Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
PECS appeal
l l l U N l N A T l N G P R A T l E
ISSN 1368-2105
vlNTER oo
http://www.speechmag.com
Early
intervention
Doing it
with EAZe
ICU-Talk
A can do attitude
to research
Unemployable
or
unemployed?
Working with
aphasia
In my
experience
A framework
by consensus
NEW SERIES!
Sociological
perspectives on
inequality
How I use
therapeutic
listening
My Top
Resources
Child speech
vn Scays
vord o Verbs
Do you struggle to find meaningful
material for working on verbs with
children? Then get in on the action
with Scally, a little alien who has
come to earth to learn English -
and been adopted by Topologika
Software and its special needs
consultant Bob Black.
Scallys World of Verbs can be
operated by a variety of input
devices - switches, touch screens, Intellikeys
- so that it is easily used by young children and those with
disabilities. Scally acts out more than 400 verbs, and there are
five activities to get children thinking about verbs in different
ways.
The normal retail price starts at 39.95+VAT, but Topologika has
copies to give away FREE to three lucky readers of Speech &
Language Therapy in Practice. To enter, send your name and
address to Topologika/Speech & Language Therapy in Practice
competition, 1 South Harbour, Harbour Village, Penryn,
Cornwall TR10 8LR. The closing date for receipt of entries is
25th January, and the winners will be notified by 31st January.
Scallys World of Verbs is available from Topologika Software,
tel. 01326 377771, www.topologika.com.
vn new narratve packs
Black Sheep Press continues its prolific output of photocopiable
resources with new narrative resources. So, whats the story?
Speech and language therapist Judith Carey, in partnership with
a local Early Years Centre, has devised a comprehensive pack of
session plans, games and activities to promote language skills in
young children using the principle of Becky Shanks Narrative
Therapy Programme (see review on p.7)
Language Through Listening is aimed at children entering
nursery with limited attention and listening skills. Nursery
Narrative introduces the narrative skills model to nursery aged
children, and Reception Narrative promotes further
development and enrichment of language skills at a higher
level for those of reception age.
Black Sheep Press is offering two readers a happy ending - a
complete FREE set of each of the three packs (normal price
100+). For your chance to win, send your name and address to
Speech & Language Therapy in Practice - LTL offer, Alan
Henson, Black Sheep Press, 67 Middleton, Cowling, Keighley, W.
Yorks BD22 0DQ by 25th January. The winners will be notified
by 31st January.
Available from Black Sheep Press, see www.blacksheep-
epress.com, or telephone 01535 631346 for a free catalogue.
Other new additions are the first set of materials in the Simple
Semantics series devised by Felicity Durham (Identifying &
Describing; Can You Get Home?) and Heavy and Light / Hot and
Cold for the Concepts in Pictures series.
In the Summer 02 issue, Anglian Pharma offered Infa-Dent Gum
Massager / Baby Soft Toothbrushes packs. They were won by
Patricia Broughton, Marion McCormick, Lisa Abba, Mary Cordle
and Mary Wickenden.
The two Speechmark titles offered in the Autumn 02 issue
proved highly popular with you. The lucky winners of The
Sourcebook of Practical Communication were Margaret Purcell,
Sarah M. Harris, Judith Hibberd, Elizabeth Reid and Emma
Gonoud. Feeding and Swallowing Disorders in Dementia goes to
Kay Guthrie, Shona Harvey, Elaine Stickland, Lynn Dangerfield
and Linda Armstrong.
Congratulations to all our winners.
Winter 02 speechmag
In need of inspiration?
Doing a literature review?
Or simply wanting to locate an
article you read recently?
Our cumulative index facility is
there to help.
The speechmag website enables you to:
View the contents pages of the last four
issues
Search the cumulative index for abstracts of
previous articles by author name and subject
Order a copy of a back article online.
New article
The speech and language therapy contingent in
the tiny Falkland Islands is looking to expand.
Pippa McHaffie extols the virtues of small classes,
a Flying Santa and sitting amongst hundreds of
penguins.
Plus
The editor has selected the previous articles you
might particularly want to look at if you liked the
articles in the Winter 02 issue of Speech &
Language Therapy in Practice. If you dont have
previous issues of the magazine, check out the
abstracts on this website and take advantage of
our new article ordering service.
If you liked...
Kathleen Taylor & Claire Besser, try Change and
Involvement - Meeting the needs of carers
(Autumn 1997): Pound, C. & Clarke, M. (010) Mary
Law lecture - Less words, more respect: learning to
live with dysphasia and difference, and Denman,
A. (011) Carers - Investigating the needs.
Sally Poole, see (115) Moore, T. & Irwin, A.
(Summer 2000) Making an impact.
Lizzie Astin & colleagues, look at (134) Hurd, A. &
McQueen, D. (Winter 2000) The right things at the
right time.
Sarah Earle, what about (153) Earle, S. (Summer
2001) Sociology: a sure start.
Fiona MacAulay, try (144) Berrie, I. (Spring 2001)
Invigorating the wheel.
Caroline Bowens My Top Resources, see (020)
Ogilvie, M., Stanbury, R. & Williams, P. (Winter
1997) How I manage speech sound difficulties.
Also on the site - news about future issues,
reprinted articles from previous issues, links to
other sites of practical value and information about
writing for the magazine. Pay us a visit soon.
Remember - you can also subscribe
or renew online via a secure server!
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lnsde cover
vnter o speechmag
Reader oers
Win Scallys World of Verbs (Topologika Software)
and new narrative packs (Black Sheep Press)
News / omment
Revews
Multiple disabilities, phonological
awareness, anatomy & physiology,
aphasia, phonetics, play, epilepsy, music,
language development, narrative.
8lmprovng
communcaton wth EAZe
Classrooms look different. Symbols,
drawings and photos are being paired
with written text to assist children in
accessing the curriculum and their envi-
ronment. Some teachers have come to
believe that symbols are a bridge to liter-
acy which can positively impact on the
childrens confidence and self-esteem.
Lizzie Astin, Katie Roberts, Emma Withey
and Melanie Crawshawtake us on a journey into the class-
room through an Education Achievement Zone programme.
+ ommuncaton - an
naenabe rght
... working closely with the intensive care unit nurse has
taught me a great deal about these patients and the
effects that having a life threatening condition and a
prolonged stay in intensive care have on the patient. These
in turn affect the patients ability to use an AAC device.
When a person wakes up in the alien environment of
an intensive care unit, they may well feel they have
come from another world - but there is light in the
shape of the ICU-Talk device. Fiona MacAulay reports.
+ lurther readng
Phonology, Parkinsons disease, voice, community-
focused intervention, aphasia.
+ lN NY EXPERlENE: Great dea -
but how do we do t'
... we can work across Trusts, with limited evidence
bases, using the wealth of expertise that undoubtedly
exists within our profession - and reach a consensus. In
addition... a special interest group can be proactive in
developing practical tools and resources for therapists,
enabling us to address the government agenda within
their relatively tight timescale.
Della Money and special interest group colleagues
produce a consensus framework for developing
communication strategies to benefit people with
learning disabilities.
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2002 +
+8 Unempoyabe or unempoyed'
Respondents who had a better understanding of their
aphasia were more likely to be successful in returning
to employment. One ... provided prospective employers
with a summary of her aphasia and strategies that can
be implemented to overcome her difficulties.
As the interaction of many factors influences whether
or not an individual returns to employment, Kathleen
Taylor and Claire Besser
discover that the
profession needs to
show a bit more
imagination to be truly
working with aphasia.
+ Socoogca
perspectves on
nequaty
seres (+)
ass o oo: an
unequa uture
...children from poorer
backgrounds are seen to
lack the appropriate
environment that is
needed to foster educational success. For example,
children from less affluent backgrounds are the least
likely to have access to constructive forms of play, and
will have poorer access to books, newspapers and the
internet.
Sarah Earle argues that, while we do need to develop
an individualised, client-centred approach, we must
also be aware of how wider socio-economic and
cultural factors influence our practice.
( How l use therapeutc stenng
In the evaluation study the children were reassessed
at the end of the programme and then left for eight
weeks before being reassessed once more. The results
were beyond my expectations: all showed an
improvement greater than one would expect from
maturation. (Dilys Treharne)
Listen up and hear why our three contributors - Dilys
Treharne (The Listening Program), Dr Colin Lane
(A.R.R.O.W.) and Karen OConnor (Therapeutic
Listening) - wouldnt be without their CDs and
headphones.
Back cover Ny Top Resources
Its free, its phonological and its fun! ... the 700 plus
participants enjoy a growing collection of clinical
resources, a therapy ideas file, and a brilliant message
archive full of clinical insights and practical suggestions
(and a few fiery exchanges).
Australian speech-language pathologist and internet
icon Caroline Bowen romps through her top ten
resources for child speech.
WINTER 2002
(publication date 25th November)
ISSN 1368-2105
Published by:
Avril Nicoll
33 Kinnear Square
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AB30 1UL
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e-mail: avrilnicoll@speechmag.com
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Printing:
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Editor:
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Subscriptions and advertising:
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Avril Nicoll 2002
Contents of Speech & Language
Therapy in Practice reflect the views
of the individual authors and not
necessarily the views of the publisher.
Publication of advertisements is not
an endorsement of the advertiser
or product or service offered.
Any contributions may also appear
on the magazines internet site.
Cover picture by Paul Reid (posed by
model). See p.4
IN FUTURE ISSUES
USER INVOLVEMENT ETHICS BILINGUALISM NARRATIVE
ADULT LEARNING DISABILITY APHASIA DYSPHAGIA
CONTENTS WINTER 2002
J
www.speechmag.com
PES appea
David ...demonstrated that he
could transfer this skill to other set-
tings. For example, [he] walked into
his brothers room and said, I want
the light off.
Finding a lack of literature on the
use of the Picture Exchange
Communication System with adults
with a learning disability, Sally
Poole starts the ball rolling with a
study of 27 year old Davids
progress.
( OVER STORY
news
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2002
Autism campaign
targets GPs
GPs have been targeted in a campaign to raise awareness of autistic
spectrum disorders and to promote a helpline to parents.
The National Autistic Societys mailing to GPs includes a questionnaire
asking them about their experiences of the assessment, referral, diag-
nosis and support of clients with autistic spectrum disorders. The
results will be published next year.
www.nas.org.uk
NAS Autism Helpline, tel. 0870 600 8585 (Mon-Fri, 10am-4pm).
Supporting staff
Locum
shortage
As the professions staffing
difficulties push up demand
for speech and language
therapists to fill the gaps, a
locum agency is reporting a
shortage of new recruits.
Action Medicals Caroline
Evans says, Were speaking to
clients from all over the country
who are desperate for short-
term staff, but despite all our
efforts were finding it increas-
ingly difficult to help them.
Many clients need whole teams
of therapists and the situation
is such that they are willing to
be completely flexible about
the candidates skills.
Locum staff are generally
required for short-term
assignments such as maternity
and sickness cover and wait-
ing list initiatives, so are
expected to be highly adapt-
able and to enjoy a chal-
lenge. Agencies compete for
locums by offering benefits
such as accident and sickness
insurance, funding for contin-
uing professional develop-
ment and high rates of pay.
Action Medical, tel. 01225
447445.
Propeller move
Propeller Multimedia, supplier
of React and Speech Sounds
on Cue software, has moved
to PO Box 13791, PEEBLES,
Scotland EH45 9YR, tel/fax
01896 833528.
Get
chatting
The national educational charity for children with
speech and language difficulties is sending out a
chatterbox challenge.
I CAN is asking nursery workers, teachers, speech
and language therapists and other professionals
working with young children to take part in this
event and get children talking. Preschool children
will be sponsored to learn and recite a joke, song,
nursery rhyme, story, or anything they can, individ-
ually or as part of a group to raise money for I CANs
work.
The charity already runs seven Early Years Centres
in England, Wales and Northern Ireland, and is
setting up a further seven this year, including two
in Scotland. The centres provide preschool chil-
dren with integrated therapy and education plus
information and training for parents and profes-
sionals.
Fundraising packs, including a free tape with sing
along songs and a Tesco Baby & Toddler Club
Parent Pack - a step-by-step guide to encouraging
childrens language development, from the
Chatterbox Challenge hotline on 0845 130 3962.
www.ican.org.uk/chatterbox.
Just not good enough
A petition signed by 50,000 people has called on the government to
make stroke care a priority.
Only 27 per cent of people with a stroke are treated in stroke units,
although national standards state that everyone should have this service
by 2004. The Stroke Association quotes research showing that every day
30 stroke patients die or are left seriously disabled because they are not
getting this specialist care.
The National Audit of Stroke Services 2001/02 had news of progress, as
nearly 75 per cent of general hospitals have stroke units and 80 per cent
of Trusts now have a clinician with responsibility for stroke. But blasting
stroke care as moving forward at a snails pace, Margaret Goose of
the Stroke Association calls for the words of
the National Service Framework for Older
People to be put into action.
www.stroke.org.uk
Can you see me
at the back?
A campaign to ensure all television programmes are subtitled is seeing
steady progress.
The Royal National Institute for the Deaf reports that proposed
Communications legislation would enshrine legal minimum subtitling
standards for all forms of television, including digital, cable and satel-
lite. The organisation is continuing to press for assurances on the quality
of editing, colour contrasting and descriptions of noise effects, and is
backing research into the preferred speed of subtitles for deaf and hard
of hearing people. It also hopes to see an increase in subtitles on DVDs
and at film screenings, and is calling for improved access to arts and cul-
ture for deaf and hard of hearing people following a report which con-
demned the majority of the UKs top arts and tourist attractions for
effectively excluding them.
RNID Information Line tel. 0808 808 0123, text 0808 808 9000.
Cleft lip and palate gene
Scientists have identified the faulty gene which can cause Van der Woude, a syn-
drome accounting for two per cent of babies born with a cleft lip and palate.
About a third of all cases of cleft lip and palate are syndromic. In the case of Van
der Woude, the childrens other physical problems tend to be missing teeth and a
pit in the lip. Much of the DNA detective work in this research was based on twins
in Brazil, one born with Van der Woude syndrome
and one without.
The researchers hope there will be immediate benefit
to affected individuals and families, especially in
genetic counselling and postnatal diagnosis.
In the longer term they believe the dis-
covery could lead to antenatal treatment
and a better understanding of why and
how cleft lip and palate occurs.
The research, funded by Action Research
and the Wellcome Trust, has been pub-
lished in the journal Nature Genetics.
The NHS needs to prepare for increasing reliance on its non-professionally
qualified support staff.
According to research commissioned by the Institute for Policy Research,
there is a need for agreement on the future role, training and regula-
tion of this diverse group. Research Fellow Rachel Lissauer said, The
ippr wants to see the future structure of our health workforce based on
how best to meet patients needs. We anticipate a significant role for
support workers in providing elements of direct patient care. But if the
current neglect of their training needs and status continues, professional
staff will remain unwilling to let go of their responsibilities or tasks.
Support Staff in Health and Social Care: An Overview of Policy Issues by
John Rogers, see www.ippr.org.uk.
www.actionresearch.org.uk / www.wellcome.ac.uk
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2002
news 8 comment
lumnatng
practce
Dark mornings and evenings make us yearn for the blue skies of summer, when
motivation is easier to come by. But, never fear - Speech & Language Therapy in
Practice is here with the fairy lights to brighten your winter days!
Our How I section (p.24) turns the spotlight on therapeutic listening. We have all
dealt with clients who make slow or even no progress, and where we cannot see a
way forward. Proponents of The Listening Program, A.R.R.O.W. and Therapeutic
Listening find their approaches light the way sufficiently for their clients to be able
to benefit from other, more specific strategies.
Lack of motivation to communicate was the main barrier to progress for the young
man in Sally Pooles shining example of a case study (p.4). Through combined use of
the Picture Exchange Communication System and a widening of opportunities to use
the skills he has, his carers see flickers of true communication.
The 1995 Disability Discrimination Act was meant to break down barriers and herald a
new dawn for people with disabilities in the workplace, including those with aphasia.
Through in-depth interviews with clients, Kathleen Taylor and Claire Besser (p.18) shed
light on the reality, but also offer bright ideas for how things could be improved.
Fiona MacAulay and colleagues (p.12) also show a real flare for research that will
benefit clients. In the light of huge developments in computer hardware and software
they set out to develop a high tech device to assist intubated patients emerging from
unconsciousness into the harsh beams of an intensive care unit. While not the usual
subject matter for this magazine, the process involved a high degree of collaboration
and responsiveness which is relevant to all client groups and therapy.
Collaboration was the key to Della Money and colleagues (p.16) achieving their
glittering prize - a consensus framework for developing communication strategies to
benefit people with learning disabilities. Enthusiasm could have been dimmed by all the
challenges such as a short timescale and lack of an evidence base but the networking
opportunities of a special interest group ensured light at the end of the tunnel.
Phonology and internet icon Caroline Bowen (basking in the Australian sunshine) is a
networker extraordinaire. She sparkles in our back page top resources which includes
her take on Magic Lantern shows for consumers.
Lizzie Astin, Katie Roberts, Emma Withey and Melanie Crawshaw (p.8) have worked
their own magic in Bridgwater, coming out of the shade into the full glare of the
classroom through an Education Achievement Zone initiative. The benefits of health
and education working together can be clearly seen even in how different the
classrooms look. Unlike most therapists, these authors work with whole classes rather
than caseloads. In the first of our new sociological perspectives on inequality series
(p.21), Sarah Earle enlightens us on the influence of social class and suggests this kind
of approach allows us to tackle social exclusion more effectively.
Like a laser beam, Speech & Language Therapy in Practice authors get straight to the
point, illuminating practice and providing flashes of inspiration without leaving you
blinded by the light.
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Forum for children
A national network forum for providers of
childrens services aims to share and spread
good practice.
In particular it is focusing on involving young
people and education services, developing a
single assessment process, strengthening
child protection, clarifying accountability
and ensuring appropriate links with youth
justice. Through the Local Government
Association website the network will publish a
series of discussion papers and case studies.
www.lga.gov.uk
Neurologists needed
The Encephalitis Support Group has urged
members to contact MPs to raise awareness
of the need for more neurologists.
The Group is backing a report from the
Association of British Neurologists showing
inequality and a lack of specialist treatment
throughout the UK. They are calling for an
increase in the number of neurologists from
350 to 1400 over the next ten years to provide
a round the clock service across the country.
A member of the Neurological Alliance, the
Group is also one of the organisations
involved in the production of a report in
consultation with people who live with
neurological conditions and their carers.
Speedy access to high quality neurological,
rehabilitation and community services is called
for, along with a care plan, access to a key
worker and annual review to achieve a coordi-
nated, seamless, patient-orientated service.
Acute Neurological Emergencies in Adults,
free from the Association of British
Neurologists, tel. 020 7405 4060, e-mail
abn@theabn.org
Levelling Up, 5 (12 for organisations) from
the Neurological Alliance, tel. 020 7793 5907,
e-mail neurological-alliance@hotmail.com
www.esg.org.uk
Media Stars
Technology is opening up new possibilities
for communication and distance learning
for deaf students.
A UK television distribution and video
conferencing system, MediaStar, has been
installed in every classroom and computer
workstation at the Junior High School 47 -
School for the Deaf and Hard of Hearing in
New York. This allows deaf students to
communicate using American sign-language
with their colleagues and across the United
States and internationally with other deaf
students using similar facilities.
The schools director of technology said they
now plan to use the technology from
Berkshire company Cabletime to broaden
our students horizons, teaching them new
media skills which they might not otherwise
have the chance to develop.
www.cabletime.com
Opportunities in the community
Davids mother wanted immediate one-to-one
speech and language therapy input for him. I
explained that no input would be offered until
David could start accessing some day services. The
reasoning behind this was to ensure there would be
a key person to carry out work with David outside
his speech and language therapy appointments and
to give David opportunities in the community to
practise any skills learnt in the sessions.
Funding for specialist outreach support
was agreed and a one-to-one worker
from a specialist autism service joined
David for three days each week. The
aim of this support was to help David
access community services. Speech and
language therapy input was then
offered in the form of fortnightly ses-
sions with David and his support work-
er. Following her mothers wishes,
Davids sister accompanied him to all
sessions and therefore became involved
in the speech and language therapy input also. I
chose the PECS approach with the aim of develop-
ing Davids ability to initiate communication as well
as his spontaneous speech and eye contact.
STAGE 1 Identifying a reinforcer
The first step of PECS is to identify a reinforcer,
something that the person finds motivating such
as a biscuit or ball. A symbol (photograph, picture
or line drawing) of the reinforcer is obtained. The
person is asked to sit opposite a communication
partner and a physical prompter is seated behind
them. The reinforcer is put in front of the person,
just out of their reach. As the person reaches for
the reinforcer, the physical prompter puts the sym-
bol into their hand and supports them to put it
into the open palm of the communication partner.
As soon as the symbol is handed over, the commu-
nication partner rewards the person by giving
them the reinforcing item. They also give verbal
reinforcement and praise by saying for example,
Oh, you want a biscuit. Good! or by verbalising
what the person would have said: I want a bis-
cuit. Good! (If the person imitates what you say,
then verbalising what they would have said can
help with problems related to pronoun reversal at
this stage.) Some communication partners also
respond by labelling the item, as in Biscuit.
Good! The person must be given the reinforcer
immediately after they hand over the symbol.
Once the reinforcer is received they can then eat
the item if it is food, or hold it if it is an object such
as a ball. If biscuit is being used as a reinforcer
then small pieces can be given rather than whole
biscuits. The prompts are gradually reduced so
that eventually no physical prompter
or open hand prompt by the commu-
nication partner is needed.
David was introduced to stage 1. At
the beginning symbols were used as
recommended by PECS and the writ-
ten word was printed underneath as
we knew David was able to read the
word. The first reinforcer used was a
food item. Initially a physical
prompter was needed to support
David to reach for the reinforcer but
this was gradually reduced until the
physical prompter was no longer needed. The ver-
bal reinforcement given was, I want a biscuit.
Good! This was chosen due to Davids echolalia
so that if he imitated the words then problems
related to pronoun reversal would be avoided.
David was very quick to learn what to do and after
a short time started to say the name of the rein-
forcer while he was exchanging the symbol for it.
STAGE 2 Spontaneity and range
Stage two involves increasing the spontaneity
and range. The distance between the person
and communication partner is gradually increased
by moving the communication partner away a lit-
tle at a time so eventually the person has to get
up out of their chair and walk over to the com-
munication partner to get their attention. Also
the symbol is gradually moved away so the person
has to move to get the symbol and give it to the
communication partner. The physical prompter
may be required initially and the amount of sup-
port needed reduced as before. PECS recommends
at least 30 opportunities for exchanges to take
place during functional activities each day. Ideally
cover story
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2002 (
your cents
ack motvaton and
opportuntes to
communcate
need structured but
exbe support
rarey ntate nteracton
Read ths
PECS
appeal
avid is a 27 year old man with a learning
disability and autism. When I first start-
ed working with him, he was living with
his mother and three siblings who were
providing all his care. He was not access-
ing any services and had few opportuni-
ties to make choices in his life or to interact with peo-
ple outside his family network. Davids mother
appeared to have a strong influence over the whole
family and was very much of the opinion that David
would one day overcome his autism and learn to
speak.
I had just attended a two day Picture Exchange
Communication System (PECS) course following a
recommendation from a colleague. Psychologist
Andrew Bondi and speech and language therapist
Lori Frost developed PECS over 10 years ago. It is a
structured behavioural programme first used with
children with autism but now used with adults and
people with other functional communication diffi-
culties. PECS acknowledges that a person may not
be motivated to communicate by social rewards
alone, and teaches them to communicate by
exchanging a symbol for a tangible reward that is
motivating for them. I decided to find out if this six
stage programme could help David.
Assessment found that David had an understanding
of three key words or more. He had difficulty
understanding complex sentences, some wh ques-
tions and emotions, but responded well to visual
information such as pictures/symbols and written
material. David was verbal but at the time of
assessment only used single words or two word
utterances. His speech was mumbled and he used
little eye contact or gesture. David had an under-
standing of turn taking and would answer ques-
tions, usually with yes or by saying single words. He
was frequently echolalic. David had good numeracy
and literacy skills and was able to read and write. He
would spend time copying and writing out large
pieces of text without necessarily understanding the
meaning of what he was writing. David initiated
very little communication, but would occasionally
write a single word on a piece of paper and give it
to someone to look at. He appeared to have little
motivation to communicate; one reason may have
been that all his basic needs were being met and he
had little opportunity to make choices.
D
PECS
acknowledges
that a person
may not be
motivated to
communicate
by social
rewards alone
the exchanges should be carried out by different
communication partners. David completed stage
2 without any difficulty.
STAGE 3 Introducing the
concept of choice
Stage three involves introducing the concept of
choice. Two items are offered, a reinforcer and non-
preferred item with the correspond-
ing symbols. If the person picks up
the correct symbol for the reinforcer,
then they get the item. If they
choose the wrong symbol, they get
the non-preferred one. An error cor-
rection process is then carried out
where the correct symbol for the
reinforcer is shown and the person is given another
opportunity to choose the right symbol and obtain
the reinforcer.
Initially there were some difficulties introducing
stage 3 with David. He was shown two types of
food, one he liked and one we knew he didnt.
When offered the symbols representing these, David
chose the symbol of the reinforcer first and received
the food that he liked - but then chose the symbol
of the non-preferred item and proceeded to eat
that food too. He continued to choose alternate
symbols. David did not seem to understand that he
was being offered a choice and was confused about
which symbol he should go for, not necessarily tak-
ing the one that he preferred. At this point we
decided to deviate from the programme slightly and
create a more natural environment to practise in.
We devised a group activity making sandwiches.
This involved getting all the items needed to
make a sandwich - bread, butter, knife, plate, fill-
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2002
cover story
Please can you briefly say why you feel some are more important than others
5. How would you recognise the following in your classroom?
A child with poor attention
A child with language delay
Low self-esteem
6. What strategies do you use with a child who has poor comprehension
skills?
Please tick all that apply
Gestures
Symbols
Slowing down rate of speech
Signing
Raising voice
you want to
deveop a research dea
transer knowedge to a
derent cent group
mprove your
coaboratve workng
Read ths
Figure 1 The ICU-Talk communication aid.
puter hardware and the limits
of what computers can do.
The department of applied
computing at Dundee
University along with the
Dundee speech and language
therapy service has been devel-
oping AAC systems for 15
years. While working on a sys-
tem for adults with aphasia we
felt that some of the principles
of reduced cognitive load, min-
imal training, and transparent
interface could be used to
develop a system specifically
for intubated patients in inten-
sive care. A three year funded
collaborative research project,
ICU-Talk, was set up to develop
and test an AAC device for
intubated patients in intensive
care. My partners in the
research were a software engi-
neer and an ICU nurse.
There were two steps in the
development of the ICU-Talk
device. The first involved iden-
tifying a suitable hardware
platform to run the software
and then mount the hardware.
The second was to develop the ICU-Talk software
that would control how the device worked.
Many restrictions apply when developing an aid
for use in the intensive care environment. Risk of
infection to and between patients is a major con-
cern, so equipment must be able to withstand rig-
orous cleaning with chemical solutions. Staff must
be able to move the device out of the way quick-
ly in an emergency and the patient must be able
to use it when lying or sitting in bed, or from a
chair. It must be able to be accessed using a range
of input devices to compensate for a patients
physical weakness.
The multidisciplinary project team addressed
these factors and a solution was found which was
limited by the available hardware at that time. A
rugged, waterproof, flat panel screen was
obtained from Dolch. This screen weighed approx-
imately seven kilograms and so required a special
heavy-duty mounting solution to allow it to be
suspended safely above a patient (see figure 1).
Specific needs
Software was developed with the specific needs
of the ICU patient in mind. It had to be simple to
use and easy to learn with minimal training. Two
interfaces were developed which each supported
use of the touch screen, mouse or single switch
scanning (see figure 2). The interfaces were
designed to be visually stimulating but not distract-
ing, and advice was sought from a computer games
company as to how best to achieve this. They told
us how we could keep the animation working from
the same direction all the time so that the user
remains focused on the important central part of
the screen. The software includes a database of
phrases organised under eight topic headings. To
ensure the phrases were relevant for their intubat-
ed patients, nursing staff from ICU were asked for
examples of phrases patients frequently use, and
researchers also observed and noted the communi-
cation attempts made by patients. Communication
partners during observations were usually relatives,
so about half of the phrases were very personal,
everyday things such as a query about a family
member, or who was walking the dog. A computer
based interview was designed for relatives. There
were thirteen questions which asked for informa-
tion like names and ages of children, and hobbies.
The answers were turned directly into personal
phrases in the ICU-Talk device, and were available
immediately for the patient to use.
The first prototype ICU-Talk device was finished in
May 2001 and introduced to the intensive care unit
at Ninewells Hospital, Dundee for trials with patients.
Using the ICU-Talk device and working closely
with the intensive care unit nurse has taught me
a great deal about these patients and the effects
that having a life threatening condition and a
prolonged stay in intensive care have on the
patient. These in turn affect the patients ability
to use an AAC device (figure 3).
Despite all the complications described, 21
patients over a 12 month period have used the
ICU-Talk device. Preliminary results show that
patients are able to use the system with only min-
imal training to communicate. Most patients only
use it for a short period of time, as the window of
opportunity is small - perhaps only 24 to 48 hours
- between having their sedation reduced so they
are awake and extubated. There have been no
admissions of people with Guillain Barre
Syndrome or of other long-term alert and com-
municating patients during the evaluation period,
the initial target group for the ICU-Talk device.
Surprised
One of the features that most surprised me was the
patients inability to remember anything about
using the ICU-Talk device or about their stay in ICU.
This phenomenon is documented in the literature
(Russell, 1999; Stovsky et al, 1988) and is commonly
seen in patients who have been ventilated.
However, it meant that we were unable to ask the
patient how they felt about using ICU-Talk or for
feedback about what it was like communicating
with it. A questionnaire we put together was only
completed by three relatives. We had difficulty
accessing relatives and patients once they were dis-
charged from the unit, and no relative returned
the questionnaire if it was posted to them. Many of
our results are therefore anecdotal - from nursing
staff, our own observations of patients using the
device and from the data recorded automatically
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2002 +
research
Figure 2.1 Boxes Interface showing topics
Figure 2.2 Boxes Interface showing questions
Figure 2.3 Bubbles Interface showing
topics
Figure 2.4 Bubbles Interface showing
phrases
Many restrictions
apply when
developing an
aid for use
in the
intensive care
environment.
Figure 3 Effect on AAC use
Presenting Possible Cause Effect on AAC use
feature
Fatigue
Generalised
weakness
Reduced
cognitive
abilities
Fear/anxiety/
denial of
problems
Low mood
poor concentration
poor ability to retain information
hallucinations
difficulty using touch screen, mouse, joystick,
trackball
tire quickly
tremor in hand or arm
reduces cooperation
short-term memory loss (unable to retain
instructions)
long-term memory loss (do not remember their
stay in ICU)
difficulty following instructions
unwilling to try something new
reduced concentration
only want to use speech to communicate
poor motivation to participate
unwilling to try something new
social withdrawal therefore dont want to
communicate
medication
general medical condition
withdrawal of sedation
being bed bound
effect of medical condition
medication
general medical condition
waking up in the alien
environment of ICU
realisation of what has happened
difficulty coming to terms with
physical problems
feeling they are not getting better
severity of medical condition
feelings of isolation
research
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2002 +(
References
Albarran, J.W. (1991) A review of
communication with intubated
patients and those with tra-
cheostomies within an intensive
care setting. Intensive Care
Nursing 7; 179-186.
Ashworth, P. (1984). Staff-patient
communication in coronary care
units. Journal of Advanced
Nursing 9; 35-42.
Beukelman, D.R. & Mirenda, P.
(1999) AAC in intensive care set-
tings. In: Augmentative and alterna-
tive communication: Management
of severe communication disorders
in children and adults, Ed.2; 515-
530. Baltimore: Paul H. Brookes
Publishing Company.
Costello, J. (2000) AAC interven-
tion in the Intensive Care Unit:
The Childrens Hospital Boston
Model. Augmentative and Alternative
Communication 16; 137-153.
Dikeman, K.J., & Kazandjian, M.S. (1995)
Communication and Swallowing Management of
Tracheostomised and Ventilator Dependent
Adults. Singular Publishing Group; San Diego.
Granberg, A., Bergbom Engberg, I. & Lundberg,
D. (1999) Acute confusion and unreal experiences
in intensive care patients in relation to the ICU
syndrome. Part 2. Intensive and Critical Care
Nursing 15; 19-33.
Hafsteindottir, T.B. (1996) Patients experiences of
communication during the respirator treatment peri-
od. Intensive and Critical Care Nursing 12; 261-271.
Mitsuda, P.M., Baarslag-Benson, R., Hazel, K. &
Therriault, T.M. (1992) Augmentative communica-
tion in intensive and acute care unit settings. In:
Yorkston, K.M. (ed.) Augmentative
Communication in the Medical Setting.
Communication Skill Builders:Tucson.
Russell, S. (1999) An exploratory study of patients
perceptions, memories and experiences of an
intensive care unit. Journal of Advanced Nursing
29 (4); 783-791.
Stovsky, B., Rudy, E. & Dragonette, P. (1988) Caring
for mechanically ventilated patients. Comparison
of two types of communication methods after car-
diac surgery with patients with endotracheal
tubes. Heart and Lung 17; 281-289.
by the ICU-Talk device, which logs all
the button presses and selections
made by the patient.
Patients often had difficulty in fol-
lowing instructions. They were unable
to take on board that their attempts
at communicating using mouthing
were unsuccessful and that, to com-
municate more effectively, they need-
ed to slow down their speech rate,
use single words and use ICU-Talk to
augment their communication.
Patients tired very quickly so sessions
tended to be short and patients
would give up unless they found what
they wanted to say very quickly.
The number of patients in ICU who
are able to use an AAC system is rela-
tively small but giving them the facili-
ty to communicate allows them to
express their needs and wants and
reduces their feelings of isolation (see
case examples in figure 4). Feedback from nursing
staff in ICU suggests they feel ICU-Talk is a good
idea but that, in practice, the device was too big
and its physical size put patients and staff off
using it.
Use of the ICU-Talk system depended a lot on
the cooperation of the nursing staff. Although
the ICU-Talk team tried to be present in the unit
as much as possible, they could not provide week-
end or evening cover. Some members of the nurs-
ing staff reported that, although they felt com-
munication was important, they would rather
that the patient was washed and all the days pro-
cedures completed before the ICU-Talk device
was made available to the patient. This limited
the patients ability to use communication to par-
ticipate in aspects of their care.
Many of the feelings and perceptions of the
nursing staff were to do with the overall size of
the device. We have since sourced and trialled
much smaller hardware, a fujitsu pentablet (figure
5), with two patients. Staff feel the smaller device
is much better although it is not waterproof so has
to be put in a plastic bag to be used, and has a
smaller and less sensitive screen and poor quality
built-in speakers. At the point of writing it has
been ruggedised to make it suitable for use as an
AAC device, and we are keeping an eye on the
constant stream of new hardware coming on the
market. The patients ability to locate what they
want to say from the large database remains a dif-
ficult area and requires some further work to
develop easy to use navigation methods.
We have written a funding proposal for a multi-
centre randomised control trial to see if using this
smaller version of ICU-Talk is more effective than
the low-tech AAC methods traditionally used in
ICU. This would be based on 160 patients in 8 ICUs
across the UK and will also allow changes in the
software and database reorganisation to be tested
by a much larger number of patients.
Fiona MacAulay is a senior speech and language
therapist at Ninewells Hospital, Dundee. See
www.computing.dundee.ac.uk/acprojects/icutalk
for more information.
Do l have a can do atttude
to my work'
Do l ask or expert or
specased advce when
necessary'
Do l adapt recommendatons
and resources unt they
meet the needs o those
usng them'
Reectons
Figure 5 The new ICU-Talk prototype
Note: All photos posed by author.
u
r
t
h
e
r
r
e
a
d
n
g
u
r
t
h
e
r
r
e
a
d
n
g
u
r
t
h
e
r
r
e
a
d
n
g
u
r
t
h
e
r
r
e
a
d
n
g
VOlE
Pannbacker, M. (2001) Half-swallow boom: does
it really happen? [review]. Am J Speech Lang
Pathol 10 (1) 17-8.
The half-swallow boom is a voice facilitating tech-
nique used for clients with low loudness and air
wastage from unilateral vocal fold paralysis, severe
bowing of the vocal folds, or falsetto voice. This arti-
cle provides a summary of the technique. Although
the technique may be useful it induces vocal hyper-
function and can damage the vocal folds causing an
iatrogenic voice problem. Clinical trials of the tech-
nique did not show benefits and resulted in an
increase of vocal symptoms. There is a need for data
about its effectiveness.
PARKlNSONS DlSEASE
Haneishi, E. (2001) Effects of a music therapy
voice protocol on speech intelligibility, vocal
acoustic measures, and mood of individuals
with Parkinsons disease. J Music Ther 38 (4)
273-90.
This study examined the effects of a Music Therapy
Voice Protocol (MTVP) on speech intelligibility, vocal
intensity, maximum vocal range, maximum duration
of sustained vowel phonation, vocal fundamental fre-
quency, vocal fundamental frequency variability, and
mood of individuals with Parkinsons disease. Four
female patients, who demonstrated voice and speech
problems, served as their own controls and participat-
ed in baseline assessment (study pretest), a series of
MTVP sessions involving vocal and singing exercises,
and final evaluation (study posttest). In study pre and
posttests, data for speech intelligibility and all
acoustic variables were collected. Statistically signifi-
cant increases were found in speech intelligibility, as
rated by caregivers, and in vocal intensity from study
pretest to posttest as the results of paired samples t-
tests. In addition, before and after each MTVP session
(session pre and posttests), self-rated mood scores and
selected acoustic variables were collected. No signifi-
cant differences were found in any of the variables
from the session pretests to posttests, across the
entire treatment period, or their interactions as the
results of two-way ANOVAs with repeated measures.
Although not significant, the mean of mood scores in
session posttests (M = 8.69) was higher than that in
session pretests (M = 7.93).
APHASlA
Murray, L.L. (2002) Attention deficits in aphasia:
presence, nature, assessment, and treatment.
Semin Speech Lang 23 (2) 107-16.
Recently, there has been growing interest in under-
standing how nonlinguistic cognitive problems such
as impaired attention might negatively affect the lin-
guistic abilities of adults with aphasia. This article
begins with a summary of research focused on the
relationship between attention and language impair-
ments in aphasia and a discussion of why it might be
important for clinicians to address the attention abili-
ties of their aphasic patients. Also discussed are for-
mal and informal measures for quantifying and qual-
ifying attention problems, treatment strategies for
directly or indirectly remediating attention problems
in patients with aphasia, and empirical support for
such treatment.
n my experence
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2002 +
First stop was the vast evidence base that under-
pins our practice. Oh well... However, there was
light at the end of the tunnel. Agencies in
Somerset pioneered work on a collaborative com-
munication strategy that identified the key ele-
ments for success (Somerset Total
Communication: Jones, 2000). We invited Jane
Jones to our Trent Region special interest group
for speech and language therapists working with
people with learning disabilities. She gave a short
presentation then facilitated discussion around
key questions such as What is a strategy?,
What is total or inclusive communication? and
What are the key elements for a successful strat-
egy? After these seemingly straightforward
questions were posed and debated, we left sever-
al hours later realising we still had a long way to
go.
Reached by consensus
Through the next two special interest group
meetings we continued to allocate time for
Communication Strategies. We worked our way
through the key elements of management,
training and resources. For each element we
identified the principles that would have to be
in place to achieve success, then identified possi-
ble suggestions or processes that might be used
to achieve the principles. The principles and
processes were all reached by consensus - in itself
an achievement.
We formed a small working party, which met
twice, to pull all the special interest group work
together. We decided we needed a framework
developed by and for speech and language thera-
pists working with adults with learning disabilities
in Trent. The framework could then be used in
partnership with other agencies and stakeholders
to develop local communication strategies that
meet local organisational needs.
One major task was to define what a
communication strategy actually is. We
agreed the following definition - which
at 73 words clearly wont be found in a
dictionary - but we feel it sums up all
the elements and adequately describes
communication. As the framework is
designed to be a working tool, this def-
inition could provide a starting point
for further discussion and negotiation:
A communication strategy is a multi-
agency plan to develop a consistent
and coherent approach to meeting the
communication needs of people with
learning disabilities, within both their
daily environments and wider contexts. This
includes facilitating the use and understanding of
a range of different means, reasons and opportu-
nities for communication. A successful strategy
has to involve the key elements of management
support, training, and networks, and be under-
pinned by agreed and adequate resources.
This collaborative approach has been a great
success. It has demonstrated that we can work
Great government ideas can be quite a challenge to put
into practice - particularly when accompanied by a short
timescale. Undaunted, a special interest group worked
on a consensus framework for developing communication
strategies to benefit people with learning disabilities.
Della Money and colleagues take us through the
process and share the end result.
n March 2001 the Government launched the
first white paper for over 30 years for people
with learning disabilities. Valuing People: a
new strategy for learning disability for the
21st Century made some bold proposals,
within even bolder timescales, and outlined four
main principles of choice, independence, civil
rights and inclusion. It stated
that, there was not enough
effort to communicate with peo-
ple with learning disabilities in
accessible ways, and that, the
challenge was improving infor-
mation and communication with
people with learning disabili-
ties. It referred to both commu-
nication training and communi-
cation plans as well as individuals
who may require communication
techniques and the effective use
of new technology.
It quickly became obvious to us
that communication was central to these princi-
ples and underpinned the whole document. The
paper even stated: The Government expects
organisations working with learning disabled
people to develop communication policies... This
of course was great news for speech and lan-
guage therapists across England and Wales,
although there remained one small niggling
question - how do we do this?
l
you
ee speca nterest groups are
underdeveoped
know we need to up our evdence
base
are workng on Vaung Peope
Read ths
Great idea-
but how do
we do it?
the principles
and processes
were all
reached by
consensus - in
itself an
achievement.
across Trusts, with
limited evidence
bases, using the
wealth of expertise
that undoubtedly
exists within our
profession - and
reach a consensus. In
addition, it shows
how a special interest group can be proactive in
developing practical tools and resources for ther-
apists, enabling us to address the government
agenda within their relatively tight timescale.
Initial feedback has been very positive, and sever-
al teams within Trent Region are using the frame-
work. There has also been much interest from out-
side the region, and from other professions and
non-NHS organisations. So, just in case you are
feeling you never want to see another strategy,
take a look at this one - and let us know what you
think.
Della Money and Sue Thurman (Nottinghamshire),
Jane Parr (Leicestershire), Hilary Berry (Sheffield),
Kath Stewart (Lincolnshire), Liz James (S.
Derbyshire) and Judy Stephens (N. Derbyshire) are
members of the Trent Region special interest
group for speech and language therapists work-
ing with people with learning disabilities. They
formed the working group to pull together the
framework for developing communication strate-
gies. Address for correspondence: Della Money,
CLDT, Byron House, Newark Hospital, Boundary
Road, Newark, Nottinghamshire NG24 4UW, tel.:
01636 685927, e-mail: della.money@hq.cnhc-
tr.trent.nhs.uk.
Acknowledgements
We would like to thank Jane Jones for setting us off
and all the therapists who belong to Trent Region
SIG and have contributed to the framework.
Reference
Jones, J. (2000) The total communication
approach: towards meeting the communication
needs of people with learning disabilities. Tizard
Learning Disability Review 5 (1) 20-26.
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2002 +;
n my experence
Do l gve sucent tme to
thnkng through my
strategy beore tryng to
put an dea nto practce'
Do l get nvoved n the
work o speca nterest
groups'
Do l see the bgger pcture
and how l can pay a part'
Reectons
1. Management
Principles
1. Commissioners and Managers of key agencies
(such as health, social services, further education
and the voluntary and independent sectors) are
involved in communication strategies. This
includes partnership boards and planning groups
2. Service Users and carers are the major
stakeholders in developing communication
strategies
3. Communication strategies are jointly owned
4. Managers recognise the integral role that
communication plays in relation to key
legislation and guidance (such as Valuing People/
Disability Discrimination Act)
5. Speech and Language Therapy services are a key
part of communication strategies. Their role and
service designs are fully negotiated
6. There is an agreed protocol for responsibilities
and accountability for communication strategies
7. Communication strategies are documented with
agreed definitions of terminology
2. Training
Principles
1. Training promotes awareness of communication,
develops communication skills and/or supports
implementation of new initiatives
2. Training is based on identified needs of
individuals, environments or communities
3. Differing learning styles and needs of
individuals, and the cultures of organisations, are
taken into account when designing and
delivering training
4. There is a clear statement and agreement for the
purpose of all training. Training is planned with
defined and agreed outcomes, negotiated with
relevant people
5. Ongoing support and supervision is necessary to
achieve the outcome. Outcomes are measured
and evaluated as part of a performance
management cycle
6. There are recognised levels of competence for
trainers
7. Training is delivered within an agreed
inter-agency training framework (eg. LDAF-
Learning Disabilities Awards Framework)
3. Networks & Resources
Principles
1. Formalised Networks are established across
services, agencies and appropriate localities in
order to support all the elements of the
communication strategy
2. Each Network has a defined purpose, scope and
support mechanism. This includes clear channels
of communication and information exchange
3. Communication tools used to support the
strategy are evidence based and agreed
4. Multi-modal resources are widely and easily
accessible, using a co-ordinated process of
selection, training and dissemination
5. Management, technical and financial support is
essential for the development of accessible
resources
Framework for developing communication strategies
Processes may include:
Identifying other peoples agendas
Identifying your local management structures
(across all key agencies)
Developing the role of the lead Speech and
Language Therapist at a strategic level
Being consistent and repetitive in the messages
given to key managers and commissioners about
communication, in order to create a shared vision
Liasing with Partnership Boards/Planning Groups
Presentations to and feedback from key people
Involvement in relevant working groups or other
appropriate development activities
Agreement to time, personnel and financial
commitments from stakeholders at a strategic
level
Agreement to a protocol
Multi agency steering group
Linking with JIP (Joint Investment Plan), HIMP
(Health Improvement Plan) and other business
planning processes
Mechanism for meaningful service user
involvement
Assessing readiness for Partnership
Processes may include:
Identifying the stakeholders who need to be
involved
Identifying the named people within each of the
stakeholder groups
Developing ways of sharing information -
newsletters, meetings, publications, IT
Developing selection and design criteria for signs
and symbols and other communication tools
Identifying business planning processes
Identifying and defining networks (user groups,
statutory agencies, advocacy) and purpose
(communication, information, professional)
Developing guidelines on accessible information
Auditing current availability of IT support and
resources and identifying shortfalls
Identifying skill mix required to support strategy
Agreeing a protocol for sharing resources and
points of access
Developing an evidence base
Processes may include:
Agreeing and evaluating a training strategy with
all agencies, including service users
Providing different models of training to meet
different needs for individuals, environments and
communities
Identification of trainers and their training needs
Analysis of training needs of participants and
their environments
Developing a training plan, including resources
required
Delivering, evaluating and feeding back to
stakeholders
Establishing supervisors
Framework for ongoing support and supervision
Agreeing levels of competence of trainers
Cascading of training
One major task
was to define
what a
communication
strategy
actually is
proessona roe
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2002 +8
ell me what you do and Ill tell you
who you are.
Gaarders statement (1995, p.329)
sums up the importance of work and
how our individual occupations are closely related
to how we define ourselves as people. But if work
plays such an important part in our lives, what
happens when external factors interrupt our life
plans?
As fourth year students at City University we
were required to design and carry out a research
project. Although this was daunting, we realised
the importance of choosing a field that not only
interested us but that answered questions we as
students had asked. We had the opportunity to
work at the City Dysphasic Group where we met a
wide range of individuals with aphasia. It became
apparent that they had a variety of unresolved
issues around their employment status. This left us
with the questions:- What factors influence the
ability of people with aphasia post-stroke to
return to work? And how can we as speech and
language therapists enable them to do so?
We aimed to establish factors that influence the
ability to return to work and identify barriers that
prevent people with aphasia from doing so. We
wanted to compare and contrast the differing
barriers that may allow some individuals to return
to work successfully while preventing others, and
establish recommendations made by people with
aphasia on any aspect of returning to work.
Interviewed in-depth
The project involved nine respondents interviewed
in-depth using a method recommended by Parr et
al (1997). We used the social and community poli-
cy research framework method as described in
Ritchie & Spencer (1994) to analyse the data. All
respondents were of working age and in full-time
employment at the time of their stroke.
They had come from a wide range of working
backgrounds, and included a lawyer, sous-chef,
T
The 1995 Disability Discrimination Act was meant to herald
a new dawn for people with disabilities in the workplace,
including those with aphasia. In reality the interaction of
many factors influences whether or not an individual
returns to work. Kathleen Taylor and Claire Besser discover
that the profession needs to show a bit more imagination
to be truly working with aphasia.
Unemployable
or unemployed?
you
are nterested n
quatatve research
have cents o workng
age
want to enabe (and not
dsabe)
Read ths
Figure 2 Themes
THEME DEFINITION INFLUENCING FACTOR BARRIER
A. Attitudinal
B. Communication
C. Emotional
D. Financial
E. Informational
F. Other
G. Physical
Personal opinions and views from
colleagues, employers, medical
professionals and the individual
respondents.
Management of the individuals
aphasia within the workplace.
These are internal to the individual.
They include comments on confi-
dence, encouragement, motivation
and self-esteem.
Changes in financial status that the
respondents were confronted with as
a result of their aphasia.
Issues relating to gaining information
about aphasia, benefits and other
options open to all parties.
This includes anything that did not fit
comfortably under the headings
above, such as previous experiences,
familial support and job role
modification.
Any difficulties resulting from
hemiplegia and loss of cognitive skills
such as fatigue and shortened
attention span.
You know I wish I hadnt had the stroke,
but the reality is that I did....10 years on, I
think I have to say that, I think Ive gained
more than I have lost out of the whole
deal....Ive gained quite a lot, coz I felt like
Id lost so much.
They tried. Everything they gave me. I
said I wanted a computer.
I thought I want to look forward and at
the present.
I automatically got invalidity benefits.
Counselling...gives you the opportunity
to explore options you might have.
My wife is really good and my kids are
fantastic.
One respondent received a left-handed
keyboard to compensate for their
hemiplegia.
I thought about being a chef but
the doctor said to me, you cant
be a chef.
Usually my speech let me down.
In a way Ive got no confidence
in me.
If I could work one or two days
out of the year, why not? But the
benefits would make a
difference.
I look forward to getting a job,
but what job should I do? I dont
have a clue.
I didnt want to re-train and go to
a lesser position.
Some days Im so tired I cant get
up.
employers
do not give
you a job
just
because
you are
motivated
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2002 o
proessona roe
following her stroke provided prospective employers
with a summary of her aphasia and strategies that can
be implemented to overcome her difficulties (figure 3).
F. Other factors cited were support from others
and job role modification. Many said their family
and friends were supportive; however, this had no
bearing on their return to work. The respondents
experiences support the finding of Garcia et al
(2000) that employers frequently offer support
through the provision of specialist equipment.
One reported that by having their job modified
they were made to feel less able and incapable of
doing their job as well as they had prior to their
stroke. As Parr et al (1997) state, aphasia does not
affect intelligence. The respondents recommend-
ed that, rather than modify the job role, it may be
better to reduce the number of hours worked.
G. Physical factors reported include epilepsy,
fatigue, hemiplegia and memory. The respondents
cited these as direct barriers to returning to work
and also as barriers that interacted with other fac-
tors such as information.
Through using a qualitative approach to finding out
about the implications of returning to work with
acquired aphasia we have gained a broad perspective
of some of the factors and barriers people with apha-
sia encounter when considering return to employ-
ment. As a profession, however, we have a lot to do.
Speech and language therapists have a strong
influence on individual perceptions of recovery.
The opinion of the medical team can have a last-
ing effect on how the individual with aphasia
views their skills and chance of returning to work.
It would be useful to investigate further the
impact of our professional opinion and the therapy
we provide on whether an individual with aphasia
returns to work or not. It may also be beneficial to
raise the profile of the true nature of aphasia with
other professionals such as the medical team to
change their attitudes, with the aim of making the
information the individual with aphasia is given
more of an enabling than disabling factor.
Full awareness
The more aware the individual with aphasia is of
their strengths and weaknesses the more likely
they are to return to work successfully. If we want
to get better at enabling people with aphasia to
return to employment, we need to focus on
developing full awareness of the true nature and
characteristics of their aphasia.
Occupational therapists play an important role
in working with and encouraging individuals with
an acquired disability in returning to work. It
would be useful to investigate their therapeutic
ethos and how they encourage and support suc-
cessful reintegration into the workplace.
In Open Hole, the Stony Wall (1998), the impact
of the 1995 Disability Discrimination Act on peo-
ple with aphasia is discussed. The authors raise
concerns regarding possible loopholes and the
lack of provision there is for adults with aphasia in
the Act. A longitudinal study would enable us to
measure over time the changes in practice and
attitudes to people with aphasia brought about
by the legislation.
It has become apparent through this study that
many factors are significant, and no one single fac-
tor stands alone. More importantly, there are a
number of interacting factors occurring. As speech
and language therapists it is our brief to enable
individuals with communication impairments to
maximise on their choices and opportunities in all
aspects of their life including work, personal and
social capacities. Traditionally speech and language
therapy has been limited by time, resources and
research; this means that skills learnt within thera-
py sessions are not only difficult to generalise but
can also be irrelevant to the working environment.
It is essential that we consider our role with regard
to current legislation, research, clinical competencies
and guidelines so we can help those individuals
wishing to return to employment.
Kathleen Taylor is now a speech and language
therapist at Whipps Cross University NHS Hospital
and Claire Besser is a speech and language thera-
pist for Newham PCT and Sure Start. The City
Dysphasic Group has been superseded by Connect.
For further information about Connect and their
programme of education and training events,
phone 020 7367 0846 or see www.ukconnect.org.
References
Action for Dysphasic Adults Working Party (1998)
Open Hole The Stony Wall. Unpublished report.
Parr, S., Byng, S. & Gilpin, S. (1997) Talking About
Aphasia: Living with loss of language after stroke.
Open University Press; Buckingham.
Gaarder, J. (1995) Sophies World. Phoenix
House; London.
Garcia, L.J., Barrette, J. & Laroche, C. (2000)
Perceptions of the Obstacles to Work Reintegration
for Persons with Aphasia. Aphasiology 14 (3); 269-290.
Ritchie, J. & Spencer, L. (1994) Qualitative Data
Analysis for Applied Policy Research. In Bryman,
A. & Burgess, R. (Eds.) Analysing Qualitative Data.
Routledge; London.
5 steps to better practice: working with aphasia
1. help clients understand their aphasia better
2. work with clients to list possible solutions for prospective employers
3. make therapy relevant to a work environment
4. discuss the possible advantages of retraining
5. share skills and planning with occupational therapists.
Figure 3 Return to work solutions
Emma (not her real name) was twenty-one
years old when she suffered a stroke. Prior
to this, she worked for a company in an
administrative capacity. Her stroke left her
with a residual right-sided hemi-paresis and
an expressive dysphasia. This was
characterised by word finding and
syntactical difficulties and acquired dyslexia,
all of which worsen under increased stress:
I cant handle pressure, it goes terrible.
Following several years of seeking work
unsuccessfully, Emma found another job.
Emma suggests that being able to describe
your residual difficulties and giving practical
solutions will show an employer how these
difficulties can be overcome. Emma
recognised and reflected the need for
employers to be sympathetic and aware of
her needs with solutions such as:
working part-time to overcome the high
level of fatigue most people with aphasia
experience.
using checklists as prompts to remind the
individual what they are meant to ask, do
or say when performing tasks.
having a voice activated computer with
grammar and spellcheckers, to overcome
writing difficulties.
asking your manager to check
letters/reports before they are sent out.
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2002 +
nequaty seres (+)
nequality is considered to be one of the uni-
versal features of all human societies. However, it
is not equally distributed. Some theorists would
argue that inequality is an integral, and even
desirable, aspect of society whereas others would
suggest that it is produced by the socio-economic
organisation of society which unfairly advantages
one group over another.
Sociologists commonly use the term social strat-
ification to describe the stable structures of
inequality between groups that persist across dif-
ferent generations within any given society. The
term social class is used to describe the type of
stratification that exists
within a modern indus-
trialised society, such as
Britain. Although sociol-
ogists disagree on how,
exactly, social class
should be measured and
defined, in general
terms social class refers
both to material circum-
stances - a persons
income and wealth - as
well as social status - a
persons social wealth
and prestige.
Since 1991, social class
has been measured using the National Statistics
Socio-economic Classification (NS-SEC). In the
most commonly used version, there are eight
classes, the first of which is sub-divided (see table
1). The NS-SEC considers an individuals occupa-
tion, as well as their employment status.
In 1946 the NHS was established to eradicate
inequalities in health in Britain. However, the exis-
tence of class inequalities soon became clear.
l
you
want to reach out beyond the cnc
beeve the NHS shoud eradcate
heath nequates
see a nk between communcaton
and estye
We all hope for a long,
healthy and fulfilling
life with the
opportunity to develop
our particular talents.
Yet our chances are
unequal, and vary
depending on our
social class. In the first
of four sociological
perspectives on
inequality, Sarah Earle
argues that, while we
do need to develop an
individualised, client-
centred approach, we
must also be aware of
how wider socio-
economic and cultural
factors influence our
practice.
Some of the most damning evidence was pub-
lished in 1980 in The Black Report (Townsend et
al, 1982), which showed that individuals in social
classes V and VI (equivalent to classes 5, 6 and 7 in
the NS-SEC) were more likely to have accidents,
become ill, and die prematurely compared with
those in classes I and II. The Acheson Report
(Acheson, 1998) confirmed these findings and
provided further evidence of a widening of class
inequalities in health.
The White Paper, Saving Lives: Our Healthier
Nation (DoH, 1999a), established targets for the
four priority areas of coronary heart disease and
stroke, cancer,
injury prevention
and suicide,
recognising the
c o n s i d e r a b l e
extent of inequal-
ity throughout
Britain. The risk
of heart disease
is, for example,
more than dou-
ble for individuals
in the lowest
employment sec-
tors (even after
controlling for
risk factors such as obesity and smoking) and rates
of depression are twice as high for those who are
unemployed, compared to those who are in paid
employment (DoH, 1999a).
Since the educational explosion of the 1950s
and 60s, education has been regarded as one of
the ways in which societies can become fairer and
more meritocratic. However, a meritocracy
describes a society in which social rewards are
a meritocracy
describes a society in
which social rewards
are allocated
according to talent
but evidence suggests
that social rewards
vary considerably
according to social
class.
Class of 2002:
an
unequal
future
Table 1 The National Statistics Socio-economic
Classification
1. Higher managerial & professional occupations
1.1 Large employers & higher managerial
occupations
1.2 Higher professional occupations
2. Lower managerial & professional occupations
3. Intermediate occupations
4. Small employers & own account workers
5. Lower supervisory & technical occupations
6. Semi routine occupations
7. Routine occupations
8. Never worked & long-term unemployed
Read ths
nequaty seres (+)
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2002
allocated according to talent but evidence suggests that social rewards vary consid-
erably according to social class.
A good predictor
Recently published government statistics (DfES, 2001) suggest that social class is a
good predictor of educational and occupational success. For example, statistics show
that academic attainment - at all levels - is strongly related to social class and that
young people whose parents are classified at Levels 1 and 2 are most likely to succeed
(see table 2). Statistics also show that the number of 16 year olds not in education,
training or employment varies considerably according to social class. For example, in
2000 only 2 per cent of 16 year olds with parents in NS-SEC 1 were not in education,
training or employment, compared with 11 per cent of those in NS-SEC 7.
There have been many competing explanations put forward to explain the persis-
tence of class inequalities in health and education and, although explanations based
on natural selection or innate intelligence have been popular in the past, materialist
and cultural explanations are currently two of the most influential.
Materialist and structural explanations focus on the material causes of inequality, such as
living and working conditions, which are often seen as arising from the social structure -
the way in which society is organised. The poorest in society are seen to lack the material
resources required to sustain health and achieve educational and occupational success.
For example, within the context of health it is widely
accepted that individuals with lower incomes tend to
pay more for their food because they cannot physically
access larger (usually out of town) retail outlets which
sell food more cheaply than local shops (DoH, 1999b).
The inverse care law also disadvantages those in lower
socio-economic groups as statistics suggest that those
living in the most deprived areas have the worst access
to good quality health care services (see table 3).
Within the context of education, children from poor-
er socio-economic backgrounds are seen to lack the
material resources they need to succeed. They are, for
example, more likely to live in overcrowded condi-
tions, more likely to have a poor diet and will have
higher rates of illness, accident and disease; all of
which impact upon childrens educational careers.
Children from poorer backgrounds are also more like-
ly to have paid employment and more domestic
responsibilities than children from more affluent backgrounds and are, therefore,
less likely to stay on at school (DoH, 1999b).
Cultural theories explain class inequalities in health and education by referring to the
social processes that create cultural differences in attitudes and behaviour. With respect
to health, the emphasis is often on lifestyle and risky health behaviours. Indeed, some
sociologists believe that lifestyle is now the most important predictor of inequalities in
health (see Crompton, 1993). Individuals from lower social classes are seen to engage
in health behaviours that are not conducive to health. For example, they are more like-
ly to smoke, and consume a diet that is high in fats and refined sugars (DoH, 1999a).
With respect to education, children from poorer backgrounds are seen to lack the
appropriate environment that is needed to foster educational success. For example,
children from less affluent backgrounds are the least likely to have access to con-
structive forms of play, and will have poorer access to books, newspapers and the
internet (see table 4).
Important role
Defining and measuring social class is a complex process and some of the key issues and
debates have been highlighted here. However, it is clear that there is a strong rela-
tionship between social class and inequality; this has been recognised by Government,
and strategies to combat inequalities in health and education have been implemented.
Speech and language therapists have an important role to play in tackling and reducing
inequalities in health and education and they are increasingly being expected to either
coordinate or participate in multi-professional initiatives such as Sure Start (see
www.surestart.gov.uk).
Two of the most common problems for therapists (and other health professionals)
are those of attendance and compliance, which often strongly correlate to class divi-
Speech and
language
therapists
have an
important role
to play in
tackling and
reducing
inequalities in
health and
education
A
Enthusasm, knowedge -
and a set o headphones
vth oo satsed cents, Karen Oonnor needs no urther
convncng o the benets o occupatona therapst Shea
lrcks Therapeutc lstenng n hepng chdren acheve
ther potenta.
training for five weeks caused marked and sustained improvements in lis-
tening and speech tasks. These improvements were statistically superior to
those being achieved from non-A.R.R.O.W. work being undertaken at each
site. The improvements covered identifying sounds of the environment,
sentence understanding, working short term memory for digits and words,
consonant discrimination and vocalisation skills.
After extensive use in Somerset schools, the A.R.R.O.W. programme was
tried with adults. A teacher of lip-reading, herself severely hearing impaired,
agreed to undertake A.R.R.O.W. training at home. She practised using the
special recorder linked to a neck loop attachment. Material was based on
various pre-recorded poems. After two weeks practice for a maximum of
15 minutes each day, she reported a considerable improvement in her abili-
ty to distinguish sounds of the environment and to hold conversation in less
than ideal acoustic conditions.
We have since developed an A.R.R.O.W. Accelerated Concentration
Programme. I had the idea of asking students to listen to their voice against
varying levels of background noise using the two-track facility available on
the A.R.R.O.W. recorder. Using carefully graded stages of listening, including
easily attainable and extremely difficult tasks, I found it was possible to min-
imise the time taken to train listening skills to a period of 40 minutes or in
some cases even less. I initially used the system with hearing impaired adults
and found marked improvements on pre-post test measures. Adults also
reported improvements in environmental listening and ability to hold con-
versations. Work with children followed and we showed it is possible to
improve listening skills with hearing impaired children inside a total of one
hours training. We have since found that the training is appropriate for
both normally hearing and hearing-impaired children / adults whilst the CD-
ROM format offers exciting new possibilities for self-help attention training.
In late August 2002 a small group of normally hearing students (n=6) were
given a background noise listening test. Five of the students were re-tested
without receiving any A.R.R.O.W. listening training. Mean scores on the
A French doctor, Guy Berard, felt the Tomatis method was too lengthy
and developed his own method of filtering sound. This Auditory
Integration Training (modulating sound frequencies at random intervals
for random periods of time) was developed to treat people with audi-
tory processing problems.
Ingo Steinbach, a German sound engineer, developed the Samonas
method. He found that by heightening his attention to the structural
elements contained in all natural sounds, and capturing them in his
recordings, immediate listening was achieved, even in unfiltered music.
He developed special technology to capture music as sound in space and
combined his spectral activation process with Tomatis method of filter-
ing (Frick et al, 1997).
The benefits of a therapeutic listening programme are extensive and
varied. When I introduce the areas in which families should expect to
see change, they are understandably surprised. Having used therapeutic
listening programmes with approximately three hundred children, I
have witnessed and recorded change in all the areas in figure 1.
The case studies in figure 2 give some indication as to how therapeu-
tic listening can be used with quite different client groups. I now use
this technique with most of my clients, in combination with other
approaches, and I endeavour to work closely with occupational thera-
pists and physiotherapists to
enhance the benefits.
Listening with the
Whole Body - courses
Karen OConnor (Ireland) e-mail
speechtherapyservices1@eircom.net.
Sandra deWet (UK), tel. 01892
513659 (also supplies the
Listening with the whole body
book in the UK for 37 inc p+p).
Further information
www.vitallinks.net - includes
case studies
www.samonas.com - Samonas
CDs, developed by Ingo
Steinbach.
References
Ayres, A.J. (1979) Sensory
Integration and the Child. Los
Angeles: Western Psychological
Services.
Ayres, A.J., & Mailloux, Z. (1981)
Influences of sensory integration
procedures on language develop-
ment. American Journal of
Occupational Therapy 35 (6); 383-
390.
Frick, S. & Hacker, C. (2001)
Listening with the Whole Body.
Vital Links, Madison, WI.
Madaule, P. (1994) When listening
comes alive. Norval, ONT., Canada:
Moulin Publishing.
Semel, E., Wiig, E.H. & Secord, W.
(2000) Clinical Evaluation of
Language Fundamentals - Third
Edition (UK). The Psychological
Corporation.
Tomatis, A.A. (1996) The Ear and
Language. Norval, ONT., Canada; Moulin Publishing.
Stark, R.E. & Tallal, P. (1981) Selection of children with specific language
deficits. Journal of Speech and Hearing Disorders 46 (2); 114 -122.
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2002 8
how l