
young peope
The vaue o speech and anguage therapy
or dea chdren s now wdey recognsed,
but the debate about how we can best
organse and dever our servce contnues
aganst a pocy background whch emphasses
ncuson and servces cose to home.
The rapd ncrease n the number o dea
chdren recevng a cochear mpant or more
sophstcated hearng ads s key to contnue
ntatves such as unversa neonata hearng
screenng acheve ther ams o eary dagnoss
and tmey habtaton. Yet hgh tech can
brng as many questons as answers and s
not aways approprate and, or condtons
such as otts meda, tmey habtaton s a
moot pont.
Here, three therapsts present some ntatves
whch are empowerng themseves and
coeagues, parents and young dea peope.
Liz Fairweather is a
specialist speech and
language therapist with
Fife Primary Care NHS Trust.
Liz Kraft is a specialist
speech and language
therapist with Highland
Primary Care NHS Trust and
a tutor of lip-reading to
adults.
Susan Howden is a
specialist speech and
language therapist with
Tayside University Hospitals
NHS Trust, a Royal College
of Speech & Language
Therapists Advisor and a
tutor of lip-reading
to adults.
you want to
network eectvey
empower peope
dever an equtabe
servce
Read this
SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2002 26
how I
any researchers from varying professional back-
grounds have for years debated otitis media, often
called glue ear or otitis media with effusion, and
the possible effects on the developing child. As
yet, there are no definitive answers as its nature makes it diffi-
cult to monitor accurately the progress of the disease and to
make objective judgements.
I work as the specialist therapist for deafness / hearing loss in
Fife, offering advisory visits as requested. The majority of ques-
tions come from my colleagues working in the community and
involve conductive hearing loss problems. A few years ago, I
decided to investigate otitis media, language and behaviour
when I came to do my MSc project.
Within the speech and language therapy profession there
would be general agreement with Friel-Patti & Finitzo (1990)
that there is a direct causal connection between hearing and
language and an indirect causal connection between otitis
media with effusion (OME) and language, based on the rela-
tionship between OME and hearing. Although a link between
otitis media and language delay may be more reasonable to
accept than reject, there are still problems in suggesting it is the
sole cause. Otitis media is an extremely common occurrence in
children under the age of five years. Haggard & Hughes (1991)
put forward the idea that the prevalence is so high that it could
be viewed as part of normal childhood development.
In some cases, there are factors that make a child otitis-prone.
Smoking in the same room as a child is now widely accepted as
exacerbating otitis media. Having a number of siblings in close
living conditions is another factor, and some say that dairy
products can make a child more otitis-prone, though there is no
clear evidence for a strong link. Cranial osteopathy has been
suggested as a way of decreasing otitis media but, again, there
is no clear evidence to say that this is of any benefit at all. The
Scottish Intercollegiate Guidelines Network (SIGN) guidelines
on otitis media, due to be published in 2002, will include a lit-
tle information for patients, families and carers.
Not every child with otitis media presents with speech and / or
language delay - therapists only see those children with speech
and / or language difficulty presumed to be associated with it.
With this in mind, it is important to treat the child and not the
otitis media. Many of us think that once the child has an ENT
appointment the problem will be resolved, and we can feel
frustrated when the child is refused grommet treatment.
There are often good reasons for not rushing into surgery; oti-
tis media can resolve spontaneously within three months, so
many areas, including Fife, adopt a watchful waiting
approach. Each area varies in its criteria and it is a good idea to
find out what happens in your own - Do you have a Community
Paediatric Audiology Service? What are the criteria for referral
to ENT? What is the ENT policy on otitis media?
Value the message
In 1994, Sue Simms reported that prolonged repeated upper res-
piratory tract infection (URTI) during the first year, has had a signif-
icant effect on both mothers and babies as interactive partners. I
often return to this article and value the message that it gives to
everyone working with children who are otitis-prone; interaction
suffers, not necessarily speech and language development. It has to
be our role to pass on this information to the mothers of children
who present with otitis media - instead of reacting to your childs
quiet periods by being quiet, be proactive and ensure that the child
is included in conversation and that responses are expected. Direct
therapy may not be appropriate, but the parent needs information
on how to manage the language development of their child,
despite any periods of otitis media.
Lous (1995) argues that there is catch-up time available to the
child to develop cognitive skills when they are free of otitis media
and this can be up to the age of five years. Some might say there
is therefore no need to rush into early speech and language ther-
apy intervention. However, what about those times when the
child is not otitis media free? Early intervention is more important
at these times and we should be involved with the child and the
family rather than waiting to see what might happen at ENT.
From the literature there is some agreement that otitis media has
an effect on some aspects of auditory processing - in particular, those
Be
proactve
ln her roe as a
specast
therapst, lz
larweather s
requenty asked
or advce on
managng
chdren wth gue
ear and speech
and anguage
dcutes.
Athough there
are no dentve
answers, she
expans why
therapsts shoud
be proactve and
adopt a hostc
approach to the
deveopng chd.
tasks that involve changes of Signal-to-Noise Ratio, where sig-
nal means what you want to listen to, usually speech, and
noise is anything else that gets in the way of the signal. For
most of us, we can still attend to speech in a lot of background
noise but, for others, the noise can begin to interfere with
understanding (see Hall et al, 1995; Gravel et al, 1996; Schilder
et al, 1994). With this information in mind, children with otitis
media should have access to surroundings that provide good lis-
tening conditions. The clinic room should, at least, have a few
soft furnishings (piece of carpet, padding in chairs / cushions,
curtains), and some wooden furniture is better than metal. In
Fife, the Educational Audiologist can visit children at school
who have hearing aids or prolonged periods of otitis media,
and make recommendations for improving the acoustic envi-
ronment so they are not disadvantaged.
Remain diligent
I would encourage therapists who receive referrals for children
with otitis media to remain diligent in following up audiologi-
cal review. I am a member of the Childrens Hearing
Assessment Clinic (CHAC) and can often provide hearing status
information to therapists. If your area does not have a thera-
pist as part of a multidisciplinary hearing assessment clinic,
results of Audiology / ENT appointments can be obtained by
phoning the ENT secretary or checking with the Health Visitor
to see if there is any information in the childs medical notes.
Find out the assessed hearing levels; tympanometry results;
were tests of hearing for speech administered and results; what
is the outcome? The outcome is likely to be either discharge,
review (watchful waiting), medication (less likely), surgery or
in some areas, again as in Fife, the prescription of hearing aids
during the otitis media episodes.
Therapists offering therapy to children with otitis media could
try and ascertain the childs functional hearing levels at the
beginning of each session. Ask the child to identify a named
item from a choice of six:
1st - facing the child and at normal voice level;
2nd - behind the child and at normal voice level and
3rd - behind the child and at reduced voice level.
Note any different responses and amend the session accordingly.
Work on perception rather than production. Perception of
sounds in words / phrases (to give the sound a context) is better
than individual sound work. For language work, follow a semantic
basis, again to give the word a context. Many of us target vocab-
ulary using categories of words. Giving the words a context -
which words can go with which other groups of words - assists in
retention and recall. For example, working on all the things you
can catch (a bus, a cold, a mouse) gives a wider experience to
the word than just catch a ball. Speechmark offers good
resources in the Early series - Early Listening Skills, Early Sensory
Skills and Early Communication Skills.
For parents who want to know more about glue ear, the
National Deaf Childrens Society (NDCS), offer lots of family
friendly publications. At the Childrens Hearing Assessment
Clinic in Fife, parents are given a leaflet Glue Ear which is
always well received because of its clarity.
The effects of otitis media on the development of the grow-
ing child remain unsettled. The literature does point to the
possibility that there is a link between children who have a his-
tory of otitis media and language delay, cognitive problems
and behavioural difficulties. However, from the wealth of
information available, it is apparent that otitis media may not
be acting on its own and that a synergy is in operation.
As a profession we should continue to inform ourselves about
the possible consequences of otitis media and the effects of
combinations of factors involving socio-economic status,
parental interaction, age at onset, number of episodes and
duration of those episodes. It is important to continue to note
this type of information and not only hearing status. We
should consider a holistic approach to the developing child and
remember not to attribute poor language development to oti-
tis media alone.
References
Friel-Patti, S. & Finitzo, T. (1990) Language learning in a prospec-
N
s
e
e

w
w
w
.
s
p
e
e
c
h
m
a
g
.
c
o
m
in
s
id
e
fr
o
n
t
c
o
v
e
r
The effect of otitis media with effusion at pre-school age on some aspects
of auditory perception at school age. Ear and Hearing 15: 224-231.
Resources
National Deaf Childrens Society, www.ndcs.org.uk, Information
and Helpline tel. 020 7250 0123.
Defeating Deafness, www.defeatingdeafness.org, Information
Service Freephone 0808 808 2222.
Royal National Institute for the Deaf, www.rnid.org.uk, tel. 020
7296 8000 (England), 0141 554 0053 (Scotland), 029 2033 3038
(Cymru), 028 9032 9738 (Northern Ireland).
Scottish Intercollegiate Guidelines Network, www.sign.ac.uk,
tel. 0131 225 7324.
Speechmark, www.speechmark.net, tel. 01869 244644 for a free
catalogue.
Cranial Osteopathy see for example www.cranial.org.uk
SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2002 27
how I
work for Highland Primary Care NHS Trust and since 1994
have been full-time as a specialist for the hearing impaired.
The Trust covers an area of 10,000 square miles with a pop-
ulation of just over 200,000 and is divided into nine Local
Health Care Co-operatives. There are approximately 20 full-
time equivalent therapists in the service.
My job, based in Dingwall, is to support any hearing impaired
clients referred to the speech and language therapy service
either directly or indirectly by supporting and advising local
therapists, other professionals and families. The geography and
weather can be problematic, my longest trip to visit a child tak-
ing up to five hours for a round trip of 200 miles, half of the trip
being on single track roads.
Recent challenges in Highland include the introduction of universal
neonatal hearing screening, the provision of digital hearing aids
and the fast developing area of cochlear implants. These develop-
ments increase the pressure on my service to provide best possible
practice and equity of service to hearing impaired clients regardless
of location, geography and weather in order to maximise the
opportunity for them to fully achieve their potential in their acqui-
sition of spoken language. This is of course easier said than done!
My work is totally integrated with the Highland Deaf Education
Service which has a child centred, needs led, total communication
policy. Almost all staff, including myself, have a British Sign
Language (BSL) stage 2 qualification, and BSL sign language tutors
are involved with children and families. At present 17 children travel
daily to Dingwall for education and are seen in the support base
by myself for regular speech and language therapy. Of these 17
children, eight have cochlear implants. All hearing impaired chil-
dren receive the same provision from the Deaf Education Service
and the speech and language therapy service regardless of
whether they have a cochlear implant or a hearing aid.
There are approximately eight children with severe / profound
hearing losses that live too far from Dingwall to travel daily,
three of whom have cochlear implants. The Highland Deaf
Education Service supports these children in their local school
or, in the case of preschoolers, at home. The local speech and
language therapist provides regular speech and language ther-
apy with support from myself. Joint assessments and visits with
the education service are frequent and, if I am visiting a child
who lives some distance away, joint travel with the teacher of
the deaf allows ample time for liaison and discussion in the car.
The majority of implanted children in Highland are under the
supervision of the centre in Crosshouse, Kilmarnock (approxi-
mately 240 miles from Dingwall). Any technical support for the
device comes directly from the implant centre. Following the
implant, families travel regularly to Crosshouse for tuning of
the device and to attend appointments with other members of
the implant team; for some Highland children this can involve
being away from home for up to three days. All Highland chil-
dren with cochlear implants are visited at key stages by the
implant centre therapist who is able to link with other members
of the team in Kilmarnock, for example medical staff and the
physicists. It is reassuring for the families to meet the implant
centre therapist prior to the operation. The implant centre ther-
apist also provides us with practical ideas and information for
therapy and carries out regular standardised assessments that
Enthusasm,
empowerment
and equty
ls t possbe to
provde an equtabe
servce to dea
chdren when the
specast therapst
covers a vast, remote
area ncudng many
snge track roads'
lz Krat draws on
the sks o generast
therapsts and other
proessonas to
ensure best possbe
practce s avaabe
to a.
will eventually provide objective material indicating the
progress in language development of these children. She also
provides guidelines as to the individual progress made / expect-
ed by each child, liaising both with myself and the local speech
and language therapists who provide the regular therapy for
the children in the more remote areas. The implant centre ther-
apist also meets and advises local education staff.
Time to tune in
Unlike hearing aids, it is difficult to know exactly how the child
with a cochlear implant is perceiving sound. Implanted adults
are able to give fairly accurate feedback as to how they perceive
sound but children are unable to do this, so a knowledgeable
and trained individual is required to observe their behaviour,
responses to sound, and phonological development. Adults who
have had an implant have informed me that, particularly in the
initial year following the implant and following initial tuning
sessions, it takes them some time to tune in to new speakers,
sometimes as long as a day or two. Assuming this is the same for
children, it has a big impact on my job as, unlike the children
wearing conventional hearing aids, children that I do not work
with regularly may spend all session getting used to my voice,
making it difficult for me to assess their progress accurately. It is
therefore vital that I work closely with their teachers and local
speech and language therapists to observe how the children
perform in listening tasks with more familiar speakers.
The local therapists have large generalist caseloads and are
extremely skilled in providing therapy for any communication
disorder they encounter. They often express a need to acquire
new skills in order to provide therapy for a child with a cochlear
implant. However it has been my experience that, while there is
new information that has to be taken on board, these therapists
have a such a huge depth of knowledge about child language,
listening and development that, rather than having to teach
new therapy methods, I just have to point out which skill they
already possess and how to implement that skill for the child
with a cochlear implant. I firmly believe that my role with the
local speech and language therapists is to empower them to
manage the child on their caseload and not de-skill them.
I encourage local therapists to attend courses on cochlear implants
and hearing impairment so that they have the opportunity to devel-
op their own skills and confidence. Unfortunately costs are a big
issue here and travel and course fees often cannot be justified for
one child on a large caseload where specialist advice can already be
provided locally. Recently Crosshouse have provided affordable,
practical study days which so far one local therapist working with a
child with a cochlear implant has been able to attend.
Generalist therapists often comment that, as that they may
never have had a profoundly deaf child on their caseload before,
they are not sure how that child is performing in relation to other
hearing impaired children. I encourage them to visit the support
base in Dingwall in order for them to have a picture of how their
child is performing in relation to hearing impaired peers.
A problem when supporting these children is the recruitment
difficulty in the remoter areas of the Highlands which can occa-
sionally mean an area being left without local cover. (Anyone
interested in a job?) When this is the case I attempt to visit the
l

tive study of otitis media with effusion in the first two years of
life. Journal of Speech and Hearing Research 33: 188-194.
Gravel, J.S., Wallace, I.F. & Ruben, R.J. (1996) Auditory conse-
quences of early mild hearing loss associated with otitis media.
Acta Otolarygol (Stockh) 116: 219-221.
Haggard, H. & Hughes, E. (1991) Screening Childrens Hearing:
A review of the literature and the implications of otitis media.
Medical Research Council - London HMSO.
Hall, J.W., Grose, J.H. & Pillsbury, H.C. (1995) Long-term effects
of chronic otitis media on binaural hearing in children. Archives
of Otolaryngology, Head and Neck Surgery 121: 847-852.
Lous, J. (1995) Otitis media and reading achievement: A review.
International Journal of Pediatric Otorhinolaryngology 32: 105-121.
Simms, Sue (1994) Mother and child - building the bonds
beyond speech. Human Communication 4 (1): 22 -24.
Schilder, A.G.M., Snik, A.F.M., Straatman, H. & van den Broek, P. (1994)
SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2002 28
how I
or most deaf children, the development of their com-
munication skills requires long-term commitment from
themselves, their parents and therapists. For deaf chil-
dren, communication covers sign, lip-reading, talking,
use of gesture and the ability to read contextual clues. All of us
who have been to signing classes know just how difficult this is
- especially signing and speaking simultaneously.
For deaf children born to deaf parents, British Sign Language (BSL) is
the first language of the home. BSL has its own grammatical structure,
lip patterns and facial expressions, and therefore does not follow spoken
English word order. After many years of hard work following the 5-14
curriculum (the Scottish equivalent of the National Curriculum for
England and Wales) taught in sign supported English, many of these sec-
ond-generation deaf people become skilled lip-readers, perhaps because
they had a well established first language at an early age. But for many
deaf children, lip-reading does not come naturally. Slow language acqui-
sition, difficulties in understanding, limited vocabulary development, and
so many words that look alike on the lips, all make lip-reading difficult.
Deaf people - mainly children, but also deafened adults - make
up my entire caseload, and I have a cross-Tayside advisory role. I
see children from birth through to the end of secondary school if
necessary, including those in units and others who are supported
in mainstream school. Like most speech and language therapists,
I am all too familiar with the task of keeping teenagers motivated
in therapy. Many have lost interest and some are too embar-
rassed to practise their communication skills. For a long time I
looked for a reward for these hard working deaf teenagers - a
certificate that would show colleges of further education, and
future employers, that these students had reached a recognised
standard and proficiency in lip-reading, and that it was not just
naturally acquired. I also wanted to highlight the deaf students
who were lip-reading in a second language.
The Scottish Qualifications Award in Lip-Reading is a free
standing module with no formal entry requirements which
enables the hearing impaired student and / or the deafened stu-
dent to develop lip-reading skills. There are four learning out-
comes and, by the end of the module, students should.
1. know the factors which affect lip-reading and be able to
apply coping strategies.
2. be able to lip-read short sentences presented at a slow
conversational rate and within a known context.
3. participate in and respond to a series of related short
sentences presented at a slow conversational rate and in a
known context by a variety of speakers.
4. participate in a group discussion.
Learning outcome one teaches the students about difficult lip-
reading situations. This can cover everything from trying to lip-
read someone who talks with their hand over their mouth, to
someone who over-exaggerates and talks too slowly. This also cov-
ers badly lit rooms and people sitting with their back to the light.
Deaf children, like most children with special needs, very seldom
have to think about how other people communicate with them.
We have all been trained to sit still, to speak carefully, and to ensure
good lighting and quiet rooms. As a result, these students have
never had to think what to do about other peoples poor commu-
nication styles - they have always been busy perfecting their own.
It is difficult for any of us to ask for clarification or repetition, but it
is particularly difficult for deaf teenagers lacking in confidence. As
one teenager said to me, But youre a teacher - we cant say.
Then we wonder why so many deaf adults nod and smile politely...
Learning outcome two teaches the student to keep their mind
focused on a theme. For the examination, they have to lip-read
and give the gist of ten short sentences full of information.
Learning outcome three tests the students ability in holding a
one to one conversation on a known familiar topic. Learning
outcome four tests the ability to participate in a group discus-
sion. This is particularly difficult for people with a hearing loss;
trying to locate who is talking and also to contribute to a dis-
cussion without interrupting.
Functional knowledge
I felt that all of these outcomes were areas that I would be cov-
ering in therapy, and that the students could achieve this module
through planned cooperative working between the teachers and
myself. The teachers of the deaf within the secondary unit were
not only interested but totally supportive and involved, as were
the mainstream teachers. I had not initially realised the extent
of involvement that would be required from the other profes-
sionals within the school, but this became clear as the module
progressed. This was not just about passing an exam, but about
being able to lip-read different people in different settings with-
in the school, therefore demonstrating functional knowledge.
Throughout the school year I led a team of teachers making up
worksheets and checklists, giving in-service training and devising
record sheets to record the pupils progress. There was only one
significant problem. The Scottish Qualification Agencys (SQA) rules
would not permit me to assess the module because I was not a reg-
istered secondary teacher. To overcome this, the Trusts Training and
Development Centre made the decision to put me through the SQA
Assessors Award, thus enabling me to deliver and assess the mod-
ule. This involved an incredible amount of work. Throughout the
year I attended tutorials at the Training and Development Centre,
the head teacher of the unit assessed me assessing the pupils, and
a verifier came from SQA and assessed all of us.
Meanwhile, the school pupils were entered for their exam, which
I found daunting as I had now taken on a teachers role, and I
found myself willing these children to pass. Success was important
as the module would appear on their leaving certificate. I had to
find people to test learning outcomes three and four. This turned
into real interagency working as I brought in social workers for the
deaf, lip-speakers (who convey a speakers message to lip-readers
accurately), teachers and other speech and language therapists.
For learning outcome one, I enlisted the help of another speech
and language therapist and a deafened adult who was a retired
actor. Between us we made a video of a role-play of an interview
situation with the interviewer being un-deaf aware. This was
fun, but difficult to make because we all found it so hard to be so
un-deaf aware and to have such poor communication skills.
The morning of the exam dawned. I was relaxed until I arrived
at school to find a line of chairs outside the medical room for the
candidates. Inside, the room was all set up examination style, with
a video camera ready to run. The day went well and the candi-
dates were relaxed and confident - even though the participating
adults were nervous and anxious about their communication
skills! We put everything on video because this was the first time
this module had been used for many years in Scotland.
The students passed the module and I passed my assessors
award. At that time speech and language therapy was part of
the Primary Care Trust, and the Chairman and Chief Executive
presented the certificates at a special ceremony. The module
appears on the pupils leaving certificates as part of a group of
modules including deaf studies and an introduction to signing.
Since then, several other speech and language therapists in
Scotland have run this module and I run and assess it in school. It has
given us all a sense of achievement and the students well deserved
recognition. But it also makes the ultimate outcome measure.
Resources:
For further information on the module discussed in this article, see
www.sqa.org.uk then click on QUALIFICATIONS DATABASE, then click on
National Unit by title, then insert lip-reading into the search box. This
will take you to the National Certificate Module Descriptor for E7M3
(Intermediate) Lip-Reading Skills (SEN Hearing Impaired).
The
utmate
outcome
measure
lor many dea
chdren, p-readng
does not come
naturay. Susan
Howden ound out
how derent
agences coud
work together to
ensure that the
eort needed by
dea teenagers to
master ths sk
coud be
recognsed and
rewarded.
l

children, regardless of geography or weather. However, good

multidisciplinary relationships provide the key as the speech and
language therapy service would be struggling were it to go it
alone. Working so closely with generalist colleagues as well as
those from other disciplines provides an extremely satisfying
and enjoyable working environment.
child at least monthly to provide therapy for the children and
also to advise the teacher of the deaf on their speech and lan-
guage development. I often leave a plan of therapy, which is to
be implemented by the teacher of the deaf.
I am aware that sometimes the service may fall short of my aim
which is to provide best possible practice to hearing impaired