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Summer 2007
Summer 2007
Summer 2007 ISSN 1368-2105 Assessments assessed Child language, aphasia, bilingualism Total communication Shifting
Summer 2007 ISSN 1368-2105 Assessments assessed Child language, aphasia, bilingualism Total communication Shifting
Summer 2007 ISSN 1368-2105 Assessments assessed Child language, aphasia, bilingualism Total communication Shifting

ISSN 1368-2105

Assessments assessed Child language, aphasia, bilingualism

Total communication Shifting perceptions

Sharing your experience Doing the write thing

Face value Specialist treatments

HowI extend the reach Partnerships in children’s services

“I know exactly where it is but I don’t know where it’s going…”

Images as signposts

PLUS…Winning Ways – Following the arrow…Here’s one I made earlier…more great reader offers… My Top Resources for new technology…and featuring self-help groups.

£

£ Win the forthcoming 4th edition of The Psychology of Language! Trevor Harley, who co-wrote our

Win the forthcoming 4th edition of The Psychology of Language!

Trevor Harley, who co-wrote our article 'I know exactly where it is but I don't know where it's going' (p.6), is also author of comprehensive psycholinguistic textbook 'The Psychology of Language'. And with a 4th edition due out soon, Psychology Press is giving THREE readers the chance to win a FREE copy. The text focuses on the processes involved in understanding and producing language, covering reading, writing, speaking and listening. An accompanying CD ROM includes materials to test your understanding of each chapter. While our student readers might be particularly interested in this offer, it is also relevant to any therapist working with children or adults with speech and language difficulties. For your chance to win, e-mail your name and address to competitions@psypress.com by 25th July. The lucky winners will be notified by 1st August 2007 and will be sent their copy on publication. For more information on Psychology Press publications see www.psypress.com. The Psychology of Language will retail at £27.50 Paperback or £54.95 Hardback.

will retail at £27.50 Paperback or £54.95 Hardback. Win Interactive Literacy software for Years 3 &

Win Interactive Literacy software for Years 3 & 4!

Do you work with education professionals? Are you looking for new ways to deliver the literacy curriculum strands of reading, writing, speaking and listening? Then the award-winning Smart Learning Interactive Literacy software for Years 3 & 4 (Scotland P4-P7) could provide an answer – and Speech & Language Therapy in Practice has a copy to give away FREE to a lucky reader. This software won a BETT Award 2007 for Digital Content (Primary Core Subjects). It can be used by non-specialists at whole class, small group or individual level. It is designed for use with interactive whiteboards, and to cater for pupils with different learning styles. To enter this free prize draw, simply e-mail your name and address to prizedraw@smart-learning.co.uk by 25th July. The lucky winner will be notified by 1st August 2007. Smart Learning’s Interactive Literacy Series is also available for Years 1 & 2 and Years 5 & 6. Interactive Literacy for Years 3 & 4 retails at £125 + VAT. For further information,

3 & 4 retails at £125 + VAT. For further information, see www.smart-learning.co.uk. Summer 07 speechmag

see www.smart-learning.co.uk.

Summer 07 speechmag

As this issue goes to press we are making exciting changes to the speechmag website – so keep an eye on www.speechmag.com and be part of it!

REPRINTED ARTICLES – VIEW FOR FREE! Cook, L. & Trim, K. (2006) ‘Interactive white- boards: the long and the short of it’, Speech & Language Therapy in Practice Winter, pp.22-24. McCollum, D. (2006) ‘Listen and learn’, Speech & Language Therapy in Practice Autumn, pp. 4-6.

www.speechmag.com

D. (2006) ‘Listen and learn’, Speech & Language Therapy in Practice Autumn, pp. 4-6. www.speechmag.com
D. (2006) ‘Listen and learn’, Speech & Language Therapy in Practice Autumn, pp. 4-6. www.speechmag.com

Summer07contents

INSIDE COVER: Reader Offers, Summer 07 Speechmag Win Interactive Literacy Software and The Psychology of Language.

2

NEWS &

COMMENT

The Psychology of Language. 2 NEWS & COMMENT 10 ASSESSMENTS ASSESSED Our series of in-depth reviews
The Psychology of Language. 2 NEWS & COMMENT 10 ASSESSMENTS ASSESSED Our series of in-depth reviews
10 ASSESSMENTS ASSESSED Our series of in-depth reviews continues with Teaching Talking (2nd edn), One

10 ASSESSMENTS ASSESSED Our series of in-depth reviews continues with Teaching Talking (2nd edn), One Step at a Time, CELF-4UK, Stroke Talk and the

Bilingual Speech Sound Screen (Pakistani Heritage Languages).

Bilingual Speech Sound Screen (Pakistani Heritage Languages).
14 DOING THE WRITE THING “Writing with another person can be a great motivator, having

14 DOING THE WRITE THING “Writing with another person can be a great

motivator, having to produce work to show your co-author often proving a great incentive to write. And it can be fun. You may also find yourselves supporting each other in unexpected ways, particularly if physical and emo- tionalwritingpeaksandtroughsarecomplementaryratherthansimultaneous.” Have you considered writing about your work but not quite found the courage? Myra Kersner and Jannet Wright help you to get started - and keep going all the way to the finishing line.

13

16

20 FACE VALUE “There is no quick fix for facial palsy and cli- ents do

20 FACE VALUE “There is no quick fix for facial palsy and cli-

ents do not move from the list quickly; we are talking years not months. It draws on many of our skills to work with these clients as the effect of facial palsy is devas- tating both physically and psychologically.” Penny Gravill outlines the benefits of two specialist facial palsy treatments which she offers on the NHS and more recently at a Satellite Centre for an independent provider.

24 HOW I EXTEND THE REACH Across the UK we are moving towards integrating children’s

services - but learning to work more closely with other agen- cies is not a straightforward task. Our contributors focus on two imaginative partnership projects that are succeeding in breaking down barriers. (1) PREPARING FOR INDEPENDENCE With many children unable to access therapy, school training needs unmet and jobs for new graduates at a premium, Debbie Halden, Kirsty Ferguson and Jill Kennedy report on a 6 month collabora- tive project between a cluster of primary schools and a speech and language therapy service. (2) FUNDING GAPS Julie Coley welcomes the opportunity to be part of a properly resourced and managed Children’s Fund project to improve the speaking and listening skills of children who would not normally access speech and language therapy.

to improve the speaking and listening skills of children who would not normally access speech and
to improve the speaking and listening skills of children who would not normally access speech and

28 REVIEWS Management, voice, Asperger’s Syndrome, AAC , working memory, developmental dyspraxia.

Summer 2007 (publication date 28 May 2007)

ISSN 1368-2105

Summer 2007 (publication date 28 May 2007) ISSN 1368-2105 Published by: Avril Nicoll, 33 Kinnear Square

Published by:

Avril Nicoll, 33 Kinnear Square Laurencekirk AB30 1UL Tel/fax 01561 377415 e-mail:

avrilnicoll@speechmag.com

1UL Tel/fax 01561 377415 e-mail: avrilnicoll@speechmag.com Design & Production: Fiona Reid, Fiona Reid Design

Design & Production:

Fiona Reid, Fiona Reid Design Straitbraes Farm, St. Cyrus, Montrose Angus DD10 0DS Printing:

Manor Creative, 7 & 8, Edison Road Eastbourne, East Sussex BN23 6PT Editor:

Avril Nicoll, Speech and LanguageTherapist

6PT Editor: Avril Nicoll, Speech and LanguageTherapist Subscriptions andadvertising: Tel / fax 01561 377415 ©Avril

Subscriptions andadvertising:

Tel / fax 01561 377415

©Avril Nicoll 2007 Contents of Speech & Language Therapy in Practice reflect the views of the individual authors and not necessarily the views of the publisher. Publication of advertisements is not an endorsement of the advertiser or product or service offered. Anycontributionsmayalsoappear on the magazine’s internet site.

Cover photo of Helen Gowland and Laorag Hunter by Paul Reid.
Cover photo of
Helen Gowland
and Laorag Hunter
by Paul Reid.

4 SHIFTING PERCEPTIONS “As the project progressed there was some increase in use of the tools with the learners. Some carers became more confident in using them and two achieved the induction level in Somerset Total Communication. This was a particularly exciting aspect of

the project as we had hoped it would develop a more standard communication in different areas of the learners’ lives.” Julia Tester reflects on a small scale curriculum action research project using Somerset Total Communication with two groups of learners with severe and complex needs resulting from congenital or acquired difficulties.

6 COVER STORY: “I KNOW EXACTLY WHERE IT IS BUT I DON’T KNOW WHERE IT’S GOING…” “When Helen feels confident that she has captured the production she practises and celebrates by playing with the word. Around

Christmas time she delighted in exclaiming ‘Have a piece of Stollen’, ‘Do you like Stollen?’, ‘Would you care for some Stollen?’” Laorag Hunter, Helen Gowland, Siobhan MacAndrew and Trevor Harley discuss the use of images as signposts in therapy – and the kind of service we need to provide to ensure such opportunities are not missed.

HERE’S ONE I MADE EARLIER News and weather round-up; Newspaper headlines; Soapbox.

E-MAIL TO THE EDITOR Cochrane Systematic Review – speech and language therapy for aphasia following stroke.

17 FEATURE SELF-HELP ME IF YOU CAN

“Speech and language therapists are acutely aware of how isolating a communication disability can be. Many people with communi- cation difficulties face a particular challenge in finding and participating in social activities including self-help initiatives.” Avril Nicoll asks what contribution self-help groups can make to how someone adapts to and manages their communication diffi- culty, and where speech and language therapy comes in.

23 WINNING WAYS: FOLLOWING THE ARROW “…the ordinary everyday often does present us with chal- lenges that we sidestep because we don’t think that we have

the guts or determination to follow through. My personal challenge is to follow through on what I have set myself.” Breaking an arrow with her throat confirms for life coach Jo Mid- dlemiss that, with the right attitude and support, we can all follow through our goals.

BACK COVER: MY TOP RESOURCES “Social networking websites … are useful in therapy with individuals who have maintained a site prior to acquiring a communication dis- ability, perhaps as a result of a brain injury. They enable therapists to find out more about the individual’s past, replacing or enhancing infor- mation from carers. The site can help initiate and inspire conversation and may act as a potential forum for clients to contact others who are also members.” New technology is developing at breathtaking speed, but are we up- to-date with its potential use in therapy? Tayside speech and language therapists Gill Cameron, Jaclyn Dallas, Judy Goodfellow, Lorraine Hope, Caitriona Hutton, Gillian Nixon, Rebecca Richardson, Karen Rodger and Lesley Smith discuss some of the developments they have seen across paediatric, adult learning disability and adult services.

IN FUTURE ISSUES: SERVICE REORGANISATION

OUTCOME MEASURES

TALKING MATS

ORAL

MOTOR

NLP

DYSARTHRIA

CARE

PATHWAY (FEEDING)

STUDENT

PLACEMENTS

NEWS

Hearing

Dogs

Hearing Dogs for Deaf People is encouraging children and adults to learn about deafness and support its work. The charity has produced free information packs to complement National Curriculum Key Stages

1-2 and 3-4 and one for adults. The children’s packs include card games using sign language symbols and

a drama workshop to

encourage children to empathise with deaf people and think about the impact of their own actions and attitudes. Packs are available from 01844 348133 or e-mail togsfordogs@ hearingdogs.org.uk

Fraser and Robbie Nicoll say thank you to Frances, and give her a handbag as
Fraser and Robbie Nicoll say thank you to Frances, and give her a handbag as a leaving present.

Frances retires

After more than 7 years as administration assistant for Speech & Language Therapy in

Practice, Frances Eddison has handed in her keys and is preparing to move to Yorkshire with her husband Alan for their retirement. Frances spent one day a week in the home office managing subscriptions, deal- ing with finance departments, organising book reviewers and generally ensuring the smooth running of the business. Editor Avril Nicoll says, “Frances was a real find. She started working for the magazine shortly before I had my second son, when I was feel- ing completely overwhelmed. It has been fantastic being able to rely on someone who pays attention to detail and is so good with people. More than that, Frances has been like an extra member of our family. While we are delighted for her that she is returning to an area she loves, we are going to miss her.”

to an area she loves, we are going to miss her.” Beverley Hughes, Minister for Children

Beverley Hughes, Minister for Children and Families, and Ivan Lewis, Minister for Care Services, launch the Early Talk roll-out at South Acton Children’s Centre in West London.

Strategic partnership announced

Children’s communication charity I CAN, the Department for Education and Skills and the Department of Health are to roll-out I CAN’s Early Talk programme to up to 200 Sure Start children’s centres across England. Early Talk is an evidence-based programme designed to aid the communication development of all pre-school children through integrated therapy and educational approaches. It operates in settings that provide day care and / or education to children under five, such as children’s centres. By ensuring that all children learn in communication- friendly environments the ultimate aim is for children with severe and complex communication difficulties to have their needs met in one comprehensive service. I CAN Chief Executive Virginia Beardshaw said, “We are delighted to be working with the government to create

a new model of third sector and statutory sector collaboration. Central to this is the way that I CAN’s expertise in

children’s communication will shape Children’s Services. Effective language skills are essential for children to achieve

and are fundamental to the achievement of all five Every Child Matters outcomes. This strategic partnership acknowl- edges the critical importance of children’s speech and language skills to their future life chances.” www.ican.org.uk

Book magic

Bookstart is promoting its free book gifting programme with an online marketing campaign emphasising the magical and rewarding experience of reading to children. The ‘You Baby Book Magic’ campaign aims to increase awareness of the free book scheme, which provides three packs of free books to every child at key stages of their development. Packs are distributed to children at 7 months, 18 months and 3 years old through health visi- tors, libraries and nursery schools. The website also provides parents with advice on which books to read with their children, book reviews, a message board and the opportunity to sign up to the Bookstart newsletter and receive an introductory book- let about reading with children. www.youbabybookmagic.org.uk

about reading with children. www.youbabybookmagic.org.uk From www.youbabybookmagic.org.uk HPC appointment Professor

From www.youbabybookmagic.org.uk

HPC appointment

Professor Karen Bryan has joined the Health Professions Council as the registrant speech and language therapy member. Karen was selected through a public appointment proc- ess to fill the vacancy created when Anna van der Gaag was elected President in July 2006. She is a consultant speech and language therapist in forensic mental health and a Professor of Clinical Practice and Director of the Healthcare Workforce Research Centre at the University of Surrey. Anna van der Gaag said,“Karen has joined the Council at an exciting and challenging time, when the govern- ment has recommended that the HPC regulate applied psychologists, psychotherapists and counsellors as well as health care scientists. Having worked closely with psychologists during her career Karen will no doubt be involved in the preparations for regulation of these pro- fessions. Her policy work and research skills will also be of great benefit to the work of the Council.” www.hpc-uk.org

The Puncs – special offer

Compass Books is offering Speech & Language Therapy in Practice readers the full set of ‘The Puncs’ at a special price of £25, inc. p&p. This compares with a retail price of £4.99 for each of the 7 books. The Puncs include Fer- gus Full Stop and Henrietta Hyphen-Hyphen. The Puncs were reviewed positively in the Winter 05 issue. www.thepuncs.com

Suzanne and Tracy do the RABBIT sign as they sing ‘I dig my garden’ Singing

Suzanne and Tracy do the RABBIT sign as they sing ‘I dig my garden’

Singing Hands

Singing / signing duo Singing Hands recently contributed to five episodes of Cbeebies’ ‘Something Special’. Suzanne Miell-Ingram and Tracy Upton – both parents of a child with special educa- tional needs – teach children Makaton through nursery rhymes, action songs, games and stories. Their two new signed songbooks produced in conjunction with the Maka- ton Vocabulary Development Project will be reviewed in a future issue. www.singinghands.co.uk

Ataxia guidelines

Ataxia UK has published a set of clinical guidelines for healthcare professionals, cover- ing the diagnosis and management of progressive ataxias. Dr Anja Lowit of Strathclyde University represented speech and language therapy on the guideline development group. Early referral for information and support is rec- ommended. A dedicated appendix details appropriate management of dysarthria and how a therapist can support the client and their family in dealing with the impact of a progressive communication and swallowing difficulty. A summary document is available for GPs, but does not specifically mention speech and language therapy. Ataxia UK says that some 10,000 adults in the UK have a form of cerebellar ataxia. www.ataxia.org.uk/page.builder/clinical_guidelines.html

Transition care pathway

The Association for Children’s Palliative Care has worked with young people to produce a framework to help those with a terminal illness or life-limiting condition, their families and professionals plan for their future and move from child to adult services. The emphasis throughout is on holistic teams for therapy and care, with a person- centred plan and adequate funding. One young person is quoted to illustrate why this is so important: “I need a speaking valve. I saw an ENT consultant last summer and he is really slow. I’m still waiting to hear from him. It gets a bit complicated. He said I could speak. He had to speak to some people before he could come back to me and say that.” The Transition Care Pathway: A Framework for the Development of Integrated Multi-Agency Care Pathways for Young People with Life-threatening and Life-limiting Conditions, down- loadable at www.act.org.uk/dmdocuments/transition_care_pathway.pdf.

Rehab in Scotland

Scotland has a new model for rehabilitation. The development of this ‘delivery framework’ has been led by service users including Olivia Giles who lost her lower legs and lower arms to meningitis in 2002, necessitat- ing a lengthy period of rehabilitation. The process involved consultation with over 250 service users and 300 professionals from health and social care. A national group will oversee the implementation of the framework. Each NHS Board will have a local reha- bilitation coordinator and there will also be a managed knowledge network accessible by health and social care practitioners and service users. The framework emphasises the importance of thinking differently from before: “All health and social care professionals involved in developing or delivering rehabilitation services should…look beyond traditional methods of providing services and engage in service redesign and role development in partnership with individuals and carers. This will enable them to create new models of service that reach across historical profes- sional and service boundaries.” Coordinated, integrated and fit for purpose: A Delivery Framework for Adult Rehabilitation in Scotland, see www.scotland.gov.uk/Publications/2007/02/20154247/12.

NEWS AND COMMENT

comment

Comment:

Signposting the way

NEWS AND COMMENT comment Comment: Signposting the way I once wore out my shoes in Glasgow

I once wore out my shoes in Glasgow looking for

Sauchiehall Street. I have driven across Aberdeen trying

to find Union Street. I knew where I was - and where

I wanted to be - but I didn’t know where I was going.

(Naturally I preferred to go round in circles rather than ask for directions to such major thoroughfares.) With a strong sense of purpose but a poor sense of direction, I rely on road signs to get from A to B. ‘Signposting’ is widely used in aphasia therapy to describe one of the roles of a speech and language therapist, particularly for people in the acute phase. Seven years on from her brain haemorrhage, Helen Gowland (on p.6 with her co-navigators) continues to discover new signposts to guide her on her journey with aphasia as, “I know exactly where it is but I don’t know where it’s going.” Our self-help feature (p.17) shows such are tools essential, but we each have to choose where we want to go and when, and how we want to get there. Speech and language therapists help clients by making sure the signposts are in place and don’t get obscured over time by neglect just when they might prove useful. We also recognise that, to a large extent, people are happiest when they plan and find their own way. There are always alternative routes to the same destination, and a choice of travelling companion. Myra Kersner and Jannet Wright (p.14) share their significant experience of writing together for publication but also emphasise its intensely personal nature and the need to develop your own style. Sometimes a journey is focused and uni-directional, like our need to find out more about assessment options (p.10). But when we want to negotiate the Spaghetti Junction of multi-agency partnerships, the number of routes and the complexity of intersections means specific direction and considerate driving are essential to keep things moving. Governments across the UK and a series of guideline groups (see news pages) have clearly stated this is the way forward. How I extend the reach (p.24) looks at how we can make it work on the ground. Just as technological innovations have added computerised notices to our roads signage, Penny Gravill (p.20) demonstrates they are also assisting clients and informing the direction of therapy. I have so far avoided sat nav (for fear I would end up in the sea or a field), but have taken on board what the top technology resources (back page) say about social networking; watch out for developments with www.speechmag.com. Sometimes we just need to slow down to notice signs. Julia Tester (p.4) describes her emotional response when a learner who generally spent group sessions with their eyes closed filled an extended pause with an unexpected communication. At other times we need to make a conscious decision to make use of what the signs are telling us. For life coach Jo Middlemiss (p.23), an arrow proved to be one of the strongest indicators that we can all follow through our goals. So if you’re feeling a bit lost or lacking in direction remember there are lots of experiences out there for you – and that Speech & Language Therapy in Practice offers signposts to help you on your way.

in Practice off ers signposts to help you on your way. Avril Nicoll, Editor 33 Kinnear

Avril Nicoll,

Editor

33 Kinnear Square, Laurencekirk AB30 1UL

tel/ansa/fax 01561 377415

e-mail avrilnicoll@speechmag.com

TOTAL COMMUNICATION

I work as a curriculum leader and a teacher of com-

munication in a large further education college. The

learners on my course all have cognitive difficulties,

either from birth or acquired later in life. In 2005 a

group of us - teachers, learning facilitators, families and carers - agreed we would run a small scale curriculum action research project to clarify the benefits of using

Somerset Total Communication with our two groups of learners. We wanted to know if:

both groups could be taught in the same way

individuals in both groups could learn to use Somerset Total Communication tools

there was a measurable increase in self-confidence

all would show an interest. In class we use the communication tools of Somer- set Total Communication, mainly with the learners with congenital difficulties. Somerset Total Communication

is a multi-agency partnership led and jointly funded by

Somerset County Council and Somerset Health Com- munity “to ensure a consistent ‘cradle to grave’ strategy”

(www.somerset.gov.uk/somerset/socialservices/pi/stc/, accessed 2 November 2006). At our college we have a

service level agreement with Somerset Total Communica- tion which allows us to access support from the speech and language therapist who works there and the network

of Somerset Total Communication co-ordinators.

This partnership provides a service that includes life- long support for people with communication challenges,

a library of resources that can be used to support com-

munication for this client group, and training for those working with them. All our learners respond well to the resources - objects of reference, pictures and symbols to support the spoken word - and we use them in class. Our research project was to be submitted for my Masters dissertation (Prince, 2006). My personal journey to this point began when I volunteered to work with a child with a brain injury in the early 1980’s. This set me on a path that led me to work in clinics designing home programmes for families and people with brain injury. I then set up and provided a massage and aromatherapy service to people with both congenital and acquired difficulties before moving from this into support and education. To fulfil these roles I have studied ITEC (The International Examination Board) massage, anatomy / physiology, and aromatherapy, British Sign Language to level 2, Somerset Total Communication and Deaf Blind communication skills. I have a Certificate in Education and a Masters in Special Education which later included consideration of speech and language difficulties. I have also studied Damaged Brains and Neural Nets with the Open University.

Perceived relevance

Prior to starting the research I liaised with the Somerset Total Communication speech and language therapist and the speech and language therapist at the local hos- pital. This was invaluable for us in starting the project as, before we carried out the work, we wished to ascertain its perceived relevance to colleagues, related profession- als, clients, carers and families. We also wanted to identify specific focus points and any prior appropriate research that could inform the team. I found information relating to the positive use of Somerset Total Communication with people with congenital learning difficulties but was unable to find

Shifting

perceptions

Photo by Mark Palmer (www.allaboutcapture.co.uk)
Photo by Mark Palmer (www.allaboutcapture.co.uk)

Julia Tester reflects on a small scale curriculum action research project using SomersetTotal Communication with two groups of learners with severe and complex needs resulting from congenital or acquired difficulties.

reports of its use with people with acquired brain inju- ries of the severity experienced by some of our learners. Those with the greatest challenges to learning move on a scale from being asleep - or with their eyes open and unable to communicate with intent - through to having their eyes open and being able to communicate with in- tent. People who seem to have low levels of awareness are not easily assessed and may appear to fluctuate in their responses. I found articles dealing with people on the minimally conscious scale of value for increasing my understanding of the issues (Laureys et al., 2000; Katz, 2001; Weil 2005).

The project was in two phases. It set out to teach five signs or symbols to six people (three with congenital dif- ficulties and three with acquired), all between their late 30’s to early 50’s. These symbols were person specific and chosen as a result of input from the clients and / or carers, family or learning facilitators. The aim was to es- tablish communicative abilities for each learner and to identify any problems with methods, as well as familiar- ising the learners and everyone involved with the proc- ess. It was then repeated five months later to clarify the initial results and identify retained skills. To do this we observed and recorded responses to previously learned

signs or symbols and gave the learners the opportunity to learn five new signs or symbols and thus develop the process further. During the project the learners were all exposed to Somerset Total Communication at college during their weekly communication session. On our programme the learners have an option to attend several short sessions per week. The choices include: Communication, Infor- mation Technology and a Craft subject. When not at col- lege the learners are supported by carers in residential or nursing homes. During this time they have opportuni- ties to access the community; for example, two learners with congenital difficulties attend a bread making class.

More standard communication

As the project progressed there was some increase in use of the tools with the learners. Some carers became

more confident in using them and two achieved the induction level in Somerset Total Communication. This was a particularly exciting aspect of the project as we had hoped it would develop a more standard communi- cation in different areas of the learners’ lives. The method used for our recording was participant observers. We recorded on a formal checklist any com- municative response observed, including eye/hand movements, vocalisations, gestures and signs. I found

it extremely exciting to see the increase in communi-

cative behaviour between the learners and staff. On

one occasion I was greeting the learners who all sat in

a communication circle. Some spoke, some signed and

one learner generally remained with their eyes closed. This particular morning I paused, longer than usual, to

I found it extremely exciting to see the increase in communicative behaviour between the learners and staff.

allow time for response. My mind was elsewhere, on the next stage of the lesson. Suddenly I heard a colleague draw in a breath and I refocused on the learner who had now opened their eyes and was moving their hand and arm up to sign good morning. They were smiling and appeared excited by their own ability to respond. I felt very emotional at this point and wondered what had triggered the learner to communicate that particular morning. Had I approached them differently? Was the temperature in the room different? Was it the extra time given? Was it that this was one of their waking times? As they had previously responded more during one-to-one time, we were very excited that they seemed happy and had responded in the group circle situation. This incident marked a shift in my perceptions. As Brown et al. (2003) said, “The necessary concentration on the learner in order to encourage and extend these ex- changes is also likely to make us aware that the learner has in fact a number of expressive actions of which we may have been unaware…”(p.33). The outcome of the project was that both groups were able to learn and use Somerset Total Communica- tion when taught in the same way. Two learners with congenital difficulties achieved certificates for recog- nising five or more symbols and one learner achieved a

certificate for recognising three symbols. We were aware that it is possible these learners had experienced Somer- set Total Communication previously in attending a day centre or in a residential home and that prior learning may have predisposed them to engage with it again. We are also aware that we had used Somerset Total Com- munication with them - albeit in a less focused way - so it wasn’t totally new.

This project taught me a

the need

to give time to our learners to respond.

great deal about

Two of the learners with acquired difficulties were less likely to have encountered signs and symbols prior to their disabilities and one had used them but we were not aware of duration or intensity of their involvement. All three had been exposed to Somerset Total Commu- nication at college prior to the research but again in a less focused way. Of this group two people achieved cer- tificates for recognising five or more symbols and one learner for recognising three symbols. Two of this group had not spoken in college and have started doing so (single words and couplets). We feel it is not possible to judge to what degree the increased at- tention given by learning facilitators during the project and the stimulation of using an accessible communica- tion method contributed to this and how much was nat- ural progression and recovery from their brain trauma (with a resulting increase in wakeful periods). However, having observed the learners’ increase in attention and developing confidence in using Somerset Total Commu- nication, I personally do not doubt that the communica- tion tools were beneficial. We found learners with congenital difficulties re- quired a longer period of input before they showed con- fidence in using signs and/or symbols. We felt that this may be due to the fact that they had never developed a wide vocabulary at any point in their lives in the way that learners with acquired difficulties had. Dyer (2001) com- ments, “…what we speak and what we write and how we read form only a minuscule part of the language we use in our waking and indeed in our sleeping hours. It fol- lows … that much of language development takes place … in the head. Partly this is a factor of brain maturity” (p.79). As the groups require different amounts of input we feel it is more appropriate to teach the two groups separately. Due to fluctuations in attention, it wasn’t easy judging whether learners showed increased interest in their ses- sions. However the fact that learners with acquired dif- ficulties spent more time with their eyes open, and that all learners acquired a certificate, indicates engagement in the sessions.

Time to respond

This project taught me a great deal about my own re- ceptive communication skills and about the need to give time to our learners to respond. I have also become aware of the difficulties of analysing responses to ques- tionnaires (and of all the potential for genuine under/ over attributing of skills) and the difficulties for those filling in questionnaires (whose role may be carer, learn-

TOTAL COMMUNICATION

ing facilitator or family member with little or no experi- ence of this type of recording). Also on reflection I have become aware of the problem of possible inconsistency when different people complete questionnaires for a cli- ent due to staff availability and response. The project is small scale and focuses on individuals at a specific time in their lives. This makes it difficult to repro- duce. However it is exciting that our learners with acquired severe and complex communication needs responded positively. On a personal level I learned a great deal from my studies, not least about how little I knew then and now, and how much there is still to learn in order to provide the best service to these amazing learners. I would hope that others may feel motivated to offer these communication tools to people with acquired brain injury, to give them fur- ther opportunity to start to communicate again. If anyone wishes to do so I would value the opportunity to liaise and

support in any way possible.

SLTP
SLTP

Julia Tester is a curriculum leader and a teacher of commu- nication at Somerset College of Arts and Technology, email:

Greystarh@yahoo.co.uk.

References

Brown, N., McLinden, M. & Porter, J. (2003) ‘Sensory Needs’, in Lacey, P. & Ouvry, C. (eds.) People with Profound and Multiple Learning Disabilities. London: David Fulton,

pp.29-38.

Dyer, C. (2001) Teaching Pupils with Severe and Complex Difficulties. London: Jessica Kinglsey Publishers. Katz, D. I. (2001) Minimally Conscious States [Online] Available at: www.kurzweilai.net/articles/art0161.html (Accessed: 9 March 2007). Laureys, S., Faymonville, M-E., Degueldre, C., Del Fiore, G., Damas, P., Lambermont, B., Janssens, N., Aerts, J., Franck, G., Luxen, A., Moonen, G., Lamy, M. & Maquet, P. (2000) ‘Auditory processing in the vegetative state’, Brain 123(8), pp. 1589-1601 [Online]. Available at: http://brain. oupjournals.org/cgi/content/full/123/8/1589 (Accessed 9 March 2007). Prince, J. (2006) An Evaluation of Teaching & Learning Somerset Total Communication in a Further Education Col- lege to Two Groups of Learners. One group with Acquired and the Other with Congenital Severe and Complex Needs. MEd dissertation. The University of Birmingham. Weill Cornell (2005) ‘Giving Voice to Hidden Lives’, The Weill Cornell Scope July-August [Online]. Avail- able at: www.med.cornell.edu/publications/pdf/the- scope/2005-07-08 (Accessed 9 March 2007).

Resource

• Information on Somerset Total Communication is at www.somerset.gov.uk/somerset/socialservices/pi/stc/.

REFLECTIONS

• DO I PAUSE SUFFICIENTLY FOR LEARNERS TO RESPOND?

• DO I THINK LATERALLY WHEN SEARCHINGTHE LITERATURE?

• DO I APPRECIATE THE LIMITATIONS OF USING QUESTIONNAIRES?

COVER STORY: THERAPY

“I know exactly whe but I don’t know wh

READ THIS IF YOU ARE INTERESTED IN

USING COMMUNICATION AIDS AS THERAPY TOOLS

HOW IMPAIRMENT

AND FUNCTIONAL

THERAPY

APPROACHES

WORK TOGETHER

DESIGNING

THERAPY

COLLABORATIVELY

WITH CLIENTS

Trevor Harley is also author of comprehensive psycholinguistic textbook 'The Psychology of Language'. For your chance to win a FREE copy of this book, see the Reader Offer on the inside front cover.

Photo: Paul Reid. Photo: Paul Reid.
Photo: Paul Reid.
Photo: Paul Reid.

COVER STORY: THERAPY

re it is ere it’s going…”

When Laorag Hunter offered Helen Gowland a high-tech aid as a communication strategy, neither suspected it would become a means of facilitating Helen’s use of multi-syllabic words in everyday speech. Here, with Siobhan MacAndrew andTrevor Harley, they discuss the use of images as signposts in therapy – and the kind of service we need to provide to ensure such opportunities are not missed.

T his article describes a specific component of therapy, a solution-focused approach that is sim- ple to implement. This therapy evolved collabo- ratively when the introduction of a high-tech

aid as a communication strategy opened up unplanned possibilities. We find it particularly exciting because it is having a measurable impact on a client with conduction aphasia seven years after onset. Our story starts seven years ago, when Helen Gowland settled down one evening to watch Jools Holland on TV. This was a moment of relaxation in a schedule involving many roles. Helen worked full-time as a specialist physiotherapist, researcher at an international level, Chair of the school Par- ent Teacher Association, wife, mother to three teenagers and daughter to an elderly father. She remembers wondering that evening why paramedics were in her house. Helen’s next memory is ten days later in neurosurgery finding herself with a large surgical wound in her skull, unable to speak or to understand what people were say- ing. It took a long time to fully grasp what had happened. Helen had suffered a sub-arachnoid haemorrhage from a large left middle cerebral artery aneurysm. An emer- gency craniotomy was required to clip the aneurysm. Two days later Helen experienced delayed ischaemia with seizures and severe aphasia.

Changing needs

Helen’s partnership with speech and language therapist Laorag has continued and developed over the seven years. Episodes of care have responded to her changing

years. Episodes of care have responded to her changing Figure 2 Meta-linguistic awareness A print showing

Figure 2 Meta-linguistic awareness

A print showing how Helen senses her aphasia. Reprinted by kind permission of Christine Kingsley.

needs and varied in type and length. Reasons for thera- py have included assessment, rehabilitation, supporting and enabling (Malcolmess, 2001). Additionally, Helen has opted in to resources and projects including group work, computer classes and visual arts. Complicating factors affecting rehabilitation have included wound infections, removal of her temporal bone-flap with later cranioplasty to close the skull, and issues relating to epi- lepsy and side effects of medication. Helen’s communication profile resembles that of the syndrome of Conduction Aphasia (Goodglass & Kaplan, 1983). Key features are fluent and grammatical speech; difficulty in the sequential order of speech sounds in naming and repetition; greater difficulty with longer words; good awareness of errors; repeated attempts at error correction (a characteristic known as conduite d’approche) and relatively spared comprehension. Helen has excellent conversational skills and is excep- tionally resourceful at getting her ideas across through total communication methods. When she is unable to express the full content of her message she will use drawing, fragmentary writing, pantomime, circumlocu- tion and even singing. Helen’s speech is easy to under- stand and is fluent and grammatical. These strengths contrast with a history of severely im- paired noun production in spontaneous speech, spoken naming, written naming and repetition. Helen’s under- standing in everyday situations is good but vulnerable to errors in times, days and numbers. She notices increased difficulties understanding in groups where there are

rapid shifts of turn and when there is background noise. Formal assessment shows comprehension breakdown in sentences if the context does not assist in understand- ing the relationship between items. In terms of naming (figure 1), Helen’s assessment record shows a history of word form errors (literal para- phasias), many of which are non-words. Alternatively, attempts are aborted after inability to start the word or after producing only the initial phonemes. Helen’s errors increase with word length and she makes more dele- tions or substitutions towards the end of words. Less frequently, Helen makes semantic errors, such as substi- tuting“father” for “husband”.

Figure 1 Naming examples

Mug “muck” “monk” “mug” Hoover “hoola” Cigarette “sigarant” Speakability “speakaleekie”

Cognitive neuropsychological models of speech pro- duction detail the component processes in speech pro- duction (see for example Levelt, 1989). With reference to such models, Den Ouden & Bastiaanse (2005) conclude that the symptoms of conduction dysphasia are associ- ated with impaired phonological encoding. This stage - between word form selection and articulatory planning - incorporates a ‘slot-filler’ mechanism that maps the sounds (fillers) onto their position (slots) in a word frame (Nickels, 1997). Den Ouden & Bastiaanse (2005) suggest

(Nickels, 1997). Den Ouden & Bastiaanse (2005) suggest SPEECH & LANGUAGE THERAPY IN PRACTICE Summer 2007
COVER STORY: THERAPY that, as well as a mapping defi cit, the error patterns of

COVER STORY: THERAPY

that, as well as a mapping deficit, the error patterns of some people with conduction aphasia are secondary to a verbal memory deficit. In these cases speech errors result from difficulties retaining the activation of the phonological plan.

Meta-linguistic awareness

Helen’s descriptions of her experience when naming sug- gest having word form knowledge with inability to com- plete the phonological form. These descriptions show a high level of meta-linguistic awareness (see figure 2, p.7):

“I know the meaning of the word but I don’t know what it looks like.”

“I know exactly where it is but I don’t know where it’s going.” “Sometimes I can start it but I don’t really know how to say it properly.” Helen’s written naming follows a similar pattern to her speech in that she writes partial word forms. She fre- quently writes more letters of a word than sounds she can say. When letters are omitted she can often indicate the correct number of letters or syllables. Helen’s reading is slow and limited to short pieces. She has great difficulty recognising function words such as prepositions, conjunctions and determiners. This is

a symptom of phonological dyslexia. Impaired reading by letter to sound conversion (grapheme to phoneme

route) forces reading via the semantic route (Harley, 2001). Words with poor semantic representations such

as function words are therefore read poorly (Friedman et

al., 2002). Helen compensates for this difficulty by using text-to-speech software to aid reading comprehension.

Speech production‘stuck’

Throughsemantictypetherapy(Nickels, 2002)andpractice of specific word sets Helen slowly made modest gains in naming. At the start of this therapy Helen’s speech produc- tion was stable; this could be re-phrased as ‘stuck’. Laorag offered a communication aid as a back-up to speech to help transfer of information such as address, phone number, numbers, and commonly used family details. Helen liked

the idea of using the aid to practise speech but using it in interactions did not appeal. She felt the aid was too big, too slow and difficult for people to read. She thought that peo- ple would be“too busy”to attend to it and that it negatively affected perception of her competence. Helen wanted to say letter names as they frequently occur, for example, in addresses, clothing sizes, names of companies and medication (for example, DD2, RAC, CPR). Letter names cannot be read by letter to sound conver- sion and are disadvantaged in reading via a semantic route because they are low in semantic value. Friedman et al. (2002) increased function word reading in two people with phonological dyslexia. Using paired associate learn- ing Friedman improved reading of function words (low semantic value) by pairing with homophones high in se- mantic value (not/knot, knows/nose). This is an example

of a reorganisation of function where intact processes are

used to compensate for impaired processes. We linked the alphabet with semantically rich homo- phones and near homophones that Helen found mean- ingful (figure 3). Near homophones begin with a sound that is the same as the letter name. These links were re-

inforced by storing a picture of the link word along with

a recording of the letter name in a Dynamo digitised speech communication aid.

Figure 3 Alphabet links Letter Link word Link Picture Homophone type A “eight” Near homophone
Figure 3 Alphabet links
Letter
Link word
Link Picture
Homophone type
A
“eight”
Near homophone
B
“bee”
Homophone
C
“sea”
Homophone
D
“Delia”
Near homophone

Helen found the discipline to practise challenging but her ability to say letter names improved. Interestingly, the method enabled Helen to say letter names in se- quence (eg. MP). This suggested a potential to sequence single syllables to produce multi-syllabic words if each syllable was associated with a picture cue. Helen was enthusiastic and quickly identified long words she want- ed to say such as aphasia, Glenrothes, Victoria. Laorag was concerned that this was too ambitious as until now work on spoken output had mainly been on single syl- lable, picturable words. For our multi-syllabic words therapy, Helen makes lists of words that she wants to say and use but is unable to produce (target words). The lists typically consist of written fragments of each word (1-3 letters) accompa- nied by a drawing for picturable items. For more abstract words (eg. policy, resources) additional clues in the form of gestures or associated words are required from Helen before Laorag can identify the target word. Helen’s cho- sen vocabulary reflects personal, family and professional interests, needs, seasons and world events. Most items are 2-5 syllables in length (figure 4).

Figure 4 Target vocabulary (selected by Helen)

Figure 5 Target word examples

vocabulary (selected by Helen) Figure 5 Target word examples Fun Laorag segments the target word into

Fun

Laorag segments the target word into syllables and sug- gests single syllable words that are homophones or near homophones for each syllable. An image to represent each single syllable word is selected from the Picture Communication Symbols set (Mayer-Johnson, 1981). Where there is more than one possible image Helen se- lects the one that is most meaningful to her. Associating each syllable with a Picture Communication Symbol has drawn upon Helen’s strengths in word meaning, foreign languages, wide-ranging knowledge and creativity. It has also been a fun part of therapy for both of us! We make a page for each target word on the Dynamo. Each syllable is represented by a picture of the associated image from the Picture Communication Symbols accom- panied by the written form of the word. The syllable is re- corded so that when the picture is touched the syllable is heard (figure 5). Initially, Laorag made the recordings but after two to three months of therapy Helen could independently say and record the single syllable words. By activating the pictures in sequence Helen hears her recorded production of the whole word built up syllable

Aphasia

Relations

Antique

Sandwich

Human Resources

Glenrothes

Continence

America

Sainsbury

Cathedral

Victoria

Chlamydia

Islam

Age Concern

Elephant

Hospital

University

Computer

Address

Animal

Manchester

Paddington

Politics

Stepney

Policy

Inverness

Psychology

Czech Republic

Anatomy

MSP

Ambulance

Budapest

Graduate

HRT

Novel

Pharmacist

Communication

Exam

Theatre

Concert

Greece

Australia

Leaflet

Courgette

Ozone

Management

Thorburn

CBIR

Broccoli

Lebanon

International

Ipswich

Aneurysm

Coleslaw

South

Marks and Spencer

Cambridge

Internet

SR flour

Columbia

St Andrews

First Aid

Sociology

Statement

Falkland

Hideko

Africa

Pakistan

Parliament

Prescription

Japan

Sudan

Tsunami

Bric-a-brac

1955

Mackinlay

Switzerland

Neurology

DVD

 

Egypt

Umbrella

Stollen

Strathearn

 

COVER STORY: THERAPY

COVER STORY: THERAPY REFLECTIONS • DO I RECOGNISE THAT ‘STABLE’ CAN FEEL‘STUCK’? • DO I OFFER
COVER STORY: THERAPY REFLECTIONS • DO I RECOGNISE THAT ‘STABLE’ CAN FEEL‘STUCK’? • DO I OFFER

REFLECTIONS

• DO I RECOGNISE THAT ‘STABLE’ CAN FEEL‘STUCK’?

• DO I OFFER A SERVICE BOUND BY ARBITRARY TIME LIMITS OR FLEXIBLE TO A CLIENT’S CHANGING NEED?

• DO I EVER THINK ABOUT WRITING AN ARTICLE WITH A CLIENT?

by syllable. After listening a few times and considering the image associated with each syllable Helen is usually able within the session to record the target word as a whole item on the Dynamo page. At this point, her pro- duction often automatically alters to accommodate the normal stress pattern of the target word. It is as if Helen’s memory for production of the word is reactivated. When Helen feels confident that she has captured the production she practises and celebrates by playing with the word. Around Christmas time she delighted in exclaim- ing “Have a piece of Stollen”, “Do you like Stollen?”, “Would you care for some Stollen?” She also confesses to continu- ing this practice by talking to herself on the bus ride home. Helen is comfortable to delete words from the Dynamo once she is satisfied that she can independently recall the graphic for the single syllables which subsequently cue her spoken production of the whole multi-syllabic word. When a previously used syllable occurs in a new target word Helen sometimes feels the addition of the graphic in the Dynamo is unnecessary and the written form of the syllable appears alone. Occasionally Helen requests that a Picture Communication Symbol is changed, if she finds it “doesn’t mean anything.” For example “trail” to represent the second syllable in Australia was changed from a path to a child trailing a pull-along toy. Therapy sessions are approximately bimonthly and no preparation is required by the therapist secondary to ses- sions. Helen feels this schedule is appropriate to establish new vocabulary and it also accommodates Helen’s ac- tivities including volunteer work, committee work, family commitments and holidays. Four to six target words are added each session and in 17 months Helen has mastered the production of over 70 target multi-syllabic words. Helen is now occasionally able to generate images for two syllable words independently of therapy sessions.

Self-generated cues

Helen’s ability to say target words and use these in real com- municative situations shows notable increase. Additionally, there are signs of carryover in her use of self-generated cues. Within sessions Helen has become faster at produc- ing target words. Qualitative changes are also apparent in Helen’s reflections. Helen has a sense of achievement and feeling of progression as opposed to previously feeling stuck. The positive outcome for Helen is also clear as she describes imagined fears, for example, “what if we hadn’t tried this?”, “what if you had discharged me?”, “what if you have to take the Dynamo away?”

We agree with Nickels (2002) that “for the clinician understanding how the therapy worked is a luxury” and would add that given the complex variables in typical therapy this can feel like impossibility! However, our method draws upon several therapy ap-

proaches, functional, re-organisation and stimulation:

1. The goal is functional to allow Helen to say the words she wants to use and is driven by Helen’s require- ments and aspirations.

2. We achieve production of previously errorful words through an alternative route (re-organisation). The pictures in sequence give Helen sufficient information to allow phonetic encoding. This may be a direct effect of improved phonologicalassembly.Alternatively,improvedproduction could be a consequence of improved monitoring. Each pic- ture allows Helen to know the one syllable target which she can check and correct at a pre-speech production stage.

3. Once production of the multi-syllabic word is enabled, Helen can go on to practise in a stimulus-response manner (stimulation). This strengthens the connec- tions between semantic and phonological processing giving the possibility of the therapy being effective through rehabilitation of impaired processes.

Helen has rated features from most to least important for her. (The comments are in Helen’s own words.)

1. The picture is most important. I don’t look at the let- ters at all. The picture opens it (the word) up for me.

2. Quick results.

3. The words are always there for me to check if I’m not sure. That’s reassuring.

4. The words are the ones I really need and want to have.

5. I can practise on my own, even in my bed. It (the Dy- namo) is easy to carry around in my bag.

6. It’s interesting to show others what I’m doing in thera- py and I can explain that it’s about pictures.

7. I’m not bothered whether it’s my own speech or not,

but I am glad that it’s not American. Our success illustrates that therapy to improve a production disorder can be effective many years post-onset. Although we don’t know if this would have worked earlier for Helen, it has prompted Laorag to earlier and more creative trialling of stimulability in speech production with other clients.

Flexible service

Aspects of our organisation and management have been vital in enabling this work. Our service is flexible to deliver therapy according to client need and potential for change

rather than within set time boundaries. The method devel- oped through dedicated time for continuing professional development activities, particularly Laorag’s attendance at British Aphasiology Society conferences. Of equal im- portance is a management commitment to provide and maintain communication aids for clients. Client need, therapist knowledge and the availability of technology changes over time. In this therapy these vari- ables came together to give a rewarding outcome. Giving people with aphasia the opportunity to review therapy options could be of benefit long after their initial period of rehabilitation.

Laorag Hunter is a speech and language therapist at the Centre forBrainInjuryRehabilitiation, Royal VictoriaHospital, Dundee, DD21SP, e-mail laorag.hunter@nhs.net. HelenGowlandisChair of Tayside Speakability and a member of the Aphasia Scotland project steering group. Siobhan MacAndrew is a psychologist in the division of psychology at Abertay University and Trevor Harley is Dean of School and Chair of Cognitive Psychology at Dundee University and the author of ‘The Psychology of Language’ (see reader offer on inside front cover).

References

Den Ouden, D.B. and Bastiaanse, R. (2005) ‘Phonological encoding and conduction aphasia’, in Hartsuiker, R.J., Bas- tiaanse, R., Postma, A. and Wijnen, F. (eds.) Phonological Encoding and Monitoring in Normal and Pathological Speech. Hove: Psychology Press, pp 86-101. Friedman, R.B., Sample, D.M. & Nitzberg Lott, S. (2002)‘The role of representation in the use of paired associate learning for re- habilitation of alexia’, Neuropsychologia 40, pp.223-234. Goodglass, H. and Kaplan, E. (1983) The assessment of aphasia and related disorders. 2nd edn. Philadelphia: Lea and Febiger. Harley, T.A. (2001) The psychology of language. 2nd edn. Hove: Psychology Press. Levelt, W.J.M. (1989) Speaking: From intention to articulation. Cambridge MA: HIT Press. Malcomess, K. (2001) ‘The Reason for Care’, Bulletin of the Royal Col- lege of Speech and Language Therapists 595 (November), pp.12-14. Mayer-Johnson (1981) Picture Communication Index. Solana Beach CA. Nickels, L. (1997) Spoken word production and its breakdown in aphasia. Hove: Psychology Press. Nickels, L. (2002) ‘Therapy for naming disorders: Revisiting, revising and reviewing’, Aphasiology, 16(10/11), pp. 935-979.

Resources

• The British Aphasiology Society, www.bas.org.uk

• The Dynamo Communication Aid is available from Dynavox Systems Ltd, Sunrise Medical Building, High Street, Wollas-

ton, West Midlands, DY8 4PS (www.dynavox.co.uk)

SLTP
SLTP

ASSESSMENTS ASSESSED (2)

Assessments assessed

We continue our series of in-depth reviews to help you decide if an assessment or programme would meet your needs.

Teaching Talking

While this programme provides a sound introductory framework for education professionals, Gila Falkus believes they should be trained to this level before they start working with children.

One Step at a Time

Sarah Colquhoun and colleagues welcome this programme’s evidence for teaching spoken language in nurseries and primary schools, but find it short on practical activities for early years settings.

One Step at a Time (A structured programme

for teaching spoken language in nurseries and primary schools) (2006) Ann Locke with Don Locke

Network Continuum Education

£24.95

I ncreasingly therapists are being called upon to provide consultative advice / intervention and support to set up language groups within education or early years pro- vision rather than providing direct input. A ‘structured programme for teaching spoken language in nurseries and primary schools’ which proposes to make this proc- ess clearer and easier will always be welcome. This programme consists of a single manual / book containing the theoretical basis for the approach, the procedure in stages and the checklists to be used initial- ly and afterwards for evaluation. Suggestions of session plans are included along with an age related description of language and communication development from birth to nine years. The theoretical basis is faultless and Ann Locke presents a lot of evidence based research to help justify running it. She identifies several fundamentally impor- tant aspects which may well be beneficial for our col- leagues who work in educational settings and are pres- sured by other curriculum demands. These include the importance of oral language development over literacy skills and the use of familiar everyday routines. However, the programme later appears to adopt a ‘literacy based’ approach of choosing, explaining and then displaying target words, which seems more suited only to schools rather than early years settings as well. While it is stated that the programme can be adapted, obvious adaptation is lacking. For example, the use of real objects or pictures is recommended as an entry in the main body of the text rather than as a clear, salient bullet point. The programme contains useful advice about pro- moting oral language skills. It repeats the teaching method mantra of ‘modelling, prompting, highlighting and rewarding’ in each section and provides examples of activities. However, the two example planning sheets relate only to the ‘listening’ and ‘narrative’ sections of the programme. For the remaining sections rather more general advice and examples are provided within the body of the text, which makes finding out what one should be doing rather more arduous. The most common feedback from nursery staff was that the programme is very text dense, and extracting the information required was quite time-consuming.

selected from the activities handbook. The third level

is ‘Detailed Profiling’ which equates to Early Years or

School Action Plus in the Code of Practice. Children who are not benefiting sufficiently from Small-Group Inter- vention are assessed in greater detail and further teach- ing activities are selected. The programme is comprehensive and sound. One disappointment was that the importance of early refer- ral to speech and language therapy was not stressed. The authors advise that “Any child whose speech is very difficult to understand or whose language, understand- ing or use appears to be particularly delayed should also be referred to SLT, particularly if they are over the age of 3½.” This seems far too late. Empowering educational

professionals should mean that referrals to speech and language therapy are made more promptly, not de- layed. Two pieces of advice seem particularly suspect. The suggestion that teachers should not “feel any need” to identify children with specific language impairment “before the age of five or six” could lead to a child miss- ing out on a place in a language unit. The recommenda- tion that children who stammer should be referred ‘over five years’ runs counter to the drive for early referral. The authors complain (justifiably) that involving outside agencies can be ‘extremely complex and time- consuming’. But the same can be said about the task of getting to grips with the system and paperwork of this programme. In addition to the two manuals, there is the Early Years Screen (in two parts) or the Primary Screen, 5 different levels of Language Records for the Early Years, the Primary Speaking and Listening Charts andTeaching Charts, the Starter Record Forms, and the Detailed Pro- files. Staff could easily be worrying about the procedures

of the programme instead of focusing on the children. One final gripe, though more against government

than the authors: why do educational professionals

need programmes like this? We know that language is the key to education and that communication skills are essential to children’s social and emotional well-being. We also know that speech and language difficulties are the most common developmental problem of the pre- school years and are often responsible for subsequent literacy difficulties. The information in this programme

is at an introductory level. Shouldn’t all educational pro-

fessionals be trained to this level before they start work- ing with children? However, until this happy day arrives, Teaching Talk- ing provides a sound framework. I might recommend it to settings that have a particularly dedicated and well- organised SENCO or Manager. But speech and language therapy services certainly need to ensure that they have

a much stronger profile in early years settings than the

authors envisage here. Gila Falkus is manager for early years speech and language therapy with Hammersmith & Fulham, Kensington & Chel- sea, Westminster PCTs.

Teaching Talking (2nd edn) – A screening and

intervention programme for children with speech and language difficulties Ann Locke and Maggie Beech

nfer Nelson

£76.00

T eaching Talking is a screening, assessment and in- tervention programme for children with speech or

language difficulties. It is intended for use in early years settings and primary schools with children up to the age of 11. The authors are both highly experienced and knowledgeable. Ann Locke is a qualified speech and language therapist, teacher and educational psycholo- gist. Maggie Beech is an Education Consultant with a wide experience of working in Special Needs. The programme is clearly written and contains a great deal of information and sound advice. Its basic philoso- phy of wanting to empower educational professionals to provide appropriate support and to understand how communication is fundamental to all areas of the cur- riculum is unexceptionable. The programme requires a ‘whole nursery’ or ‘whole school’ approach led by senior management. A typical roll-out would extend over the course of a school year. The first edition was published in 1991. This second edition aims to reflect the revised SEN Code of Practice, changes in legislation and the ‘plethora’ of new guid- ance and curriculum objectives. The original procedures and materials have been revised, partly in the light of user feedback, to provide more background informa- tion on communication difficulties, particularly dys- praxia, autism, selective mutism and stammering, and to make the programme more user-friendly. There is one completely new chapter that provides 8 illustrative case studies. The programme has three components: a procedures handbook, an activities handbook and assessment and intervention materials, some of which can be photo- copied, though the ‘Detailed Profiles’ forms need to be purchased separately. There are also three levels of in- tervention that tie in with the special education needs (SEN) frameworks. First comes ‘Identification and Initial Support’. All children are screened; those who may be having difficulty with some aspect of language devel- opment are identified and classroom strategies to sup- port them are put in place. The next level is‘Small Group Intervention’ (this equates to the level of Early Years or School Action in the revised Code of Practice). Children who are not benefiting sufficiently from‘Initial Support’ are assessed in more detail and teaching activities are

They would have preferred visuals, text boxes and bullet point summaries of the most relevant information. The checklists are relatively simple for a speech and language therapist to use. However feedback from the nursery teachers suggested some confusion about the procedure of ‘banding’ the children. They were also re- luctant to adopt the practice of carrying on with the current word selection until all children had grasped them fully. They felt this had the potential to bore some children who either knew them already or learnt them quickly, whilst putting pressure on others to catch up. There is also a lack of concrete guidance about what exactly should be changing in terms of teaching practice

in the two early stages. For example, it states: ‘Almost any nursery activity can be used for teaching conversa- tion skills, but two activities are particularly useful’. These activities - ‘Talk Time’ and ‘Circle games’ - are then given

resources out there which could be combined to good effect with the strongly theoretical / curriculum-based approach of this programme. Sarah Colquhoun is a speech and language therapist with Waltham Forest Primary Care Trust. She thanks Lloyd Park and St Andrew’s nursery staff and children for their help in carrying out the review.

CELF-4 UK

Jine Milton and Mary Moore find this latest version of the Clinical Evaluation of Language Fundamentals thorough for assessing language performance and its relationship to educational tasks.

a

brief explanation but no detailed information about

CELF-4 UK

how to do them more effectively vis-á-vis promotion of

Eleanor Semel, Elisabeth H. Wiig & Wayne Secord

oral language skills.

(2006)

The very useful ‘Eight tips for promoting talk with young children’ only appears on page 104 after the two

Harcourt Assessment

£519.35 (inc. VAT)

early sections ‘Getting started’ and ‘Conversation Skills’.

It would have been more usefully presented right at the

very beginning. Indeed, re-ordering the information to start with tips / general advice followed by stages / activities and ending with supporting research would prevent duplication and help readers filter out the infor- mation not directly linked to the programme. Whilst the principles of teaching methods are repeat- ed throughout, we felt that more session plans or real life examples for adapting some of the principles would

be useful. The advice for activities within the earlier sec- tions seems too general with few specific procedures suggested and little in the way of linking it to more spe- cific advice about the adult-child interaction principles outlined in the ‘Eight tips’. Despite the initial assertion of working through fa- miliar daily routines, the programme also advocates several potentially time-consuming activities requiring additional staff resources. These include carrying out the initial screening over the course of at least a week and using two members of staff, and daily ‘talk time’ of 10-15 minutes for all children either in small or large groups.

In my experience some nursery staff struggle to achieve

regular time for small group sessions without support from management. On the other hand, management support may be a positive effect of implementing the programme. The longer group sessions also advocated may prove even harder to set up in some settings; again, full backing from management is needed. At just under £25.00 ‘One Step at a Time’ is a cheaper resource than many. However its text dense nature means that a significant investment of time is needed to get to grips with the stages, procedure and also the checklists and then impart this to nursery staff who are themselves under pressure of time. The programme contains many useful tips and re- search. Within the right setting - where support from management and time for running the groups is freely available – it would be a valuable resource. Where staff:

child ratios are already stretched to the limit it is proba- bly not practicable. I am sure there are more user-friendly

T he Clinical Evaluation of Language Fundamentals – Fourth UK Edition (CELF-4 UK) is an individually ad-

ministered clinical tool for the identification, diagnosis,

and follow-up evaluation of language and communi- cation disorders in clients aged 5-16. The authors had some specific goals in mind when they redesigned the CELF-3UK. They aimed to:

- make it more user-friendly

- determine whether or not a client has a language disorder by administering only 4 core sub-tests

- expand the test to include descriptive and authentic measures of communication skills

- include sub-tests that probe underlying clinical behaviours. The stimulus books have been improved by the addi- tion of section markers. Many therapists will be happy to see the back of the geometric shapes in the Concepts and Following Directions section. Now you do not have to rely on clients knowing the name of the shapes. These have been replaced by familiar objects, which are in colour for the younger children. Clients told us they preferred this new colour format and design. Fortunately, a separate question sheet has been provided for administering the Concepts and Following Directions section. Reading the instructions - now on the back of each page of the ‘easel’ format book - and observing the client’s response would be very difficult. The absence of this section’s questions on the record form means that, without the manual at hand, you don’t know which errors the child made. The Word Classes section for younger children now has pic- tures, therefore reducing memory load. There are now two record forms specific for age-bands. Unfortunately the item analysis summaries are no longer in the record forms. Again, this means that the therapist will have to consult the manual, which won’t always be available. The CELF-4 can now be used for children between 5 and 16, therefore covering all school-age children. The CELF-4 now features a Core Language score in- volving four sub-tests (Concepts and Following Direc- tions, Word Structure, Recalling Sentences, and For- mulated Sentences), which can be used to determine whether there is a language disorder or not. The clini-

ASSESSMENTS ASSESSED (2)

cian then decides which of the other sub-tests should be administered. An expressive section has been added to the Word Classes sub-test. As well as saying which two words go together the client now has to say why. There are two new vocabulary sub-tests: Expressive Vocabulary in the younger test and Expressive Vocabulary and Definitions in the older test. Working Memory and Phonological Awareness sections have also been added. There is a comprehensive Pragmatics Profile as well as an Obser- vational Rating Scale. The latter is filled in by teachers, parents and clients and is a useful measure of pragmat- ics and use of language in context, something missing from the CELF-3. The CELF-4 is a comprehensive, clinically useful as- sessment covering all aspects of language, other than phonology. It is expensive and you could be duplicating assessments you already have in the clinic. We would recommend it as the authors have taken on board previous criticism regarding how thoroughly the test covers language performance and its relationship to educational tasks. The CELF-3 acknowledged that fur- ther additional formal and informal assessment would need to be undertaken to assess, for example, word and concept development, language use and interpersonal communication abilities. The CELF-4 assesses these and also other underlying skills, such as working memory and phonological awareness, which are fundamental to planning intervention. Jacqueline Milton and Mary Moore are speech and lan- guage therapists with Aberdeen City Speech and Language Therapy Team, NHS Grampian.

Stroke Talk

Used selectively, Sarah Harwood and colleagues and patients from a stroke unit recommend this resource for people with aphasia.

Stroke Talk: A Communication Resource for Hospital Care (2006) Sophie Cottrell and Alex Davies

Connect Press

£60 (inc. photocopiable material)

T his resource is aimed at people with aphasia follow- ing a stroke. It is designed to improve the accessibil-

ity of the information they receive during their acute and rehabilitation hospital stay. The format helps them to understand and remember the information and it can be used to ask questions. The book covers the roles of the different multidisciplinary team members and the tests and procedures that can occur during the hospital stay, and provides information about the stroke journey. There is also a section describing medications and com- mon infections, such as MRSA. Photocopiable aphasia- friendly appointment cards are included that can be left with the client to remind them when they are going for specific tests / procedures. The sections are ordered alphabetically; each section contains a description using written words, pictures, pho- tographs and symbols to explain that particular area to

ASSESSMENTS ASSESSED (2)

the client. The written language is kept short and simple, with key words highlighted. The appropriate member of staff should go through the relevant section of the book with the client, slowly reading over the text, while point- ing to the parts of the book, and repeating if needed. The person with aphasia is to be encouraged to use the re- source to ask for more information or for clarity on topics, or to express their feelings about different matters. We trialled the pack over a period of 8 weeks during No- vember and December 2006 within our acute and rehabili- tation stroke units. Different members of the multidiscipli- nary team used the resource with a number of people with aphasia, who were also asked to give feedback.

The response from the people with aphasia was de- pendant on the severity of their aphasia. For those with less severe difficulties, the feedback was positive. They in- dicated that it had helped clarify issues and enabled them to find out more about things that were relevant to them, which they previously would not have been able to do. For some people with a more severe aphasia the pack was less beneficial. It was evident through non-verbal com- munication that they were still struggling to understand the information being given and that there was too much information on the page for them to follow. The general feedback from the multidisciplinary team was positive, although the following comments were made:

Not all areas that therapists would have liked to be covered in the book were, for example, the physio- therapists felt that a basic description of “chest physio”, - with diagrams for deep breaths etc. would have been very useful.

The layout of the resource was difficult to follow. Sec- tions that intuitively would follow on well from each other were separated, as the book is arranged alpha- betically, and this made it more difficult to use.

Speech and language therapists felt that the layout for describing our role would have been better if it had separated the descriptions for eating / drinking from communication. The resource was felt to be very useful for some peo- ple with aphasia. It improved their understanding, and enabled them to ask questions that they would not pre- viously have been able to ask. It covers areas that may previously not have been discussed with people with aphasia, due to their comprehension difficulties. The resource was felt to be good value, and will continue to

be used regularly with the appropriate people on the ward. All staff that used it felt they would recommend it to other stroke units for use on their wards. Sarah Harwood is a speech and language therapist at Glas- gow Royal Infirmary.

Bilingual Speech Sound Screen

Although it has limitations, South Birmingham speech and language therapy staff find this a useful tool.

Bilingual Speech Sound Screen: Pakistani Heritage Languages – Mirpuri, Punjabi, Urdu (2006) Carol Stow & Sean Pert

Speechmark

£44.95+VAT

T his assessment has been designed to be a rapid screen for use with Pakistani heritage children who

have Mirpuri, Punjabi and Urdu as their mother tongue. It consists of 21 target words as well as supplementary word lists, which allow the speech and language thera- pist to probe the child’s skills in more depth. The assessment has been designed to be administered by a speech and language therapist who does not speak the identified languages. However if a monolingual thera- pist administered it s/he would not recognise some of the phonetic errors that we have noticed in the transcription. For example:

• the /t/ in /topi/ (hat) is not a dentalised ‘t’ but more a retroflex sound

• the/u/ vowel in /dud/ (milk) is a shorter /u/ vowel for the Mirpuri and Punjabi language whereas it is the longer /u:/ vowel in the Urdu language

• the /d/ in /anda:/ (egg) is a retroflex and not an alveolar sound. It would be useful if these could be amended in any future version as they mean that a monolingual therapist will think correct realisations are errors, or mispronounce words they want a child to imitate. In the meantime we strongly recommend that the assessment should be ad- ministered by a bilingual speech and language therapist or a bilingual co-worker working with a monolingual therapist so that phonetic errors can be minimised and natural speech patterns maintained. We used the screen with children from 3 to 8 years, as these are the ages the assessment has been designed

for. It’s easy and straightforward and it is useful to have the target words for each language on the record form. The vocabulary chosen is appropriate and children from this community will be familiar with it. The pictures are a good size. Some were quite clear and elicited the target words. However others were dull, of a poor quality, and did not elicit the target word. For example, responses for the target‘clothes’ included:

‘mummy doing work’

• ’sweeping’

• ‘cleaning’ and for the target pot/dish/meal a child responded by saying ‘it’s messy’. This shows that the pictures are not as clear as they have been thought to be, and perhaps it would be better with fewer items on each page. Some children found some pictures scary, such as the boy to elicit the target word‘eyes’. A couple of children respond- ed to this by saying it was a ‘monster’! The parents were also not totally happy with the pictures and one mum commented ‘even I didn’t know that’ for one of them. The assessment has been designed to elicit a speech sample in the children’s mother tongue. However we all noted that, although we were using the mother tongue to encourage the child to speak in his/her mother tongue, the children were deciding which language to respond in. For example, they used the English names for the animal pictures. Children under the age of 4½ who had not been exposed to the English language for long responded in their mother tongue and it was easier to obtain a sample of speech in the mother tongue from them. This assessment may not be a valid tool with children 5 years and over as they have had longer exposure to the English language and may prefer to communicate in both languages or in English only. To some extent this invalidates the speech sample. Our overall impression is that this particular screen is easy to use and handle. If used with the help of bilingual co-workers and considering some of the issues we have noted it can be a useful tool for everyday clinical work. This assessment was reviewed by a team of speech and lan- guage therapists and speech and language therapy assist- ants fromthe Children’s Speech and Language Therapy De- partment in South Birmingham NHS Primary Care Trust.

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“Here’s one I made earlier ” Alison Roberts with yet more low-cost, fl exible therapy
“Here’s one I made earlier ” Alison Roberts with yet more low-cost, fl exible therapy

“Here’s one I made earlier ”

Alison Roberts with yet more low-cost, flexible therapy suggestions suitable for a variety of client groups.

Alison Roberts is a speech and language therapist at Ruskin Mill Further Education College in Nailsworth, Gloucestershire.

News and weather round-up

MATERIALS

• Cassette or CD player

• 2 recordings of the news and weather, one from

some time ago (preferably

a month or more back) and

one very recent one. It’s best to use news that is not too upsetting or disturbing.

“This is a useful memory exercise as well as a helpful way of demonstrating how topical events can enrich conversation. It is not an easy task; most people listen to the weather forecast and promptly forget most of what was said. As far as the news is concerned they are more successful, but not brilliant. (Try testing it on yourself – be honest, it wasn’t easy was it?) This exercise really needs forward planning as you should have some ‘old news’ to practise with at first.”

IN PRACTICE (1)

Play the‘old news’first. Ask for a volunteer to repeat the main headline.

Now ask other group members for any further points they remember. Play the news back again and see howmuch was remembered.

Now try the weather forecast. See if anyone can remember the fore- cast for the local area, then see if the weather for other areas can be recalled. Repeat the whole exercise using a recent broadcast. The trick is, of course, careful and active listening.

IN PRACTICE (II) Make the point that knowing what is in the news will be a valuable as- set for making contributions in conversations, especially if your client has the problem of not being able to think of what to say. Have a short discussion about the main - or most interesting - points of the news, and see if anyone has any opinions they would be willing to share.

Newspaper

headlines

MATERIALS

• Newspapers (Tabloids seem to be best at pro- ducing both intentional and unintentional puns. Local papers are also good sources).

Soapbox

MATERIALS

• Video or DVD recordings of radio or TV soaps, such as The Archers,Eastenders,Coronation

Street,Neighbours.Usewhich-

ever programme is deemed to

be‘cool’. Find a longish piece

of conversation in which 2 or 3

peoplearetalkingpleasantly andevenly–notarguing.

Equipment to play back recordings.

• Paper and pens

• Stopwatch

“This activity will further the clients’ work on ambiguity, and should be a source of humour.”

IN PRACTICE Present the puns on the list one at a time, and work out together which is the ambig-

uous word in each headline. Now go through the papers and see if anyone can find any new puns.

Examples:

Miners Refuse to Work After Death

• Drunk Gets Nine Months in Violin Case

Hospitals are Sued by 7 Foot Doctors

• Panda Mating Fails;VetTakes Over

Squad Helps Dog BiteVictim

• Shot off Woman’s Leg Helps Golfer to Victory

• Enraged CowInjures Farmer with Axe

• Juvenile Court to Try Shooting Defendant

Stolen Painting Found by Tree

• Two Sisters Reunited After Fifteen Years in Checkout Counter

Red Tape Holds Up New Bridge

Man Struck by Lightening Faces Battery Charge

Kids Make Nutritious Snacks

• Sex Education Delayed, Teachers Request

Training

IncludeYour ChildrenWhen Baking Cookies

Head Seeks Arms

These are notices rather than headlines

– but just as ambiguous!

Cats Eyes Removed

Baby Changing Rooms

• Eye Drops Off Shelf

“This is a listening, remembering, understanding and analysing activity which can be applied to conversational technique, especially length of turn/contribution. Because it uses popular TV programmes, there is usually no trouble motivating clients to do this work. Many clients on the

autism spectrum find they can learn useful tips about chatting to people from TV conversations, because they can observe in a detached way. It works well for a group of 4-5 teenagers.”

IN PRACTICE (I) Introduce the recording carefully, setting the conversation in its context.

Ask one client to time the conversational turns and another to write this data down. Listen to or watch the piece, jotting down the turn timings. You will probably find, as we did, that most conversational

turns last for about 4-6 seconds. This can be quite a revelation for the conversational ‘ramblers’! If you feel it to be appropriate for your

group you could then time the length of the real conversational

turns in your session.

IN PRACTICE (II) You can use this method for other aspects of conversation such as eye contact, facial expression, or topic choice. You may be able to find pieces of the programme that illustrate friendship skills like compromising on what to do, letting the friend go first, telling the truth, or offering a compliment. Be careful only to analyse for one skill at a time.

WRITING FOR PUBLICATION

D oes your heart sink when a colleague says, ‘That’s a really interesting piece of work, you should write it up’? After reading an article do you think, ‘I could do that’, but never get

round to doing anything about it? ‘I haven’t got the time’, ‘I’ll write when I retire,’ or ‘I can’t write,’ are the most

common excuses people hide behind for not writing up their work, but the real reason is often fear of the writing itself. And the fact is, if you have conducted an interest- ing piece of work, investigated a different approach or developed some new materials, you owe it to yourself and your fellow professionals to disseminate your ideas more widely. Of course every speech and language therapist can write. However difficult it may have seemed at the time all therapists have written essays or dissertations at col- lege, or client reports since beginning work. However, it

is true that many people feel overwhelmed by the pros-

pect of writing and even the most prolific writers often find it hard to begin – and complete – the next article, the next chapter, the next book; each new project feel- ing like the first. So, how can you break this deadlock? How can you get started, and even more importantly, keep going? Writing a considered article or chapter is a process over time; it is not something that happens in one crea- tive burst. And, as with any process, it begins with the first step. That is, facing the blank page, the stage at which many falter. Of course there are some who have no difficulties starting. For them fear of the ‘blank page’ (or writers’ block) may occur somewhere in the mid- dle or at any stage of the process, but let us consider how to overcome the initial fear that so often prevents the potential writer from getting beyond the opening paragraph.

A task to be completed

There is no point in waiting for the muse to take you.

It probably won’t. Writing is a task to be completed like

any other, so make an appointment with yourself, set aside a realistic period of time in which to work, and be- gin. The assignment – should you choose to take it – is to fill as much of the empty white space on the page or the computer screen as quickly as possible.

One of the most satisfying ways to do this is to ‘brain- storm’. This word often has a bad press but it is an effec- tive way of launching into a new project. Give the opus a working title then write down anything and everything that comes into your head about the topic. This does not have to be in complete sentences, write odd words or phrases as the thoughts gain momentum. Scribble

– that is, whether you are writing or typing, don’t worry

about spelling, grammar, or coherence. Don’t try to cen- sor, or arrange your thoughts in any sequence or order. Let your mind roam freely. No thoughts are too ‘off the wall’ at this stage. You will have time to organise and classify the ideas later. You may even find that what you eventually write is quite different from what you first planned in your mind, but there is nothing wrong with that, it will pay to be flexible in your thinking. Another way of covering the whiteness of a blank doc-

ument quickly, particularly if you are writing directly onto

a computer screen is to import some previously written

material to act as a trigger or starting point. For example, you may already have some references, with quotations

Doing the write thing

Have you considered writing about your work but not quite found the courage? With a treasure trove of experience and an enviable publishing record amassed over 20 years, Myra Kersner and Jannet Wright are well placed to help you get started - and then to keep going all the way to the finishing line.

from relevant sources you have been reading; you may

have a file or notebook of random thoughts you have jotted down when first thinking about the project. It is

a good idea to make notes as thoughts occur to you;

you always imagine you will remember them, but it is amazing how quickly you will lose even momentous- sounding ideas if they are not immediately committed to paper or the computer.

Maintain the momentum

You may not be able to get beyond the ideas stage

during the first session so make sure to book a series of realistic appointments with yourself; for the first flow of idea-generating adrenalin is often accompanied by

a burst of enthusiasm that needs to be capitalised as quickly as possible to maintain the momentum.

identify the main theme of what you want to say, and the ‘take home message’ for the reader

In order to organise the brain-stormed ideas it may be helpful next to identify the main theme of what you want to say, and the ‘take home message’ for the reader. You can begin to put ideas together, organise similar thoughts under headings, now judging and discard- ing those that no longer seem pertinent. Writing under headings even if these are removed later not only helps with organisation and sequencing of thoughts but is a

way of breaking the writing into manageable chunks.

In addition, if appropriate to the journal, headings help

break up the text for the reader.

A useful technique at this stage can be to write the

article as if you were telling a story, expanding the main ideas and points in everyday, colloquial language not

worrying about grammar or punctuation. Crafting each sentence to perfection at this stage is likely to inhibit the thought flow. It is usually more advisable to let the ideas flow freely as this may lead in novel directions, and pre- vent you losing important detail.

It is not a problem if you write an excessive number

of words because these will no doubt be lost at the re- vising and editing stage. In fact it is much easier losing words in order to meet the word count target than add- ing them; additional words often appear as padding. Unfortunately a slowing of pace and enthusiasm,

a sudden dearth of ideas, followed by a dip in energy

levels, emotional stability and self-belief is an inevitable

part of the writing process for even the most seasoned

writers. This is the stage when many articles are lost as the writer tosses the unfinished pages into the waste basket in a fit of despair. But it is only a part of the proc- ess – albeit a critical one. Now is the time to recognise that muses are definitely not to be relied upon, only hard, regular work. This is the time when it is crucial to ensure you have several writing appointments with yourself booked ahead in the diary. They do not need to be long sessions, but they do need to be regular and as closely spaced as possible so that you don’t lose the thread of what you are trying to say.

If you have been able to maintain the discipline thus

far, you will by now be coming to the end of a completed version of your work, and you will probably feel pleased with it. But, however carefully you have crafted and nursed it to reach this stage, this is only the first draft.

READ THIS ARTICLE IF YOU WANT TO: • OVERCOME A FEAR OF PUBLISHING • FILL
READ THIS ARTICLE IF YOU
WANT TO:
• OVERCOME A FEAR OF
PUBLISHING
• FILL THE DAUNTING BLANK
PAGE
• WRITE WITH OTHER PEOPLE

What many potential writers do not realise, is that this is when the real work begins.

Revision

As any published author will tell you, ‘good’ writing is all about revision, so be prepared. There are those who claim they never revise their work, but it shows. Either the work is ill-considered and rushed or it is written by someone who cannot com- mit their thoughts onto paper until they have honed each sentence to perfection. Such people usually write extremely slowly and may not always complete their projects, for the end product remains distant for so long, they are likely to become dispirited and lose interest. Most writers prefer to work more speedily following the flow of ideas and then to sit back and enjoy the editing and revising stage of the process, polishing the words and sentences until they are the best they can make them. It is not always easy to undertake serious editing as each word you have written may feel pre- cious, but it is important to remove redundant language, ensure there is no repetition, and check that the major points are sequenced logically and that each idea is ex- pressed as clearly and succinctly as possible. Now is the time to reduce verbiage and ensure that the language is appropriate for the journal that is being targeted. This is often a good time to seek the opinion of someone you trust; someone who understands what you are trying to say and can give you some honest feedback. (However, discourage them from marking your manuscript with a red pen; too close a reminder to schooldays!) It is usually helpful if you can space out your revision sessions so that each time you return to your work you have had time to gain some distance and consequently perspective, enabling you to see it afresh from the reader’s point of view.

Of course when you are ready to submit your article for publication it is critical to research the market – if you haven’t already done so – to ensure that you have writ- ten your piece in a style appropriate to that journal. For example, there is no point in sending a reflective non- referenced article to a journal that only publishes data- driven research. It is normally helpful to do this before you begin writing, but it is possible to make the appro- priate adjustments at the revising and editing stage. All journals have their own format and requirements about the presentation of a manuscript, so make sure you re- search the journals that you wish to target.

Would you be interested in reading it if the manuscript arrived on your desk?

Let go

How do you know when to stop editing? How do you know when it’s time to let go and accept you have the final version? The answers are mainly: when it feels right; when you have said what you wanted to say concisely and to the best of your ability. The check list below might help.

Read it aloud – if you get tongue tied by impossible phraseology or inappropriate wording then it may still need a final polish.

Ask the opinion of someone you trust.

• Check the presentation – is it double spaced, printed on A4 paper, with appropriate paragraph line-spacing?

WRITING FOR PUBLICATION

• Does it comply with the requirements of the specific journal you are submitting to?

Have you checked the punctuation and grammar? If you are uncertain about this there are several books you can read which are fun and easy to follow.

Is the language and style appropriate for the journal to which you are submitting?

• Would you be interested in reading it if the manuscript arrived on your desk? Hopefully, your submission will be accepted. Al- though most commonly there may be some suggested, often minor, changes. If comments are included or there is an indication that, with changes, the article might be resubmitted, then it will be important to look at it again - after you have calmed down - and to consider the sug- gested revisions. You will usually find they are right. Unfortunately, it is possible that your article may not be accepted for publication, but although every rejection is painful reviewers are only commenting on your work, not rejecting you. The article may just not be suitable for the journal’s current needs, or they may already have a similar one in their publishing pipeline. You always have the option of revising it to suit a differ- ent journal and hopefully will feel able to write another article.

Write collaboratively

One of the most effective ways to ease the pain of writ- ing is to write collaboratively with someone else. Where this is possible you will often find that together you are far more productive than either of you would be writing alone. Writing with another person can be a great motivator, having to produce work to show your co-author often proving a great incentive to write. And it can be fun. You may also find yourselves supporting each other in unexpected ways, particularly if physical and emotional writing peaks and troughs are complementary rather than simultaneous. Writing collaboratively highlights other issues that will need to be agreed, such as order of authorship which may relate to the amount contributed or may be alphabetical, and who will be the author for correspondence. As writing is essentially an individual experience it is important to adjust to each other’s style, to find a rhythm that suits you both, and this is true each time you write with a different partner. In our writing partner- ship we find that a half-formed thought from one will often spark a more considered idea from the other, an ungrammatical phrase from one will trigger a syntactic gem from the other. But no clumsily expressed notion is ever judged or dismissed without being fully discussed. It is also helpful if within the partnership you are able to take on complementary roles irrespective of your natu- ral skills. For example, both of us are ‘finishers’ but when writing only one takes the role of obsessive perfection- ist. We are both capable of generating ideas, but usually at different stages of the writing; one particularly enjoys tracking the logic of the arguments while the other spe- cialises in spotting omissions. But essentially we each appreciate the other’s contribution and together have learned to hone our craft. Naturally there are many potential pitfalls when work- ing closely with someone who has their own views, their own style, their own vision, but the secret of a successful

own style, their own vision, but the secret of a successful SPEECH & LANGUAGE THERAPY IN

WRITING FOR PUBLICATION

WRITING FOR PUBLICATION partnership hinges around enjoyment, trust and com- mitment. We keep our writing promises

partnership hinges around enjoyment, trust and com- mitment. We keep our writing promises to each other and as far as possible meet deadlines that are critical to our agreed targets. Our partnership survives because it continues to develop despite one of us having changed tracks to pursue a fiction-writing career, and the other having moved two hundred miles away. But the part- nership continues because we have fun, the writing is stimulating and we still enjoy working together.

Personal style

Finally, despite all tips and suggestions, it has to be said that writing is an intensely personal activity and there is no one way to write; we each have to develop our own style. There are however a few general tips that will help all writers.

Type each reference in full into a reference list as soon as you find it. You can be sure you will not remember where it came from if you leave it till the end.

Each time you begin work on the computer save the piece again with the current date. That way you will not only be able to identify the current version easily, but will also have previous versions on file in case you need to reinstate deleted passages.

Back up at least one version of your work separately from your computer each night, such as on a CD, pen drive, or by emailing it to someone as an attachment.

Your work is important. Happy writing!

SLTP
SLTP
an attachment. Your work is important. Happy writing! SLTP Myra Kersner is a Senior Lecturer at

Myra Kersner is a Senior Lecturer at University College London and Jannet A. Wright is the Professor in Speech and Language Therapy at De Montfort University, Leicester.

REFLECTIONS

• DO I HAVE A CLEAR ‘TAKE HOME MESSAGE’?

• DO I RECOGNISE THAT THE REAL WORK OF THE WRITING PROCESS BEGINS AT THE REVISING AND EDITING STAGE?

• DO I ASSESS MY WRITTEN WORK FROM A READER’S POINT OF VIEW?

E-mail to the editor

Dear Avril,

Speech and Language Therapy for Aphasia following stroke – Cochrane Systematic Review

As speech and language therapists we are very much aware that evidence-based practice is fundamental to the provision of good quality healthcare. Research evidence linked with clinical practice provides us with essential information regarding the effectiveness of healthcare interventions for our patients. There are a number of different ways of exploring aphasia therapy outcomes and issues, for example, individual case studies, case series and group studies. However, currently randomised control trials (RCTs) are con- sidered the most robust methodology to evaluate clinical interventions, i.e. measure and demonstrate the effectiveness of therapy. Systematic reviews of such evidence are crucial as they synthesise the findings of RCTs, helping inform therapists' decisions about rehabilitation interventions and highlighting current knowledge and potential research priorities. The Cochrane Collaboration (www.cochrane.org) is an international independent organisation whose function is to disseminate accurate up-to-date information about the effects of available healthcare worldwide. It produces and disseminates systematic reviews of healthcare interventions and promotes

the search for evidence in the form of clinical trials and other studies. It has reportedly had a significant impact on practice, policy decisions and research around the world. In 1999 a Cochrane systematic review was published which presented the evidence for speech and language rehabilitation of aphasia following stroke (Greener et al., 1999). Since this publication additional evidence has been generated or is currently ongoing in many countries around the world. The review is now being updated to reflect these develop- ments. The objective of the review is to assess if:

1. speech and language therapy is more effective than no speech and language therapy

2. speech and language therapy is more effective than support from volunteers or non-speech and lan- guage therapy professionals

3. one speech and language therapy intervention is more effective than another speech and language

therapy intervention. Relevant trials have been identified through a number of different methods including the Cochrane Stroke Group’s Specialised Register of Controlled Trials as well as Medline (1966-2007) and Cinahl (1982- 2007). Academic institutions and other researchers were also contacted in order to identify further pub- lished and unpublished research in this area. The findings of this updated systematic review will be published later this year in order to provide speech and language therapists with the latest evidence for the rehabilitation of aphasia upon which they can base their clinical decisions. If readers are aware of any published and / or unpublished trials that would be appropriate for inclusion in this review update could they please contact me with the details?

Dr. Helen McGrane Nursing, Midwifery and Allied Health Professions Research Unit Iris Murdoch Building University of Stirling Stirling, FK9 4LA Telephone: 01786 466285 Fax: 01786 466100 Email: helen.mcgrane@stir.ac.uk

Reference Greener, J., Enderby, P., Whurr, R. (1999) ‘Speech and language therapy for aphasia following stroke’, Co- chrane Database of Systematic Reviews. Issue 4. Art. No.: CD000425. DOI: 10.1002/14651858.CD000425.

FEATURE

Self-help me if you can

Many voluntary agencies support a diverse network of self-help groups. Avril Nicoll asks what contribution this can make to how someone adapts to and manages their communication difficulty, and where speech and language therapy comes in.

search of www.amazon.co.uk for ‘self-help’ books produced over 40,000 results. The first page included classics such as Susan Jeffers’s ‘Feel the fear and do it anyway’ and Stephen

Covey’s ‘7 habits of highly effective people’. (Also ‘The Goddess’by Gisele Scanlon with“life-enhancing content” including“what you should have in your make-up bag to tackle every problem”, “plucking the neatest eyebrows” and “looking after cashmere”…) Whatever the perceived problem, it seems that someone has written about how you might help yourself handle it. This proliferation is reflective of a sea-change in opin- ion on who holds the power to bring about change. In an essay on NHS transparency, Edwards (2006) quotes Rowe et al. (2002) as saying “The professional paternal- ism that traditionally characterized public experiences of the health service, with patients being passive re- cipients of technocratic and medical expertise, now ap- pears outmoded.” Initiatives such as the Expert Patient Programme and the drive for Patient and Public Involve- ment recognise that individuals have much to offer not only themselves, but also their peers and health profes- sionals. While books can open minds to different ways of cop- ing, not all people with communication difficulties will find books accessible or applicable – and in any case books do not address our need for social support. As Klein (2000) recognises, “A community of kindred souls affirms for us that we are not alone. To find that com- munity, you may need to shed your cynicism and scep- ticism. You may need to swallow your pride and admit that people do need people in order to be fully human.” (Preface xiii) Speech and language therapists are acutely aware of how isolating a communication disability can be. Many people with communication difficulties face a particular challenge in finding and participating in social activities including self-help initiatives. So do we do enough to facilitate and support such groups? Do we value this as an integral part of our role, committing time and acting as a resource? Liverpool speechandlanguagetherapistAnitaWilliams has a history of following a social model of working with

A

“When I was younger, so much younger thantoday I never needed anybody’s help in any way. But now these days are gone, I’m not so self-assured, Now I find I’ve changed my mind and opened up the doors.”

Lennon&McCartney(1965)

READ THIS IF YOU WANT TO GIVE CLIENTS OPPORTUNITIES TO

USE THEIR COMMUNICATION SKILLS

GROW IN CONFIDENCE AND SELF-ESTEEM

RAISE AWARENESS OF THEIR NEEDS

peoplewithlong-termconditions. However her attempts to get self-help groups going had in the past started well but fizzled out and she was “left with the feeling that I had done something wrong”. A course at Connect – the communication disability network – provided welcome inspiration, and Anita has worked with John McCreadie and other users of Alternative and Augmentative Com- munication (AAC) to start CALLUP. A funded and statutory communication aids service means Anita has a number of able clients with sophisti- cated aids. With an IT student, she set up a Communica- tion Aid Practice Group which meets fortnightly. Anita observes that users no longer feel so isolated and be- come competent very quickly – and they also get a lot out of meeting and supporting each other. The self-help group CALLUP was the next step. Its mission is for peo- ple who use communication aids to support each other. Those involved also meet other people – in a group or one-to-one – to help them reach a decision about whether or not to use a communication aid. In addition, CALLUP has a buddy group where an experienced user helps a new user to manage their aid. CALLUP is also educating health staff and others on what it means to be communication disabled. John and

Anita deliver training to local staff together, John using his aid and Anita using speech. They hope to expand this to other NHS professionals. CALLUP is consulted by statutory services and is ac- tive in attending awareness days and conferences. Fun- draising has been essential to securing transport but the speech and language therapy and assistant time and premises are offered by the Primary Care Trust, with a shared desk and phone line planned. CALLUP is keen to alert manufacturers, commission- ers and potential users to AAC issues. John was shocked when they encountered difficulties opening a bank ac- count. “A number of us were in wheelchairs and none of us could speak without an aid. The bank wasn’t wheel- chair accessible but they asked us to attend a meeting in the bank! Then they wouldn’t accept that a bunch of such disabled people could run and control a bank ac- count.” A banker eventually came to a group meeting to take the request to open an account – and the group made their views very plain. John feels that more speech and language therapists could do with setting up self-help groups “as being un- able to speak knocks the confidence out of you and tak- ing some responsibility upon yourself starts the process of regaining that”. Friendship is vital to John’s adapta- tion, both maintaining old relationships and forging new ones. He was delighted to be asked to give a Best Man speech on his Lightwriter, and talks fondly of support gained (in relation to his percutaneous endoscopic gas- trostomy) and friendship from CALLUP members from a variety of backgrounds. John “lost the power of speech” comparatively recently and describes the act of forming the group as a form of therapy. He is keen to offer posi- tive advice to anyone thinking of starting a similar group (e-mail J.McCreadie@yahoo.co.uk). Anita points out that people with long-term conditions have lots of different experiences and skills; she finds the more we can draw on that the better our service becomes and the more empowered and fulfilled the users feel. Voluntary sector organisations which actively campaign on behalf of people with communication difficulties started out when the founders recognised this exper- tise – and the need to find a voice for it. Not surprisingly,

– and the need to fi nd a voice for it. Not surprisingly, SPEECH & LANGUAGE
FEATURE then, Afasic, Speakability and the British Stammering As- sociation all have national networks of

FEATURE

then, Afasic, Speakability and the British Stammering As- sociation all have national networks of self-help groups which they actively support and promote. Safety in Stumblers is a Glasgow self-help group for people who stammer, with a dedicated website and e-mail forum as well as a monthly meeting. The group is held in a private area of a city centre bar and gener- ally 5-6 people attend. The initial idea was to provide a follow-up to intensive therapy groups, so people could practise techniques such as block modification and vol- untary stammering in a safe, supportive environment. The original members planned a speech / social mix, with the occasional invited speaker talking about a par- ticular approach to managing stammering. When I visited the group, Chairperson John Mann observed that “Some people come for a long time, oth- ers for a time, others for one night only and others never come.” He noted that people come with different expec- tations but he welcomes the fact that there is “no sign of embarrassment or ridicule on the faces of the people around you – and you realise it’s not that bad after all.” Callum, who is training to be a speech and language therapist, described his first self-help meeting (in Ire- land) as “a revelation”. He explained, “I had never really talked about it. Suddenly it was very easy to talk about it

– so open – I felt a weight lifted off my shoulders.” James wasn’t fearful about coming to this, his first meeting. “I was looking forward to it; for the first time, I wouldn’t have to worry about whether I would stammer.” Dev agreed. “I don’t really hear stammering around me, so it’s helpful. It shows I’m not stupid – they’re fine, all func- tioning human beings, so I don’t feel so bad about stam- mering.” Susie had been before but tonight she “had second thoughts, because I would have to confront the stammer, and over the past 8 years I have avoided it. I want to feel able to be more open about it. My speech and language therapist said I have to be OK with my stammer. In the end, I’m happy that I came.” The group members discussed what they get from Safety in Stumblers:

• Humour

• Confidence

• Opportunity to practise (e.g. booking rooms, ordering drinks)

• Friendship

Learning

• Ideas and options

Inspiration

• Telling your story

Chance to hear other people stammering This fits with Klein’s description (2000) of the three ele- ments of successful groups: a place to be heard; a place of acceptance; a place where one can feel cared for. It’s clear that the group really appreciates the practical support of speech and language therapist Carolyn Allen, who not only encourages clients to participate but of- fers to accompany them to their first meeting. Carolyn herself commends the group’s “great support networks as they accommodate the most active of participants as well as those ‘feeling their way’ in the beginning.” Members suggest therapists could join more online groups so that they are really aware of what is most con- cerning people with communication difficulties. They also hope therapists tell people about organisations such as the British Stammering Association. They would

such as the British Stammering Association. They would On a Voyage of Discovery in Dundee with

On a Voyage of Discovery in Dundee with the British Stammer- ing Association

like speech and language therapy students to attend self-help groups to broaden their knowledge of the lived experience of communication disability. Whether people prefer an online forum, a Telephone Support Group – both particularly useful for people in more rural areas – or face to face contact, it is clear that in time those who benefit turn their attention to support- ing newer members, and gain confidence and insight as a result. I attended a British Stammering Association Open Day in Dundee, organised as a mix of speakers and workshops catering for children and young people who stammer. Dr David Lilburn explained that he worked through the theory of stammering with his speech and language therapist “but I had to put it into practice – to tame this beast that was taking control.” He went on City Lit courses,“taking care of myself, getting out there – and so much changed.” According to David it is important to take risks, as “the most rewarding time can be when you go out on a limb”. But he doesn’t believe you can do this alone, and advocates self-help groups which offer social chat and support, and participation in the British Stam- mering Association – “where people actively embrace you because you stammer”. Another speaker Claire Pirnie had a revelatory mo- ment when attending a European group in Holland. Far

mo- ment when attending a European group in Holland. Far John Mann of Safety in Stumblers

John Mann of Safety in Stumblers scales Ladhar Bheinn for the British Stammering Association

from trying to hide their stammer – as she had always done, even in speech and language therapy groups

– she noticed that “everyone just got on with it”. As a

result Claire stopped trying to hide it, talked about it and started public speaking to spread awareness – and found it gave her a real buzz. The impact of these speakers was clear during speech and language therapist Liz McConnell’s workshop on teasing and bullying, when one mother told me it had given her real hope for her son’s future. Meanwhile the young people clearly relished the opportunity to have a laugh brainstorming potential solutions with their peers (bury them alive, put their head down the toilet…!) The British Stammering Association open day was held at Discovery Point, a non-medical venue. When the Speakability-affiliated Speakeasy group was formed in Aberdeen for people with aphasia, those involved were also determined to meet in a hotel not a hospital. Speechandlanguage therapist AnnetteCameronhas been associated with the group since its inception. She believes that the focus of speech and language therapy is now different in the early stages of stroke – actively listening to the client’s agenda, revealing competence and providing signposts. Some clients may wish to par- ticipate in a self-help group at an early stage. However, she also sees there is still “a long way to go” in provid- ing opportunities that people will want to take up. Any established group can be a daunting prospect for new people. Speakability suggests that people who already know each other can be referred to attend their first meeting together as one way of overcoming this. Code et al. (2001, p.45) noted that membership of Speakability’s 50 groups “comes from a relatively well defined section of the aphasic population”. This includes people who are mainly ambulant, living at home and with access to transport. They also tend to be relatively young and have a long-standing and relatively less se- vere aphasia. People who take on leading roles in such groups are more likely to have professional and manage- rial backgrounds. At different stages the Aberdeen Speakeasy group has concentrated on communication support; enabling peo- ple to tell their own stories; campaigning; and now social support. One successful initiative was to set up computer classes, so some members can now produce invitations, menus and lists of meetings. The group members them- selves initiated the classes, and the speech and language therapist - Annette - conducted training for the staff who provide the computer classes. Annette has observed that many factors can change the course of a group – per- sonalities, deaths of members – and that the speech and language therapy link has to be very flexible as a group changes. Annette cautions that there is a danger of a speech and language link therapist being overly protec- tive of a group. “It takes courage to stand back and let it take its course, remembering that they are adults with responsibility for their own lives”. The therapist’s con- cern is that the group may fold, but another group can emerge. Klein (2000) talks about four basic developmen- tal phases of successful groups. Phase one is exploratory, where people are sussing the group out, seeing if they

can trust it and if it will meet their needs. Phase two sees

a growing sense of closeness where people begin to feel

more confident about revealing themselves. Phase three gets to the heart of the matter, searching for meaning

and uncovering coping strategies. Finally phase 4 looks to the future, with people leaving, or the group re-evalu- ating its aims. Throughout, Klein describes the facilita- tor’s role as shifting “from leader to cheerleader” (p.17). Annette finds great satisfaction in “seeing people whom you have worked with from the onset of their communication difficulty move through to a stage where they don’t need you any more”. However, she con- stantly questions “at what point does a specific aphasia need / identity become a broader need which no longer requires input from the speech and language therapist? And are we then meeting the needs of other people with aphasia?” She has seen situations where people want to develop and use certain skills but group dynamics at the time were not conducive. Code et al. (in press) point out that Self-help in aphasia is still evolving and, like other hu- man groups, things do not always go smoothly. Mis- understandings may arise. Arrangements for meetings and outings can be casualties of impaired communica- tion. Members may have different expectations of their groups and some may go away disappointed. Some members may be unwilling or unable to recognise the need for facilitation and support. As in other groupings of human beings, leaders may be insensitive or over dominant which can impact on the development of au- tonomy in members. For Annette the most rewarding part of her involve- ment with Speakeasy has been supporting members to effect change. Recently members have been involved in

two projects using Talking Mats. This approach not only encouraged communication skills, but also developed their confidence and self-esteem. The first project was part of the Grampian Disability Action plan. Members gave their views on GPs and hospitals, rating aspects as good / bad / indifferent. These views were then incorpo- rated into the action plan. When a local MSP helped to set up a meeting with the First Bus Operations Director, Annette again used Talking Mats to help members think through, discuss and prepare their views.The Operations Director was delighted to find that this included posi- tive comments and some practical suggestions, and he came back to the group with feedback. As these projects needed commitment from the speech and language therapy department and a determination not to lead or bias proceedings, Annette was particularly pleased when the manager of the Managed Clinical Network for Stroke who viewed the Talking Mats commented, “That looks really empowering.” And there you have it in a nutshell. Working together, clients, carers and speech and language therapists have opportunities to set up and nurture groups and online forums or blogs. Such initiatives can “open up the doors” to a powerful vehicle for adaptation and change.

“… I do appreciate you being round. Help me get my feet back on the ground…” Lennon & McCartney (1965)

FEATURE

References

Code, C., Eales, C., Pearl, G., Conan, M., Cowin, K. & Hickin,

J. (2001) ‘Profiling the membership of self-help groups

for aphasic people’, International Journal of Language & Communication Disorders 36 (suppl), pp. 41-45.

Code, C., Eales, C., Pearl, G., Conan, M., Cowin, K. & Hickin,

J. (in press) ‘Supported self-help groups for aphasic peo-

ple; development and research’, in Papathanasiou, I. & de Bleser, R. (eds.) The Sciences of Aphasia (Vol.1): From therapy to theory. Elsevier. Edwards, N. (2006) ‘The transparent NHS?’ AIMS Journal 18(4), pp. 16-20. Klein, L.L. (2000) The Support Group Sourcebook. New York: Wiley.

Resources

Afasic www.afasic.org.uk

• British Stammering Association www.stammering.org/selfhelp_groups.html

Expert Patient Programme www.expertpatients.co.uk

• Safety in Stumblers www.safetyinstumblers.org.uk

Speakability www.speakability.org.uk

Talking Mats www.talkingmats.com

Acknowledgements

Thanks to Chris Code, Jan Anderson, the Safety in Stumblers e-group and all the interviewees (names in bold) for giving so generously of their time and expertise

to help me with this feature.

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EXTENDED ROLE

Face value

I have worked in the acute sector at Aberdeen Royal Infirmary for 15 years, specialising in the field of acute neurosurgery since 1995. Some clients in this specialty have facial palsy following surgical removal

of an acoustic neuroma. My role in managing any swal- lowing difficulties immediately post-operatively was clearly defined and manageable - but how to cope with the devastating effect of a face which won’t work was another story! Although its effects can be profound, acoustic neu- roma is not that common; the British Acoustic Neuroma Association cites incidence as 1 in 80,000. Both the tu- mour itself and its surgical removal carry risk to the VIIth Cranial Nerve, or Facial Nerve. As this nerve sup- plies a number of areas, damage can produce a variety of symptoms:

SUPPLY TO

SYMPTOM

Lacrimal Glands

The most usual symptom is a dry eye, but the other extreme (overwatering) may also occur.

Stapedius (a muscle of the middle ear)

Hyperacusis (an acute sensitivity to hearing)

Anterior 2 / 3 of the tongue

Taste affected

Submaxillary and

Saliva production

sublingual salivary

disturbed

glands

Facial muscles (subtle role in swallowing and to prick the ears back; very obviously in facial expression and movement)

Swallowing and facial expression / movement affected.

The rehabilitation of facial palsy is frequently associ- ated with our colleagues in physiotherapy but I am a firm believer that as speech and language therapists we are as well equipped to meet the challenges. The physiotherapist is much more knowledgeable about the transmission of nerve impulses and the functioning of muscles but we have substantial understanding of the anatomy and physiology of the head and neck and can soon revise and extend our knowledge accordingly.

Facial nerve palsy is devastating, and rehabilitation places many demands on therapists as well as clients. Penny Gravill outlines the benefits of two specialist treatments which she offers on the NHS and more recently at a Satellite Centre for an independent provider.

READ THIS IF YOU

• ARE INTERESTED IN BIOFEEDBACK TOOLS

• FEEL SECURING FUNDING FOR EQUIPMENT IS TOO DIFFICULT

• MIGHT CONSIDER INDEPENDENT PRACTICE

Promising

The initial frustration and limitations of treating facial palsy quickly became apparent and I was left wonder- ing what else could be done. Diana Farragher, a physi- otherapist based in the Manchester area, had pioneered and developed a treatment for facial palsy using trophic electrical stimulation and the results were promising to say the least. She had done a couple of study days in Aberdeen by the early 1990’s and there appeared to be some hope of treating this debilitating condition. In order to appreciate the principles of trophic electri- cal stimulation, it is important to understand the func- tion of the nerve and the muscles it serves. In a normally functioning system the nerve feeds the muscle and keeps it in good health. When a nerve is damaged, the muscle undergoes degenerative changes. The amount of muscle function lost is dependant upon the extent of nerve damage. By applying trophic electrical stimu- lation, the atrophy can be prevented and the nerve en- couraged to grow back into healthy muscle. The client begins to notice better resting symmetry as the condi- tion of the muscle improves, which has untold benefits on self-esteem and confidence because, as well we know, so many judgements are made (literally) at face value. Learning to apply the trophic electrical stimulation is not difficult for clients; it is a matter of sticking on elec- trodes, turning on the machine, setting it to the correct level and letting the machine do the work. Clients hire

the equipment (pictured) so they can use it independ- ently at home. The road to recovery is not straightforward and, as the nerve recovers, clients can develop a condition called synkinesis. This is the stage where the nerve has es- sentially recovered but mass movements occur and the nerve fails to ‘switch off’. So, for example, instead of just one branch being activated when the client tries to close their eyes, the mouth also moves on the affected side. The face characteristically feels tight and so the weak eye - having once drooped and appeared larger than the normal eye - now appears smaller. The mouth may turn up in a sneer where before it had drooped. Trophic stimulation continues to encourage accurate movement but a different programme is also used to encourage the nerve to shut off and relax.

Where to go next

Having learned the principles of this form of treatment I still felt I was groping in the dark; clients made progress and I didn’t know where to go next. I attended a course at Diana Farragher’s clinic, The Lindens, near Manches- ter. As well as active exercises, I was introduced to the benefits of another tool, surface electromyography (sEMG). I was instantly a convert and set about acquiring funding to purchase one for our speech and language therapy department. (Needless to say this was not easily achieved!) The facility of managing clients with the use of elec- tromyography has made my practice a lot easier and effective. It allows accurate objective measurement of nerve function and helps set goals for treatment as well as measuring change. Electromyography is a painless procedure where elec- trodes are attached to the face, ideally with the client ly- ing down, and the function of the weak side is compared to the good side in the temporal, zygomatic, buccal and marginal mandibular branches of the facial nerve. The readings are viewed on the computer screen in the form of graphs and these can be analysed statistically. Elec- tromyography allows precise objective measurement of nerve function, better planning and goal setting and more accurate prognostic information. It is a significant boost to a client with an apparently completely floppy face to see the graph change as the nerve tries to tell the muscle to move. Equally, synkinesis can be detected and managed. As well as a diagnostic tool, electromyography can be used for treatment in the form of biofeedback. Until the use of biofeedback I relied upon a mirror which allows the client to see what they are doing rather than encour- aging them to feel what they are trying to achieve. Bio-

feedback allows to client to learn to feel a movement again and to balance it by matching the two sides of the face in an expression. In the same way, if they are experiencing synkinesis and the muscle is not relaxing, they can be taught to feel the relaxed and more normal resting levels.

Many skills

There is no quick fix for facial palsy and clients do not move from the list quickly; we are talking years not months. It draws on many of our skills to work with these clients as the effect of facial palsy is devastating both physically and psychologically. Candid and comprehen- sive information from a client’s perspective is available on a blog by Jon Kelly, who had an acoustic neuroma removed in 2005 (www.20six.co.uk/headcase). My caseload is wide and varied. Common causes of problems include Bell’s Palsy, post surgical Facial and Acoustic Neuroma, parotidectomy, temporo-mandibular joint replacement, Ramsey Hunt Syndrome as well as neurological conditions including Guillain Barre Syn- drome, sarcoidosis and Moebius Syndrome. There is also application within upper motor neurone and lower motor neurone stroke but frequently in these cases the facial palsy is incomplete and not one of the client’s pri- orities for rehabilitation. In general, my experience has made me consider my approach to dysarthria management and particularly facial weakness. The face works as a whole, and we tend to think about exercising the weak side to encourage return of function. Instead, I now look at working the face bilaterally, encouraging small, equal movements that the weak side can cope with. This dampens down the good side to allow the weak side to match it and increase the size of the movement while maintaining balance and not encouraging dominance and over- compensation of the unimpaired side. There is a lot of work ongoing into the use of electro- myographic biofeedback in swallowing which is excit- ing. We are in a good position to move forward with this as we have the equipment in Aberdeen and experience in its application, albeit to date in facial rehabilitation.

Independent practice

Last year I decided to move into the field of independ- ent practice and do this one day a week in addition to my NHS work. The Lindens Clinic asked me to join them and so The Lindens Clinic (Aberdeen) was started as the Scottish Satellite Centre. For the majority of people in Scotland it is easier and more convenient to venture to Aberdeen rather than Manchester.

convenient to venture to Aberdeen rather than Manchester. 1 2 3 4 REFLECTIONS • DO I
1
1
2
2
3
3
4
4

REFLECTIONS

• DO I LOOK FOR NEW WAYS TO MAKE THE BEST USE OF MY EXPERIENCE AND SKILLS?

• DO I APPRECIATE THE ROLE OF SELF- ESTEEM AND CONFIDENCE IN RECOVERY?

• DO I HAVE COPING STRATEGIES FOR WORKING WITH PEOPLE LONG-TERM?

EXTENDED ROLE

Top: Penny Gravill Below:

1. A client 4 months post acoustic neuroma surgery (no treatment)

2. A client 5 months post acoustic neuroma

surgery (trophic electrical stimulation begins).

3. A client 18 months post acoustic

neuroma removal, with 12 months use of Neuro4. No movement but symmetry at rest is achieved.

4. The Neuro4 trophic electrical stimulator

Working independently is a tremendous challenge but the 6 months it took to set it up has definitely been worth it. I remember feeling totally daunted by the prospect of data protection statements, statements of terms and con- ditions, BUPA recognition, tax, insurance and public liability to name a few. However, if you are considering it, you are not the first and there is a lot out there to help! People with their own businesses - whether speech and language ther- apists or those in other areas - are tremendously generous in sharing what they have, from advice to spreadsheets. A course run by the Association of Speech & Language Thera- pists in Independent Practice gave me very helpful direc- tion and was well worth the expense. In spite of its frustrations, I get much pleasure from my NHS employment and find the working environment stimulating and challenging (as well as providing boring essentials like a pension!) The friendship and support of colleagues should not be underestimated as working in independent practice is often solitary. We may have many gripes about the NHS but, in spite of all the ex- tras which have crept up over the years, there are sys- tems and administrative support - and these things are tremendously time-consuming when working on your own. I still feel awkward asking for payment but remind myself that for every hour of face-to-face contact there is an awful lot more in paperwork and preparation for that session and the running of the facility. I have had, and continue to have, tremendous support from the experts at The Lindens. In this fascinating field which bridges traditionally defined medical specialities as well as paediatrics and adult caseloads, I feel that the more I learn I realise how much more there is to learn.

Penny Gravill is a specialist speech and language therapist at Aberdeen Royal Infirmary and The Lindens Clinic, Aberdeen, e-mail pgravill@nhs.net (see also www.dianafarragher.co.uk).

References

BANA leaflet (2005) A Basic Overview. Mansfield: The Brit- ish Acoustic Neuroma Association. Farragher, D.J. (2005) A Loss of Face. Facial Paralysis – A Guide to Self Help. 3rd edn. Manchester: Diana Farragher. Kingsley, R.E. (2000) Concise Text of Neuroscience. 2nd edn. Philadelphia: Lippincott Williams and Wilkins. Lindsay K.W., Bone I. & Callander R. (1991) Neurology and Neu- rosurgeryIllustrated2nd edn. London: Churchill Livingston.

Resources

The Association of Speech & Language Therapists in Independent Practice, www.helpwithtalking.com

• The British Acoustic Neuroma Association,

see www.bana-uk.com

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