Speech & Language Therapy in Practice, Winter 1998

ISSN (online) 2045-6174 www.speechmag.
com
quickl y and easil y
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ISSN (online) 2045-6174 www.speechmag.com
www.sol.co.uk/s/speechmag
WINTER 1998
(publication date 30th November)
ISSN 1368-2105
Published by:
Avril Nicoll
Lynwood Cottage
High Street
Drumlithie
Stonehaven
AB393YZ
Tel/fax 01569 740348
e-mail:
avrilnicoll@sol .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 1998
Contents of Speech & Language
Therapy in Practice r e ~ e c t 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.
Any contributions may also appear
on the magazine's Internet site.
Cover picture:
Speech & language therapist
Elspeth Leit ch with Craig
and the PTU (see page 9).
News/
Comment 2
Eating and drinking
difficUlties ~
Margaret Dumble
explains how her
team responded to a
request to survey all
adults with learning
disabilities for
eating and
drinking difficulties.
Conference
report 7
Speech a Language Therapy in
Practice at the Royal College of
Speech a Language Therapists'
Communicating tne Evidence
conference.
COVER STORY
Speech
disorders 9
practical reports, providing
input to Individual Education
Plans and setting joint targets for
the classroom.
Electropalatography
is only available
in a few clinical
centres. Elspeth
Leitch, Fiona
Gibbon and Lisa
Crampin reveal the
innovative portable training unit.
Reviews 13
Stammering, speech sciences, voice.
Reader offer 14
Win a free copy of REACT, the
new computer software.
II I
CONTENTS
~
Augmentation or
extra effort? 15
Clients with aphasia can benefit
from unique features of computer
technology. Alison MacDonald
and Linda Armstrong provide an
evaluation.
More reviews 18
Linguistics, writing skills, adult
acquired, early intervention, child
language, aphasia.
Further Reading 20
Learning through
drama 21
In a two-part article Myra Kersner
argues we have much to learn
from the way drama sessions
are structured. Part 1 addresses
Beginnings and Endings. Part II
will focus on The Middle.
How I write for
education 24
Therapists explain some of the
ways they are building
effective collaboration with
teachers through writing
MyTop
Resources 30
Jayne Comins, a speech and
language therapist and counsellor,
chooses ten things she could not
do without when using counselling
in speeoh and language therapy.
SPRING '99 will be published on 22nd February 1999
IN FUTURE ISSUES
dysphagia assistants Right from the Start
drama (part II) velopharyngeal incompetence
SPEECH & LANGUAGE Tli ERAPY IN PRACTICE Wlr-Tl"ER 1998 1
NEWS & COMM ENT
Be prepared
The structure of drama sessions, with a clear beginning,
middle and ending, is equally applicable to speech and
language therapy. Myra Kersner highlights the importance
of a beginning, of adequate preparation for the main work
to come, if its potential is to be realised. In an ambitious
How I write jor education, again and again the point is made
that preparation prior to writing for or meeting with
teachers is essential for collaboration to be effective. We
should question how often our workloads mean we go
into meetings or sessions ill-prepared, or write reports
without having first gathered all the information we need.
What impression does this give of the profession and,
more importantly, how much does it reduce the impact of
our involvement for clients?
Margaret Dumble and COlleagues could have thrown up
their hands in horror at a request from commissioners to
identify need for therapy, knowing they would be unable
to provide any additional therapy required within their
existing resources. However, through time spent in careful
preparation, they came up with a method of surveying the
population which satisfied all parties.
While this magazine recognises limited resources and
strives to offer realistic ideas, it also has a responsibility to
prepare readers for changes such as developments in
technology which would benefit clients and services.
Therefore, in addition to the magazine's recently launched
Internet Site, this issue features a competition to win new
software, offers other software for review and includes an
article where Linda Armstrong and Alison MacDonald draw
some conclusions about the way computers will change
our therapy. Our cover story also provides convincing
evidence that technology is for all and not just those in
specialist centres.
The preparation involved in the RCSLT Communicating the
Evidence conference was obvious, although the comment
was made that the profession's general lack of access to
computers, printers and e-mail hampered its organisation.
Attending the event gave me the opportunity to meet
many subscribers and to learn more about how you feel
about the magazine. My Top Resources for example is
clearly a popular feature. This quarter
we are fortunate to benefit from the
experience of Jayne Comins as she
shares her counselling ideas.
A quote from the Conference sticks in
my mind: "Excellence is a direction not
a destination. " Readers can rest assured
that Speech & Language Therapy in
Practice is committed to this route.
N0coll.
Avril Nicoll
Editor
Lynwood Cottage, High Street, Drumlithie
5tonehaven AB39 3YZ
tel / ansa/ fax 01569740348
e-mail avrilnicoll@sol.co.uk
Unacceptable d e l a ~
The system that provides equipment for
everyday life, including communicalion
aids', has come under fire from disabled
people.
Delays causing "prison-like" lifestyles are
reported in a survey by SCOPE, with
problems including bureaucracy, bias,
confusing or incorrect information,
finance and poor relationships with
professional staff. The charity has
recommended there should be national
guidelines, centralised information, better
planning and more resources.
(. Nine per cent of res pondents had expe
rienced problems with "s peech aids".)
For information on Equipped for Equality,
contact SCOPE, tel. 0171 619 7100.
Ocrupational health
The Health & Safety Executive is set to tackJe
the problem of work-related ill health.
A discussion document reflects preliminary
work and is intended to stimulate ideas
for what can be done by 2010 to make
sure that work activities do not make
people ill. Contributions are welcome.
Developing an Occupational Health Strategy
for Britain is available free from HSE Books,
tel. 01787 881165.
Dysphasia [OlumS
A voluntary
ACTION FOR
organisation for
DYSPHASIC ADULTS
people with aphasia
is holding regional
forums to increase
members' involve
, Unlocking words'
ment in its activities.
The Action for Dysphasic Adults (ADA)
forum in Manchester included a
presentation from members of the ADA
Working Party on the Disability
Discrimination Act (1995), the first time
people with dysphasia have participated in
this way.
ADA, tel. 0171 261 9572.
Better outcomes after
brain injwy
A coalition of orgalllsations and individuals
has been formed to promote the interests
of survivors of acquired brain injury and
their families and carers with policy makers.
By addressing prevention, treatment.
rehabil itation, heal th, social welfare.
education, housing, vocational and
occupational work financial, lega!, civil
rights and ethnic issues, the UI>: Acquired
Brain Injury Forum aims 10 real ise better
outcomes after brain injury In addition to
research, debate and planning, lobbyi ng of
Parliament based on expert evidence of
best practice will be a key function.
Membership is open t professi onals,
organ isations and indi vi duals, including
those who have sustained a brain injury.
Details. Elizabeth Han-ison, tel. 0115924 0800.
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 1998 2
ra
- - -;

Technology
show
Supporting children with speech and language dif
ficulties with Information and Communications
Technology (ICf) will have a high profile at a
major UK educational
technology event.

BElT '99's seminar pro
gramme indudes speakers
from AFASIC and the
British Dyslexia
Association, and Mike
Detheridge on New devel
opmen cs La support literacy
through symbols. Exhibitors
include Widgit Software
with their Writing With
Symbols 2000 and Crick
.. ...... .... ...
1 _fIII __

Software continuing its development of
materia.ls for literacy and special needs
with Wordbar, a flexible on-screen word
bank suitable for older children and
adults and Quickfire, a new set of grids
combining speaking with writing for use
with Clicher 3. Topologika's Speahing for
M)'self (Communi cat ion, Speech and
Reading Developme nt), a CD-ROM
developed by Bob Black of the Down's
Synd rome Association can be viewed on
the REM and Potential Software stands.
BErr '99, 13-16 January 1999, Grand Hall, Olympia, London,
Tichet Hotline tel. 01203 426458.
Matthew Crompton
(third from left) who
plays PC Sam Harker
in television's The Bill
has his blood pressure
taken by his mother
Anne (second from
right), a family support
organiser for The
Stroke Association.
The actors are supporting
the charity's campaign
to raise awareness of
stroke and how it can be
prevented or minimised.
Free in/ormation: tel.
08453033 100/
FREEPOST STROKE
ASSOCIATION.
Awareness concerns
Following research showing poor public understanding of speech
and language impairment, a national charity is launching a nation
wide drive to raise awareness and improve provisi on.
A Gallup survey for I CAN found 24 per cent of those questioned
had no idea about speech and language impairment, whil e the
awareness that there was centred on stammering, lisps and deaf
ness rather than other severe and more prevalent disorders. By rais
ing awareness, I CAN wants to prepare parents and teachers and
prevent children being wrongly labelled as "difficult ", "disruptive"
or "slow learners", Chief Executive Gill Edelman said "Early identi
fication and specialist help can change lives, but without proper
recognition and understanding these children will slip through the
net and be denied the same opportunities in life as other children".
A short film of experiences 0/ children and parencs "Giving Children A
Voice" is available from I CAN, tel. 01 71 374 4422.
Building a database of informa
tion about speech disability is
being heralded as potentially
the most valuable function of a
new state-of-the-art clinical
research centIe.
In addition to facilitating inter
disciplinary research and pro
viding an innovative clinical
service, The Scottish Centre for
Research into Speech Disability
will use anonymous data from
clients to compil e databases of
normative and disordered
speech which will inform thera
pists' future diagnosis and man
agement. Five recording studios
linked to a central recording /
control suite will enhance the
educa tion of undergraduate
students and the development
of new assessments and treat-
Project gets
resUlts
The success of
an early
intervention
The British
project for
Stammering
stammering
Association "
has led to
speculation that
stammering could be
eradicated in future generations.
The Briti sh Stammering
Association' s Early Intervention
Project aimed to inform parents
and health professionals of the
value of early referral to and
treatment by speech and
language therapists. Preliminary
results show a doubling in the
rate of referral. Speech and
language therapists have also
reported that parents taking
their children for therapy are
now more informed and better
able to help their child
themselves.
The BT supported campaign
induded the production and
distribution of leaflets
containing advice for parents
on spotting the signs of
stammering and where to go
for help.
British Stammering Association,
tel. 0181 983 1003.
ment procedures. The Centre,
based at Queen Margaret
College, Edinburgh, also plans
to extend computerised links
originally developed for cleft
palate centres in Scotland to
benefit other client groups.
The Centre has a working dinic
staffed partly from local NHS
Trusts. At a Reception to mark
the opening, Clinical Co-ordina
tor Dr Elizabeth Dean said,
"These close links with the NHS
work in two ways. The links
ensure the Centre dinic remai ns
grounded in the reality of CUI
rent speech and language thera
py practice. The links also Dahle
NHS speech and language thera
pists to benefit from the excel
lent faciliti es provided.
SCRSD, eel. or 31 317368 .
SPEECH & lAJ'-JGUACE THERAPY IN PRAcnC- ncR 199 3
ALD
~
~ I M U M
HEALTH
SERVICES
n
e +ngan
drinkin
d+ cu
A request to survey all adults with leaming disabilities
for eating and drinking difficulties posed manpower
and ethical problems for the Lewisham speech and
language therapy service. Using an approach
transferable to any dient group, they overcame the
Wendy Tuson difficulties. Maf9aret Dumble explains how.
I
n 1994, the speech and language therapy service for people
with learning disabilities in Lewisham was asked by its Joint
I I Commissioning Agency to carry out a survey of all adults with
learning disabilities in the borough (approxi mately 800) to
enable the purchasers to identify clients who have eating and
drinking difficulties due to an underlying physical cause. This
includes those who have experienced problems with eating and
drinkLng from birth as well as those who have suffered gradual or
traumatic loss of the essential skills.
We had concerns about the implications of this request:
1. Professional guidelines meant that the speech and language ther
apy service would need to act lIpon any infonnation regarding a
client having eating and drinking difficulties as well as gathering
data for the providers. This would have major implications for
resources - at the time the service had only one 0.5 whole time
equivalent specialist speech and language therapist qualified to
work in dysphagia, and a large existing dysphagia caseload.
2. It was also felt that it was not the role of the speech and language
therapist actively to seek out referrals - which is what the sUIvey
would actually entail - as clients normally access the service through
staff, carers or medical sources. Any blanket screening may also
infringe on clients' rights to choose to receive services and result in
duplication of assessments where these had already been done.
3. Response options such as 'direct screening and using a question
naire were impractical due to reasons such as insufficient resources
and problems devising reliable and valid measures.
Briefing sessions
After discussions with the Joint Commissioners it was eventually
decided that the most efficient way of responding to the request
would be to carry out a phased programme of briefing sessions for
staff about clients' possible eating and drinking difficulties. Staff
would then be asked to refer those clients they felt needed to be
seen thus fOllowing the usual procedure for access to the service.
This way it would be possible not only to gather the requested
information about the prevalence of eating and drinking difficul
ties but also to be able to respond to referrals generated by each
briefing session within the time frame outlined in the Royal
College of Speech & Language Therapists' professional guidelines
(RCSLT, 1990). In addition it was hoped this approach would raise
awareness of the importance of eating and drinking issues amongst
staff, thus benefiting future clients in their care.
We decided to begin briefing sessions for each of the res idential
provider organisations in the borough in turn. Senior support
workers from each house run by the providers were invited as this
was more practical than inviting the whole staff team.
Briefing sessions consisted of a 45 minute presentation including
information on:
the nonnal swallow (demonstrated using a videofluoroscopy video)
definitions and causes of eating and drinking difficulties (Figure 1)
signs of acute and chronic eating and drinking difficulties (Figure 2)
clients at risk - staff were asked to relate the above informJtion to
their clients to see if any of it applied, and told of other tactors such
as cerebral palsy, Alzheimer's disease / Down's syndrome
the referral process and the nature of the multidisciplinary
assessment and intervention.
Staff were then asked to consider in turn all the clients Jiving in the
house they worked in and decide whether they considered it neces
sary to refer the client to the speech and language therapy service
for specialist assessment. Record forms were completed for each
house indicating clearly whether each of the clients was to be
referred or not (Figure 3). Referrals were then taken in the usual
way, that is, the senior would complete a referral form, and a GP
referral was then requested by the speech and language therapist,
either verbally by telephone or by a form letter.
Table 1 shows the details of briefings to date, the number of clients
referred and how many of these were confirmed as having eating
and drinking difficulties.
ALD
Table 1 - clients referred following briefings
PROVIDER DATE OF
BRIEFING
NO. OF
CUEt-rrS
NAMED
NO. ON
EXISTING
CASELOAD
NO. OF
NEW
REFERRAlS
NO. OF
NEW
CONFIRMED
EATING &
DRINKING
REFERRAlS
A 14.12.95 18 5 0 0
B 7.02.96 19 2 3 3
C 27.02.96 52 5 11 9
D 14.11 .96 28 11 3 3
E 23.04.96 30 3 8 5
F 03.11.97 49 1 0 0
TOTAL 196 27 25 20
As Table 1 shows, 20 clients (80 per cent) referred as a result of the
briefings were confirmed as having an eating and drinking problem
due to an underlying cause. Of the remaining 5 clients (20 per
cent) who did not have an eating and drinking difficulty, two
clients (and their support staff) were given advice by the speech
and language therapist regarding more suitable food textures.
These figures suggest that staff involved in the briefings were more
likely to be 'erring on the safe side' but were not generating unnec
essary work for the service by excessively over-referring clients.
Six providers were briefed in the reporting period. The remaining
five providers and the Day Services will be briefed next. It was orig
inally expected that the service would be able to cover one provider
per month but this was not possible. Factors such as the length of
notice needed for all seniors to be present at briefings and the
complexity and number of referrals resulting from several of the
briefings meant that the specialist speech and language therapist
needed to spend more than the expected amount of time complet
ing intervention before moving on to the next briefing.
Table 2 - rating of referred clients
Eating and
Drinking Status
Number of
Referred Clients
Percentage of
Referrals
o=no eating and
drinking problems
5 20%
1 - minor problems
ego no teeth,
malocclusion
9 36%
2 =physical
difficulties
modified textures
requWed
3 12%
3 =physical
difficulties
modified texture
plus some support
ego staff present
3 12%
4 =modified
textures and total
support requi'ed
5 20%
TOTAL 25 100%
Planning based on need
The briefings also provided useful information for the loint
Commissioners in terms of each client's Support Needs Profile.
T h ~ s e are records which are used in planning services and allocat
ing resources according to the client's present and prospective
needs. The client's eating and drinking status was rated from 0-4
according to the type of eating and drinking problem diagnosed
and the level of staff support needed at mealtimes. Details are
shown in Table 2.
Figure 1 - definitions and causes discussed in
bnefing sessions
1. What are eating and drinking difficulties?
Taking food I drink from spoon I cup
Forming a seal
Chewing and moving food
Moving food to back of mouth
Controlling palate to shut off nose
Delay, incoordination or absence of
swallow reflex
2. Causes of eating and drinking difficulties
Progressive neurological disease
Stroke
Tumours
Cleft palate
Surgery to the head and neck
Cerebral palsy
Alzheimer's disease (linked with older
people with Down's syndrome)
Figure 2 - Warning signs of a swallowing problem
ACUTE CHRONIC
(Immediate) (long-term)
coughing and loss of weight
choking
dehydration
requent chest
gasping infections
for breath
coughing
and spluttering
'gurgly' sounding
at mealtimes
voice immediately refusing
after eating I drinking to eat
Figure 3 - referral form from briefings
Eating and Drinking Difficulties Briefing for
On
(organisation) (date)
HOUSE I SiTE...... ... .. ................. NAME OF SENIOR' ..........................
CLIENT'S NAME REFER REFERRAL ALREADY ACTIVE WITH
UNNECESSARY EATING & DRINKING TEAM
SUMMARY
REFERRAL FORMS COMPLETED ON
1.
2.
3.
-
4. ,.
5,
SIGNED HOUSE / SITE SENIOR
RECEIVED BY
SPEECH & LANGUAGE THERAPIST DATE
Staff awareness
Clients with learning disabilities are usually dependent on their
staff / carers for referrals to the special ist speech and language ther
apy service if they are showing any signs of having an eating and
SPEECH & LANGUAGE THERAPY IN PRAcnCE WIi'.'TER 1998 5
ALD
drinking difficulty. Staff / carers need to be aware of what these signs
are and how to make a referral. It is therefore vital that all new staff
are made aware of these facts by the senior support staff in the hous
es i n which they work as well as during their induction training.
Effective use of resources
The briefing sessions are proving to be a useful way of responding to the
loi nt Commissioner's request to identify clients who have eating and
drinking difficulties as well as raising staff awareness of these issues. It
has also provided some data on the prevalence of eating and drinking
difficulties in a sample of dients with learning disabilities in Lewisharn.
Provi ded sufficient time is allocated to respond to referrals made
during each briefing session, this process appears to be an effective
use of limited speech a nd language thera py reso urces. However, it
must not be forgotten that the inevitable cost of pursuing such a
proactive process is that other clients on the caseload with lower
priority needs - defined in Lewisham as a low risk client who may
be in some distress but is not considered to be vulnerable - will
have to wait longer for a service.
We now have other therapists on the team who are already dyspha
gia trained or are developing their skills in this field as part of thei r
job. This means we can manage the clients already referred and new
referrals. However, we a re aware of the need to complete the briefing
programme to the remai ning providers and the day services and are
considering how best to carry this out with the resources available.
Margaret Dumble is a speech and language therapist with the Lewisham
Community Team for Optimum Health Services NHS Trust. The main
speech and language therapists involved in the briefings project were
Wendy Tuson and Magda Moorey. Wendy now works for Newham
Community Health Services NHS Trust.
Note
The term 'eating and drinking difficulties' subsumes the defi niti on of
'dysphagia' as defined in Communi cating Quality (RCSLT, 1990) and
is the preferred term in this service for adults with learning disabi lities.
References
RCSLT (1998) Clini cal Guidelines by Consensus for Speech and
Language Therapists
RCSLT (1990) Communicating Quality
Questions lAnswers
Why is a full screening
1 Screening means duplication, lack of client choice,
programme
waste of specialist time and ethical dilemmas if more
problematic'?
people are referred than can be seen.
What are the benefits
Educating the people who make referrals means direct
of a systematic
rM speech and language therapy contact can be targeted.
briefing programme'?
How can briefings be
MM.MM Staff need to be able to see how the problem under dis
made most effective'?
cussion relates to their clients.
RESOURCE REVIEWS. .RESOURCE REVIEWS. .RESOURCE
ARTICULATION CHILD LANGUAGE
Emphasis on production Quite earned away!
Say and Do Articulation certificates at the end are rewarding. Cause and Effect ColorCards I. Role play assumi ng a role. One
Worksheets (various. p, t, k, z, Unfortunately, American vocabu- Win slow 23.75 child plays the part of mother; one
ch,l) lary is used. There are not a huge This pack contains 24 two card plays the part of the naughty child.
Photocopiable booklets number of American words but sequences of everyday events. The 2. Applying general knowledge.
Winslow 1999 each or 289.00 they are scattered throughout the cards are colourful , strong and Have you ever broken anything?
(or 16 worksheets.The books use upper portable. They introduce the basic 3. Relating personal experience.
These articulation books are well case letters which will not be concept of one event leading to How did you feel when your
ill ustrat ed and full of fun activities popular with teachers.The K work- another. The pack is grouped into favourite toy was broken?
such as matching, odd one out, hid- book gives k for cat and cup which four cat egories: 4. Problem solving. How can you
den pictures and join the dots, with again is confusing for chi ldren. Accidents, eg. The children play mend that toy?
amusing drawings that children will Some of the workbooks are more roughly and break the doll. Some of the cards are suitable for
enjoy. They focus on articulation useful than others. I have used the Difficulties, ego The boy puts too adult cl ients. Personally I do not like
work in a well structured way, The P one with two dyspraxic children much salt on his dinner and does the card of the boy playing with
sounds are given in isolation, with a who need lot s of practice and not li ke the taste. matches and setting fire to the
vowel. in words (initial, medial, final reinforcement and my colleague Time, eg. The woman plants a bulb papers as it sets a dangerous
positi ons) and then at phrase level. likes the L one. The Z workbook is and eventually it blossoms. example.
The same sound is repeated in not recommended and it would Emotions, ego The woman receives I used the cards in a group situation
many acti vities giving lots of scope be very expensive to buy the a present and is delighted with it. and the children really enjoyed the
for reinforcement without the task complete set. They can be used for basic lan- role play, One little girl had to be
becoming dull and repetitive.There These books are fun for children guage work such as cause / effect, discouraged from hitting her friend
are some examples of li stening and therapists and great for home sequenti al thinking, organisation of as she was quit e carried away,
work, minimal pairs and auditory practice. The drawbacks are the thoughts. They could also be used Therapy mat erials are always
discrimination but the emphasis is American vocabulary and the edu- in a wider way, for example expensive but, if your budget
on production. The congratulation cati onal aspects. through: allows it. this is a useful set to buy
Ann Gosman is a Speech and Language Therapist with Orkney He alth Boord.
SPEECH & lANGUAGE THERAPY IN PRAGnCE WINTER 1998
0
6
CONFERENCE
CONFERENCE REPORT
C

t e eVI ence
Delegates at the Royal College of Speech & Language
Therapists' Communicating the Evidence conference were
asked what they had heard that would encourage them to
LcxaJ researm ard
develqxrent
Several delegates plan to approach their
managers with ideas following the two
part presentation by Margaret Meikle from
Portsmouth HealthCare NHS Trust.
[n outlining her service's local research and
development strategy, which included col
lecting and collating all papers held in her
department so ideas could be shared, she
stressed staff need:
basic research methodology
library skills
critical appraisal skills training.
Clinical governance challenges all staff to
take responsibiliry for what they do. She
believes it is up to the manager to:
make sure all staff understand this
provide support in life long learning
be explicit about guidelines and standards
implement change as a result of audit
ensure the service is knowledge based
and knowledge driven .
The WILSTARR effect
Deirdre Birkett and Sally Ward revealed
the results of their follow-up study of the
first W1LSTAAR' children, now aged seven
and believe they suggest there is an early
period where making environmental
changes can have a considerable and last
ing effect.
Comments from delegates included:
OUT Trust is choosing between introducing
WILSTAAR and Hall en. Being here has given
me more idea of the research behind the
approaches.
Julie
I was interested in this follow-up research.
Service managers need the best information
and IlI/ll here 10 collect information and maliC
decisions regarding priorities.
Deirdre
I worll with children in foster care. It is diJJ/
cult to persuade social worlwrs of the need faT
early referral. Sally Ward's wadi gives me extra
ellidence.
Melanie
change their practice.
Gathering ideas
One of the main benefits of the Conference is
networking and meeting people, but I have
been gathering ideas too. I work in the Forces
and now want to look at considering providing
support to secondary schools. I would also like
to audit how our referrals have changed, to see
where we should be targeting rraining.
Dawn
Male than impaimlent
It's good to see the confidence and diversity of
the profession. I would have liked the confer
ence to be more creative, though, rather than
being organised mainly by impairment. For
example, learning disability appeared under
represented but there are many links across
client groups that could have been shown if dif
ferent themes had been chosen.
Carole
Making priorities
Several speakers came up with good ideas on
prioritisation. Ann Rice for example had really
thought through this complex issue - ethics,
efficacy, efficiency etc. - and I plan to ask her
for a copy of her framework for good practice'.
With another delegate, / am considering set
I.ing up a study day on p1ioritisation.
Sue
Summary of framework
l.specify the health benefits
2.consider the values of all involved
3.set criteria for priorities
4.examine for ethics
5.develop ranking measures
6.record measures for decision making
7.inform purchasers / clients / users
B.review and revise.
Readiness for therapy
I was impressed, along with many others, by
Pamela Butt's non-lierbal reasoning test of
problem solving in aphaSia, as she is suggesting
the clients without these skills are not ready for
relwb. I hope it will be published S0011.
Also, after attending Maggie lohnson's work
shop on inter-disciplinary outcome meaSllre
mellt, / will definitely be looking to do some
thing similar.
It was useful to have the wn'tten proceedings as
I found it frustrating that, with so much going
on at once, I couldn't attend everything / was
interested in.
Catherine
Therapy in action
I like to see other therapists in action so partic
ularlyenjoyed the video case study of a five year
old boy who, following two years of therapy, was
still lin intelligible and so aware that he refused
to cooperate with confrontation naming for
assessment. Instead, the therapist focused on
what he could do, for example, discriminating
between real words and words containing his
errors as spoken by the therapist.
I would have liked more opportunity for ques
tions in the sessions and, as a generalist, found
it impossible to cover all my areas of interest. It
was good to have the opporwniry between ses
sions to meet other therapists I refer on to, as /
am rather isolated in my job and don't often
get the cha /lce.
jane
Poster possibilities
The poster presentations have given me ideas
about how to share information about what we
are doing. The therapists from our local TI1ists get
together for study days and a presenuuion always
seems such a big thing - this would be a good
altemative. The posters were all interesting and it
was good to see what other people are doing.
Angela
The video view
Ray Wilkinson gave a presentation on a
conve.rsation analysis approach. A person
with aphasia and their spouse videoed
conversations in natura,! settings and then
viewed and discussed the recordings wim
the therapist. In the case example used,
both partners thought the spouse wa
being helpful by correcting 'errors' wh i h
actually had no impact on the meaning of
what was being said. Seeing the vid 0
.. ...... ............... .. .......... ...,o'ltiIl U d 111''''' ~
SPEECf j & LANGUAGE THERAPY 1."-1 PRACTICE WI Il:R 1 9 ~ 7
CONFERENCE
helped them to see how much it adually
interfered with conversation and alterna
tive strategies were suggested.
I have used audio recordings before but it's not
the same as being abLe to see what is happen
ing too. I have also been in a situation where I
recommended phonemic cueing to carers as a
strategy for a client with word finding difficul
ties but it ended up with them guessing words
wrongly and the client haVing no flow to her
conversation. This could be an effective way of
finding a balance.
Ashleigh
Taigeting volunteeis
You would assume that more training of vol
unteers working with people who have had a
stroke would effect change, but it doesn't actu
ally correlate. It was reassuring to find that all
areas of the country have this difficulty. Action
is needed at a national level, but I am plan
ning to target certain volunteers and develop
protocols for people being volun teers.
Helen
Diiving deliveiy
My idea that the carer's perspective should
drive service delivery has been reinforced, so I
will continue down that road.
Thelma
Clinical teaching
The session on student learning seems to
have converted delegates:
In our department, we don't take many students
and always assumed they would be a burden.
I've now realised that they have time to do in
depth analysis and case studies which can be
very useful if the results are fed back to clinicians.
Rachel
I heard about PATSy (Patient Assessment Training
System), a tool developed for student training, but
I think it would be lISeful for clinicians LOO, espe
cially if you had students on placement. I also see
now that groups or pairs of students can be an
opportunity rather than more work.
Lynne
I've learnt that peer placements with big
groups are a good idea, using time of therapists
and students effiCiently.
Vida
Impioving inforTnation
After hearing about a Norwich project 'into the
views 9f people with dysphasia, I'm going to offer
clients more information in future and give more
time to hearing the views of carers. It 's applica
ble to adults with a learning disability too.
Lucy
Education plans
I'm planning to put together a specific curricu
lum to mirror the National Curriculum, so
that th e children we see are really accessing the
curriculum and not sitting in and missing
loads.
Nancy
Claire Topping 's paper on team working
between educational psycho109), language sup
port and speech and Language therapy for
mainstream children provided a good model.
Alison
Researching the
evidence
In what Chair Sally Byng described as a
ligh t-hearted way of looking at a serious
issue, one group debated the motion: This
House believes that current research is
irrelevant to clinicians developing evi
dence for the effediveness of intervention
by speech and language therapists.
Rebecca Lacey and James Law present ed
the opposing arguments and there was
keen interest from the floor. Some of the
key practical points raised were:
1. research evidence should be made more
accessible to clinicians, with a variety of
publications used
2. there is a perception of polarisation
between clinicians and academics, and a
need for more collaboration to bridge the
gap
3. we should address how to move from
small-scale descriptive studies into large
scale studies
4. clinicians must have access to the tools of
research - a computer, printer and e-mail
5. the 'exclusion criteria' for subjects
means research does not always appear to
relate to 'real' clients, and there is a need
for a different type of research focus, for
example on packages of delivel)' and qual
ityofJife
6. there should be publication of negative
results as well as positive ones, so we can
stop doing what doesn' t work and do more
of what does.
The conference generally has prompted an
enthusiastic view of research:
I now see that research is achievable locally - I
didn't think it wO'uld be.
Christine
I like the idea of a whole departmental
a{l(Jroach to research and development and will
encourage my manager to do a library skills
workshop.
Janet
One of the speakers managed to get money out
of their Trust for an oucome measure - I'll now
explore the possibilities of that for myself
Dorothy
In Portsmouth HealthCare NHS Trust, all
newly qualified physio, occupational and
speech and language therapists have to do a
project in their first year. I liked this idea, but
for longer-serving staff too.
Jan
I've almost been convinced to write up my
research into training staff and carers of people
with learning disabilities.
Trisha
Qualrty assured
Several delegates mentioned their interest
in Signed up to Quality, RCSLT's new
Accreditation scheme. It is seen as the log
ical step after professional standards and
registration, as it is an independent mea
sure of a service's compliance with the
identified standards. The process can also
be used by a service to bring about change
for the better.
RCSLT has developed the scheme in part
nership with the Health Quality Service
(formerly King's Fund Organisational
Audit) who will train experienced speech
and language therapists to act as external
assessors ('surveyors' ).
Launching the scheme, Philip Turner said,
"The world of the public sedor seems con
tinually'to be reorganising and putting
challenges before us without necessarily
showing us how to deal with them.
Accreditation is a powerful weapon in our
armoul)'.
Accreditation Information line: 017] 6] 3
6400
The Royal College of Speech &.
Language Therapists' conference
Communicating the Evidence - the
Case for Speech and Language Therapy
ran from 15th - 17th October 1998 at
the Adelphi Hotel in Liverpool.
Approximately 500 attended, joined by
250 students for their conference on
the 17th. There were over 120 papers,
15 workshops and 45 posters.
Proceedings are available in the
International Journal of Disorders of
Communication Vol. 33, Supplement,
1998. Details: RCSLT, 7 Bath Place,
Rivington Street, London EC2A 3DR,
tel. 0171 6133855.
students
report from the Royal College of Speech & Language Therapists' stu
dent conference
advice from a new graduate
SPEECH & lANGUAGE THERAPY IN PRACTICE WINTER 1998 8
ARTICULATION
Portable trai

for
speech disol1 ers
W
hen conventional speech
and language therapy tech
niques did not have much
impact on the speech of
Craig (1 0), the first author sought access t o
electropalatography (EPG) as it has been found
to contribute to three central clini cal tasks:
I . speech assessment and diagnosIs: EPG
records precise details of abnormal lingual
articulations often not detected by perceptual
analysis
2. measurement of change: EPG data recorded
before and after therapy provide an objective
way of monitoring progress and quantifying he
effects of therapy
3. provision of real-time visual feedback: this
facility helps clients to monitor and change
their articulation patterns as part of a therapy
programme.
Craig was having particular difficulties produc
1ng velar sounds, consistently fronting them to
the al veolar pl ace of art iculation. Although
Craig has long-term speech and language ther
apy needs, it was fel t EPG would be potential
ly useful In resolving hi s specific problem with
velar front ing. An innovative approach was
requi red, howevec as Craig lives 140 miles from
the nearest centre offering this technique.
Safe procedure
The tongue is one of the most important
speech organs, and is actively Involved In the
production of the majority of consonants and
vowels. Howevec its behaviour is not oriously
difficult to record due t o its visually inaccessible
location and the speed and complexity of its
movements. Electropalatography (EPG) is a
safe procedure that records detai ls of the loca
t ion and timing of tongue contacts with the
hard pal ate during speech (Hardcastle et al.
199 I ; Hardcastle and Gibbon, 1997).
An essen ial component of EPG is a custom
made artificial palate, moulded to frt as com
fortably as possible against a speaker's hard
palate. Embedded in It are 62 electrodes
exposed to the I ngual surface. When contact
occurs between the tongue surface and any of
the electrodes, a signal is conducted t o an
external processing unit and displayed on a
computer- screen. EPG registers characteri stic
patterns for the Engli sh sounds ItJ, Idl, Ik/, I 9I,
lsi, hi, iiI, Id}i, M/, /1/, In/ and I fJ l. The value of
EPG in the treatment of articulation disor-ders
has been demonstrated in a number of studies
(M ichl et ai, 1993; Dagenais et al. 1994; Dent et
ai, 1995; MorganBarry, 1995).
Poor accessibility
Although EPG has been shown t o be a val u
able chnical tool. a number of factors have pre
vented its widespread use in clinical contexts.
Firstly, EPG requires a PC (computer), which
makes it a relatively expensive technique and
not cost-effective for clini cs with limited case
loads of cl ients requiring EPG t herapy.
Secondly, there may be a lack of technical or
specialist support for clinicians who wish to use
Instrumental procedures. EPG IS relatively
st lClightforward to operate, but some technical
support is often needed in the initial stages. In
additi on, data analysis is a time-consuming task
and interpretation is aided by those with spe
Ci ali st EPG knowledge. Thirdly, although families
are often prepared to travel for one-off con
sultati ons at centres with an EPG system, there
can be practical and financial difficulties where
frequent and I or numerous sessions are
required.
In an effort to solve the accessibi lity problem. a
portable traini ng unit (PTU) was designe ~
Wil f Jones Gones and Hardcastle, 1995) 10 be
used in conj unction with the Reading EPG3
system. It is envisaged that centres WIth tht: full
. ...................... ....con li/wed Ol't!r -+
SPEECH & LANGUAGE THERAPY IN PRACTICE WI NTER 1998 9
- - -
- -
ARTICULATION
Figure I. A portable training unit
(PTU) showing a typical alveolar
contact pattern, ego for a./tl,/dl
or Inion the screen
disorders associated with cleft palate (Gibbon
et ai, in press). In the circumstances, project
staff also allowed Craig the use of a PTU.
Range, timing and
accuracy affected
Craig has a non-progressive neurologically
based developmental motor speech disorder;
diagnosed as cerebellar ataxic dysarthria (also
(a) Craig's production of word-initial /k/ in Kevin (transcribed as It))
.. .. ..
"
os
.. o.:!oo

000 .. 00 , 000 . 000
00 . .00 00 . .. 00 00 . .. . 00 00 .. . 00 00. .0<1
o . .... 0 0 .... .. 0
O. . 0 00:. .. 00
00 , . 00
0 0 o. 0 0 . 0 o . .0 o. . 0 0._ .. 0 I
t
.. ..
" -000
" " "

000 .. 000 000 .. 000 000 . . 000
00" .. 00 00 . .. 00 00 .... 00
. . . 0 0 .. . (I .. 0 o . . O. o.

00 . . . 00 00 . 00 .. . 0 0 . 0 . . ..0 o ..... 0 ... 0 O . . 0 o . . 0
00 .... 00 . 00 00 ... 00 .. . 0
00.... 00 00 . .. 00 00 . 00 00 ... 00 .0 . 0

(b) Normal adult speaker's production of word-initial /k/ in Kevin
k 0 .. .. 0 0. " . . 0
0... 00 ... .. 0
00 . . .. (I 00 . ..00 QOOOo . 00 OOOOOOOQ
....OAO< ....,.... IlnIlAJI O-'
TO "'-"<UU
"",,,""
""'"""
(e) Craig's production of within-word /k/ in looking (transcribed as It])
m no m
. .. 0 . 00 0 .. . 00 -000 '" '"
. . . 0 .
_ 00 .
. 0. - . 000 . . 000 000 .. 000

o. 00.. 00 00 . . 00 00 . . 00 00. . 00 00 . . 00 00 .. ... 0
o. o ..... 0 0 . . . 0
." .0 0 .. . " .0
.. .. 0 0 . ... . 0 0 ..... . 0 0 . ... . 0 00 . ...0 00 ... 0 00 ..... 0
.. 00 00 00 .. . 00 00 . .. 00 00 . , .00 00 .... 00 00 ... . 00
...",....
...""'"
TO c.o.ou
""'UCT
t
". ,.. ,..
O ..
'"
000 . ' .0
Q ... 0
'"
-
'"

'"
.- -. . 000 . . 000 000 . 000 00. .00 .. 00
0 . _ . 0
0 0 . o . . o. o.
. 0 o . . .0 o .. .0 o .. . 0 . 0 .0 O. .0 .. 0 0 ..
.. 0 .0 . o ..
. . . . . . . . 00 00 00 . . . 00
(d) Normal adult speaker's production of within-word /k/ in looking
0 ... 0 ..... . .
. 0 0 ..... 0 0 .. .. 0 0 ...... 0 0.. .. 0
k
. ,00 00 . .. 00 00 . ... 00 00 . 00 00 .... 00 00 .. . . 00 . 00
000.. 000 00

Figure 2. Examples of Craig's EPG patterns for velar targets before therapy compared with a normal adult
speaker's patterns of the same target.
... continued from previous page.......... .
system wil l carry out the EPG recordings
essential for assessment, diagnosis and measur
ing change over time. Each centre will also have
a number of PTUs that can provide visual feed
back therapy for clients at a convenient loca
ti on. The PTU was designed purely for therapy
purposes, in other words to provide visual
feedback of tongue activity onlyThe equipment
consists of a PTU processing unit (Figure I), a
multiplexor and an EPG artificial palate.
The major design features of the PTU are:
it provides visual feedback on ly, so is designed
specifically for therapy
it is a small, lightweight unit and highly
portable
it is simple to operate
it has a large, real-time di splay of tongue
palate contact, consisting of light emitting
diodes (Figure I)
it has no recording, display or data analysis
facilities, so cannot be used for assessment,
diagnosis or monitoring progress
at around 060, it is relatively inexpensive.
PTUs have been undergoing cl inical trials as
part of a research project, Cleft Net Scotland,
which is Investigating their use with articulation
referred to as Disequilibrium Syndrome). His
speech has a slow scanning quality, with impre
cise articulation. Intelligibility is variable and all
subsystems of speech are affected (respi ration,
laryngeal control and supralaryngeal function
ing). Craig attends a mainstream primary
school. He has difficulties in balance, and the
range, timing and accuracy of all movements
are affected. Craig sees the speech and lan
guage therapist once a week at school and his
class auxiliary continues with his speech and
language thel"apy programme on other school
days.
It was decided that. following the manufacture
of an artificial palate and an EPG assessment,
CI'aig would have a week of daily therapy at
the nearest centre - Glasgow Dental Hospital
with the third author; using the Reading EPG3
sy>1:em. ThiS initial period of intensive therapy
ould be evaluated and therapy would contin
ue using a PTU locally if needed.
Accommodation 'or a week in Glasgow and a
six hour return Journey from Argyll 0 Glasgow
were arranged.
The EPG assessment confirmed that Craig's
velar targets were fronted to an alveolar place
of articulation. Figure 2 shows two examples of
Craig's EPG patterns for velar targets before
and compares these wrth a normal
adult speaker's patterns of the same targets.
The palatograms in Figure 2 are numbered and
read from left to right. and occur at 10 ms
intervals. Three frames are marked: (a)
approach to closure (b) maximum contact and
(c) release of closure. Craig's production of 11<./
in word-inrtial Kevin and within-word looking
(Figure 2a and 2c) shows atypical alveolar stop
pattern.
Progress with velars
During the week of Intensive EPG treatment in
Glasgow, Craig progressed towards achieving
velar placement, and at t he end of the week
was able to produce a velar fricative/plosive
sequence in a hi gh vowel environment
(eg. [ixki]) but could not manage a singleton
plosive (eg. II<./) in any vowel context. Since
velar plosives were not achieved adequately at
this stage, therapy continued in the local setting
using a PTU a few months later for four
months on a daily basi s under the supervision
of the speech and language therapist. Craig
continued to make progress towards achieving
a velar place of articulation. Initially, he could
achieve appropriate contact in the velar region
for 11<./ targets, but only in a close vowel envi
ronment (eg. Ikif) . In more open vowel con
10 SPEECH & LANGUAGE THERAPY IN PRACI'lCE WINTER 1998
- -
- -
ARTICULATION
00 .... 00

texts, placement reverted to alveolae The effect
of the Iii vowel environment in faci litating IkJ
was presumabl y due to the tongue being in a
relat ively high position in anti cipation of the fol
lowing vowel. Thi s high position could have
encouraged tongue body movement upward
towards the palate for velar placement.
Maintaining alveolars
After three weeks of therapy using the PTU,
open vowel s were introduced in consonant
vowel (CV) contexts, initiall y without accompa
nying voicing for the vowel. Gradually, as vel ar
placement became more consistent, other
sounds such as alveolar pl osives were intro
duced to alternate wrth the target velae At first,
alternating between IkJ and Itl had the effect of
destabi hsl ng alveolars, maktngthe EPG patterns
for alveolars appear variable, imprecise and
sometimes at a more retracted palatal place of
articulation. Thi s meant that Craig used the
PTU not only to assist in establishing velars, but
also to ensure that accuracy of placement for
al veolarswas maintained. In the last four weeks
of therapy, velars in a range of contexts were
introduced, incl uding: voiced velars/(j. I rj in VC
sequences: voicing of vowel s In CV and CVC
sequences: velar plosives IkJ and 191 in within
word contexts: and IkJ in consonant clusters.
Other feedback
Therapy sessions Included time to practise
articulation skills with and without the artificial
palate In situ, to ensure that articulatory skil ls
learned with the aid of visual feedback are
maintained even when visual information IS no
longer provi ded. The absence of visual feed
back meansthe child hasto rely more on other
feedback channel s such as tactile, kinaesthetic
and auditory cues to maintain accurate pro
duction. Ultimately, the child will depend on
feedback from these channels rather than the
visual modality when prodUCing and monitor
ing speech in naturalistic contexts. It is there
fore good EPG practice to remove the vi sual
Information as soon as the child can achieve an
appropriate art iculatory gesture (see
MorganBarry. 1989 and Dent et al, 1995 for
summaries of EPG as a therapy procedure).
In addition to discussing he EPG patterns for
different target sounds, Craig eVas encouraged
to describe the new ge>tures in terms of
tongue movement and placement and how
they sounded to him. Craig experienced no dif
ficult ies in relating the EPG patterns to the
result ing perceptual consequences of his
behavioue Figure 3 showsexamples of
Craig'svelar targets after the period of therapy
using t he PTU. Craig's EPG patterns are again
compal-ed with a normal adult speakers pro
ductions. These EPG sequences show appro
priate tongue-palate contact in the velar region
for velar targets, illustrati ng how Craig's pro
ductions of 'Ielars Improved following therapy.
Articulatory placement for velars is clearly
much more like a normal speaker's after thera
py. However. one obvious difference IS t hat
(a) Craig's production of word-initial /k/ in Karen (transcribed as [k])
"
0
. . .. . 0 . 00 .... 0
0 "
. . ... 00
-
00 ... 000
-
:::;, . OOO
-
.

-
.
""'''''...
"""ACT
OJ
0 ..
... 00
-.
(b) Normal adult speaker's production of word-initial /k/ in Karen
o. 0 .. ' . 0 .... 0 0 ..... 0 00 .... 0 00 .... 0
o 00 " 00 00 .. 00 00 . .. 00 00 . CO 00 ..00
oooooooo 00 . 0 00 . 00

(c) Craig's production of within-word /k/ in making (transcribed as [kD
.
0 .... 0 0 .... .. 0 0.. ..0 0 ...... Q
00 ... . 00 00 ... . 00 . . 00 .... 00 00 .. .. 00 .00
000 . 000 000 . 000 000 .. 000
-..-
- - - - -
.,"""""
ro c.oso>l
0 ..... 0 0 .... 0 0 .. .. 0 o .. 0 o .
00 .... 00 00 ....00 00 ... 00 00 . 00 00 .. , 00 00 . .00
000. 000 00... 000 00 ... 000 00 .... 00 00 00 00 ,., . 00
0000 . _
-
- -
........ o.
""'""""
(d) Normal adult speaker's production of within-word /k/ in making
".
0 .. 0 0 .. ... 0
00 .... 0 00 .... 00 00 . .. <701 00 ... 00 00 .... 00 00 .... 0;0 00 ... 00
00 .... 00 000 ... 00 000 . . 11<1 000 ... 00 000 . ,,00
000 .. 000

00 ..0 000 0 000 ..00 000 .. ,00 000 ... 00
-
Figure 1 Examples of Craig's EPG patterns for velar targets after EPG therapy compared with a normal adult
speaker's patterns of the same target
Craig's productions are much slower. in other
words they have longer durations of the clo
sure period. For example, the duration of the
velar gesture from approach to release of clo
sure in Craig's production of IkJ in making is
160 ms (Figure 3c frames 230-246; duration is
the number of frames during closure multiplied
by 10 ms). In contrast,the adult's production in
Figure 3d is about a third of the durat ion of
Craig's, at 50 ms (frames 15 1- 156). It is difficult
to know whet her t his is due to Craig'S age - it
is well established that young children with typ
ical speech development have slower speech
than adults. On the other hand, the longer
durations might be due to his motor speech
disorder This is a li kel y explanation, since slow
ness was one of the perceptual features noted
earlier as being a phonetic characteristic of
Crillg's speech. W ithout EPG data from an age
matched chi ld with typical speech develop
ment, it is not possible to say whet her Craig's
slower velar gestures are wit hin normal limits
or part of a speech pathology.
The full Reading EPG3 allowed an assessment
of tongue-palate contact to be made prior to
therapy, giving an accurate diagnOSIs of the pre-
k
00 ..
00 00 ..
k
0000 . 000 00
0 ..... 0 Q .....0
00 ... 00 00 . .. 00
-.
-

k
. 0
-
.

0.. .0 o .
00 .. 00 .. , 00
000 ... OG' 00
000. , 000 k
000, .. OC' 000 , , UO
senting problem. From the pl-e-therapy record
ing It could be seen that Craig was not making
any clear articulatory distinction between It!
targets and fronted velars. The post-therapy
EPG data made it possible to quantify Craig's
progress in articulatory placement after visual
feedback therapy. The EPG data revealed addi
t ional information about the long durations of
pl osive gestures in Craig's speech.
underlying
Principles
The use visual feedback therapy was felt to
have been an essential component in the suc
cessful outcome in Craig's case. Although EPG
is not currently a widely used therapy tool, its
use rel ies on t he same underlying principles as
other therapy procedures. For example,a thor
ough assessment of the pl-esenting prob em is
needed before deciding where to start_Also.
the gradual int roducti on of more (ample
phonet ic contexts is typical 0 any "bcttom
up" approaches to treating speech s rder.:.
Finally, most speech and langu3
0
e theraD::;iS u,e
a variety of approaches dunng erapy .o
."continued 0I't?)- -+
SPEECH & LANCUAGf, THERAPY IN PRACfI CE WI rrER I 9 11
ARTICULATION
+- continued from previous page.... .......... ... ... . .
the individual needs of the chi ld. This was also
true in Craig's case, Although visual feedb ack
was an integral part of his therapy, especially at
the initial stages, additional strategies were
used, including heightening Craig's metalinguis
tiC awareness of the articulatory features of
sound classes, encouraging discussion of rele
vant aspects of speech production and moni
toring the communicative adequacy of hi s own
attempts at productions,
The combination of the Reading EPG3 system
plus PTUs potentially enables clients living in
any geographical area to have access to EPG
therapy. Through collaboration and effective
team work it is possible to extend the use of
innovative techniques, such as EPG, to a rural
situation to the satisfaction of client, carers and
clinicians al ike,
Elspeth Leitch is a speech and language therapist
with Argyll and Bute NHS Trust Fiona Gibbon is
based at Queen Margaret College in Edinburgh
and Lisa Crampln is a specialist speech and lan
guage therapist at Glasgow Dental Hospital.
Acknowledgements
The Reading EPG3 and the PTU device were
designed by Wilf jones, CleftNet Scotland pro
vided Craig wrth the use of the PTU. CleftNet
was funded by the Scottish Office Department
of Health (Grant number KJRED/4 /C30 I). For
further information contact either Elspeth
Leitch, Department of Speech and Language
Therapy. Aros Blarbuie Road, Lochgilphead,
Argyll PA3 18LD (01546 604 923) or Dr Fiona
Gibbon, Department of Speech and Language
Sciences, Queen Marganet College, Clerwood
Terrace, Edi nburgh, EH 12 8TS (01 31 317 3000),
References
Dagenais, PA, Critz-Crosby. P and Adams, j
(1994) Defining and remediating persistent lat
lisps in children using electropalatography:
preliminary findings.j ournal of Speech-Language
Pathology 3, 67-76,
Dent, H.. Gibbon, F, and Hardcastle, W (1995)
The application of electropalatography (EPG)
to the remediation of speech disorders in
school-aged chi ldren and young adults.
European journal of Disorders of Communication
30, 264-277.
Gibbon, F, Crampin, L, Hardcastle, W J., Nairn,
M, Rauell, R, Harvey, L, and Reynolds, B, (in
press) CleftNet Scotland: a network for the
treatment of cleft palate speech usi ng EPG. To
appear in Proceedings of the 1998 Conference of
the Royal College of Speech and Language
TIlerapists,
Hardcast le, W.j, and Gibbon, F. (1997)
Electropalatography and its clinical applications,
In: M.j. Ball and C Code (eds.) Instrumental
Clinical Phoneti cs, Whurr Publi shers: London.
Hardcastle, Wj. , Gibbon, F,E. and jones, W
( 199 I) Visual display of tongue-palate contact:
electropalatography in the assessment and
remediation of speech di sorders. British journal
of Disorders of Communication 26,4 1-74,
jones, W, and Hardcastle, W-J (1995) New
developments In EPG3 software, European
j ournal of Disorders of Communication 30, 183
m,
Michi , K, Yamashrta, Y, Imai , S .. Suzuki, N, and
Yoshida, H. ( 1993) Rol e of Visual feedback
treatment for defective lsi sounds in patients
wrth cleft palate. journal of Speech and Hearing
Research 36, 277-285.
MorganBarry, RA ( 1989) EPG from square
one: an overview of electropalatography as an
aid to therapy. Clinical lingUistics and Phonetics
3,81-91.
MorganBarry, RA (1995) EPG treatment of
a chi ld with Worster-Drought syndrome.
European journal of Disorders of Communication
30,25 6-263. 0
Questions
What are the main features of the
portable training unit?
Why is the full Reading EPG3 also
needed?
How does EPG therapy relate to
other approaches to therapy?
Answers
The pru is lightweight, relatively inexpensive and
used for therapy only.
The full system facilitates thorough
assessment and monitoring of progress by a
clinician with specialist knowledge.
EPG is used in a systematic way along with
encouraging self-monitoring and meta-linguistic
skills.
RESOURCE UPDATE...RESOURCE UPDATE.. . C,?mpetition
aphasia
servrces
A revised guide for Commissioners
and Managers on purchasing
speech and language therapy ser
vices for people with aphasia is
now available.
The British
Aphasiology
Society leaflet
includes: a defini
tion; incidence
and prevalence;
how speech and
language therapy
services can help;
and evidence
based treatment.
For a copy, tel.
Susie Parr on
...-- .......-
-
0117921 1192.

New signs
A third job-specific
signing resource is
available from
SIGNALONG.
Horticulture
&Animal Husbandry
provides 800 signs
for organisations
offering training
and for commercial
and sheltered
working
environments
where people with
language difficulties
are or could be
employed.
From SIGNALONG,
price 17.50, tel.
01634819915.
winners
The winners of the RDLS III
AdVOcacy not enough
in the Autumn 98 issue
Research showing that support systems fail
competition were Barbara
to help parents with learning difficulties has
McLennan and Emily
led to the publication of good practice guid
McArdle from Wirral and
ance for advocates.
West Cheshire NHS Trust
The action research project Parents
with their no-nonsense
Together used an advocacy approach to
entry:
challenge discriminatory views regarding
We believe that RDLS III is an
competence and to lighten the load on fam
essential tool for the new mil
ilies by reducing the environmental pres
lenium.
sures that undermined them. The report
Advocacy for People with Learning
but seriously ........
we've seen it.
Difficulties evaluates the project and gives
we like it,
"advocacy can successfully challenge specif
we want it,
ic instances of bad practice, but it cannot
we're broke!
change the system that generates it."
Thanks to all entrants and
Advocacy for People with Learning Difficulties,
sorry there can only be one
13.95 + pap from Pavilion Publishing, tel.
winner. The RDLS III will be
01273 623222.
reviewed in a later issue.
detailed practice guidance. It accepts that
12 SPEECH & lANGUAGE THERAPY IN PRACfICE WINTER 1998
REV1EWS
HIGHLY RECOMMENDED HIGHLY RECOMMENDED
Reassurance and hope
The Stammering Handbook - a
Definitive Guide to Coping
with a Stammer
Jenny LewIs with the BSA
ermiflon
ISBN 0 091 8 6602
I
Weighty but worthwhile
The Voice Clinic Handbook
Tom Harris, Sara Harris. John Rubin & David
Howard
Whurr
ISBN 1-86156 0346 45.00
This book is wri en for a wide range of specialists and
professionals n olved in the diagnosis and manage
ment of voice pattents. It takes its unique perspective
from the vantage point of a well-established multi-dis
Intelligible,
non-patromslng
The Speech Sciences
R. Kent
Singular
ISBN I 565 93689 2 3 3.00
You t hink acoustic phonetiCs IS just for
fanat ics? Speech productron and perception
models are muddles to you?Your physics of
sound lectures were held apparently in a
8. 9
This IS an inspiring book that offers
practi cal support to stammerers and
those who live or work with t hem. It
examines stammering from the 'inside'
so that the reader begi ns to feel some
of the frustratIOns and achie ement s or
people who stammer. To Illustrate the
impact of dysfluency, life stories are
woven into each chapter. giving a very
personal touch to the book
Encouragement is provided alongside
advice, so that the reader leaves each
chapter convinced th t stammel-ing need
not dominate a person's life. The author
is refreshingly realistic and honest about
the difficulties of being a stammerer but
encourages the reader to look beyond
the dysfiuency, taking a pro-actve role in
overcoming the difficulties.
Jenny Lewis discusses the impact of
stammeri ng on chiidl-en. teenagers and
adults. incl uding the problematic issues
of poor self esteem and limited confi
dence. The advice provided recognises
the need for a wide ariety of support
that meets very Individual needs.
Speech and language therapy IS dis
cussed as one pal-t of the process of
change for the stammerer, with under
standing and acceptance of the dysflu
ency and developing communication
skill s playing an equal part. There are
vel-y hel pful techniques such as desen
sitisation. block modifi cation. slow pro
longed speech. and al so complemen
tary therapy. The author avoids making
judgements about how appropriate
these methods are, all owing the reader
to make his or her own Judgement
about the various types of treatment
availabl e.
Thi s book provides reassurance and
hope to stammerers. It is written in a
'.
very personal and easy style that wi ll
apDeal to many readers and therefore
win be particularly useful for stammer
ers, thei r fami li es. friends and col
leagues. It is unusual to fi nd a book that
IS practical, reassuring and a pleasure to
read: highly recommended!
Koren Da'll es is Clinical Co-ordinator for
Speech and Language Therapy. Stockport
Healthcare NHS Trusc.
ciplinary voice cl inic and recognises that dysphonia is
a symptom resulting from multiple causes and individ
ual predisposing factors.
This is a weighty book. not easy to read but certai nly
worthwhile to use as a resource and reference point
The book is roughly divided into three parts. The first
part is a sol id review of the structural anat omy and
physiol ogy 0 the vocal and respiratory tlacts. It pro
vides a helpful overview of the most common non
malignant causes of voice disorders.
The second part of the book deals with a number of
therapeutic approaches and IS probably the most inter
esting for the speech and language therapist working
with voice. It provi des an outline of assessment consid
erations, an overview of traditional voice exercises. and
describes briefly Jo Estill 's Compulsory Figures and the
Accent method - two approaches used in teaching con
trol over vocal mechanisms. It makes frequent references
to the many facets of voice therapy where Input from
other professionals may be of benefrt and provides
examples where manual therapy and psychotherapy
may be helpful in either individual and / or glUup ses
sions. Manual therapy and methods are desmbed in
some detail but wrt:h the proviso that manipulation and
palpation should only be carried out by experienced
practitioners. Thi s particular chapter may feel daunting
but there is much that can be learned from it in terms of
an Increased awareness of postural problems and effects
on the vocal mechanism. A chapter on the treatment of
psychogenic factors in dysphonia takes a Freudian per
spective in that unexpressed feelings and emotions are
thought to be somatised in the body reSUlting in hyper
tonicity and dysphonia. A group approach based on psy
chotherapeutic prinCiples IS outlined
Further chapters in this section deal wi th speci fIC
problems encountered by professional and semi -pro
fessional singers and provides examples of the type of
pressures these cl ient groups may be subjected t o. A
useful chapter outlines some of the drugs which have
an effect on the vocal tract. There is much to gain
from this chapter although it is written in a less than
user-friendly form; a char t outlining major drugs and
effects on the voice would have been helpful here fOI
those not familiar with pharmacology and biochem
istry. Pros and cons of phonosurgery are discussed in
a brief chapter. with some information about t he pos
sible outcomes for voice quality.
The final section deals with current technology and
the objective measurement of vocal qualities.
Overall. this book provides a wealth of materiaJ for
those interested in voice, with a very clear focus on
interdisci plinary approaches. It is Informat ive in its detail
and can be used as a resource for individual therapists
working without a voice cl ini c as well as those working
or starting to work within a multidiscipl inary team.
Elsje Prinsis 0 Specialist Speech and LanguageTherapist
with Harrogate Health Care NHS Trust
foreign language? The relationship between
net ral substrate, phYSiology. coustics and per
ception of speech is as clear as a foggy
November day to you? Books and articles you
have turned to for help are laden with mpene
trable jargon)
If these scenarros apply, or you are simply eager
to delve into these fascinating areas so central
to lhe speech cl inic and the knowledge base
and research that li es behind it, then Kent' s
book. with its clear diagrams and intelligible,
didactJc, yet non-patronising style. is a recom
mended read.
Fourteen chapters, the fil,t an overview of lhe
book. Introduce the major branches of speech
science. Chapter 2 explains baSI C concepts in
the physics of sound. Chapte(s 3-7 deal wrth the
basic arlatomy, physi ology and neural substl-ate
of the speech and hearing system. Chapte -5 8
I I outline physiological and acousti c phoneti cs
and speech percepti on and production With an
ease t hat readers whose ni ghtmares are popu
lated by terms and formulae from these fields
can never have guessed possible.
Chapter 12 highlights appl ications of speech sci
ences to communication disorders; forensic
phonetics; digital speech coding; human
machine speech communi cati ons; and speech In
art and culture. The penulti mate chapter con
siders what makes speech Uniquely human. The
one concern embryological development
of the speech organs. A glossary supplements
definitions in the main t ext
Thi s is an introductory text. deli'lering concep
tual and factual frameworks on which t o hang
deeper and broader exploration of the fiel d. To
the latter end each chapter concludes with an
annotated list of recommended further reading.
Readers can check t heir progress with self
assessment exercises foll owing each chapter:
I found thi s book attractive not only because of
the painless w y It deals with highly complex
topics, but also because of the overall philoso
phy behi nd it Even a book over 500 pages, such
as thi s. cannot supply the ultimate on every
aspect of speech sciences. Most people Will not
need or want such a degree of detail and rgu
ment anyway. Kent aims for and achieves a com
pleteness suffiCient to impart understanding of
frameworks, terms and issues, but does not
leave readers not seeing the wood for the trees.
Nevertheless he imparts a confidence at
armed with his int roduction, one could ",0 01) iO
tackle theory and appllcatlol- of any of the
themes the book embraCe>.
NIck. Miller ;$ based in the Department o( Speffh.
Umversrty of NewcastJe-Upon-Tyne, NE I 7RU.
SPEeCH & LANGUAGE THERA PY IN PRACn CE \ I ITER 199 13
Speech &Language Therapy in
Practice has acopy of React,
courtesy qf Propeller
Multimedia and Borders
Community Health Services
NHS Trust, for awinning
subscriber. React normally retails
for 425 +VAT and is one of
the most comprehensive and up
to date interactive
programmes available for
working with dysphasics.
To enter, simply state, using no
more than 30 words, why you
should win this software. Send
this with your name (and, if you
know it, your subscriber
number) to Avril Nicoll, Speech
&Language Therapy in Practice,
FREEPOST SC02255,
STONEHAVEN AB39 3ZL*or
e-mail to avrilnicoll@sol.co.uk.
Please note the winner will also
be required to review the
software or provide acase
study based around it for the
Summer 99 issue.
*For readers outvvith the UK the
< address is Lynwood Cottage, High
Street, Drum/ithie,Stonehaven
AB393YZ.
10
14 SPEECH & LANGUAGE THERAPY IN
er

a new, interactive computer programme devel
Borders Community Health Services NHS Trust
_YN\OOller Ltd for use by adults with dys
programme is also suitable for clients with
AllWU."" I III.I'""", and delayed or disordered language
the benefits of working with an interactive multimedia pro
underWindows 95. The programme is simple and intuitive to use,
use of video, audio and animation and has acomprehensive system of
There is acomp h ' ,
in to the ro re enslVe sconng module built
feedback to whthlch gives instant
, 'I bl WI more detailed
ae __ I
" feature allows tne
AcustomlSI(I% elect s?eCWlc tasKS React will r
tnera?lst to atnera?y top PCs Or most desk
flOm tne me(l 'I Gto meet tne rUnmng VVJ gop computers
sess\O(l to be tne c\'le(lt. fitted with n OWs 95 Or 98
s?eClllc (lee CD_ROsaMund card and
dove.
dsfacribe to Speech &Language Therapy in Practice and only one
subscriber number.
..;..M by the on or before 31 st December 1998.
therapist nominated by the editor will select the winning
who the entrants are.
be notified by 6th January 1999.
to Rrovide either areview of the software or acase study
it to &Language Therapy in Practice by 22nd March 1999.
frorrJ Multimedia, Unit I Hardengreen Industrial Estate,Eskbank
EH22 3NX tel. 0131 663 2334, http://www.propeller.netlreact
Reader OfferReader Of{E
APHASIA
Using
entatIon
a
computers with
A
s part of the clinical caseload in Queen Margaret
College's speech and language therapy clinic, people
with aphasia are seen for group therapy during the aca
demic year. Typically the groups include men and
women in their mid-30s to mid-60s who have aphasia and associ
ated communication problems. Usually clients attend the group
after the period of spontaneous recovery can be assumed to be
complete (mainly six months to three years) and, indeed, some are
several years post-onset. Since 1996, clients here have been using
computer-based writing therapy to promote their sentence level
written - and spoken - output.

spelling monitor which can provide auditory feedback through
synthesised speech at the end of a letter, word, sentence or para
" .... can benefit from teatmesd
Linda Armstrong
__wW, lh an evaluation
graph so that the user can hear (repeatedly if required) as well as
see their output. Co:Writer is an intelligent prediction pro
gramme which can be used in conjundion with Write:OutLoud
or other word processing package. It has two useful functions in
lexkal and grammatical prediction (ie word choice and sentence
construction) as well as being a spelling-aid. Its producers suggest
that it is helpful for people with language difficulties or physical
limitations. By inputting the first letter(s) of a word, Co:Writer
will predict what the target may be, based on its own vocabulary,
the user's frequency and recency of word use and British English
people who
have aphasia
spelling (see figure 1 for an example). Users can select the target
from the list by typing the associated number. It also provides a
degree of grammatical prediction, ego subject-verb agreement (see
figure 2 for an example). Together, the programmes can aid written
expression and provide a speech output for people with a variery of
levels of difficulry, from those with single word written production
to those able to write long passages of text.
Such programmes were
originally designed to help
people with physical dis
abilities, such as those
resulting from cerebral
palsy, to reduce keystrokes
thereby reducing physical
effort and resultant fatigue
and decreasing message
transmission time. They are
now used with other groups
of people, such as those
with learning disabilities or
language delay and as strate
gies to improve qualiry as
well as quantiry of written
output. Both can be used
on Windows-based or
Macintosh computers and
importantly are available in
British English.
Kingand Hux (1995) exam
ined the reduction in word
level selection and spelling
errors made by their client
with mild aphasia when he
used Write: OutLoud at six
years post-onset and report
a significant change in wfltIng qualiry with the most striking
change in his written output occurring immediately after introduc
tion of the talking feature. In their review of word prompt pro
grammes, Wood et al (1997) include Co:Writer. It rated \vell
among seven other such programmes evaluated.
Variety of aims
The aims of the computer-based therapy are individual to the cl ient
and priorities for individuals will differ according to their abili ties
......... ....... . . ............ ..... ................. ... lomirlll ed Oliff ...
SPEECH & LANGUAGE THERAPY IN PRACflCE WINTER 1998 15
APHASIA
+- continued from previous page .. ... ..... ..... ...... .... ...... ........... ...... ... ...... .
and needs. Some of the common aims are:
to assist the production of written sentences
to provide combined visual and auditory feedback on appropri
ate use of function words in sentence context, by offering multiple
choice options using grammatical prediction and synthelic speech
confirmation of choices
to provide visual feedback on correct spelling of words, byoffer
ing multiple choice options using word prediction and synthetic
speech confirmation or visual confirmation of choices
to offer opportunities for the production of modelled spoken
output at sentence level.
Quiet
envrronrnentneeded
Initially sessions were organised so that pairs of clients were with
drawn from group sessions to work in parallel with the pro
grammes on the two computers available. Ultimately the plan was
to provide a working environment such as that found in computer
workshops, \"here a room has a number of computers and one
member of staff to help with any problems. Very quickly it became
evident that clients required the quiet environment provided in an
individual session - synthesised speech output from the other com
puter was very distracting and clients required individual support
as they were learning how to use the keyboard and the pro
grammes.
Sessions therefore became one-to-one, usuaJly 30 minutes in
length throughout the two-hour group sessions in the two semes
ters of the academic year with a long break over the summer vaca
tion, that is, approximately 30 sessions per annum. Materials used

SPEAKING FOR MYSELF E
Communication, Speech & Reading Development - l
Speaki ng for Myself was deSIgned by Bob Black Development Officer for The
Down's Syndrome ASSOCIatIon in Devon and West CornwaJl with adVIce from
Grll ian Bird at the Down Syndrome Educational Trust.
Speaking for Myself is a CD ROM designed to support eady language
development in maInstream and special educat ion. It provide; a bank of
resource and eachlng programs to develop whol e wond sight vocabulary.
progressIng in small steps to early sent ence building and simple three word
stories- The pack Includes lots of extra nash cards and stories to prin out.
JUst Itke t he examples provided. Easy-to-use menu structure includes:
Il lustrated Talking First Word
Flash cards with opt onal Rhebus
and Mabton symbols (sUUs and
videos)
Simple Talking St ones
Putting two words together to
encoucage pnoductive language
and baSIC reading . Us.
Movi ng on to three >, vords
Optional Makaton Signing support Placement of objeC1:s
BasiC skil ls exercises Li stening exel'cises
'MiSSing Word' nursery I hymes Shape sorting and mat ching
Number games and activities Avail abl e on 30 days approval
For Wi ndows 11 /95/98. Requi re s a 486 or better processor. 8mb Ram
( 16mb recommended). 256 (or better) colour VGA, sound ca . CD-ROM.
[45 ex.VAT. t:3 p & p. VISA/ACCESS. Please allow 28 days for del ivery.
TOPOLOGIKA SOFTWARE
\Natef5ide House. FaJmouth Road
PENRY . Cornwall TRIO aBE
.1 0 I 326 377771 fax 01326 376755
""",I
web htrpJltopolgka.deman.co
.. File Edll format Options fan1 Speech 4:21 om .1J 161.
Unhtl,' l1 ,

The man is eating his lunch.
I

I
co :U) rlt er Sample Write r

,.
He has some spa
1 : spaces
2: spacy
3: spaghetti
4: spacing
Figure 1 - Prediction (Co:Writer )
varied according to clients' ability but consisted mainly of action
pictures and compos.ite pictures to elicit sentences or paragraphs.
For some, composing a diary became the focus. A hierarchy is evi
dent here in which clients usually began their computer sessions
using the action pictures as a stimulus from which to produce sen
tences. Some remained at this level whilst others developed their
skills to the more abstract and challenging task of creating diary
entries. Composite pictures presented an intermediate degree of
diffICulty where t.he client still had an external stimulus but had
more choice in what to write.
The examples from four typical clients in figure 3 show how the
two programmes can improve the quantity and quality of written
output. For CR and JM, pre- and post-intervention assessments are
shown using ' cookie theft' picture (Goodglass and Kaplan, 1983)
and action picture descriptions respectively. Some quite dramatic
examples of change in written output occurred. However this type
of intervention is not wit.hout problems for the current age-cohort
of clients with acquired aphasia. Problems include:
l.unfamiliarity with the QWERTY keyboard
2.unfamiliarity with computers
3.remembering to check the screen for options
4.the need to be able to access the first letter
5.slow output (eg. typically three sentences written per 30 minute
session)
6.over-learning and overuse of particular structures after accessing
an initial function word
7.generalisalion (of the clients only JM had a computer with the
programmes installed at horne and reported using the programmes
functionally) .
On the other side, many benefits were evident, including:
l.increased client confidence which led to Illore wi .llingness to
attempt written output
2.increased self-esteem through the feedback of the permanent
computer print-alit of clients' written output, which looks much
more 'adult ' than the hand-writing of many clients with acquired
aphasia who have to use either their non-dominant hand to write,
or write with a weak or spastic dominant hand
3.increased self-esteem also through the visual evidence of their
achievement in learning and using the programmes
4.although this type of therapy proved labour-intensive, in that
only two of the clients developed independent skill with t.he pro
grammes, it can also be considered time-effective as spoken pro
duction and written expression can be targeted together.
Generalisation
This type of intervention has both advantages and shortcomings.
Whilst there is no doubt that, for some people with agrammatic
type problems, the programmes can improve written output,
progress is slow and labour-intensive for both the therapist and the
. client. For the current clinical population of people with aphasi a,
effort initially has to be devoted to becoming familiar with the
technology before any intervention for language can be attempted.
For the next generation this effort should not be required. They
16 SPEECH & LANCUACETHERAPY IN PRACTICE WINTER 1998
.. rile Edi1 ronnel Opllons ront Speech
4:32 pm '" li!!l
tJnlitl('(I I

The man is eating his lunch.

Co:Writer Sample Writer
,.
He
1 : is
2: was
3: has
4' and
FIgure 3 - examples from four clients
Client 1 PW
Word processed without a boy is ir. (7 minutes) ('A
help of therapist or the man is ironing')
programmes: lady wo (5 minutes) ('A
ladv was bakino a cake'i
Next session - a week later The lady is knitting a sweater.
with the programmes and The lady is smelling the flowers.
some therapist support:
One year later - with the Today my daughter-in-law
programmes and very little and my son came to visit me.
therapist support: They came to have their tea
with us. They brought some
things with them.
Client 2 - CR
Word-processed description The woman is dishes, tap is
of the 'cookie theft' picture overflow and water a own
(Goodglass and Kaplan, 1983) fl oors. The two children top
without help of therapist or cookie fall off the stool.
the prOClrammes:
Next session - a week later The man is playing cards.
action picture description The woman is eating a roll,
with the programmes and lettuce and tomatoes.
some therapist support: The man is writing a letter to a
friend.
The woman is writing on a
I but she has gloves on.
Seven months later, the The woman is washing the
'cookie theft' picture dishes and the sink is over-
description using the flowing. The water is flowing
programmes independently: down onto the floor. The
children Are playing with the
cookie jar and On top of the
stool and the boy is falling off.
Client 3 - JM
Word-processed action picture The chiznie is the iron the
description without help of ironstichs ('The Chinese man
therapist or the programmes: is ironing (on) the ironing
board')
The woman is bineggs the
dinck. ('The woman is break
ing egCls (into) the ?bowl')
Next session - a week later THE MAN IS KICKING THE
with the programmes and BALL.
some therapist support: THE MAN IS DRINKING HIS BEER.
THE WOMAN IS RIDING A
HORSE.
THE MAN IS PICKING UP THE
PARCEL.
Four months later with the The man is ironing on a ironed
programmes and minimal board.
therapist support: The woman is making a cake.
Client 4 HC
Figure 2 - Grammatical prediction (Co:Writer )
will also probably have more computer literate family suppon, As
ever with speech and language therapy intervention, generalisation
of benefi t is the long-term goaL which can only be achieved when
dients have the technology at home, One of the clients who
achieved most success with the programmes had both a computer
at home with the programmes installed and a daughter who was
able to help if needed,
With the general increase in use of computers, an interesting new
dilemma is emerging for speech and language therapists, If a client
is given a low tech letter board, should it have an alphabetic or the
QWER1Y layout?
References
Goodglass, H, and Kaplan E, (1983) Boston Diagnosti c Aphasia
Examination, Philadelphia: Lea and Febiger.
King, J,M, and Hux, K. (1995) Intervention using talking word pro
cessing software: an aphasia case study. Me 11, 187-192,
Wood, L.A., Rankin, J.L. and Beukelman, D.R. (1997) Word
prompt programmes: current uses and future possibilities,
American Journal of Speech-Language Pathology 6,57-65,
Resources
Write:OutLoud and Co:Writer are available from Don Johnston
Special Needs, teL 01925 241642,
Acknowledgement
Much of the therapy with individual clients was carried out by
supervised third year undergraduate speech and language therapy
students.
Alison MacDonald and Linda AnnslTong are based in the Department of
Speech and Language Sciences, Queen Margaret College, Edinburgh.
Word-processed without granny in daughter house
Co:writer
Same session, word- A granny is in
processed with Co:writer her daughter'S house.
Questions
What i6 the advantage of ogether, the6e programme6 provide word proce66ing,
1J6il1g Co:Writer ' and 6pelling check6, auditory output and prediction of word6
Write:OutLoud c together? , nd grammar.
Why i6 group computer Programme6 with auditory output are di6tracting for
ba6ed therapy not client6 and one-to-one 6upport i6 needed in a quiet
recom mended? environment.
How will computer-ba6ed The next generation of client6 will be more familiar with
therapy become more ..__ and the QWERTY layout, will be able to carry
valuable? on u6ing the p,rogramme6 at home and will have more
informed family 6upport.
SPEECH & lANGUAGE THERAPY IN PRACTICE WINTER 1998 17
REVIEWS

ExceDent
overview
Children Learning
Language - A Practical
Introduction to
Communication
Impairment
Rita Narmore and Robert
Hopper
Singular
ISBN 1-56593-856-9
25.00
This American book provides
an excellent overview of lan
guage development and the
development of communica
tion and literacy.
It is primarily written for teach
ers to learn how to develop
chi ldren's language in the class
room.
It provides information on pre
verbal development the devel
opment of phonology, seman
tics, syntax, pragmatics, literacy
and the inter-relation of lan
guage and cognition. Language
diversity, ie 'linguistically differ
ent children: is a good chapter.
The book is a slim volume at
208 pages but covers each sec
tion well, using recent research.
Their main theme is that chil
dren learn language by being in
a variety of language situations,
for example, refusing some
thing, asking permission. Each
category of communication has
suggestions about how to teach
it
There is one short chapter on
speech and language disorders.
They state that therapy should
use more realistic communica
tion srtuatlons. They say that
training in general cogniti ve
tasks, for example, solving puz
zles, may sharpen children's
learning strategies to t he point
that they learn to communicate
and that children should be led
into interpersonal encounters
in which language and commu
nicati on ski lls can be used to
accompli sh goals for the chil
dren. If only it was so simpl e
l
The authors refer to recent
research which is of use to new
t herapists and for more experi
enced therapists in backing up
observations and to give new
insights Into one's work. I highly
recommend it for the excel
lence of the overview chapters.
Connne Garvie is a private
speech and language therapist in
Cambridge.
More pieces of
theptizzle
Clinical Phonetics and
linguistiCS
Ed. Wolfram Ziegler &
Karin Deger
Whurr
ISBN I 86/ 56 054 0
3500
Thi s book is a collection of
research papers presented at
an International Cl inical
Phonetics and Linguistics
Conference in 1996. As such,
rt covers a diverse range of
topics from these fields with
relevance to both paediatnc
and adult speech and lan
guage therapy. The topic
based layout allowsthe read
er to concentrate on specifi C
areas of interest while dip
ping Into other related sec
tions. Some topics provide a
useful overview of the cur
rent literature.
To get t he most out of this
book and to understand the
detail of the research and rts
relevance to current thinking,
a working knowledge of lan
guage models would be ben
eficial. However, with less
knowledge, there is still much
to be learned.Those looking
purely for direct pointers to
therapy wil l not find many of
them here. What they will
gain are a few more pieces
to the jigsaw puzzle of lan
guage understanding and t he
benefit of a wide range of
client studies.
This book could be a useful
addition to a speech and lan
guage therapy department
library, particularly where
therapists are undertaking
research or case study vork.
Its value is in providing a
wide ranging resource wrth
the potential transfer of ideas
across the fields as well as in
to the clinic. For me, rt pro
vided a further insight into
the awareness that
researchers are gaining of
t he complexity of communi
cation and rts encoding, a
deepened respect for this
complexity whi ch, as clini
cians, we deal with on a daily
basi s and rt sent me away
inspired to broaden my own
understanding.
Tiffany Birch is a speech and
language therapist in London.
I
Adifferent perspective
Coping With Aphasia
Jon G Lyon
Singular
ISBN 1-879/05- 75-6 [ 31 00
Jon Lyon has spent more than thirty
years working in both research and clin
ical settings. He is passionate about shar
ing insights into ways in which life can be
lived normally, despite the presence of
aphasia. This is therefore a practical book
aimed at supporting aphasics and their
families. It does not assume that rts read
ers are fami liar with speech and language
impairment and contains Jargon-free
information and advice. It al so provi des
clinicians with a perspective other than
that found In classic aphasia texts.
The book is divided into four main sec
tions. The first section describes what
aphasia is and is not Lyon also spends
time provi ding the reader with an
overview of the rest of the book.
Section two is wrrtten as a 'journey';
from onset of aphasia and initial hospi
talisation, through rehabilitation to life
several years on. My feeling is that Lyon
overdid the metaphor of a 'Journey' .
Within this section key points are high
lighted and boxed and are wrrtten from
the perspective of the caregiver or the
person with aphasia. For Instance, In the
chapter about leaving care and going
home. Lyon has Identified several wor
ries that the aphasic might have. He then
makes suggestions as to what t he care
giver might want to say or do in
response to such worries. Section three
consists of concise and readable expla
nations of speech, language and commu
nication and t he changes that can occur
following aphasia. It also includes
descriptions of causes of aphasia and
how to reduce further risk.The last sec
tion contains a selection of personal sto
ries. Each of these deSCrIbes how others
have ri sen to the challenge of living wrth
aphasia. The appendices which mainly
provide advice and addresses of where
to look for help are less helpful for those
not resident in the USA However, they
do Include a useful 'glossary of terms'.
Overall I feel the book provides insights
of particular interest to newly qualified
clinicians. Cl inicians responsible for pro
viding training to volunteer groups or to
other health profeSSional s may also
enjoy dipping into it Unfortunately I am
not sure this is a book I would recom
mend to patients or their families.
Although it is almost entirel y Jargon-free
and full of useful information I was
uncomfortable with Its tone which
seemed patronising.
Mary-Lou Pevolin is a speech and language
therapist wi Plymouth Community NHS
Trust work.ing in a Strok.e Unit
Useful for every
department
A Coursebook on Scientific
and Professional Writing for
Speech-Language Pathology
(2nd ed.)
ME Hegde
Singular
ISBN /-56593-868-2 [3/00
This American coursebook, a
lengthy, spiral-bound tome of 424
pages, is presented as a practical
teaching tool and resource manual.
The main body of the book con
sists of exemplars and exercises
each heralded by a detailed and
pedantic heading in the contents
page (eg. AI.l I. Join Independent
Clauses W rth a Semicolon When
the Clauses Are Not Joined by a
Conjuncti on; B.3.3I . Cite Both
Names in the Text When a Work
HasTwo Authors). Indeed, the fi ve
contents pages are presented in
such a manner as to constitute a
pocket-guide all by themselves
The book is divided into parts A B
and CAt the back is a useful glossary
of terms and a small bibliography.
Part A is designed to teach the
basic ski ll s of good wrrting and cov
ers composrtion, grammar and a
useful section on commonly mi s
used words such as Incidence and
Prevalence.
Part B teaches scientifiC writing
skills and focuses on accurate and
appropriate presentation of papers
for publicat ion. This specifiC style of
writing is also required for research
or bursary applicati ons. Topics
addressed incl ude the correct cita
tion of references and the accept
able format for papers.
Part C offers information and
examples of formal. well-construct
ed professional reports such as
referral letters and comprehensive
treatment plans.
Professional wnting skills are a must,
not just for students or those
engaged in research. Audrt is now
high on the agenda as is communi
cating with purchasers and colleagues
in health and education and our wrrt
ten communications should be of the
highest standard. Dr Hegde's book IS
a useful tool for every department.
This is not an elegant book. but nei
ther is it frightening. Easily digestible
and cleverly laid out, it will serve as
a rererence work for the experi
enced to dip into and as a confi
dence buil der for those considering
writ ing an article.
Kate Padfield, speech and language
therapist
18 SPEECH & LANGUAGE THERAPY IN PRACTI CE WINTER 1998
May be useful for parents
Child Language Development
Learning to Talk
Sondra Bochner, Penny Price, Jane Jones
..
Whurr
ISBN I 861560400
[19.50
This book is based on the interactional
model of language development and
the language programme described in
the book was developed in Australia.
Part I gives the background to the language
programme, with an overvie'll of theories of
language development and developmental
stages of language development Of more
use, particularly to those unfamiliar with
interactional models, are chapters 3 and 4
which nefer to contexts for learning: routine
events and play, and talking to childnen.
Part 2 contains the main detail of the pro
gramme. Chapter 5 gives an overview of
how to set up a language programme, whilst
chapters 6 to 10 detail the five programme
levels: preliminary skills Uoint attention; turn
taking; imitation; play); pre-verbal skills (pro
towords); first words; early sentences and
communicative intentions.
Part 3 explores the Issues of phonological
development, signing as a stepping stone to
speech, working with childnen within group
settings, such as playgroups or pre-school
units, and finally an early language model
support project is described.
The authors state that the book has been
written for any professional working with
language-delayed childnen and that it may
also be useful for parents. Certainly, it is nel
atively Jargon-free and it would be possible
to work with a parent through Part 2 of the
book. Howevec the content and activities
will alneady be familiar to most experienced
paediatric speech and language therapists.
The auihors suggest that the programme
can be Impl emented with any child having
expnessi ve language difficulties, including
those "with learning disabilities, developmen
tal delay or Intellectual impairment" It is a
shame that more detail and discussion as to
the progress of different sub-types of chil
dren could not be incl uded and that evalua
tive data of programme impact was limited
to before and after language scores of thir
teen children completing the programme.
A large proportion of t his book (at 44
pages, almost a fifth) IS given to resource
rl}aterlals In the form of an appendix. It is
unfortunate that these are not copyright
free, especially as some of this material could
be very usefully employed with parents.
In spite of this, Child Language Develop
ment: Learning to Talk would be a useful and
very readable addition to departmental
libraries.

Practical ideas lacking
Early Intervention for Special
Populations of Infants and Toddlers
Ed Louis Rosetti & Jock Kile
Singular
ISBN 1-56593-798-8
[1995
This book contains a compilation from
the first seven years of the In(ant- Toddler
In tervention: The Transdiscipilnary Journal.
Some of the most pertinent articles,
from authors in t he USA and Canada
have been selected for inclusion.
The book is arranged around five key
themes. The kst section addresses issues
around the identi fication, assessment and
management of heari ng impairments. The
second looks at enhancing the overall per
formance of childnen with physical limita
tions. Section three examines the effects of
pre-natal cocaine and drug exposure. The
fourth deals with tracheotomised children
and the fifth provides information on the
development of premature and low birth
weight infants.
The editors provide a brief introduction to
the papers at the start of the book but fur
ther commentary would have been useful at
the beginning of each section, particularly in
aiming to pull key Issues t o g e t h e ~
All 17 articles in this volume make fascinat
ing neading, but clinicians expecting practical
and definitive ideas - which may be suggest
ed from the actual title - could be disap
pointed. Being journal articles, many papers
describe studies undertaken, presenting
methodologies and results which are dis
cussed, invariably leading to suggestions for
future studies. Section one is probably the
most practically based and hence most use
ful for clinicians, with some helpful papers on
intervention for infants and toddlers with
hearing impairment It also serves to high
light current diffenences in procedures in the
identification and assessment of hearing
impairments between the US and UK.
This book would potentially be of interest to
speech and language therapists working in
any of the above areas. Howevec as some of
the sections contain only a few articles, clin
icians who are able may be advised to access
them via The Transdisciplinary Journal. The
book may also have limitations for UK clini
cians in that it is obviously concerned with
American services and aimed at American
readers.
This book would be a useful addition to a
resource library for a multidisciplinary early
intervention team, such as in a child devel
opment centre, and would be Interesting
reading for clinicians working with hearing
impaired children, but is unlikely to be vital
reading for many other clinicians.
REVIEWS

Interesting but not
recommended for UK
Adult Neurogenic Language Disorders
- Assessment and Treatment
Joan Payne
Singular
ISBN 1-56593-729-5 [3400
This book is well written, well researched
and easy to read. However, its usefulness for
therapists in this country is likely to be
largely academic. A detailed account is given of
ethno cultural diffenences in an ageing popula
tion, something that would be useful for all clin
icians working with the elderly but, as this book
is American, the many statistics and details given
are based on the background of various
American ethnic groups.
The book concentrates on a socio-linguistic
approach to patient care and begins by looking
at the social/cultural attitudes we as therapists
br,ng to our work. Current research groups the
elderly population together; this can make it
appear that the elderly ane a discrete and simi
lar group who "lose their individual cultural
Identities" and may, as a result, be treated as
such by professionals. Payne instead suggests
that, as we age, we become more like ourselves
and mone individual.
The book itself is divided Into concise readable
chapters looki ng at various disorders and their
effect on elderly adult language, prefaced by sta
tistics on risk factors and pnevalence in various
ethno cultural groups. The information on disor
ders is well written and up to date and includes
many references. The broad principles of the
book are excellent with strong emphasis on
functional therapy and emphasising cultural
background of the client, along with useful
guidelines for working with any patients who
come from a different cultural background from
your own. (ThiS may include being a Southerner
working in Manchester
l
) Joan Payne exhorts us
to treat each patient individually and encour
ages us to read more information about the tar
get cultural groups we work with.
The author's concern that therapy should be
culturally appropriate is surely relevant to all
clinicians. The only drawback of this excellent
book is the fact it is so firmly based on informa
tion applicable to the American nation and that
this alone may make it inappropriate for a
department looking for a useful general clinical
book on a tight budget
The book would be useful for students or t her
apists with a speCial interest in social linguistics.
What would be more useful however in the UK
is a Similar book based on the ethno cultural
groups living here, and how their cultural hls{o
ry has developed and evolved since their mclu
sion here in British society Such a boo": lNOu'd
be an invaluable clinical tool. As it is. rt remai)s
an interesting read but couldn't be recom
mended for its practical appli ea ons ,n ilosp-",_,
in the United Kingdom.
Dr Deborah Gibbard is Chief Speech & Language Therapist (Paediatrics) (or Portsmouth HealthCare Jane Scott is a Specialisl Speech & La gl.'a,;--e
NHS Trust Thera pist working In South Manchester HosP.l5..
SPEECH & lANGUAGE THERAPY IN PRACTI CE WI NTI R 1998 19
L.
Q)
L.
Q)
FURTHER READING
further reading...
This regular feature aims to provide information about articles in other journals which
may be of interest to readers.
The Editor has selected these summaries from a Speech & Language Database compiled by
Biomedical Research Indexing. Every article in over thirty journals is abstracted for this data
base, supplemented by a monthly scan of Medline to pick out relevant articles from others.
To subscribe to the Index to Recent Literature on Speech & Language contact
Christopher Norris, Downe, Baldersby, Thirsk, North Yorkshire Y07 4PP, tel. 01765
.; 640283, fax 01765 640556. Annual rates are: Disks (for Windows 3. 1, can run on
Windows 95): Institution 90; Individual 48. Printed version: Institution 60; Individual
36. Cheques are payable to Biomedical Research Indexing.
HYPERNASALITY
Schmaman, L.. Jordaan, H, Jammine, GH (1998) Risk factors for permanent
hypernasa lity after adenoidectomy. So uth A(rican Medical Jo urnal 88 (3).
OBJ ECTIVES: To investigate the causes o( apparenrJy permonent
hypemasal speech (ollowing adenoidectomy in 10 subjects without overt
palates, and to establish a protocol to be (ollowed before thiS operauon is per
(orm ed. DESIGN. Retrospective and descriptive design. PARTICIPANTS: Ten sub
jects, (ulfiliing the (o llowing ({I tena, were included:(I) subjects had undergone
adenoidectomy which resulted in hypernasal speech thot persisted for longer
than three months (ond was therefore considered to be permanenr), (ii) sub
je IS did not have a clefc lip or overt deft polate:(iii) there wos no heanng loss
o(SUfficient magnlwde to account (or the hypernasal speech: and (rY) the hyper
nasolity was rated as severe by a speech therapist could not be remedied by
speech theropy alone and required furth er management by plastl( surgeon
through pho yngoplasry Ten subjects were (ou nd through the cflnical records o(
speech therapists and plastic surgeons workmg in hospitals and private rac
uce. The (a llowingin form ation was obtained through interviews or by reading the
case files. (i) in(ormauon: (ii) the presence o( any o( the fac ors
reported in the literature to be associated with the permanent hypemosallty or
asal emISSion, as well as the method o( ide nfication: and (iii) whe ther these
(actors had been idendfled before or after the adenoidectomy. RESULTS: Nin e
out o( a total o( 10 subjects showed preoperavve perceptual and structural
characteristics andlor case history (actors that hove been documented to con
svtute nsk (actors (or the development o( nasal speech, should on adenOidec
tomy be performed. The methods used to InvestJgate these (actors pre-opera
tJvely appear to have been In adequate. CONCLUSION: ThiS undeSirable sequel
to sur ery can be prevented i( certarn case history and speech (actors are loves
vgored and (ollowed up with radiographic procedures i( necessary
LARYNGECTOMY
Watterson, T, Cox, TL., McFarlane, S.c ( 1998) Speech intelligibility using
four different electric -neck larynges. Phonoscope I ( I).
This study investigated vowel identification and sentence rntellrgibll,ty in eight
alaryngeol speakers using each o( (our electric-neck artifiCIal larynges. The
Servox Inton. t'1e AT& T5E. and the Neovox were not significanrly different (or
erther vowelldentJficauon or sentence Intellrgrbdity The Park Jedcom scored srg
nrficanzJy lower on both measures bu t the absolute drfferences were small The
most rdenti fiable owel was lalphal and the least idenU(rable was lui. On 0
scale (rom I to 5 With 5 berng "highly inteilrglble," the mean sentence mtelligi
bility raung (or all ar!i(iciallarynges co mbrned was only 2 98.
SLEEP DEPRIVATION
Hamson. y, Horne, JA (1997) Sleep deprivation affects speech. Sleep 20
(10) .
His orical accounts o( sleep loss studies have descnbed changes in the content
and patte'ns of speech, although to date these claims h 'e not been system
atically sWdied. We examined the effects o( sleep loss on the spon taneous gen
eratlon 0 words during 0 verbal word Vuency task and the articulation o(speech
during 0 ocalised reading task. Nine subjects underwent two counterbolanced
36-lJour trials involVing sleep depnvation (SO) and no sleep deprivation (NS D).
After So. there was a signlficam deterioration in lord generaIJon and a ten
dency (or subjects to become (ixated within a semanIJc category There was a
Ignlficant redJC 'on in the subjects' use o( approprrote rntonatlo In the vOice
alierSO, wrth subjeas dIsplaying more monotonic or rattened voices. These (rnd
ings are discussed in light 0 neuropsycho/ogicol evrdence concerning the (unc
tlors o( sleep In reiauon to the {rontal cortex nd in Irght o( the implicauons (or
interpersonal communication in the event o( sleep loss.
20 SPEECH & LANGUAGE THERAPY IN PRACTtCE WlNTER 1998
APHASIA
Holland. A.L. (1998) Functional outcome assessment of aphasia following
left hemisphere stroke. Seminars in Speech and Language 19 (3).
ThiS afficle discusses issues regardrng the assessment o( (unetional outcomes in
mdrYrduals who have aphaslO (ollowmg stroke. Some different approaches to
functronal outcome measurement are critically reviewed, ranging {rom general
measures of stroke outcome to measures that have been designed speCifically
for aphasic rndividuals, to measurements fOCUSing on aphasra's effects on qual
ity o( li(e. Examples of how (0 relate rreaunent o( aphasia drreczJy to functional
outcomes assessment are also prOVIded.
ACCENTS
Nathan, L, Wells, B., Donlan, C. ( 1998) Children's comprehension of unfa
mi liar regional accents: a prel iminary investigation. Journal of Child Language
25 (2).
The effect o( regional accen on children's processing o(speech IS a theoretically
and practically important aspect of phonologrcal development that has been lit
tle researched. Forty-erght chrldren (rom London, aged four and seven years old,
were tested on their ability to repeat and define single words presented In heir
own accent and in a Glaswegian accent. Results showed that word compre
hension was signr{!cant./y reduced In the Glaswegian condiuon and that (our
year-olds performed less success(ul'y than seven-year-o/ds. Both groups mode
Simrl ar numbers o( lexrcal misidentificatrons, but the younger children were more
likely to (ail to access any word at 01/ On the repetrtion ask, the younger chil
dren showed a different pattern o( errors to the older children, therr productions
being apparent.1y more by the phonetics o( the Glaswegian svmuli. It
rs suggested that such phonetic responses are related to the younger children's
farlw'e to map the unfamrliar accent onto therr own phonological representa
rion s. It is proposed that the leXical misidenuficatrons, common to both age
groups, are more Irkely to be induced oy lock of context The paper concludes
with discussion of if plicotions o( these findings (or our underswndmg of how
children develop the ability !O process unfamllrar regional accents
DYSPHAGIA
Harrington, 0.B, Duckworth, J.K., Stal-nes, C.L.. White, P, Fleming, L,
Kritchevsky, S. B., Pickeri ng, R. ( 1998) Srl ent aspiration after coronary artery
bypass grafting. An als o(Thoracic Surgery 65 (6).
BACKGROUND.' "Silent" asplraIJon vas recognrsed to be a more frequent com
plrcatJon at till S hosprtal in po ems who ave had coronaryartery bypass oraft
ing thcm In the general surgrcol populolJon. METHODS. A case-mntrol retJ'o
specuve sWdy covenng a 4. 5year penod wos conducted to determine risk (Oc
tors (or pharyngeal dys(uncuon resultJng rn silent aspiration. RESULTS.' Significanr
predlctols o( sr1em spirauon were age, hrs tory of cerebral vascular disease,
msuJin-{}epe dent diabetes mellitus, myocardral rn(arcMn, ond chronrc obstruc
uI'e pulmonnry drsease. IntrDaOrtlC bailoon pump ond number o( units 0 fresh
frozen plasma were the only independent intraoperative (act ors associated with
sitent asprratio In a model using continuous variables directly. Cold /ibrillalion
vIas used rn 7 0(53 study cases but no control patients, so it could not be mod
elled. Pos peratlVe mplrcations occumng WIth greater (requencyincluded neu
rologic com lica/lons, adver e ulmonary outcomes, repeClt surgical interven
uons, Infection, and death USing an Asp,rat/on RIsk Profile developed (rom the
retrospecuve study. In a detailed pros eCUve stucP/ o( I 0 three o( (our
pauenrs '<Vith ostoperalNe dysphagra had objective e.tidence o( stroke. CON
CLUSIONS: These findrngs suggest thot postoperatrve coronary artery bypass
graff dysphagia may be the resu/r ofintraoperaUve cerebral rnjury. and thot core
(ul postoperative clmiC(}1 ev luation o( coronary artery bypass graft patients with
nsk (actors may result In eady' diagnosis of pharyngeal dysfunction wrth the
goals of prevenung srlent ospir'O 'or; and reducing morbidity, marta ity. and hos
pital cost.
A creative
Pad I
,.
B e ! l . ~ ~ ~ and
Endings
...
I
In a two-part
article on the use
of drama in
speech and
language therapy
groups to improve
clients' language
development,
social interaction
and pragmatic
skills, Myra Kersner
argues we have
much to learn in a
wider sense from
the way drama
sessions are
structured. Part 1
addresses
Beginnings and
Endings when
working with
communication-
impaired children.
In the Spring 99
issue, Part II will
focus on the main
part of a session
l The Middle.
-
rama is of value to speech
and language therapists in
two important ways.
Firstly, through the use of
dramatic techniques
which may be adapted for
groups or individual
clients, of any age, irrespective of the
nature of their communication impair
ment, as a medium through which creative
expression may be encouraged. Secondly,
through an understanding of the nature
and structure of a typical drama session:
the beginning - warming up; the middle
the development of the work, and the end
ing - closure (see Kersner 1997), as this
may enable therapists to reflect on the
structure of speech and language therapy
sessions.
Interactive process
Essentially, drama is a shared, interactive
process involving other people (Jennings,
1998), and dramatic techniques may be
used in a variety of ways. For example, they
may be used specifically as part of a thera
peutic process such as in dramatherapy; or
in dramatic play where the therapeutic
effect is merely a serendipitous conse
quence (Kersner, 1989). Drama may also
be developed as theatre, when the partici
pants work towards a performance to be
received and 'judged' by an audience.
However, it is the development of creative
drama which may be particularly helpful
when working with communication
impaired children as this does not neces
sarily require an audience and the value of
the work lies in 'the nature of the experi
ence itself; (McGregor el at, 1977). There
is no 'right way' to do creative drama so
that it provides scope for pupils of all abil
ities to work to their respective strengths,
using it as 'a medium for learning and shar
ing and expressing meaning'(Peter, 1994).
A natural conduit
Creative drama encompasses a wide variety
of activities and dramatic techniques
which may range from pre-drama, such as
sensory stimulation, to dramatic play
involving the development of character,
the use of role play, and the development
and acting-out of stories (Kersner, 1997).
Activities within a creative drama session
may also incorporate other creative arts
such as music and sounds; art; movement
and dance; all aspects of non verbal com
munication; mime; puppetry, and play; as
well as voice work including speech; and
language work - spoken, written, or signed.
Thus, when working with communication
impaired children, creative drama may be
used in a variety of ways, usually with
groups, as a medium through which com
munication skills may be developed, ver
bally, or non verbally, for it provides 'a nat
ural conduit through which communica
tion may flow; (Kersner, 1997).
Preparing for drama
Setting the boundaries
When working with creative drama, it is
important 'to provide a safe and accepting
environment in which clients may gain the
confidence to experiment and explore
areas they may otherwise have avoided'
(Kersner, 1989). Thus, drama sessions nor
mally take place in what Jennings (1998)
refers to as a 'space-set-apart' that is, in a
separate place at a specifically designated
time. This is not only for practical purpos
es, but also to indicate to the children that
this is ' their' set-aside time and space, with
in which they will be given 'controlled
freedom' as a means of enabling them to
be creative. The drama session is a place in
which the therapist wi .11 strive to create a
relaxed, comfortable, non-j udgmental
atmosphere and provide opportunities for
. .............. .... ... ........ c(lntillued OI!eT -+
SPEECH & lANGUAGE THERAPY IN PRACTICE WI NTER 1998 21
GROUPS
+- continued from previous page................... .
the children to play and experiment so
that, through drama, they may be encour
aged to explore aspects of communication
and to express themselves freely - with or
without words. .
Contracts and rules
To help create a 'safe and accepting envi
ronment' it is important at the outset to
make the contract clear and to set the rules
- by negotiation - for the life cycle of the
group. Then the atmosphere within the
group may be conducive to encouraging
the children's engagement and active par
ticipation (Canenach, 1992). For example,
if from the beginning the children know
the number of sessions planned within the
series, then they will be better prepared to
accept their inevitable ending. If rules such
as the open or closed nature of group
membership, basic approaches to disci
pline and what constitutes acceptable
social behaviour in the sessions are estab
lished, then there can be no uncertainty
about expected behaviour. Similarly, if it is
agreed by the group that they wiil take con
versational turns, listen to each other and
not talk over each other, then the founda
tions have been laid for the potential
development of social interaction and
good working relationships within the
group. The approach to confidentiality
may also need to be addressed, particular
ly when working on social skills where sen
sitive issues may be raised.
Structuring the sessions
I f the overall as well as the individual ses
sions are carefully structured, then the
most effective use may be made of the time
and space set aside for creative drama. It is
important that the children are aware of
this structure and have a broad under
standing about the aims and expectations
of the therapist and the work which will be
undertaken within the sessions, as uncer
tainty over such issues often leads to anxi
ety. For example, it is helpful if the sessions
can be arranged for the same time each
week and for them to start and end on
time, so that the children may develop a
sense of routine - and trust.
It is important at the beginning of each ses
sion for the children to have a gradual
lead-in to the major piece of work, and it is
even more critical that there is adequate
preparation for ending. All of the children,
irrespective of their sense or concept of
time, should be made aware that the ses
sion is drawing to a close.
Thus, most successful drama sessions have
a carefully pre-planned, three-section
structure in which the beginning, middle
and ending of each individual session are
clearly defined . In this way during the
Beginning section the children have an
opportunity to prepare themselves for the
main body of work, they are able to develop
the work in the Middle section, and during
the Ending section they have the opportuni-
Myra Kersner is a Sen iar Lecturer in the
Department of Human Communication
Science, Unillersity College London.
ty to unwind. The repetition of this basic
structure will become part of a familiar rou
tine and may in itself become a ritual.
Of course, there can be no specifically pre
scribed ratio of time aUotted to each of
these three sections. Jennings (1986), how
ever, suggests that approximately a quarter
of the overall session time should be aUol
ted to the beginning, a quarter to the clo
sure, with the remaining half of the session
being devoted to the main development of
the work in the middle. Although Jennings
was writing with reference to drama, this
useful structure may be appropriate for any
speech and language therapy session.
Working with drama
Beginnings
The beginning of a session is often referred
to as 'the warm-up'. In movement sessions
initial flexing and stretching activities are
particularly necessary so that the muscles
are eased rather than shocked into action.
It is equally important with any creative
drama that the children are given time to
limber up and prepare for the activities to
come. As the sessions progress, and some
of the activities in this section become
familiar to the children, this helps to pro
vide security and acts as a reminder of
work undertaken previously by the group
(BrudenelL 1987).
Initial exercises may be specifically geared
towards helping the group to reassemble
and re-form. These might be name games,
involving throwing a baiL a cushion or a
bean bag if they are still getting to know
each other: or a game of observation and
description could be substituted if they are
already familiar with each others' names so
that they are asked for example to ' pass the
ball to the boy with curly hair' , or 'the girl
with the black sweatshirt: Alternatively, a
round of ' hello and welcome' may be sung,
or spoken, or they may acknowledge each
other in different ways non verbally.
Sometimes, a warm-up may take the form
of more general activities to enable the
children to settle in and adjust to the
change of environment. One such activity
may be carried out while Si tting in a circle.
Depending on their verbal abilities and
any underlying aims regarding speech and
language development, each child could
give a 'before and now' statement such as:
'before I was in the classroom writing, now
I am with the group for drama'. Or it may
be more expedient to involve the children
in a physical activity such as touching a
number of objects in the room within a
specified time limit. The time given would
depend on whether the tempo of the group
needed to be speeded up or calmed down.
Warm-up activities may also be more
speCifically related to the ensuing activities
planned for The Middle section (to be dis
cussed in Part II). Thus for instance, in a
social skills group where the main body of
work will ultimately involve improvisation
and role play, the children may begin with
activities which lead-in to the task of tak
ing on a role and developing a character.
For example, they might walk round the
room as an athlete, then as a model, then
as an old man, or they could pretend to
wear different modes of dress noting how
this affects their movements and gestures
as they walk, run or sit. They could be
introduced to imprOvisation by having to
pantomime a worker's movements such as
being a window cleaner, operating a com
puter, or preparing to jump off a high div
ing board. All of this preparatory work
would then enhance their abilities to con
duct an appropriate, improvised role play
in the middle part of the session.
Of course the lead-in time provides an
opportunity for the therapist to deal with
any administrative details, for example to
remind the group about the rules and
boundaries. It also enables the therapist to
observe the group and to check on the phys
ical and emotional state of the individual
children (Cattenach, 1992) so that the
ensuing work may be focused appropri ately.
Endings
It is important that children who are
involved in anyon-going groups such as
speech and language therapy groups or cre
ative drama groups should be aware of
endings - the ending of the series of ses
sions as well as that of each individual ses
sion. They need to be able to wind down,
mark the end, and say goodbye to the peo
ple involved so that they are not left with
the uncertainty - and potential anxiety
which often surrounds incompleteness. If
the ending of the series is referred to in ear
lier sessions, the final ending will not
come as a shock. However, if they are told
'By the way, we won't be here next week,
this is the last time we'lJ meet: suddenly at
the end of the final session of the series,
they may be surprised and bewildered.
They may feel guilty, not realising that the
work has reached its planned end and even
feel angry that they have not had an oppor
tunity to say goodbye.
It is equally important within each indi
vidual session for the children to be able to
' make a grad ua l transition from the focus
of the session back to the focus of everyday
life' (Jennings, 1986). They must have an
opportunity to wind down at the end of
22 SPEECH & LANGUAGE TH ERAPV IN PRACTICE WINTER 1998
GROUPS
each session and to prepare themselves
mentally 'IS well as physically for their
return to the classroom, or the prior activi
ties with which they were engaged. It is

also necessary 'to provide time within
drama sessions for children to complete
the work and disengage themselves from
any emotions and feelings which may have
been aroused by it' (Kersner, 1997).
Closure activities which become part of the
routine or ritual of the group sessions have
the additional benefit of offering the chil
dren an opportunity to recap and talk
together about the session's activities,
enabling them to reflect and evaluate the
experience in their own way, even if they
are not able to do so vocally, or verbally
(Cattenach, J 992). For example they could
be asked, using single words or whole sen
tences, to name one aspect of the session
which they have enjoyed, or one thing
which they are taking away with them
from the experience. Non verbally they
could strike a pose or create a short move
ment sequence expressing how they feel, or
draw an image or a symbol either individu
ally, or collectively on a large sheet of paper.
If they have been expending much energy
during the session they may need to spend
some time calming down during the c10
sure, either resting, relaxing or J,istening to
music or a story. A group song or recitation
of a familiar poem is often a successful rit
ual with which to mark the end or, without
words, they could find some way of saying
goodbye to each other individually and /
or collectively. This may be done by stand
ing in a circle, each person silently making
eye contact with everyone in tJhe group. Or,
they could hold hands and pass on a gentle
hand squeeze from one to the other until it
has passed around the whole group.
What we can learn
frOl1l drama
Many parallels can be drawn between cre
ative drama sessions and speech and lan
guage therapy groups, particularly when
they focus on language development, social
interaction and pragmatic skills, and many
dramatic techniques may be used equally
effectively in both kinds of groups.
Although it is not always appropriate for
speech and language therapy sessions to be
separate from classroom activities, there are
occasions when it is more effective for
groups to be run separately. It is useful for
speech and language therapists to reflect,
however, on the parallels in structure and to
recognise the importance, whether working
with groups or individuals, of enabling the
children not only to 'war.m-up' to their
work, but also ritualistically to 'wind down'.
References
Brudenell, P. (1987) Dramatherapy with
Peop le with a Mental Handicap in S.
jennings (Ed) Dramatherapy: Theory and
Practice for Teachers and Clinicians.
Beckenharri: Croom Helm.
Cauanach, A. (1992) Drama for People with
Special Needs. London: A & C Black Ltd.
jennings, S. (1986) Creative Drama in
Groupwork. Bicester: Winslow Press.
jennings, S. (1998) Introduction to
Dramatherapy. London: jessica Kingsley
Publishers Ltd,
Kersner, M. (1989) Drama in therapy is
more than acting. Speech Therapy m
Practice 5 (5).
Kersner, M, (1997) The use of drama in
working with chitdren with learning dis
abilities in M. Fawcus (Ed) Children with
Learning Difftculties. London: Whurr
Publishers.
McGregor, L., Tate, M. and Robinson, K.
(1977) Learning Through Drama . Oxford:
Heinemann Educational.
Peter, M. (J 994) Drama for All. London:
David Fulton Publishers.
Address for details of drama courses and correspondence: Myra Kersner DHCS, UCL, Chandler House, 2, Wakefield SI, London WClN 1PG
Tel: 0171 5044217 e-mail M.Kersner@UCL.ac.uk
See our web site at http://www.sol.co.uk/s/speechmagforareprintofMyraKersner.s 1989 artide in Speech Ther.apy in Practice (courtesy of Hexagon Publishing).
Questions Answers
What can a warm-up
11111111I1-IGroup members need time to cope with change, to build
period achieve for group
up relationships and trust and to be physicafly and
members?
mentally prepared.
How do beginnings
Therapists have time to observe and adjust plans and
benefit a speech and
MtiWl tempo depending on the participants' needs .
language therapist?
Why are clear endings
M I i I ~ H People need time to reflect and disengage, to relax and to
necessary?
say goodbye.
NEWS... NEWS... NEWS... NEWS... NEWS... NEWS... NEWS
User groups iInprove seJVices
Happy pupils
In contrast to the mainly negative experi
The success of a local user group in improving sent an authentic picture of how the views,
ences of life reported by disabled adults, a
services has led to the publication of guide feelings and aspirations of people with a
survey of children in mainstream education
lines to encourage others to get together. sensory loss can be taken seriously and
has found that disabled children are happier
A local group of people with a visual and / developed into effective service provision."
at school than their non-disabled peers.
or hearing loss formed to take an active The detailed guidelines cover planning; ini
Children aged seven to eleven years were sur
role in the local service planning process is tial steps; communication; environment;
veyed on behalf ~ COPE. More,D[.th dis
now consulted by East Devon health and information; understanding; consultation;
abled child an the non-dtsaDItiI fell
social services before any other body, to networking / action / targets; and results /
th elonged and were O"ea1ed falrly, t
ensure decisions on budgets and expendi integration / satisfaction. Throughout, the
001. Thwmari s Chi Exerufu'e Ri ani
ture reflect real needs. In support of The experience of the group is detailed with the Brewster, aid the results Were li tlY
Living Options (Devon) report, Lord key practical points highlighted. ing but very encouragi ng. He "'Quid n -like
Ashley of Stoke commented "The findings The Sensory Project - Living Options Devon by to see investment in support an services for
are based on priceless human experience. S. Bourne, C. Calder and D. Spooner is free, disabled people after they leave school
They are a guide to the future and they pre- lei. 01392203450. SCOPE, lei. 01 71 619 7100.
HOWl...
Howl
efor
edu 'on
Kathleen Williamson is Team Leader in the
Special Needs Schools Team of Sheffield
Speecll and Language Therapy Agency.
Liz Shaw is Chief Speech and Language
Therapist: Schools for Northwick Park &
St. Mark's N HS Trust.
Liz Baldwin and Rachael Hughes are
Specialist Speech and Language Therapists
employed by Salford Community Healthcare
NHS Trust and Salford SEN Support Service
and working with language disordered children
in mainstream schools.
24 SPEECH & LANGUAGE THERAPY IN PRACTI CE WINTER 1998
Speech and
language therapists

of
working with
teachers if the
needs oftheir
school aged clients
aretoiJemet
Effective
collaboration
deP.ends on mutual
unCierstanding and

shared
Three therapiSts
explain some ofthe

bUilding this
writin
practical
providing input to
IndMduat Education
Plans and setting
joint targets for fhe
Classroom.
\ l - " 1'1'\
tricky business - make the report too long
Clarity offocus
Kath how a standardised report fonnat desieJ1ed
to sumJ11anse ent and planned managEment has proven
useful In other ways too.
Writing reports for teachers can be a
and detailed and you risk only the summary
CO ,,\ : \ :n-\ being read; make it too concise, and you risk
Ll L: . \ \) minimising your message and the child's
S \\ E r \. \ r. , d iffirul ties. Obviously one answer is to get
to know your teacher and make your report
fit the needs of a particular situation. However, I have
found it helpful from a number of perspectives to use a fairly stan
dardised format (see figure 1) that allows for additional detail as
required.
For me, the starting point for devising such a format was the chal
lenge of working with a large caseload of children with severe to
profound learning difficulties_ I needed to have something that
would act as a summary form of the assessment process, would
serve to reinforce the key issues I wanted to convey, and would
allow me to draw attention to important aspects of the commu
nicative context as well as the child's strengths and difficulties.
In addition, I found it helpful to have my observations on all the
children in a similar format so that I could readily identify
children whose needs could be met by grouping for therapy
and
potential fOOlS areas for school INSET (in-service training) sessions.
Teachers under pressure
My work now involves supponing children with statements across a
range of educational provision. I have therefore been able to extend
the use of the format to other settings. In many ways the issues are
the same. In particular, the tremendous pressures that teachers work
under means that time for developed discussion can be limited.
Thus, meetings about individual children need to be well structured
and clear in purpose. Ideall y, such meetings are quickly followed up
by a summary of observations made and actions agreed.
Inevitably the format will be subject to changes over time, but
teachers in both segregated and indusive settings have responded
favourably to the clarity of focus it provides. Panicularly positive
comments have been received about highlighting the strategies that
the teacher needs to be using to support the child in class. From my
perspective, as well as laying bare the issues of concern, it readily
leads to a direct consideration of:
i) responsibilities within the therapy process, for example, whether
the teacher / assistant requires my initial support in the area of skill
building
ii) the nature and phrasing of the targets to be included in each
child's Individual Education Plan (lEP).
In addition, I have found that it for ces me to sharpen my thoughts
about each child, asking
What exactly does this child need at the moment ?
Can his / her communication needs be met solely in the class
room context?
Figure I - standardised format
Speech and Language Therapy Summary Report
Re: Name:
D.o.b.:
School:
a) Communicative strengths and difficulties:
b) Main aims of support in the area of communication:
c) Recommended supportive strategies to be used in the classroom:
d) Recommended torget areas for speech/language/communication objectives:
e) Action agreed:
What aspeas of the communicative context might need addressing
7
Does this child need to focus on building particular speech / lan
guage skills
7
Who is best placed to provide this type of support
7
Figure 2 shows one example of the standardised format in use,
regarding a child MR.
Figure 2 - Example of a report
Speech and Language Therapy Summary Report
Re: MR
D.o.b. 10/7/92
School APrimary School
a' Communicative strengths and diHiculties:
Very variable aHention and listening skills within and across tosks.
Concentration fades quickly.
Better when actively involved.
Can follow simple instructions within routine contexts.
Often needs things repeating.
Echoes the last word heard when he hasn't understood.
In very clearly structured contexfs, can understond
instructions and comments contoining up to 3 key words.
Shows evidence 01 understonding range of descriptive terms
leg. happy/sad; big/little; up/down).
Uses language for number of functions ego questioning, commenting, requesting
and directing.
Generally using 2/3 word phrases.
Is trying to tolk about a sequence of linked ideas.
Some word accessing difficulties.
Speech not yet very clear.
Con imitate a word accurately when asked to "listen
corefully" to the word.
b, Main alms of support in the area of communication:
to develop aHention and listening skills
to develop abilities to pracess language
to develop attention to word patterning
to develop descriptive language skills
c) Recommended supportive strategies to be used in the
classroom:
ensure that M is listening well before speaking to him
simplify instructions and explanations
repeat what you have said
slow your rate of speaking
use routines wherever appropriate
use visual support whenever possible Ihighlighting aspects of the context,
very clear tosk layout, demonstration, eft.)
particular support around a change of activity or around the introduction
of something new
provide oppor1unities for discussion around a joint facus
d, Recommended target areas for speech/language/
communication obiectives:
developing ability to maintoin concentration within tosks
developing extended listening ability within the context of a simple group
story that is well supported visually
developing ability to listen more carefully to the sound patterns within words
leg. through clapping out syllables in a word, identifying initial sounds in
words, identifying a word when presented with the onset and rime portions)
developing ability to repeat a word accurately
developing ability to have a simple conversational exchange around
something of interest to M
developing ability to describe simple pictures using a basic sentence strvcIure
develaping narrative ability in the context of describing a short sequence of
pictures leg. 3 picture sequence: 1 idea per picture)
e, Action agreed:
To be reviewed at the request of the teacher
Further support is available if required to help in refining the target areas
for inclusion in the IEP.
SPEECt-1 & lANGUAGE THERAPY IN PRACfICE WI NTER 1998 25

A
r
("""<'1 Apowerful tool
liz Shaw's team is rPtothe challel12e of teC02J1isirn;tand takine
/OS
P
fti'-'-S QP.P..Ortunities tp have
InclMdual Education PIa
Our team of speech and language therapists
works within schools. The efficacy of all our
work depends upon the level of suppon we are
able to obtain from school staff. Individual
Education Plans (IEPs) are a useful focus for
obtaining this suppon. Looking at the Code
of Practice definition of an IEP (Figure 1), we see that it
encompasses all the areas which a speech and language therapist
aims to identify and agree when deciding upon targets and strate
gies with school staff. It therefore follows that, if we can work with
in and use IEPs, we can avoid duplication and link in with estab
lished and respected systems, thus becoming more effective in the
therapy we provide.
Figure I - Code of Practice definition
Importance of preparation
The Code of Practice defines an IEP as setting aut:
Evaluation of how our team
nature of child's learning difficulties
works identifies seven 'stages' to action required, ie. special educational provision, staff
inputting successfully to an IEP: involvement (including frequency of supportl, specific
programmes, marerials and equipment needed
guage priorities for the period
1. Identifying speech and lan
help from parents at home
of the next IEP
targets to be achieved in a given time
any pastoral care or medical
2. Finding out schemes of work
monitoring and assessment
/ topics / curriculum plans
review and dare.
3. Translating priorities into
aims
4. Writing aims as targets
5. Pulling targets to pieces and writing
them as ' Performance Targets' (This fol
lows training from the Local Education
Authority and some work in the team
on objective setting)
6. Meeting with staff in school to nego
tiate content of the IEP
7. Writing strategies to support the
agreed IEP targets.
Obviously events do not always follow
this exact sequence, and many things
happen simultaneously, but the prepa
ration stages are exuemely imponant,
especially for therapists with limited
experience of inputting to an IEP.
A real challenge
Writing performance targets is a real
challenge for therapists, and can not be
done in isolation. Again, lifting from
the training we received from our LEA, a
performance target is
a specific objective which it is planned
the pupil will achieve
derived from assessment and pan of continuous assessment
relevant , a priority, realistic, practicable, achievable, clear and
agreed
a constituent pan of an overall learning objective
curriculum focused.
We can all nod smugly as we read through the first two points here.
It is when we stan reading through the third point and beyond that
the smiles can get a bit shaky. Yes, of course our targets are relevant
and a priority to us, but are they for school staff? The further we
read, the more obvious it becomes that preparation before an IEP
planning meeting is vital.
Therapists need to know what the child's school day entails, what
the curriculum plan is for the period of the IEP (right down to the
vocabulary to be used and any specific activities or themes to be
followed), and any concerns / priorities the school staff have
regarding the child. Once armed with this information s/he can
produce some proposed performance targets to bring to a meeting.
26 SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 1998
Figure 2 - Examples of IEP tarj1ets
Moths Project IEP Target

Aim
To Increase self other IClass sur;;/, to
I the nd
awareness-developing food likes dislikes (use of voce :leu ppy" a
ofemohons. "sad" to pictures on
Using hol!? / sad faces to
Graphsl.
the score sheet
indicale is on score sheets.
ISuggested by
IEP Target Speaking & lisrening
Aim
To develop stralegies for

To fallow two part whole Child to use symbol
aiding auditory memory class instruction, ego "Collect checklist to record
and understanding instruction and to plan
instructions.
your maths books and go
and sit in yo.x work groups.' action
c&wn
guage History (Group Workl IEP Target
pyAim
Child to explain one part
structure verbal back /
To use mind to To explore worn
by the Victorians rough of his group's findings,
retelling of reading and museum visit. referring to a mind map
Groups to feed back
with support
his Learning
Suppert Assistant.
findings to whole class.
inputting to I EPs we have become more adept at fitting our targets
in to those of other people (see figure 2 for examples) .
As speech and language therapists we are lucky that there is usual
lya "Speaking and Listening" Target on a child's IEP. We have to
hone our skills so that we can convince teachers that our target
meets their priorities and is achievable or squeeze our targets in to
theirs if there is space for nothing else.
The challenge for our team is to continue to ensure that therapists
have access to training and support which enables them to fully
understand the IEP process and its variability across schools, to
write tight targets and to recognise opportunities for speech and
language therapy targets amongst those of others.
References
Depanment for Education & Employment (1994) Code of Practice.
HMSO.
Harrow LEA (1995) Guidance on Individual Education Plans.
Shaw & Wood (1998) Joint Goal Setting in Schools. Nonhwick Seminars.
and language'therapy targetS'induded iii'
Adapting and negotiating
The presentation of what has been prepared is also very imponant.
When we first began working in schools we devised a standard 'liai
son sheet' which therapists used for all children to record targets
and strategies. This sheet was based on what we thought was the
LEA proforma for IEPs. In reality, many schools have chosen to
devise their own format and we have needed to adapt our practice
in response to this. We have found that, if written input looks
familiar, it slots in to an IEP more readily.
What we aim to do is to come to a meeting with school staff with
targets which are tight and measurable, written in language which
is as near to "education speak" as we can manage and as closely
linked to curriculum planning and the school's IEP
format as we can make them.
There then needs to be discussion and negotiation
with school staff in order to agree what and how
much is going to go in to the IEP. My clinical work is
entirely in our school for children with severe learn
ing difficulties. Many of the children have occupa
tional therapy and physiotherapy input in addition
to my own and to their educational input. Likewise,
in mainstream, many of the children we see receive
additional suppon from other services, all 'compet
ing' to ensure their priority is focused on.
The teacher is the person
with a view of the whole
child. S/ he is also going
to have lead responsibil
ity (supponed by the
SENCO) for implement
ing the IEP; as such s/he
needs to own it.
Ustening to priorities
Therapists need to be
able to listen to the pri
orities of others and to
compromise in their
priorities if needed. It
may be that something
that is one of our lower
priorities is key to what
the teacher is targeting.
It makes sense for that
to become the rEP tar
get, with agreement to
work on other areas at
a later date. As we have
gained confidence in
\ 11' 1m'l
(tlIOj,j
C , f{) f .ll
o c'\1111 ,, ;.I t ""'"
" ,,,,,,
HOWl..
Working together
Workine of a Local Education Authoritv Suooort Service has
enabJed1..iz Idwin and Rachael Hwmes to lookttitiQ\lIv at their S
' lL[nHI ll ll lllli \ IT\ Ik .l l1h ( ,I[[ nracticean
Show. hQW successf1l1 target settiIJg relies on gatherftlg infonnation an
cOllSldenng the teacher'sperspecuve.
Successful collaboration with schools and information concerning:
joint target setting starts with careful future subject material and curriculum information to ensure rel
... I' T' . . d h
panning. lme spent In preparatIon an gat - evant target setting
ering information results in useful and positive liaison with who is available to work with the child in class, small groups or
teachers. We find it helps to clarify in our own minds, and then even on a 1: 1 basis
convey to the schools, the following information: the teacher's need for support and advice in planning for the
the purpose of the visit (eg. for observation, assessment, discussion) individual needs of the child.
who we want to see (eg. child, support worker,
Figure I - Information gathering questionnaire
class teacher, SENCO )
SALFORD COMMUNITY HEALTH CARE NHS TRUST
length of time required (with child and staff).
SAlFORD EDUCATION AUTHORITY
Timing of the visit needs to be negotiated with the
SPEECH & LANGUAGE THERAPY DEPARTMENT
staff taking into consideration the structure and
demands of the school day. We ensure the school Information Gathering for Speech / Language Therapist
knows how to contad us should arrangements
Name of Child: ..................................................................................................................................... ..
need to be altered, avoiding wasted visits. We have
Teacher. ...................................................... Subject: ..................................................................
found it invaluable to ask the teacher to fill in a
pre-visit questionnaire (see figure 1). This not only
Please comment on the following:
provides us with relevant information, but also
Listening to instructions and concentration in discussion time:
focuses the teacher on the areas we will want to
discuss further. Receiving this information before
making the visit helps us to plan the content of
Ability to follow instructions and understond new vocabulary:
our discussion, ensuring the teacher's priorities are
also addressed.
Ability to express self - to you individually - with a group:
Familiar context
Seeing the child in the everyday context of school
provides a significant contribution to understand
Social Skills and behaviour.
ing the impact of the child's speech and language
difficulties. Evidence can be gathered from play
How do you feel the child's language or speech difficulties are affecting:
ground and classroom, structured or informal sit
Reading:
uations, small group or in class. As before, prepa
ration and negotiation ensures that we will see
what we want to see. We need to bear in mind how
Writing:
the teacher may feel having another professional
observe their lesson. Clear explanations when
setting up the visit with the teacher should avoid
Any other comments:
misunderstandings. We have found the
'Observation Guide' in the NASEN publication
(see references) to give a useful framework for
Please return to: ............................................................................. by: ................................................
planning an observation.
Speech / Language Therapist
We feel that traditional assessment provides only a Salford Support Services
limited view of the child's functioning. [n school Halton House
we can see the range of materials and expectations 36 Eccles Old Road
with which the child is faced on a daily basis. Using Salford M6 7AJ
the child's text books, reading books and class
leI. 01619250530
work we are able to make judgements regarding his
/ her understanding and ability to talk about and apply what they
have learnt. Displays around the school and awareness of school Meaningful dialogue
routines provide a wealth of subjects for discussion. The child is Having gathered evidence within school, we are now in a positio n
more at ease when talking in this familiar environment, providing to have a meaningful dialogue with the class teacher:
a clear picture of his / her strengths and weaknesses. we can share our conclusions on the nature of the child's speech
and language difficulties, feeding back results from formal assess
ments, observations and discussions
Ustening to the teacher
we explain the implications of these difficulties and their pos
To complete the information gathering on the child, it is essential
sible effect on behaviour and performance within the classroom
to set aside time to listen to the teacher. This allows us to:
we highlight the potential problems for the child in both ada!
give the teacher opportunity to express his / her concerns and pri
and curriculum areas
orities which may be different from ours yet still valid.
we offer advice and strategies for general management a issues arise.
gather detailed information on how the child functions in rela
Throughout discussion in school we ascertain what Jevel of
tion to his / her peer group, providing us with some idea of the
involvement is going to be appropriate in meeting the needs of the
expectations of that age group.
child and the school.
probe specific areas of concern through discussion (eg. phonic
awareness, social interaction, skills of reasoning / inference, recep
tive language). Joint commitment
In order to begin planning meaningful input we need to gather We have found that target setting with teache.rs a(111.01 ledges oJ
SPEECH & LANGUAGE THERAPY IN PR}\c[ICE WI mTR 1990 27
HOWl...
Figure 2 - Example of targets, including evaluation
SALFORD SEN SUPPORT SERVICE
SPEECH AND lANGUAGE THERAPY
SUPPORT PlAN . FORM 2
joint commitment to addressing the child's speech Pupil: Ap, age 7
and language difficulties. Effective targets are set Personnel involved: Teacher, Nursery Nurse INNEB), Speech & Language Therapist ISLT)
through agreement on the following points:
Evaluation and Date !or Implemenlotion
what is the nature of the target?
To develop awareness of rules for SlT weekly group. work very difficult to
what are the arrangements for implementation?
listening, AP knows the rules and hand .
(eg. who, where, when)
Work continued through 1: 1 . can apPly them in simple activities. Follow-up work by NNEB.
how and when will the target be evaluated?
9.9.98
The nature of the targets we set is affected by :
To practise semantic linking for 1: 1work from SLT and NNEB. AP can link and categorise
the severity of the child's speech and language
familiar vocabulary. as listed.
difficulties and their ability to cope within the
9.9.98
AP able by location,
function, arid category Ia classroom
the amount of speech and language therapy
Continued assessment of AP's Formallests ond observations. Tests completed;
available SlT Observation evidence gathered. undentanding and pragmatic skiDs/
behaviour. NNEB 9.9.98
Class teacher
the level of suppon, other than the class teacher,
available to the child.
This results in us agreeing targets which are Regular contact has token place.
diverse, ranging from specific developmental work
To train NNEB in order to work Weekly contoct with NNEB in
with AP. school. 9.9.98
(eg. grammatical structures, phonological
Signed: Liz Baldwin Date: 18.6. 98
processes) through to functional skills (eg. listen
ing skills, understanding topic vocabulary, com
Figure 3 - Example of next set of targets
prehension suategies).
SALFORD SEN SUPPORT SERVICE
We have recently designed a standardised profor
SPEECH AND lANGUAGE THERAPY
ma for planning with staff. This includes: SUPPORT PLAN - FORM 2
a summary of the child's speech and language
Pupil: AP, age 7
difficulties
Personnel involved: Teacher, Nursery Nurse INNEB), Speech & Language Therapist ISLT)
a record of the shared discussion, highlighting
Target for EvoJuation and Date
concerns raised and advice given
Target in closs vocabulary for Discussion with teacher.
effective understanding and use.
a record of the specific targets set / arrangements
Input from NNEB both 1: 1and
for implementation / arrangements for evaluation.
in closs.
Figures 2 and 3 show examples of the first in-school
Guidance from 51.T.
speech and language therapy targets set in this way
Develop understonding 01 SlT and NNEB work 1: 1 with
for a child with disordered language in the area of
emotion words AP
semantics and pragmatics. Figure 4 summarises
hapy
what is required for successful target setting.
angry
We know that working alongside teachers and set
warned
ting joint targets can at times be challenging. Our
Develop effective listening SlT guidance to NNEB.
experience tells us it is wonhwhile task, enabling
skills in class. NNEB support in class
both professions to develop skills in working Backed up by teacher.
together for the benefit of the child.
Develop effective listening skills SlT and NNEB work in 1: 1.
in conversation.
Resources
Signed: Liz Baldwin Date: 18.6.98
Wright, J.A. and Kersner, M. (1998) Supponing
Children with Communication Problems (Sharing the Workload).
Figure 4 - Target setting
David Fulton Publishers.
Successful torget setting relies on:
Daines, B., Fleming,P. and Miller, C. (1996) Spotlight on Special
1. gathering of accurate and relevant information
Educational Needs - 'Speech and Language Difficulti es'. NASEN
2. consideration of how the child's speech and language difficulties affect his / her
Publication.
functioning in the classroom
Lees, J. and Urwin, S. (1991) Children with Langu age Disorders. 3. acknowledging the therapist's and teacher's differing perspectives and skills
Whurr Publishers. 4. establishing joint responsibility for implementation and evaluotion
Manin, D. and Miller, C. (1996) Speech and Langua ge Difficulties 5. making dear records of agreed plans.
in the Classroom. David Fulton Publishers
Practical points
1 . Preparation is vital if meetings with teachers and reports are to be of use.
2. Using an questionnaire prior to a meeting means the teacher's priorities
are understood too.
3. Structured classroom observation increases understanding of a child's needs.
4. Link in with existing and respected systems such as Individual Education Plans to ensure your
aims are considered.
5. Vary recommendations depending on the severity of the child's problems, the amount of
support available and the teacher's aims.
6. Teachers are particularly receptive to strategies for supporting the child in the classroom.
7. Write for teachers in a way that is as near to "education speak" as possible.
8. Request LEA training to increase speech and language therapists' understanding of teachers' needs.
9. Follow-up meetings with a written summary of what was discussed and agreed.
28 SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 1998
r
Pll'" le, 98 'f <. ~ " ' g or
-epnnted amcles
System treats intractable
disorders (Fiona Gibbon. Sept
1988)
Drama in therapy is more
than acting (Myra Kersner.
Oct 1989)
Sharing knowledge with
teachers (Fiona Cann and
Lorraine Britton. Nov 1992)
(from Speech Therapy In
Practice I Human
Communication. courtesy of
Hexagon Publishing)
SLUder ts
report from the Royal
College of Speech & language
Therapists' student conference
advice fro m a new graduate
Top T ps
for therapy for children with a
voice problem
'"1 (]I ~ t f ~ 'Ed Ie Its! o! book!
avad-tle 'or ~ v 'oN Ise" .,.;r Ie for us'1
http://www.sol.co.uk/slspeechmag
Contributions to
Speech &Language
Therapy in Practice:
Contact the Ed,lor for
ore mformation and / or
to discuss your plans.
Please note:
artldes must be of
practical use to dlllicions
use case examples and
fist useful resources
rength is general/ )!
around 2500 words
suppfy copy on disk i(
pOSSible
keep sLUtistical
informotlon to a minimum
photographs and
illustrations will be rewrned
M'6
ToD
Res urtes
Jayne Comins is a voice specialist in pri
vate practice and at the Royal Free
Hospital in Hampstead. Her cli ents range
from the professional voice user with
benign but anxiety-making symptoms. to
pati ents with head and neck cancer who
experience loss of speech. eating and a
normal facial appearance. She is also an
experienced. accredited counsellor. and is
training as an analytical psychotherapist.
She writes two regular bylines for The
Singer magazine on voice-related topics.
Here. she' describes the ten items she
could not do without when using coun
selling in speech and language therapy.

Speech & Language Therapy in Practice, Winter 1998

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Speech & Language Therapy in Practice, Winter 1998

Speech & Language Therapy in Practice, Winter 1998