Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
com
The big
breakthrough
on a small
scale
T
he new DynaMyte is a lightweight,
capabilities which introduces a new dimension to
augmentative communication by offering greater
freedom to the ambulant user.
portable device with powerful communication
DynaMyte is just half the size of DynaVox 2 and yet it retains all its
advanced communication capabilities, and uses the same software. A built-in
remote control unit allows the user to
access computers and other household appliances, and it
The DynaVox 2
features a system of alarms capable of performing a variety
augmentative
communication aid of preset tasks. A clear, easy to operate touch display
has introduced a
provides access to the full range of DynaMyte's
new era of freedom to
communication power. Its long life battery and durable,
people of all ages who
have speech disabilities. rubberised casing guarantees easy to carry communication
for people of all ages with speech disabilities.
DynaMyte is a natural product extension from the
advanced DynaVox 2 communication device which
successfully enables many users with mobility impairment to
develop a greater sense of self expression and
independence.
For full information and demonstration, contact
DYNAMIC
DYNAMIC ABILITIES LTD
A ~
LIMITED
THE COACH HOUSE, 134 PUREWELL
CHRISTCHURCH, DORSET BH23 1EU
TELEPHONE: 01202481818
FAX: 01202 476688
~
ISSN (online) 2045-6174 www.speechmag.com
guage
Therap
in Pra ice
Autumn 1997
(publication date 25th August)
ISSN 1368-2105
Published by:
Avril Nicoll
Lynwood Cottage
High Street
Drumlithie
Stonehaven
AB393YZ
Tellfax 01569 740348
e-mail avrilnicoll@rsc.co.uk
Production:
Fiona Reid
Fiona Reid Design
Straitbraes Farm
St. Cyrus
Montrose
Printing:
Manor Group Ltd
Unit 7, Edison Road
Highfield Industrial Estate
Hampden Park
Eastbourne
East Sussex BN23 6PT.
Editor:
Avril Nicoll RegMRCSLT
Subscriptions and advertising:
Tel/fax 01569 740348
Avril Nicoll 1997
Contents of Speech & Language
Therapy in Practice rerect the views
of the individual authors and not
necessarily the views of the publish
er. Publication of advertisements is
not an endorsement of the adver
tiser or product or service offered.
Cover pictures:
John and Monica Clarke
News/
Comment 2
Video - a
reflective tool 4
Keena Cummins and Sarall
Hulme focus on the strengths of
video playback as a reflective
tool both in therapy and
professional development.
8
ALD and
Training
for
Kenya
lessons
for
all 19
Julie Marshall outlines the
lessons to be learned from an
in-service training project in
Kenya, where formal services are
extremely limited.
22
Reviews
dysphagia: issues
Assessment,
treatment,
and practice
articulation,
interpersonal skills,
Janet Hickman explores the
hearing
concept of dysphagia in ALD,
impairment,
summarises a survey of
language devel
working practices and reports on a
multidisciplinary protocol.
Resource
update 1 1
COVER
STORY
Special
feature
meeting
the
needs of carers
Two articles, the first the Mary Law
ledure 1997, consider how we as
speech and language therapists
should be assessing and meeting
the needs of carers.
SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 1997 1
opment, cerebral
palsy, dysphagia
and anatomy.
H9W I manage
vOice 25
Three speech and language
therapists set out their manage
ment of a client, Sheila.
MyTop
Resources 29
Carole Charters who
works with adults with
a learning disability
describes ten
resources she could
not do without.
ISSN (online) 2045-6174 www.speechmag.com
r
NEWS & COMMENT
Meeting the needs
John and Monica Clarke's lives were shattered
when he became aphasic following a stroke.
Traditional speech and language therapy focuses
on the client with aphasia but increasingly efforts
are being made to include carers In the rehabilitation
process; we are still in the early stages of learning
how to do this effectively. In a special feature,
Carole Pound - with the assistance of Monica
Clarke - and Ashleigh Denman challenge us to
push out the boundaries of our work with carers to
meet their specific needs as well as what we
perceive their needs to be in relation to our clients.
In this feature, and in Julie Marshall's description of
in-service training in Kenya, we are urged to listen
to people and find out what they really want
without presupposing that we know. In the end,
this must lead to more effective provision.
The importance of people being dynamic In their
own management is emphasised throughout the
articles, particularly How I manage voice. Jayne
Comins encourages us to consider whether a
client's attitude falls into the category of ( have a
problem: what can ( do about it? Monica Clarke is
following this course, actively working to establish
a pen club for carers to reduce their isolation as
part of the long and uncomfortable rebuilding
process.
Recognition that there is a problem is the first step
to solving it and one of the challenges of working
with anyone - client, carer, student, peer - is getting
them to find out for themselves when things are
not going to plan, why, and what the solution
might be. Keena Cummins and Sarah Hulme find
video playback has implications beyond therapy
sessions, for professional and service development
as it allows them to question what they are doing
in minute detail.
Janet Hickman's investigation into dysphagia
service developments for adults with a learning
disability also throws up many questions. She
compares the needs of these adults with those in
the acute sector and calls for a re-think of RCSLT
dysphagia policy to allow more appropriate ALD
provision.
Carole Charters also works with clients with a
learning disability and, in the first My Top Resources,
explains the ten items she would not be without in
her clinic and why. This new feature aims to remind
readers of half-forgotten items
at the back of their cupboards,
to suggest innovative ways of
using eqUipment and to
recommend the most useful
new materials available.
If you would like to share your
own experiences and thoughts
on therapy through the pages
of this magazine, please let
me know.
Avril Nicoll
Editor
Lynwood Cottage, High Street, Drumlithie
Stonehaven AB39 3YZ
tel/ ansa/ fax 01569740348
e-mail avrilnicoll@rsc.co.uk
SPEECH & LANGUAGE THERAPY IN PRACilCE AUTUMN 1997
Centre ofexcellence
Queen Margaret College has been awarded 320000 to set up a
centre of excellence for interdisciplinary research into speech
disorders and their treatment.
The Scottish Centre for Research into Speech Disability will pro
vide state of the art facilities customised for specific client
groups including children with phonological disorders, adults
with aphasia and clients using Me.
The Centre, directed by Professor Bill Hardcastle with Dr
Elizabeth Dean as clinical co-ordinator, is expected to be fully
operational by May 1998. There will be close liaison with the
speech and language therapy services of Edinburgh Sick
Children's NHS Trust in particular, although involvement from
services across Scotland will be encouraged.
Funding has been provided by the Scottish Higher Education
Funding Council's 1997 research development grant scheme.
Detnils: Liz Dean, 0131 3173682.
Parkinson's
Talking Point
Charter
The importance of talk for
young people has been
The Parkinson's Disease
highlighted in The
Society believes sufferers are
Samaritans' Week.
not always made aware of the
The charity is concerned
benefits of services such as
that the rate of attempted
speech and language therapy.
suicide by young men has
In a Charter aiming to
risen by 63 per cent since
improve the care and services
1990 and believes young
available to the 120 000 people
men in panirular face
in the UK with Parkinson's
barriers to resolving
they set out claims including
situations because of
the right to access such sup
port services in addition to
problems talking about
diffirult feelings_
drug therapy.
A film resource for 10 - 11
with Parkinson's have the
They state further that people
year olds, Talking Point,
right to: addresses the problem at
an early stage by
a special interest in
be referred to a doctor with
providing information
Parkinson's about who might be
receive an acrurate diagnosis trusted to listen to
receive continuous care anxieties from causes
take part in managing the
such as bullying, name
illness.
calling and the transition
Details: PDS, 0171 391 6705.
to secondary school. No
direct reference is made to
suicide. now the second
NASmove
most common cause of
The National Auti stic Society
death among young
head office has moved to
393 City Road, Islington,
people.
London EClV 1NE
Details: The Samaritans,
tel. 0171 833 2299
01753532713.
fax 0171 833 9666.
SeIVices for stammerers
The British Stammering Association is developing its advisory and
counselling services.
From the autumn, a telephone counselling service funded by a
three year grant from the National Lotteries Chariti es Board and
operated by Clare Lindsay will be available to stammerers and par
ents of children who stammer.
A Schools Liaison Officer is also being recruited for two years as a
result of charity funding. Responsibilities will include developing
and co-ordinating a national programme of teacher training about
stammering which affects 100000 pupils in the UK.
Details: BSA, 0181 983 1003.
2
ISSN (online) 2045-6174 www.speechmag.com
I CAN appointInent
The national educational charity for children with
speech and language difficult.ies has appointed
Gill Edelman as Chief Executive.
Her main responsibility is to lead I CAN forward
in its provision of educational services and sup
port for children with speech and language diffi
culties. Qualifying in 1979 as a speech and lan
guage therapist, Gill Edelman has extensive expe
rience in management within the profession and
more generally in t.he NHS.
She states, "The future of provision for children
with speech and language difficulties will depend
on finding innovative ways to work collabora
tively wit.h Health and Education Authorities and
Social Services and ensuring specialist services are
tailored to children's specific needs. I CAN will
have to carefully balance residential services with
provision delivered in the community, in main
stream schools and in nurseries. We will need to
look carefully at parents' needs and expectations,
as they are often frustrated at the gap between the
services their children require and those that are
available to them."
Details: I C ,0171 374 4422.
Profession not
marginalised
In spite of fears, a Dew report
finds the NHS internal
market has not adversely
affected the provision of
speech and language therapy
services.
The King' s Fund report
reveals managers within the
profession have not really had
their control of budgets and
staff reduced, but are taking
on greater responsibility for
management, administration
and the future shape of their
own services without
necessarily having the
required training, formal
managerial qualifications
and extra resources.
Since 1991 the number of
qualified therapists and the
range of services provided
has increased but managers
perceive demand has also
increased. The report's co
author, Nicholas Mays, has
called for better training and
support from the NHS and a
positive response from the
profession to managerial
developments.
Mays, N. & Pope, C. (1997)
Speech and Language Therapy
Services and Marwgement in
the Intemal Market from
King's Fund bookshop, 0171
3072591, 12.50.
Support for children
A good practice model of therapeut.ic and emotional support for
children in need is being developed in London primary schools.
The charity, The Place to Be, uses art, play, drama and movement
to help children communicate, express their emotions and develop
a sense of self-awareness. It believes it is having an impact on
children's behaviour, social interaction, moods and ability to learn.
Details: TIle BT Forum (sponsor) , 01 71 831 6262.
Helpline for deaf people
The NSPCC has launched a national child protection helpline for
deaf people.
The 24 hour service provides counselling, information and advice
to anyone concerned that a child is at risk of abuse. A textphone,
where deaf people communicate by exchanging messages through
a keyboard and small screen, can be used via the usual telephone
system.
The Society beli eves the 65 000 deaf children in Great Britain
have special child protection needs as they may be more vulnerabl e
to abuse, less able or less willing to tell when they are abused and
have difficulty participating in investigations which rely heavily
on speech. Funding for the service is from the National Lotteries
Charities Board and NSPCC counsellors have received training
from the Royal National Institute for the Deaf.
Helpline number: 0800 800 500.
Internet assessment
As an increasing number of schools go 'online', an evaluation
project is underway to help them make purchasing decisions.
The National Council for Educational Technology plans to publish
performance information on UK Internet Access Providers, such
as first attempt dial-up success, transfer rates, e-mail speeds and
http services. Jt hopes the evaluation will also help the industry
provide more suitable services for education.
Details: NCET, 01203 416994.
Stroke research
EJysarthria is one of the first
areas to be considered by a
new Therapy Research Unit.
Multidisciplinary teams at the
Salford Unit will identify the
most effective ways of helping
people regain independence
following a stroke by evaluat
ing therapy and investigating
new treatments. Other pro
jedS include shoulder pain,
unilateral neglect and retrain
ing of self-care skills.
The Unit is a joint venture
between the Stroke
Association, the University of
Manchester department of
Geriatric Medicine, Manchester
School of Physiotherapy and
the Rehabilitation Services
Directorate of Salford Royal
Hospitals NHS Trust.
Details: Sally Heath, Stroke Association, 0171 4 905089.
Educational need
Schools must regal11 difficulty
with communication as all
educational need, according to
the Royal College of Speech &
Language Therapists. .
In a polie)' statement, RCSLT
states that, for the IJUljority of
children willi special educational
needs imrolvlIIg speech and
language, responsibility for
meeting these nee(is lies with the
education sen/ice rather than the
health seroice IIkllle.
TI,e policy aims to support
therapists conllibuting to
SUllutory of children's
educational1leeds. A range of'
education and Ilealtil professionals
lrave been involved in its
development.
Details: Liz Jepson, 0115 981
4012.
Call for brain
injrny legislation
Why leave people withom
vocational rehabIl Itation and
employment SlIpport st'11
I
ices,
when thf')l lllight be earning their
keep for the next thirty or fony
years?"
Deborah Wellrillg Slimmed up a
Headwa)' semillrl r for disability
t'1nploymenL pecullis/s, who
called for to help people
after a brain injury. The
participants Ulant /0 see a Brain
Injury Act, a dt:dicated national
and local 5e11'icl' 10 provide
specialist tmmmg in put to health,
social wori;, ed'lClltion, emplo),ment
and housing age/lcies and ring
fenced fundin,l(. The illlportallce
of support and /uil'ice in the
long-tenn "'lIS elllphasised.
Details: Deoorall Wearing, 0115
9508700.
Disabili
!_c. ty
1l1lormatIon
An exhibition by cope is to
feature infomlaliOlI, actillities,
opportunities mId products for
disabled people, tlleiT families and
professionals.
This first annllal exhibition was
prompted by the harily's research
revealing 45 per cent of disabled
people have difficult}' getting hold
of the informlilioll which enables
them to access support, aid and
equipment for independent living.
The All Round Ability exhibitioll
at Norcalympia, Blackpool will
11m alongSide Ihe organisation 's
annllal confeTe1lce 011 7-8th
November; 19')7.
Details: Scope, m71 6365020.
SPEECH & LANGUAGE THERAPY IN PRAGflCE AUTUMN 1997 3
ISSN (online) 2045-6174 www.speechmag.com
INTERACTION
C
hildren who have no language dIffi
culties make interaction accessible:
however children with difficulties
immediately have the potential to throw
even the most experienced of clinicians
into a mode of poor timing. All profes
sionals need continually to assess and
reassess their skills in relation to each
child's abilities as, as with 'parents: 'stu
dents' may perceive their skills as very dif
ferent from the reality
'Student' applies in this article to all those
hoping to develop their skills further. be
they cI ient, carer. student therapi st, thera
pi st. supervisor or manager. The use of
video is not intended to be promoted in
isolation, but rather as a sensitive addition
al resource which augments the skills of
the clients and professionals involved.
Partnership with parents
'Parent child interaction' as a therapy tool
has been used within Camden and
Islington for many years. Its main principle
is partnership with parents, enhancing
their knowledge and understanding of
their child with the therapist's theoretical
and clinical experience. Its most unique
feature is the use of video to analyse in
minute detail the transitory nature of
};ommunication. It is this fine detail which
distinguishes it from the Hanen model,
although the basic philosophy of both
programmes is complementary
Both authors feel, having specialised in
working with parent child interaction in its
true form for a number of years, that the
benefits to working practice and the sub
sequent development of the service have
been dramatic.This is particularly in relation
to child language acquisition. the role of the
parent and primary carers such as nursery
workers. and perhaps even more impor
ensures we all practise
and Sarah Hulme focus
tantly - the role of the therapist and the
real development of clinical skills.
Health Centre Service
'I"'"\.' Camden and Islington
r .J....... NHS Trust's Health
Centre Service con-
CAMDEN & ISLINGTON sists of I 3 staff mem
bers - eight employed
in community clinics. two working in pre
school language units, ourselves (commu
nity clinic based) and a speech and lan
guage therapy assistant. The service
addresses the needs of children under five
who present with a variety of language dif
ficulties. classically language delay through
to language disorder. Through the parent
child model. it has been possible to offer
across the Trust an equitable service, which
prioritlses children with language disorder
and maintains waiting lists at an almost
manageable level despite the increased
referral rate of 146 per cent over the last
five years. (Children whose needs include
learning difficulties or pervasi ve develop
mental language disorders are managed
by the child development team.)
Our team consists largely of newly qualified
staff, that is, up to three years post -qualifi
cation. Our team structure is however
unique in having four members of staff
over grade 28, all of whom have spe
cialised in working within health centres in
addition to their varied experience in
other clinical settings.
One of the major tasks in managing the
team has been affording support and super
vision to posts which make potentially
excessi ve demands on team members
with little experience of working in chal
lenging situations. The parent child model
has offered appealing strategies for
addressing the needs of these clinicians
whilst continuing to provide a high level
quality service to children and their carers.
Video philosophy
As this article does not seek to describe
the parent child interaction model per se.
a brief summary of the coul-se of video
sessions is in Appendix I. (The authors
consider Kelman & Schneider. 1994. essen
tial reading for full details.)
Interacti on is a transient experience which
can never be repeated. In therapy we aim
to identify the type and timing of commu
nicative events within an interaction. to
recognise where a child is in their com
munication development process. and
how their timing moulds with the adult's.
In using vi deo a visual record of most
aspects of interaction can be achieved
from which detailed analysis can be made.
Of primary importance is that observa
tion can be made by those involved in the
interaction rather than merely by those
who have looked on. Communication
events can be captured without their
immediacy being lost, and the communica
ti ve partners are in a position to provide a
perspective inaccessible to the observer.
The student is in an active position of
identifying their own behaviour and its
effect on the child. The student can then
modify their behaviour accordingly, either
with the support of another or in isolation.
Observation not
perception
With video playback. therapists are able
not only to assess themselves along the
same parameters as parents, but to
extend self-observation and appraisal into
all areas of work. developing a personal
critique based on observation rather than
SPEECH & lANGUAGE THERAPY IN PRAcnCE AUTUMN 1997 4
ISSN (online) 2045-6174 www.speechmag.com
INTERACTION
The Video Interaction aspect of the parent child course provides a
pre-assessment session, six interaction sessions once weekly. and
a six week consolidation period followed by a review appointment
Video feedback is a sensitive tool, primarily used for self-assessment
and discussion. It is not for providing Judgements -partJcularly by
therapists who have not already analysed themselves In a similar
fashion. The main purpose should be for parents to leave the ses
sion feeling better about themselves. Feedback should therefore be
supportive and realistic, highlighting the strengths of the parent
Session I
A brief rationale is given to the parents advising them thor.
because they are the primary caregivers. they are best placed to
help their child. They are reassured that they and the therapIst will
be working together to develop the child's skills. It IS important to
stress the parent has not done anything wrong - as Fey points
out, 'there is no evidence that children's language impairments
are caused by parents' behaviour' - but that the child's behaviour
does affect the adult's interaction style. The video sessions are for
the therapist and parent to work out where the communication
is breaking down and to use certain strategies to facilitate a
quicker rate of development
The parent is instructed to spend time with the child, talking and
playing in the way they would usually do at home. Care IS taken
that the parent understands not to 'make' the child talk.
The therapy room is arranged with a variety of toys covering the
developmental play stages, from exploratory through to symbolic.
The therapist leaves the room and the session is videotaped for
five to ten minutes.
When the therapist returns to the room, the parent is invited to
comment upon whether the session was typical of how they usu
ally play together at home and, if it was different, how so. Any
issues arising at this stage should be discussed immediately A
commonly arising point may be that the parent felt unnatural
because of the camera. In such a circumstance the parent may
be reassured that. because the child is unaware initially that they
are being videotaped and later IS no self-conscious in the pres
ence of the Video camera, parental behaviour generally remains
natural because the parent responds to the child's interaction,
which is as it would be at home.
On finishing the video recording and returning to the therapy room,
the therapist should first make a positive statement about the
interaction such as 'I like the way you play on the with him'.
The therapist and parent watch the video together Parents are
asked to observe their own behaviour in general, having previously
scanned the self-rating (appendix 2) scale, so they have an idea
of the sort of things the therapist is looking for. A detailed
Interaction Profile (Kelman & Schneider, Appendix 4) is used by
the therapist to analyse the parent's verbal and non-verbal inter
action with the child, non-verbal behaviours being of equal signif
icance.The analysis is not shown to the parent but is kept for ref
erence and comparison at the end of therapy.
Having watched the video, the parent is invited to identify what
they are doing that is helping their child, and the therapist then
highlights in general terms many of the parent's strengths. The
parent and therapist diSCUSS the parameters of the Self-RatJng
Scale in turn. This has been adapted from the Interaction Profile
and is merely used as a conversational tool to
a) focus the parent
b) provide a storting point and
c) obtain the parents understanding of such terms as '{allowing
his lead'.
In utilising and diSCUSSing these terms, the therapist is able to
understand more fully the parent's perspective of the
process.
For each parameter, the parent is guided to rate their use of that
Interaction style in terms of a 0 - 3 rating scale where 0 signifies
they never do something and 3 indicates they always do it. The
ratings are purely subjective, and it is important to remember the
aim is to build parent confidence. The video can be rewound to
highlight specific oints, particularly whe:e the parent and thera
pist do not appear to agree. This is likely to be due to lack of
explanation / unde standing and the video can provide an exam
ple of the therapist's Intended meaning
Once the rating scale has been completed the parent is request
ed CO choose the parameter they would like to work on first If the
parent has difficulty identifying the most important strategy. the
therapist may suggest chOOSIng the one with the lowest score.
It doesn't matter If the therapist doesn't agree completely with
the parent's self-rating, since experience has shown that altering
one of the parameters will have a knock-on effect on the other
parameters, so you get there in the end. What seems to be most
important is that parents choose for themselves what to change,
so they are in control.
The parent is then asked to do another video using the strategy
they have just identified. This is taped once more and fed back
to the parent. Prior to playback the therapist asks the parent if
they feel they achieved their aim, and then the tope IS played
with the therapist focusing on this, for example asking, "Are you
following his lead there?", "and there?", using the pause button
between each interaction.
The aim achieved, the parent IS invited to highlight the effects on
the child. The therapist then summarises, for example, "Yes,
because you're following hiS lead he's staying with one toy for
longer, doing more things with it, asking you for help ei ther with
his eyes or words (which has resulted in more eye contact), and
he's starting to tell you what he wants to talk about."
The parent is requested to carry out a play session at home
doing exactly what they have done within the session. The aim is
also written down.
Sessions 2 - 6
At the stort of each session the parent is asked to recap on their
aim, and to feedback on how the five minute sessions have been
going A short five to ten minute video is taken and the parent
and therapist watch to see If the aim has been maintained. If it
has, the changes In the child are highlighted and a further aim is
chosen, without the use of the self-rating scale.
The parent and child are then videoed once more and if the aim
has been achieved they are requested to spend five minutes a
day using the new strategy as well as the old. Their aims are writ
ten down.
On the last session, the parent IS asked to carry out five minutes
a day during the six week consolidation period. It is stressed
progress will only continue if this is achieved.
Review session
The child is reassessed, and the parent and child videoed for the
last time. Parents re-evaluate themselves using the self-rating
scale with the previous scores concealed. They are then revealed
so the parent can observe their own progress. The first video is
shown, in contrast to the review video, to highlight the child's
progress.
SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 1997 5
ISSN (online) 2045-6174 www.speechmag.com
Please think about the following statements and rate yourself from 0 to 3 for each one.
Rating 0 - never
I - sometimes
2 - often / frequently
3 - always appropriate
DATE:
INITIAL FINAL
Letting him/her choose the t oy
Sitting where it's easy to see me
Following what s/he wants to do
Giving him/her extra t ime to talk ,
Listening t o what s/he says
Talking about what s/he is doing
-
Waiting for him/her t o start talking
Not asking questions
Praising him/her
Talking sl owly
Appendix 2 . Self rating scale
OBSERVATION SHEET
GROUPS
SKILLS UTILISED
Name:
Session I / Date Last Session / Date
Timing
Use of silence
Visual Cues - Sign system / Hands
- ' IE .
FaCia xpresslon
Praise / Reinforcement
Directly relevant language
Volume
Rate
Choices
- -
Turntaking
Anticipati on
.
No Distractions
. - - -
Modelling
Intrigue
Positi oning
- - - - ------
Organisati on
--------c-
Other
perception of their own behaviour, in as
fi ne detail as is required. The Importance
of'RefJection time' is described by Marson
et al ( 1990): we believe video maximises
its use. Therapists are also placing them
selves in a similar situation to the cl ient and
acknowledging their own ski ll s are simi larl y
league or in a group context with their peer
facilitator (Appendix 3). It is important for
the manager to allow self-assessment time
in their timetables.
A valuable tool
Supervision is a controversial concept
which means different things to different
people. W ithin our service it has proven to
be a valuable t ool for generating new ideas
and projects whil st providing support, dis
cussion and advice around complex issues.
We have adapted many of the principles
outli ned in Stengelhofen's book 'Teachi ng
students in Clinical Settings' t o provide
ongoing support for both newly qualified
staff and those wishi ng to continue sharing
their learning experiences and to benefrt
from the experience of t heir coll eagues.
Her principles of supervision have also
been complemented by the Camden &
Islington vi deo interaction technique.
Supervision without the use of vi deo play
back is dependent on the therapist's sel f
perception and awareness of a situation
which occurred in the past, in combination
with subjective observati ons by the super
visor: In recounting situations, the immedi
acy of the moment is lost, as is the behav
iour in re!ation to the emotion / feeling. A
purely objective perspective in fine detail
is difficult
When supported by video, both can be
active part ici pants in the observati on
process, providing a reflecti ve learning
experience benefiting student and super
visor. Marson et al ( 1990) speci fy that
adult learning is achieved through provi d
ing the opportunity to talk through the
experience, using positive feelings and
removing obstructive ones. In t his way, the
adult can be motivated to learn by Inter
nal rewards, such as increased sel f-esteem
and a sense of accompli shment
(Stengelhofen, 199 3). Video offers the
opportunity to complement discussion,
observe issues already discussed and t o
tryout alternative strategies and record
their effects. Students are in a position t o
think through their feelings and define an
area requiring further work. then given the
opportunity to work on that area and
have video feedback on their develop
ment This also highlight s their st rengths,
which often they find so easy to ignore.
Where therapists choose to use video
playback for their supervision sessions, it is
important they take responsibility for the
choice of video, and for obt aini ng support
and gaining confidence in this style of
anal ysis. It is the supervisor's role to pro
vi de a systematic framework for feedback.
As with parent child interaction, the aim
of the session is to 'deepen understanding
of what has taken place through enabl ing
enhancement and modification of skill s
dependent on the unique situation.
We therefore suggest that, in self-analysis
of an interaction with a child, therapists
uti lise an obser vation sheet similar to the
parent's self rating scale (Appendix 2).
Initially they may wish to do so in isolation
t hen, when more confident, with a col-
SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 1997 6
ISSN (online) 2045-6174 www.speechmag.com
being used' (Stengelhofen 1993). The
NON VERBAL VERBAL
supervisor should also identify with the
Directiveness
therapist their exact stage of'learning', and
Following child's lead
adapt accordingly, adjusting their timing in
Tum taking
teaching to gel with the student's needs.
Listening Balance of conversation
Interrupting
Evolution
Giving time to respond
Our service continues to have a long way
Pausing
to go. Supervisory therapists need to
Rate
address their own perceptions and beliefs
Gaining child's attention Intelligibility
about the supervisory process and
require a regular discussion venue to share
Observation Volume
what they have learnt from their 'students'.
Eye contact with child Fluency
Munroe describes supervision as being
Shared focus of attention Prosody
'the opportunity to share experiences, to
acquire fresh insights and new ideas which
Facial expression Complexity: semantic
naturally lead to an assessment of the indi
Animation syntactic
vidual supervisor's own skills and perfor
Intrigue Semantic contingency
mance in relation to patient management'.
Touch
It is this analytical, ongoing assessment of
Gesture Initiation:
the whole therapeutic process that hope
- questions/requests
fully will continue to assist in the evolution
- imperatives
of the service, so that all therapists are in
- comments
a position to provide ideas, knowledge,
- other
intuition and feedback on further desired
Position
developments.
- level
- mobility
Keena Cummins is Principal Speech &
- orientation Commenting
Language Therapist and Sarah Hulme
- proximity Responding
Specialist Speech & Language Therapist
Repetition
working in Parent/Child Interaction for
Camden & Islington Community NHS Trust
Manner Rephrasing
Both are based at Hunter Street Health
- warmth Maintaining topic
Centre in London. The inruence of Lena
- attachment Reinforcement Repair
Rustin in this approach is acknowledged Confiict management
Choice of activity
References
The Hanen Programme - contact UK /
Eire Executive Director Lynne Housman, 8
Campion Close, Eccleshall, Staffordshire
STlI 6SR. Fey, M. E. (1986) Language Intervention Marson, S. (1990) Creating a climate for
Kelman, E. & Schneider, C (1994) Parent with Young Children. San Diego: College learning. Nursing Times 86 (17).
child interaction: an alternative approach Hill Press. Munroe, H. (1988) Modes of operation in
to the management of children's language Stengelhofen, J (1993) Teaching Students Clinical Supervision: How Clinical
difficulties. Child Language Teaching & in Clinical Settings - Therapy in Practice 37. Supervisors perceive themselves. British
Therapy 10 (I). Chapman and Hall. Journal of Occupational Therapy 51 (10).
Questions
How does video
facilitate parent child
interaction therapy?
What are the benefits to
individuals of self
assessment using video
compared with other methods?
How can a service gain from
therapists' self-evaluation
through video?
Answers
A parent is videoed playing with their child and, within a framework
provided by the therapist, identifies from the footage adaptations
In their own behaviour which would help their child's communication.
Observing yourself on video gives a more objective than per
ceptual view of events, your actions and their effects, both
positive and negative.
The ongoing, analytical assessment in minute detail of the
therapeutic process increases understanding and stimulates
ideas for further developments.
SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 1997 7
ISSN (online) 2045-6174 www.speechmag.com
I. Qysphagia in
adults willi a
I .
sa lty
There appears to be some
debate among clinicians
around the notion of dys
phagia in adults with a
learning disability (ALD).
West Berkshire Priority
drinking difficulties.
They employed the
Logemann four phase
framework of the swal
low, (preparatory, oral,
pharyngeal and
oesophageal) and infor
mal observations over
meal-times to c1assi fy
where the difficulty in
swallowing lay and, in
addition, noted who had
DYSPHAGIA
had chest infections.
Care Services make a clear clinical
demarcation between the terms
Incidence
adults who acquire dysphagia and
The results showed an overall
adults with long standing problems
higher incidence of dysphagia
with eating and drinking. The ther
within the hospital population,
apists working in this acute hos
ALDand
36 per cent (40) against 5.3 per
pital service feel adults with a
cent (31) in the community.
learning disability fall into the
(Percentages relate to the total
laller category and do not present
population in each group; the
with dysphagia proper.
actual. number of dients affected
Past and current research also
hagia:
is in brackets.) These figures are
bears out this 'feeling'. Sloan
likely to change again in the next
(1977) studied 40 children with
few years as a result of further
cerebral palsy through barium
resettlement plans.
discerned high ISSUes and swallows and a
The most prevalent difficulty was
proponion of inco-ordination at
in the oral phase, 33 per cent (37)
an oral and pharyngeal level. He
in long stay and 4.6 per cent (23)
vOice
Three speech and language therapists, given the
case history information opposite, set out their
management of Sheila.
Myra Lockhart is Chief speech ft language therapist
for adult services in Lanarkshire and the RCSLT West
of Scotland advisor on voice and laryngectomy.
Sarah Price is a senior speech ft language therapist
(ENT) at the Freeman Hospital, Newcastle upon Tyne.
Jayne Comins is a specialist speech and language
therapist with the Lewisham and the Royal Free
Hospitals, London.
Sheila
Sheila, a 66 year old
retired clealfer who
stopped smokin ei ht
months a a, is r fe ed at
her six m nth review
followin2 an operation to
remove Vocal flodules.
Althou2h the nodules
have nnt returned and
her vocal cords are only
mil!d oedematous, her
hus voice is no better,
sDea n2 needs a lot of
effort atYd she complains
of feeling a lump ir1 her
throat. Sfle to
consider sDeech and
therapy referral
fTrst seen.
When Sheila mentioned a
friend and two familv
members died recently
from cancer, the ENT
Consultant was at pains to
reassure her. The
Consultant notes that
Sheila, divorced for ten
years, talks a lot about
her dIfficult relationship
with her witvward
wno stc}vs
nearby. She also Ifas a
son arid his family in
Australia. Most ofher
time is spent at home but
she goeS to Bingo twice a
weeR.
SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 1997 25
ISSN (online) 2045-6174 www.speechmag.com
---
HOWl.
so she feels free to make current choic
Myra Lockhart builds an
es regarding her vocal rehabilit.lIion.
individualised programme
We must not assume that she refused
because of lack of interest, as it may
on a foundation of
have been for many reasons from
objective measures.
ignorance to fear. It may also be nec
~
, , \ i , ; ;1 ; ~ Over some years now, I have been
~ : , , , ~ , ; . ~ - - - interested in using objective mea
sures to help demonstrate efficacy of therapy
with the rationale that these measurements provide
valuable information for planning therapy and
monitoring progress. However, this does not deny
the need for subjective assessments and must be
seen as part of a package or care plan which is spe
cific to each patient.
If Sheila was referred to a therapist in our area, this
would be the general package offered:
1.a full case history.
2.a subjective voice assessment using whatever for
mat or questionnaires are preferred.
3. a computer-assisted assessment (CAA) by one of
the voice specialists, covering 21 parameters of res
piration and phonation (approx. 30 minutes).
4. possible attendance at the voice clinic for
videostroboscopy (specialist therapist and an ENT
Consultant).
5.a combined report on the objective assessment and
videostroboscopy, sent to the patient's therapist, GP
and ENT Consultant. This gives recommendations for
targets of therapy, ie. the parameters most disordered,
and suggests the future management of the patient in
terms of timescale and review appointments.
6. time for explanation and discussion with Sheila
during all of the above, so she is in an informed posi
tion regarding the options for vocal rehabilitation.
7. re-assessment (CAA) at between 6-10 weeks and
an updated report sent to encourage further
progress and focus therapy on any remaining target
parameters.
The initial interview with Sheila gives the opportuni
ty to begin to relate to her, not just to give or gain
factual detail but to observe and form impressions
of her attitudes, tensions, motivation, and to assess
posture, articulation, resonance, prosody, respiration
and phonation. Generally my style of interviewing
would be conversational, gleaning the information
by focusing on certain topics, and reflecting back to
Sheila the relevance of what she is telling me.
Similarly, it is often helpful to refer to aspects of the
proposed CAA and videostroboscopy which may
clarify our understanding of cause and effect and
the likely resolution of the disorder. Towards the
end of the intelview, I would usualJy summarise her
description and history and outline my perception
of her voice production, possible contributing fac
tors and possible options for therapy. By spending
this time initiaUy, Sheila should then approach the
remaining assessment procedures with some under
.standing of their relevance.
In Sheila's history there are keys issues of:
her underlying motivation
general levels of SlIess, anxiety, and tension
her general health
the disturbance to respiration and phonation
parameters
her understanding of her disorder and awareness
of the possible solutions.
However, there are gaps in what we know.
We do know she was reluctant, at least at one time, to
be referred for therapy and it would be important to
identify the cause of this and to address it if possible
26 SPEECH & lANGUAGE THERAPY IN PRACTICE AIITUMN 1997
essary to reassure her by discussing the
discomfort and effort she experiences in voice usage.
possible causative faoors, treatment and therapy to
resolve these.
We have little information on her voice history and
patterns of voice loss, general heah.h 3l1d reaaions
to stress and it would be important to know more
about all of these. There is insuffident spaCe in this
article to detail all the possible influen es on respi
ration and phonation of health problems and/or
medication, but suffice it to say it is crucial to know
this to piece together the jigsa\\' of contributi ng fac
tors, some of which may be very physical ego gamo
oesophageal rellux or the use of inhaled teroids.
Although we ha\-e indiCollion that she. frels anxious
and stresse.d, has she ever uffered lTom any symp
toms of stress or anxie . and.
if so, how were they treated,
Finally, although she seems J
rather solitary person with
few social contacts apan from
bingo, her lifestyle may ha\
altered substantially ovcr t
years with divorce, family
breakdown and reti rement
and may not currently refl
her past behaviour vocally r
socially. This alone could be
an important area of streSS r
tension for her.
There are probably st?\ rol l
options for Sheila's rehdbill
talion. from
advice alone and review
appointments
conventional therapy, focus
ing on target pardmeters,
through to
Further reading
lockhart, M.S., Paton, F.
and Pearson, L. 0 997)
Targets and timescales: a
stUdy of dysphonia using
objective assessment.
Logopedics, Phoniatrics and
Vocology 22 (1).
Gordon, M.T. artd lockhart,
M5. Efficacy of speech and
language therapy for
dysphonia
and
lockhart, M.S., Paton. F.
and Pearson. L. Identifying
parameters of improve
ment in voice disorders
using objective measure
ment techniques in (1996)
Proceedings of the Golden
Jubilee Conference. RCSlT.
Fi gure I
counselling or dealing with her anxiety.
My own suggestion to her would be for a combina
tion, beginning with attendance al d StresS reduaion
group which I have run a number of times. This
would usually involve some informal teaching on
stress. its effects generally and on the voice, easily
understood handouts with personal targets. group
discussion, relaxation and voice produaion exercises.
The relaxation would lead illlo targeting parameters
of breathing and voice speci fic to each patient. I feel
this would address many of heila's apparent diffi
culties in a package suited to her, as she might well
benefit from the support of others in the group.
In summarising my approach, it is probably accu
rate to say I am fairly trongly in favour of a foun
dation of objective measurement (see Figure 1),
but that we then need to use everything at our fin
ger tips to build the programme that is tailored to
the individual patient whether it iJwolves certain
methods of approach such as the Accent method,
targeting parameters, stre s reduction groups, or any
combination of these. The care plan is unique to that
patient and can be monitored for its clinical effective
ness through the objective assessments and altered
or terminated when appropriate. The efficacy of
therapy is then clearly demonstrated to all con
cerned - the therapist, GP, Con uJtant and, most
importantly, the patient.
Sarah Price
believes
motivation is
the
crucial
factor
for this
client.
Sheila was
initially reluc
tant to attend
for a speech
and language therapy
assessment - the first consulta
tion is therefore crucial to
encourage motiva
tion. Sheila may
also need careful
explanations of my
role and how I may
be able to help her
improve her voice
quality. She proba
bly already has
some ideas about
speech and lan
guage therapy, pos
sibly confusing us
with elocution
teachers and these
ideas may have
influenced her origi
nal refusal. It
would be important
to discover Sheila's
expectations and
preconceptions and
I would envisage spending quite
a substantial amount of time
discussing these during the first
session.
When discussing Sheila's dys
phonia I would use her termi
nology in an attempt to put her
at ease. For example, Sheila may
refer to her voice quality as
"husky" or "rusty" so 1 would
use these words in my questions
and e>..-planations. 1 would start
by asking Sheila to tell me what
the ENT consultant had said.
This would give me an indica
tion of her understanding of her
dysphonia and its possible
causes.
During this information gather
ing I would be beginning to get
a feel for the level of Sheila 's
motivation to change. I would
stress the imponance of a com
mitment to regular therapy as
well as the need for Sheila to be
prepared to follow advice and
do voice exercises at home, if
appropriate. She would require
ISSN (online) 2045-6174 www.speechmag.com
the start of a programme of insight into her dysphonia
vocal hygiene. A printed list of and why the exercises are
"Do's and Dont's" would include imponant. I hope I would
"Drink plenty of fluids",. "Don't be able to encourage this.
She would need to learn
that speech and language
therapy is not prescriptive and that [ am not going to 'cure' the voice
problem by giving tablets or waving a magic wand. Sheila would be
required to take a vel)' active role in her ueatment.
A patient's motivation / insight - or lack of it - is crucial to my criteria
of prioritising for treatment.
Having established ground rules
of expectations and motivation I
lem directly to voice use or may
feel family stresses have played a
pan. The fact that one of Sheila's
friends and two family members
died recently from cancer may have caused an increased level of anxi
ety. She may have feared she herself had cancer, panicularly since,
until recently, she had a history of smoking. Sheila may also still be
going through the grieving process after the loss of these people.
It may emerge that counselling would be appropriate for Sheila along
side a course of therapy. Sheila has had many suessful events through
out her life. Some of these may have contributed towards excessive
muscle tension in the laryngeal area which could result in the feeling
of a lump in the throat as well as the dysphonia. Sheila mayor may
not choose to discuss these life events during therapy. I would, of
course, allow Sheila to set the pace of this discussion and be careful not
to make her feel too uncomfonable. In my experience, voice patients
tend to introduce the topic of stress and anxiety in later sessions once
a rappon has been more firmly established. The clinician needs to be
flexible enough to adapt his / her style of interviewing and indeed
treatment to fit all personality types.
Voice assessment begins the moment Sheila walks in. I would observe
her posture (standing and sitting) and breathing (at rest as well as dur
ing speech). I would notice specifically the jaw, neck, shoulders, chest,
diaphragm, general sitting position and any tension in the hands
(clenched fists). Tension in any of these areas can be addressed in
relaxa tion exercises.
The voice itself could be assessed using a number of different tools.
We use a seven point rating scale at Freeman Hospital, including:
Voice stability 234 5 6 7
Breathiness 234 5 6 7
Other areas rated are overall severity, harshness, tension, pitch level,
pitch range, loudness, resonance, diplophonia, pitch breaks, hard glot
tal attack and breath suppon. This is a useful screen to do before and
after treatment. I would also use Pam Enderby's WHO Outcome
Measures.
I am lucky to have access to instrumentation and could use the laryn
gograph and / or fibreoptic nasendoscopy to assess voice quality fur
ther. These methods may also be useful in giving Sheila visual feedback
as pan of my explanation and as a baseline for treatment.
Having assessed voice quality and taken a tape recording of her voice,
I would explain the results of the assessments. A repon would be sent
immediately to the ENT Consultant and GP.
During the first session I would give Sheila general voice care advice as
smoke", "Avoid talking above background
nOise. I would also give simple exercises to practise at home, ego relax
ation, neck and shoulder stretches, breath control or direct voice work.
These would be given in written form after I had demonstrated the exer
cises and we had gone through them together.
At the end of the session I would give Sheila a diary to take home and
would begin an informal case
Sample question from A Questionnaire
history. Much information can
of Vocal Performance, Paul N. Carding,
be gleaned from medical notes,
Freeman Hospital.
referral letters and fibreoptic
nasendoscopy results but r would
also ask questions relating to
"How much do you worry about your
Sheila's voice use, hobbies, social
voice problem?"
life, family life, smoking, drink
ing, anxiety / suess and medical a. Not at all
history.
b. Hardly at all
The answers are like pieces of a
jigsaw, some of which may fit
c. Quite a lot
together to make a clearer picture.
d. A good deal
Sheila may relate her voice prob
e. Almost all of the time.
(:igU1T 2
explain how useful this will be to
us both to establish the pattern of
her voice use and dysphonia over
one week. Attached to it is a brief
voice questionnaire (figure 2)
which is easy and quick to com
plete and again gives a clearer pic
ture of Sheila's dysphonia and
how she feels about it. The ques
tionnaire and diary also act as
indicators of Sheila's motivation;
she mayor may not bring them
back. completed, to the next ses
sion.
I would generally offer 6-10
weekly sessions of voice therapy
to someone like Sheila but this
would be flexible to fit around
her other commitments. Sheila's
case seems fairly typical of a lot of
the voice patients I see and I am
confident that, if motivated enough to attend regularly and carry out
her exercises and voice care, Sheila's voice quality would improve.
ATTENTION-DEFICIT / HYPERACTIVITY
DISORDER (ADIHD)
An Intensive Training Day for Health and Education
Professionals
Speaker: Jenny Lyon, Chartered Educational Psychologist
(100 plus VAT, including course pack / text book,
refreshments and buffet lunch)
University of Stirling - 4th September, 1997
Birmingham - 6th October
University of Manchester - 7th November
Charing Cross Medical School, London - (5th December)
Napier University, Edinburgh - 6th February 1998
In addition, there will be a Medical AD/HD Training Day
at Regent's College, London on 22nd September 1997
Speakers will include Dr Veira Bailey (Consultant Child
Psychiatrist), Dr Deborah Christie (Principal Clinical Psychologist,
Great Ormond Street Hospital), Prof. Philip Graham (Chair,
National Children's Bureau), Prof. Peter HilJ (Professor of Child
and Adolescent Psychiatry, St. George's Hospital Medical School)
We are pleased to announce ADfHD'98, a four-day residential
conference at the University of Cambridge, 6th - 9th April, 1998.
Papers, symposia and posters are invited.
A list of audio/video recordings from ADfHD'97 (held at University of
Oxford, 7th - 9th April, 1997), is now available on request, together
with the official conference publication.
Further details are available from Remy Marckus
IPS (International Psychology Services)
17 High Street, Hurstpierpoint, West Sussex BN6 9SL
Telephone 01273 835533 Facsimile 01273 833250
SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 1997 27
ISSN (online) 2045-6174 www.speechmag.com
Jayne Comins
seeks to
activate the
'doctor'
in the
patient.
I draw on several
professional
trainings in
;;:'"OSp"AL voice work,
developed over Tl'us:
, the last twenty
.. . I "'" years: speech
--- , ;. and language
therapy, psy
chology,
psychother
apy, massage and my
singing training.
What strikes me about Sheila is
how late she has got to ENTwith
her nodules. Nodules in a
woman of this age are less com
mon than some other voice
pathologies. This would not have
been a referral from any of the
ENT teams I work for, as all
patients are expected to have pre
operative voice assessment,
advice and counselling. Most
will take up the offer of therapy
to see whether the nodules
shrink, or whether any laryngeal
tension which may be exacerbat
ing the dysphoni a goes away
with therapy. I find that general
ly patients are much more likely
to pursue a course of therapy for
nodules if they are seen pre-oper-
Practical points
1. Pre-operative voice assessment,
advice and counselling allows the
relevance of voice therapy to be
established and may mal<e clients more
likely to pursue a course of therapy.
2. It is important to find out, without
making any assumptions, why someone
may refuse treatment, and to address
this.
3. Time spent initially in discussion with
a client is crucial in establishing
perceptions and motivation. It also
ensures they will understand the
relevance of assessment procedures.
4. To be effective, packages of care
must be individualised depending on
contributing factors and the wisfies of
the client. symptomatic and / or
counselling approach may be chosen. A
gtoup may provide support.
5. Assessments can be objective and
Questionnaires and a voice
(:Jiary can provide further useful
information.
6. Clients must take an active role in their
management. Methods include using
their terminology and enabling them to
decide why theyl1ave the difficulty and
what they could do about it.
7. Efficacy must be demonstrated
clearly to the therapist, GP, Consultant
and most of all the client.
I have a problem and nothing
can be done about it
I have a problem; whai are you
going to do about it?
I have a problem; what can I do
about it?
Sheila may well be experiencing
some anxieties about oncoming
old age, and may have constrict
ed her voice in response to a
number of stressful life events, It
sounds from the referral that she
is a sociable person but does not
have anyone particul arly close
with whom she shares problems,
At the first session, I would try to
establish a diagnosis and possi
ble causes of her dysphonia,
Evidence from her case history
and from the medi cal referral
will guide me on this, If she
seems ready, and it feels appro
priate, I would briefly explain
how the voice works, how diffi
cult feelings can tighten muscles
in the throat and elsewhere, and
how a voice disorder can cause
people to feel anxious, I always
say there is no one cause to a
voice problem, and that therapy
is about understanding the dif
ferent ingredients that go into
the disorder. The bala nce of the
ingredients differs with each
patient.
I like Andrews and House's work
on 'Conflict over speaking out',
While they found this to be a
problem for women with func
tional dysphonia, [ think it is
common to most voice disorders
in that there are dift1culties and
frus trati ons about self-expres
sion and being vocal.
atively, as the relevance of voice therapy can be established.
Smoking, add reflux and the side-effects of some medications can con
tribute to mild oedema as well as voice use. The psychotherapy side of
me wants to understand why someone needs to inhale from a ciga
rette, why they may feel they are 'boiling up' inside and what the ill
nesses that require medication are all about. A lot of illnesses are psy
chosomatic, and it can be a breakthrough for patients to make a con
nection between their laryngeal state and their emotional condition.
However, it can be cruel to insist on a psychological explanation when
a patient does not view their problems as being rooted in their psyche.
If you think about it, these patients would be seeing counsellors and
psychotherapists about their voice if they thought the cause was psy
chological.
Whilst I have used instrumentation in therapy and research projects, I
do think that the Vocal Profile Analysis is an excellent auditory-per
ceptual rating scale. VPA training sharpens our listening skills and
helps with planning therapy. You can get good 'before' and 'after' rat
ings, and it is non-invasive,
I would let Sheila form her own ideas about why she might have got
the nodules, By encouraging her to take an active role in therapy, we
would have a more successful therapeutic alliance, I believe there is a
'doctor-patient' in all of us, and the role of the therapist is to activate
the 'doctor' part of the patients, Likewise we as therapists need to acti
vate the 'patient' part in ourselves to understand the patient's problems.
The initial interview helps me to decide which, if any, of the following cat
egories the patient's attitude falls into:
I would give - hei la informati.on on oice care and go over any ques
tions she might still have about her diagnosis, In addition, I would
offer her the choice of \\'orki ng on releasing laryngeal
constriction and bod\' tension generally, or a counselling approach if
it became apparent that she had a greater need to talk out her prob
lems with her voice. Sometimes, neither the patient or [ know at the
first visit which would be the better approach, in which case I suggest
we meet again to se.e whether the first session has been helpful, and to
review progress. Often, when patients have time to think through their
first visit, a lot can happen. Either they may gain useful insights, or
they might 'fly into health' by suddenly getting better, to avoid having
to take part in their recovery process. This is an unconscious process,
and can lead the therapist to think they have got better when there
actually has not been any change.
My report-writing is based on 'Communicating Quality', and I would
follow up Sheila's progress in ENT or the voice cliIlic. I write down our
goals on a management plan, and evaluate progress at the end of a
course of therapy. I do a qualitative outcome measure form, and I also
rate patients on the VPA before and after treatment, In one trust r work
for, we do a symptom change wheel before and after treatment.
Sheila might need anything from four to twelve sessions to work on
her vocal nodules. Patients with long-standing voice problems may
require longer, and 1rarely treat patients for more than a year. The deci
sion for discharge is by mutual agreement with the patient. Obviously,
the aim is to reduce Sheila's oedema and to enable her to use a com
fortable voice that she is happy with.
28 SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 1997
ISSN (online) 2045-6174 www.speechmag.com
EVENTS
16 October
UK SIC in Cerebral Palsy Study
Day - Visuallmpainnent a
Cerebral Palsy
Speakers: Prof. Alislnir ReIder:
Assessment and Management of
VI; Dr John Wann: Eye Movements,
Cerebral Palsy and Co-ordination;
April Winstock: Feeding and VISUal
Impairment; Helen Hendrickson,
Mike MdJnden: Communication
and VI; Laura Pease: Teaching
O1ildren with Cortical Blindness.
Venue: Chartered Society of
Physiotherapy, 14 Bedford Row,
LONDON WCl R 4ED
Details: R Bacon (SIG in CP)
m81 -531 3426
University of East AngIia
PosIgtaduate Courses
fr70ct0ber
Emotional and Behavioural
Disorders in Language
bnpaired Children
Tutor: Kate Malcomess, Speech &
Language Therapist Fee: 95
17-18 November
Communication Disorders
Assodated with Child Abuse
Presentationsfrom a variety of
professions. Fee: 95
24-25 November
Understanding ChaDenging
and Violent Behaviour
Tutor: wdlle Bennett, Training
Consultant, BILD Fee: 95
1-2 December
Evaluation and Treatment of
Oral Feeding Disorders in the
NICU and After Discharge
Course designedjar therapists,
nurses and otherprofessionals in
neonatal intensivecare.
Tutor: Marjorie Meyer-Palmer,
Speech Pathologist and Oral
Feeding Specialist Fee: 175
15 or 16 December
Ward Infant Language
Screening Test: Assessment
Acceleration and Remediation
(WIlSfAAR)
Tutors: Sally Ward and Deirdre
Birkett Fee: 75
January
Aphasia Therapy - A State of
the Art
Tutors: various Fee: 95
February
The Udcombe Programme of
Earty Stuttering Intervention
5days -details on request
9-10 March
Communication in Children
with a Severe\IisuaI bnpaflnent
Tutor: Ian Bell Fee: 95
Venue: University of East Anglia,
Norwich. Details: Sally Wynne,
Course Co-ordinator, Continuing
Vocational Education Office, The
Registry, University of East Anglia,
FREEPOST, Norwich NR4 7BR
... . - , " , ... . .. . .
ISSN (online) 2045-6174 www.speechmag.com
Nom
6 ore assessme
D My well nts. so m
raWlngslll1 thumbed yother five ch .
Not a lot UStrarions 0 ' . Makaton y,0l ces are'
I do nor abo
u
; developed Book
language boo bOther too ept It is an es y Margaret W: of line
and get u k. symbol bo mU ch with th sentlal refere alker in 1980
sed Occasionally ok) - they are 0 e Makaton bOok for me'
. n my shelves 'pmem (pictures:
7 \s a boOk I have only had for about a year. Obi
ects
of Reference by Adam
ockelford. published by the Royal National Institute for the Blind. It only
cost 5.95 and for my work with some clients it is invaluable. It was origi
nally developed for visually impaired children who have learning disabilities
but its use has wider implications. The book is concerned with symboliC rep
"From an early age the maiority of children come to accept that people. resentation:
activities and the things that surround them in everyday life can be repre
sented symboliCally in a number of different ways through photographs.
paintings and drawings. through spoken language and later on the written
word. For some youngsters. however. this aspect of learning. whose prelimi
nary stages most of us grasp intuitively and take quite for granted may have
_
:-_-:___ One teaching methOd in which
M
--.:: obi"" ,re ",;,,,d ",dlk m""..... I'
b
18 t in this booklet" (Ockelford.
es U
Obiects of Reference is only a 30 page
es
book with lots of illustrations and ideas. I
have lent it out to care staff to read in res
1 ------ idential I day care establishments so they
can fully understand the approach before
the teaching method is intrOduced to some
of their clients. As a teaching method I have
- G))
SOUTH DUR H AM --
H NH S fRlI
f! a lthco n ' in I 1 -' ...c)ca ( o mm u ll l t. I O
Carole Charters is as " '
& Language Thera Speech
Durham NHS T Plst With South
rust, Commun'
Learning Disabilities. ,tyTeam
M . b
J am am b YJO
em er of a mult'd ' ,
working with adul ts h I Is n plinary tea m
ability. Over th e p w a have a leaming dis-
C ast seven ye '
ommullity Team Le . .ars wllh the
llature of my job ha a;;lng Dlsabilities, the
do very little "h d s c anged a great deal J
an s on" k .
more consultative . war and now offer a
ing to have very SeTVlce. My clients are tend
complex needs d -
great deal of my in volvem , indeed, a
found it very successful.
clients is as join t' ent Wlth carers and
5 Sorry.I Thl's Bella . mpllt with the team
Vlour Nurse Th '
"""m, " ,'''' , " h" nn< b"n difF'
Scheme) nb
t
D l S (DerbyCsOhm"rPerehenSion could not do with1 ICU t to select 10 items J
K
Y M
l
out 111 everyd
now'" .' M";d' >og"'g' ""''' ,rom 'h' or " " ",, "
errors.
..; >nd W 8"" deo' of'" ,mm' P''''''' """ , 1 '''' '
0
fum (. e oped as . It Was . ' cliellt programm y eqUIpment for individual
or an ESN parr of th ong es /l eeds to be h
b
,om, """"" (S) "hoo' " 'u";'u ,m'M'",d fnc 'h . ,m,-mod, " UJ
'cau,. '001 00, ,bou, d,d h", ' """w'" ";'n'.
the Pictu y use select C udlng it 10 --------- -
tarts of It _ top , 1
0
resourc
With adults. erefore a lot of mOSt excellent Rapid Screenin purely
there was a It Would be the content scheme. it is fog est and
oafs could ; adult versio Wonderful if not approp ' r children
but an so be adapte; and likeWise if t S Co uld be for Use
,'".'" WOClhWhi
h
" ,,"u'd b. ;'.<wo "'" ,,,;nd'd '0
_____.:. g-t- 's _ If so pI I e one. Mayb time consumin 109 man
_____ e-ase let me k e somewher g exerCise
now. e someone is
10 Last but not least. a human
choice my assistant!
I have had a full time assistant for tWO years noW and could not
manage without one. She does so much of the liaison work for
me between variouS residential/day care establishments and
with carers/families. She holds her own small caselo
ad
of clientS
which I oversee and assists in facilitating group work with
clients (eg- on social skills) . A large part of her lob also InvolveS
making equipment for me. for example taking personalised pho
tograPhs for client programmes. Without her I could not
attempt to meet the needs of my growing caseload.
ISSN (online) 2045-6174 www.speechmag.com