ISSN 1368-2105

SPRING 

http://wwwspeechmagcom

Dysphagia
Finger on the pulse

Sure Start
The final frontier

Dysarthria
Automatic speech
recognition

Challenger
Skills for life

How I am
keeping
up-to-date Out of the
Winning
Ways
Enjoying the ride
woods:
My top A year of
resources
Child voice storytelling
S H A P I N G E X P E R I E N C E
 READEROFFERSREADEROFFERREADEROFFERSREADEROFFERS
Spring 04 speechmag Assessing and Promoting Effective
Communication (APEC)
In need of inspiration? Do you work with Special Education teachers and classroom assis-
Doing a literature review? tants? Have you longed for an off-the-shelf training package to
Looking to update your practice? help you raise their awareness of the developmental nature of
communication, language and play, and how they can recognise
Or simply wanting to locate an article you difficulties and support the children more effectively? Well, APEC
read recently? (Assessing and Promoting Effective Communication) could be
Our cumulative index facility is there to help. what you are looking for, and we have a copy to give away FREE
to a lucky reader, courtesy of author and speech and language
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The speechmag website enables you to: For your chance to win, send your name and address to Gillian
View the contents pages of the last four issues Bolton, APEC reader offer, 47 Bilton Road, Rugby, Warwickshire
Search the cumulative index for abstracts of CV22 7AN by 25th April. The winners will be notified by 1st May.
APEC aims to help teachers and classroom assistants implement
previous articles by author name and subject the acclaimed communication framework developed at The
Order copies of up to 5 back articles online. Redway School by Clare Latham and Ann Miles. The APEC pack-
age includes a training video produced in association with The
Plus Redway School, detailed session plans, handouts, follow-up activi-
The editor has selected some previous articles you ties, a written assessment and certificates. Feedback from teach-
might particularly want to look at if you liked the ing professionals has been positive: “...the course has really made
articles in the Spring 04 issue of Speech & Language me take a look not only at the children but also at myself. It has
Therapy in Practice. If you don’t have previous issues of made me change my approach in certain areas (using more simple
the magazine, check out the abstracts on this website language, letting the children take the lead more).”
and take advantage of our new article ordering service.

New!
The full version of Sally Millar’s ‘Communication -
by the book’ from the Winter 2003 issue, with
accompanying pictures.
If you liked...
Louise Frazer, see (116) Sage, R. (Summer 2000)
Reaching the parts other don’t.
Nicola Grove, look at (151) Park, K. (Summer 2001)
Interactive storytelling: A multidisciplinary plot.
For more information, see www.apectraining.co.uk.
Peter Roberts & colleagues, what about (161)
McGrane, H. & Stansfield, J. (Autumn 2001) Strength
in compromise.
Win ColorCards®
Judi Hibberd & colleagues, you might be interested Listening Skills:
in (038) Haynes, S. & Hibberd, J. (Autumn 1998)
Managing tracheotomy and dysphagia.. Indoor Sounds
Looking for sound and picture match-
Barbara Clarkson & Angela Peel, check out (067) ing activities that reflect life in 2004?
Paulger, B. (Summer 1999) Therapy for real life. Look no further, as Speechmark has
(Reprinted in full on revised its 1995 indoor, outdoor and
http://www.speechmag.com/archives/barbara- sequencing sounds packs. Even bet-
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offering a FREE copy of Indoor
Lesley Cavalli, try (pre-dates abstracts) Hunt, J. & Sounds Revised Edition to five lucky
Slater, A. (Human Communication, 5(4), Aug/Sept Speech & Language Therapy in
Practice readers (normal price
1996) Child dysphonia - harmony and balance. £35.50 + VAT).
Alison Cooke & Dana Taylor, consider (134) Hurd, A. The revised cards come with a CD rather than a tape,
to make it easier to switch between activities. The 40 indoor
& McQueen, D. (Winter 2000) The right things at the sound cards now feature activities like word processing, playing a
right time. computer game and listening to a personal stereo.
For your chance to win, send your name and address to Speech &
Also on the site - news about future Language Therapy in Practice - Listening offer, Su Underhill,
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 www.speechmag.com
SPRING 2004 Inside cover -0 You talk 2 but what does it type?
(publication date 23rd February) Spring
speechmag “The variability of some dysarthric speakers can
ISSN 1368-2105 Reader offers usefully be managed and accommodated by the user
Win APEC and ColorCards® Listening Skills: Indoor identification, as there is nothing stopping one user
Published by: Sounds. progressively establishing him/herself with more than
Avril Nicoll one user information set.”
33 Kinnear Square  News / Comment Peter Roberts, Malcolm Joyce and Claire Philpott
Laurencekirk
AB30 1UL examine the potential of automatic speech recognition
Tel/fax 01561 377415
Finger on the pulse software for people with dysarthria.
e-mail: “The literature is less convincing on pulse oximetry
[email protected] than cervical auscultation so our hypothesis was that,  Skills for life
Design & Production: if pulse oximetry could be shown to be effective, we “We learn about teamwork, to believe in each other,
Fiona Reid could use the two tools together to create a valuable, express our thoughts and to share other peoples
Fiona Reid Design non-invasive bedside assessment system.” ideas...Learn to be patient so we can wait for people
Straitbraes Farm Although videofluoroscopy can identify dysphagia and to finish what they have to say so you don’t think that
St. Cyrus distinguish between penetration and aspiration on your ideas are the most important. We also have to
Montrose
swallowing, it is not always available or appropriate. respect each other.” (Year 10 pupil)
Website design and Judi Hibberd & colleagues investigate a possible Barbara Clarkson & Angela Peel join forces with
maintenance: alternative. their Year 8 and Year 10 pupils to offer ideas for
Nick Bowles providing effective support for secondary pupils with
Webcraft UK Ltd
specific language impairment.
www.webcraft.co.uk < COVER STORY
Printing:  Further reading
Manor Creative A year of storytelling Cochlear implants, autism, ADHD, stammering and
7 & 8, Edison Road voice.
Eastbourne “Silence for a year and a day is a good plan. When
East Sussex you are in the middle of the forest and feeling your
BN23 6PT way, it’s quite hard to explain to other people why 5 “Here’s one I made earlier”
you are there and how to get where you are going. Alison Roberts continues to generate low-cost ideas for
Editor: Now I’m emerging out of the wood, the year is flexible therapy activities: Eye instruct you, Emotions /
Avril Nicoll RegMRCSLT
nearing its end and I’m beginning to be able to see facial expressions dice and Road sign dominoes.
Subscriptions and advertising: where I’ve been and what it all meant.”
Tel / fax 01561 377415 Nicola Grove reflects on a year spent exploring 
How I am keeping up2to2date
different ways of storytelling with people with “Readers have asked for more feedback from
Avril Nicoll 2004 learning disabilities. conferences, courses and study days. Here, we hear
Contents of Speech & Language more about a toolbox for school-aged children who
Therapy in Practice reflect the
stammer, Johansen Sound Therapy and a variety of
views of the individual authors
projects in the North East of England.”
and not necessarily the views of - Sure Start: the final frontier
the publisher. Publication of Louise Frazer travels from Barbados to Las Vegas.
“During Sure Start team meetings it quickly became
advertisements is not an Meanwhile, editor Avril Nicoll goes from
apparent that they appeared alien to the other chosen
endorsement of the advertiser Laurencekirk to Edinburgh and Newcastle.
ones from around the galaxy. They had to work at
or product or service offered. being accepted. Rather than orbiting around the
Any contributions may also planet, they had to land on site regularly, especially in
Back Cover My top resources
appear on the magazine’s “Whilst the majority of speech and language
a social capacity (lunch-time).”
internet site. therapists working with dysphonic children will not
Alison Cooke & Dana Taylor report back on their
have immediate access to a Voice Clinic I would
joint mission to bring specialist knowledge of early
recommend that, whether they work in mainstream,
speech and language development to two culturally
special schools or community clinics, they identify the
diverse Sure Start locations.
location of their nearest Voice Clinic and ascertain
whether the team will accept paediatric cases.”
- Reviews
Lesley Cavalli specialises in the assessment and
Language development, adult stammering,
management of voice disorders in children and
management, child voice, language, education,
adolescents, as well as head and neck surgery.
collaboration, life skills, hearing impairment.

-
Winning Ways series () In future issues...
Enjoying the ride Sure Start
“After filling in the Wheel of Life diagram, Jennifer antenatal education
was able to pinpoint the areas of her life that she adult learning disability
needed to smooth out in order for her to be as dysphagia
effective a speech and language therapist as she autism
wanted to be.” hearing impairment
Cover picture by Paul Reid (posed by
As the wheel of life goes round, it’s easy to lose our collaboration
model). See p.7 balance. Life coach Jo Middlemiss encourages us to student training
find ways of getting things back on an even keel.

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2004 -

 news

Increasing Healthcare
awareness and the arts
Increasing interest in how the arts are being incorpo-
The overwhelming majority of nursery workers who responded to a poll of Nursery World readers rated into the delivery of health care to improve the
believe that the occurrence of speech, language and communication difficulties among preschool physical and mental well-being of patients and staff
children is growing. has been picked up by The Royal College of Physicians.
Problems observed include lack of concentration, not speaking clearly and difficulty following A new book from the Royal College covers literature,
instructions. When asked for their opinion on the reasons for this, respondents suggested a lack of the visual arts, music and architecture, including the
adult and child time spent talking together, the passive use of television and parents talking for influence of the built environment and how it can
their child. improve clinical outcomes. It also focuses on the chang-
Gill Edelman, chief executive of the charity behind the poll, said, “I CAN are pleased at the increas- ing doctor-patient relationship, and the how the move
ing awareness of children’s communication difficulties and would encourage speech and language from paternalism to partnership is changing the nature
therapists to keep working towards increased collaborative practice, particularly with early years of medicine.
workers and parents. We also ask that they support more research about whether specific and per- A spokesperson said, “This book is invaluable not only
sistent speech and language difficulties are increasing, and the underlying causes.” in providing a clear conceptual framework for under-
I CAN uses such devices such as this poll to increase general awareness of speech, language and com- standing the healing environment but also in providing
munication difficulties, and the pivotal role of professionals and parents in prevention and support. evidence and examples of good practice that are both
The UK-wide ‘Chatterbox Challenge’ is another example of how the charity is encouraging parents compelling and convincing.”
to talk more to their children. Through such strategies, I CAN hopes also to increase awareness of The healing environment: without and within is £15
the more specific needs of children with severe difficulties, and the importance of early intervention. (£18 overseas), see www.rcplondon.ac.uk, tel. 020 7935
www.ican.org.uk/chatterbox 1174, fax 020 7486 7038.

Professor appointed Express

In a major research expansion at the University of York, an expert in language
acquisition and language processing has been appointed as one of six new Chairs.
Professor Helen Goodluck is a psycholinguist whose research on language
acquisition has been mostly with preschool children and a range of lan-
yourself
In the Winter 2001 issue*, we reported on the
guages. Her most recent work has focused on special populations, particular-
Dundee Expression project, where six people
ly people with Down’s Syndrome.
with aphasia explored their feelings through
creating prints. The prints have now been pro-
QuEST
A new independent service set up by therapists and educationalists aims to
duced in postcard format to be used as a basis
for discussion to empower and inform people
with and without aphasia.
identify, target and address the factors that may underlie some
* Nicoll, A. (2001) Imprints of the mind. Speech
specific learning difficulties.
& Language Therapy in Practice Winter: 14-18.
QuEST is a diagnostic tool which looks at why someone might
A limited number of packs are available from
experience difficulties with reading and similar tasks, and then sug-
one of the facilitators, speech and language
gests how to help. A parental questionnaire is analysed and recom-
therapist Laorag Hunter, e-mail
mendations made to address the particular combination of factors
[email protected].
(auditory / visual / movement, balance and coordination / deficits in
essential fatty acids) which may be contributing to the problem.
Independent speech and language therapist Camilla Leslie, who is also
a Johansen Sound Therapist, has set up QuEST with an orthoptist, movement
therapist and educationalist / psychologist.
www.questtherapies.com

Play review welcomed

A disabled children’s charity has welcomed a government commissioned review
of children’s play.
The Children’s Play Review for England and Wales sets out how best to invest the
£200 million from the New Opportunities Fund earmarked for improving children’s
play opportunities. The chief executive of the charity KIDS said, “We applaud the
emphasis on the inclusion of disabled children and young people. At present, play
is simply not an option for most disabled children and they are routinely losing out
on all the physical, social and developmental benefits that play offers.”
The charity adds that it is concerned that distributing funds purely on the basis
of geographical areas of deprivation will mean they don’t benefit all disabled
children. It also calls for a particular emphasis on training play work staff which it
believes is the key factor in successfully introducing inclusion into play provision.
See The Children’s Play Review at:
Pat le Prévost and Thelma Grove
www.culture.gov.uk/global/publications/archive_2004/children_play_review_report.htm

 SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2004

 news & comment

Access
improved
In a bid to prevent repetitive strain injury and
improve computer access for people with upper
body disabilities, automatic speech recognition
software has been introduced across the whole
of Cambridge University.
...comment...
Scansoft’s Dragon NaturallySpeaking® dictation
software has been fully endorsed by both the
University’s Computing Service and Disability
Resource Centre. It allows the user to carry out
all computer activities by using their voice.
Avril NicollA Shaping
Distance
Editor

55 Kinnear Square
experience
“Silence for a year and a day is a good plan. When you are in the middle of the
learning Laurencekirk
AB5 -UL
forest and feeling your way, it’s quite hard to explain to other people why you
Pupils unable to attend school for medical or are there and how to get where you are going. Now I’m emerging out of the
other reasons may be able to study via The wood, the year is nearing its end and I’m beginning to be able to see where I’ve
Satellite School. tel/ansa/fax been and what it all meant.”
Around half the students of the school have
their distance learning places paid for by their -E0- 5<<
-E Nicola Grove’s reflection on her year of storytelling (p.7) has already entered my
local education authority because they have collection of classics. An enduring children’s classic, Peter Pan, is associated with
medical needs. Tutoring is e-mail and web Great Ormond Street Hospital where Lesley Cavalli (back page) works to help
e2mail
based. children find their voice. When Barbara Clarkson & Angela Peel (p.20) wanted to
www.thesatelliteschool.org.uk avrilnicoll@speechmagcom
hear from their Year 8 and Year 10 pupils, they asked them to brainstorm their
Challenger social skills programme – and the resulting short stories are
Virtual Mentor published here.
Audiologists in the NHS can now access training While our new releases from Jo Middlemiss (p.14) and Alison Roberts (p.17) are
on a virtual system. marking themselves out as best-sellers, Dana Taylor & Alison Cooke (p.10) bring
Teaching methods offered by Mentor, from the us science fiction. By comparing themselves to aliens, they could see how they
hearing systems company Phonak UK, include
an online interactive academy, a web forum would have to adapt to fit in and be accepted by their community.
and an online knowledge catalogue. For many people, computer technology continues to have more mystery than
One of the trialists commented, “As each training Agatha Christie. Our own Hercule Poirot, Peter Roberts (p.16), shows how we
session is recorded, the students are not can all use our little grey cells to modify automatic speech recognition to give
required to take notes and can have access to
people with dysarthria the opportunity to tell their story. Also playing detective
the recordings and play back relevant parts.
This allows a greater focus on the content and are Judi Hibberd & colleagues (p.4), as they find the gaps in previous research
less time scribbling notes.” into pulse oximetry, and test out their hypothesis.
www.phonak.com Following requests from readers, How I am keeping up-to-date (p.24) is devoted
to the philosophy, drama and even the occasional comedy (remember girls –

Making musical always wear your earrings) of conferences and study days.
Across the genres, in sharing their experiences, our contributors help you to
Headway handle similar situations as they occur.
Partners in a year long project to provide music “He picked up a packet of dehydrated onion. ‘Stories are like these onions – like
therapy for adults and young people who have dried experience. They aren’t the original experience but they are more than
suffered a head injury hope it will act as a pilot
nothing at all. You think about a story, you turn it over in your mind, and it
for the rest of the country.
The Friends of Henley Festival uses funds gen- becomes something else.’ He added hot water to the onion. ‘It’s not fresh onion
erated from the yearly arts festival to help its – fresh experience – but it is something that can help you to recognize
local community, in this case people who experience when you come across it. Experiences follow patterns, which repeat
attend Headway’s centre in Henley. The two
themselves again and again. In our tradition, stories can help you recognize the
organisations are working in partnership with
the charity Nordoff-Robbins Music Therapy to shape of an experience, to make sense of and to deal with it.”
provide music therapy to 26 people per week (From The Storyteller’s Daughter – Return to a Lost Homeland by Saira Shah
to help them find new ways to express them- (Michael Joseph: London, 2003, p.8). Copyright © Saira Shah, 2003. Reproduced
selves, develop new relationships and explore
by permission of Penguin Books Ltd.)
their own creativity.
www.henley-festival.co.uk;
www.nordoff-robbins.org.uk;
www.headway.org.uk

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2004 5

 research

Read this
Finger on
Although videofluoroscopy
can identify dysphagia
aspiration are distinct from those made during a
normal swallow. Hirano et al (2000) added further
weight when they found dysphagia diagnosed by
if you want to
•carry out a literature and distinguish between auscultation demonstrated an 87.8 per cent corre-
lation with that diagnosed by videofluoroscopy.
review
•test a hypothesis
penetration and aspiration Research into pulse oximetry is more contradic-
•identify non2invasiveA on swallowing, it is not tory and less conclusive. So far there is no general
consensus as to the efficacy of the tool, as results
portable solutions
always available or and their interpretation vary widely. Collins &
appropriate. Judi Hibberd Bakheit (1997), using pulse oximetry in conjunc-
tion with videofluoroscopy, concluded that the
and colleagues investigate pulse oximeter indicated a two per cent drop in
the potential of using the saturation levels in aspirators. Zaidi et al (1995)
less invasive pulse oximetry also found that saturation levels in aspirators
when eating and drinking decreased significantly
in conjunction with cervical more than in non-aspirators. Sherman et al (1999)
auscultation as a bedside too found it useful to a statistically significant
degree, commenting that, “These encouraging
screen for dysphagia. study results indicate that pulse oximetry may

R
isk assessment in dysphagia manage- become an essential component of the manage-
ment considers the likelihood of the ment of dysphagic patients.”
client being harmed from continuing Conversely, Sellars et al (1998) found no significant
oral intake, and the potential severity correlation between oxygen saturation and aspira-
of that harm. The key to risk assess- tion. Leder (2000) did find a statistically significant
ment is whether or not the client is difference between aspirators and non-aspirators
aspirating. So, how do we find out? but concluded that there was no indication that
Videofluoroscopy is accepted as the ‘gold stan- pulse oximetry is clinically relevant. Colodny
dard’ (Bastian, 1993). However, the procedure is (2000) found that, while aspirators’ saturation levels
invasive, labour intensive and resource consum- drop during feeding, this was not significant and
ing. Furthermore, it is not easily accessible and that the two per cent drop suggested by Collins &
cannot be performed at the bedside. Bakheit (1997) would not be enough to predict
Other screening tools are cervical auscultation aspiration.
and pulse oximetry, both of which are non-invasive From this contradictory research, two points
and readily available to most therapists working caught our attention:
with clients with dysphagia. Cervical auscultation 1) Controls and subjects
enables deduction of the point in the swallow Pulse oximetry will only be effective in dysphagia
where the problem occurs. Pulse oximetry allows screening if it can be shown conclusively that a
instant and continuous monitoring of the oxygen person at no risk of aspiration does not experi-
saturation of the blood, and a drop in saturation ence a drop in saturation levels when eating /
may be an important indication of respiratory drinking. Yet, in the research designs, numbers of
compromise. As the airway is not directly controls have varied from 0 (Sherman et al, 1999;
compromised either during a normal swallow or Collins & Bakheit 1997) to 77 (Colodny, 2000).
penetration, it may be that saturation levels only Leder (2000) collected all of his data from patients
drop during aspiration, allowing the therapist to in an intensive care ward; his control data cannot
distinguish between aspiration and penetration therefore be assumed to reflect what is ‘normal’.
at the bedside. Another difference between studies is partici-
The literature is less convincing on pulse oximetry pants’ medical status. Sellars et al (1998), who
than cervical auscultation so our hypothesis was that, found no significant difference between saturation
if pulse oximetry could be shown to be effective, we in aspirators and non-aspirators, noted that their
could use the two tools together to create a valu- subjects had respiratory difficulties. Perhaps those
able, non-invasive bedside assessment system. with respiratory difficulties have different results
to those without them?
A reliable tool 2) Establishment of mean baseline
Research into the effectiveness of cervical auscul- Sellars et al (1998) calculated baseline saturation
tation has firmly established it as a reliable tool. measurements to one per cent and then noted
Cichero & Murdoch (1998) hypothesised that the deviation from that point. They concluded that a
sounds generated by pressure changes during significant drop would be four per cent. This is in

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2004

 research

the pulse
contrast with Collins & Bakheit (1997) who sug-
gested a two per cent drop was significant. We
wondered if the lack of consensus establishment of
cal auscultation. The same equipment was used
for all data collection and the two collectors did
not exchange information except for notification
Data was collected over a nine month period
and analysed using SPSS Version 9.

significant percentage decrease could be due to the of when a swallow occurred during the procedure. Fluctuation
original assumption of the baseline level as a single Firstly, the finger sensor was attached and a read- The first significant finding involved the normal con-
point. If, on the other hand, oxygen saturation is ing taken to establish the participant’s baseline. This trol group. Results indicated that normals’ saturation
not fixed and stable but fluctuates within a band, took two minutes timed by a stopwatch. levels did not remain static for the two minute base-
then the deduction of level of decrease from a (Participants were excluded if the finger sensor could line establishment period but fluctuated by up to
single point will not encourage statistically signif- not be attached adequately or if they were wearing three per cent. This fluctuation continued during eat-
icant or useful results. For example, a patient who nail varnish.) The pulse oximeter then indicated that ing and drinking but, significantly, never dropped
is aspirating may drop out of their baseline band, the therapist could begin the clinical evaluation. out of the three per cent band.
while a non-dysphagic may also experience a Cervical auscultation involved the participant Having established a norm to a statistically sig-
decrease but remain within their banding level. taking three sips of liquid and three teaspoons of nificant level, we went on to investigate satura-
Taking into account these methodological prob- semi-solid food. Risk was assigned based on any tion levels in neurological dysphagics. Results
lems, we aimed: acoustic changes and without access to any infor- showed that, although the baseline level was
1.To use pulse oximetry to investigate whether mation from the pulse oximeter. Data was included lower than the controls, all of the neurological
saturation levels drop in people with dysphagia. only if the therapist completed either a food or dysphagic group also had a baseline saturation
2. To collect saturation data from non-dysphagics as drink assessment consisting of three swallows (De level within the three point band when at rest.
a large control group to compare non-dysphagics Pippo et al, 1992) but the assessment was curtailed Thus we established that, for both dysphagics and
with people with dysphagia. if the therapist felt that the risk level was severe non-dysphagics at rest, oxygen saturation does
3. To investigate if there is a significant difference in before the three swallows had been completed. not necessarily sit at one point but fluctuates by
saturation levels between those with neurological When the therapist heard the participant swallow up to three per cent.
and those with respiratory dysphagia. she indicated this to her assistant who noted When taking fluid or food, the results strongly
4. To use cervical auscultation alongside pulse down the exact time on the stopwatch which ran suggested that those at severe risk of dysphagia,
oximetry to detect the point during the swallow continuously from baseline to completion. The unlike the controls, dropped out of this baseline
where the problem occurs. therapists then downloaded the participant’s sat- band. The results were not statistically significant
Permission was granted from two local trusts in uration levels at each of the times on the data overall for this but were significant for the first
March 2000. We categorised the 92 participants sheet that indicated a swallow had occurred. We swallow of food and of liquid. This was the only
(35 male, 57 female, aged 15-99 years) into one of could therefore examine any changes at rest or unbiased sample. The lack of significance for the
four groups: during swallows. second and third swallows may be due to ethical
Group A - normal controls (n=50) Where participants were part of the therapist’s considerations preventing the therapist from con-
Non-dysphagic volunteers from the local commu- caseload, the bedside clinical evaluation was com- tinuing with the assessment when auscultation
nity with no history of neurological or respiratory pleted by communicating the results of the assess- indicated a severe risk.
problems who were non smokers or ex-smokers of ment to the relevant multidisciplinary team. Also significant was the finding that those
five years or more. ascribed mild risk using cervical auscultation
Group B - respiratory controls (n=17) tended not to drop out of the three point
Non-dysphagics with a respiratory element band. This suggests that they may not require
who were volunteers from a respiratory func- clinical compensation.
tion test clinic at the hospital, and who had The evidence for the two respiratory groups
no history of any neurological condition. followed the same pattern of the three point
Eleven had chronic obstructive pulmonary dis- band when at rest, with respiratory controls
ease and two had asthma. tending to have a lower baseline than normal
Group C - respiratory dysphagia (n=5) controls and, in some cases, lower than neu-
People with dysphagia which appeared to rological dysphagics. This suggests that previ-
have a respiratory base. One had chronic ous evidence that was not statistically signifi-
obstructive pulmonary disease and one renal cant may have been adversely affected by the
problems. When the therapist heard the inclusion of control data from participants
Group D - neurological dysphagia (n=20) participant swallow she with respiratory compromise.
People with dysphagia which appeared to The data for respiratory dysphagia also
have a neurological base. Two had no con-
indicated this to her assistant seems to follow a similar pattern as for neu-
firmed diagnosis at referral and 18 had cere- who noted down the exact rological dysphagia but, interestingly, some par-
brovascular accidents. ticipants’ saturation levels moved upwards out of
Groups C and D were part of a clinical caseload
time on the stopwatch which their baseline band when eating/drinking. Our
referred to us by a medical practitioner for a swal- ran continuously from baseline sample was very limited in number, but this sug-
lowing assessment. to completion. gests that there may be a difference between
For all subjects two therapists simultaneously neurological and respiratory dysphagia, an idea
collected data using the pulse oximeter and cervi- that further research could investigate. Is it possi- 

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2004 E

 research

ble that the lack of significant difference between Colodny, N. (2000) Comparison of dysphagics and
..resources... controls and dysphagics identified in previous
research could be attributed to the inclusion of
non dysphagics on pulse oximetry during oral
feeding. Dysphagia 15: 68-73.
Signalong both respiratory and neurological dysphagics in De Pippo, K.L., Holas, M.A., & Reding, M.J. (1992)
Hands for Talking, a partnership of two media the same group? Validation of the 3 oz water swallow test for aspi-
professionals who are parents of children with ration following stroke. Arch Neurol 49: 1259 -1261.
special needs, has produced a video to accompany Statistically significant Hirano, K., Takahashi, K., Uyama, R. & Michi, K.
Signalong’s nursery rhyme book and CD. We therefore reached two main conclusions. (2000) Evaluation of cervical auscultation: the
Sign A Song, see www.handsfortalking.com, Firstly, we established to a statistically significant accuracy and acoustic characteristics. Abstract of
£14.74 inc. VAT and postage. level that, when at rest, oxygen saturation levels presentation at the ninth annual dysphagia
And, if you are already thinking about next of all participants remained within a three point research society meeting, Georgia USA.
Christmas, Signalong also has a book of band. The sample size was such that we can Leder, S.B. (2000) Use of arterial oxygen satura-
secular celebrations to complement ‘The Little extrapolate the results to suggest that all oxygen tion, heart rate and blood pressure as indirect
Star’ with its nativity and carols. saturation levels fall within a three point band objective physiologic markers to predict aspira-
We Wish You A Merry Christmas, £11.75 inc. when at rest. tion. Dysphagia 15: 201-205.
postage. Secondly, all control subjects, and those at mild Sellars, C., Dunnet, C. & Carter, R. (1998) A prelim-
www.signalong.org.uk, tel. 0870 774 3753 risk of dysphagia, remained within that band inary comparison of videofluoroscopy of swallow
whether eating and drinking or at rest. A significant and pulse oximetry in the identification of aspira-
Computers and disability number of those at severe risk of dysphagia tion in dysphagic patients. Dysphagia 13: 82 -86.
National computing and disability charity dropped out of the band when eating and drinking. Sherman, B., Nisenboum, J., Jesberger, B.,
AbilityNet has released a step-by-step guide This was established to the highly statistically sig- Morrow, C. & Jesberger, J.A. (1999) Assessment of
on CD-ROM to help people with disabilities nificant level of p<0.001. dysphagia with the use of the pulse oximeter.
access and make the most of the opportunities Thus our hypothesis that pulse oximetry may be Dysphagia 14:152-156.
offered by computers. able to distinguish between aspiration and pene- Zaidi, N.H., Smith, A.H., King, S.C., Park, C.,
Successful computing for disabled people is tration cannot be discounted, and we suggest O’Neill, P.A. & Connelly, M.J. (1995) Oxygen desat-
£45 + VAT, tel. 01926 312847, that, in conjunction with cervical auscultation, it uration on swallowing as a potential marker of
www.abilitynet.org.uk. can be used as an effective and reliable screening aspiration in acute stroke. Age and Ageing 24:
system at the bedside. 267-270.
Helping Children Judi Hibberd, Alison Shale, Stephanie Bowers and Acknowledgements
with Feelings Karen Miles are speech and language therapists We are grateful to Rav Jayram, our research
Four new titles in Speechmark’s Helping with the University Hospitals Cov and Warwick Trust supervisor, Bill Waine, our statistical analyst, Jan
Children with Feelings series can be used by & Coventry Healthcare NHS Trust. Correspondence Lacey, Development Nurse, Jenni Hibberd and
child professionals and parents to help to: Mrs Judi Hibberd, Speech and Language Russell Miles.
children aged 4-12 resolve fear, low self- Therapy Department, Gulson Hospital, Gulson
esteem, loss and rage or hate.
Each guidebook has an accompanying
Road, Coventry, CV1 2HR, tel: 024 7624 6262.
Reflections for research
illustrated storybook (How Hattie Hated References • Do I base comparisons with the
Kindness; Ruby and the Rubbish Bin; Teenie Bastian, R.W. (1993) The videoendoscopic swallowing
Weenie in a Too Big World; The Day the Sea ‘norm’ on fact rather than
study, an alternative and partner to the videofluoro-
Went Out and Never Came Back). scopic swallowing study. Dysphagia 8: 359-367.
assumption?
£90 for all four sets, www.speechmark.net. Cichero, J.A.Y. & Murdoch, B.E. (1998) The physiolog- • Do I consider potential
ical cause of swallowing sounds: answers from confounding factors when
Bilingual assistance sounds and vocal tract acoustics. Dysphagia 13: 39-52. grouping subjects?
A teacher support pack to boost the Collins, M.J. & Bakheit, M.D. (1997) Does pulse • Do I seek expert assistance for
attainment of minority ethnic pupils in oximetry reliably detect aspiration in dysphagic supervision and analysis?
England and Wales will be released shortly. stroke patients? Stroke 28 (9): 1773-1775.
Based on research carried out in Derby, the 30
card pack recommends the use of bilingual
language assistants in the classroom, introducing Finger on the pulse: dysphagia terminology update
dual language tests, raising confidence and Aspiration: Penetration:
motivation, encouraging parental involvement, Entry of material below the true vocal Entry of material into the laryngeal vestibule above
ensuring effective leadership and introducing folds. the true vocal folds.
elements of the curriculum relevant to the child’s
cultural background. Cervical auscultation: Pulse oximetry:
www.derby.ac.uk The placement of a stethoscope on or The measurement of the ratio of oxygenated
near the cricoid cartilage to listen to the haemoglobin to the total haemoglobin in arterial blood.
Computer recycling acoustic signal generated by a swallow
Tools for Schools is a not-for-profit sequence. Respiratory dysphagia:
organisation that refurbishes surplus business A swallowing problem with a respiratory basis,
computers for low-cost sale to schools to help Oxygen saturation: (chronic obstructive pulmonary disease; asthma) or a
them boost pupil computer access. A measure of the amount of oxygen in respiratory consequence (renal failure; cardiac
www.tfs.org.uk the haemoglobin at a particular pressure. compromise) rather than a neurological base.

0 SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2004

 cover story

Picture by Paul Reid, posed by model.

A year of
storytelling
O
Read this nce there was a girl who was
put under a spell of silence
and carers be helped to share experiences
through storytelling?
if you are interested in for a year and a day; and in • What frameworks are most useful for assessing
•the difference between that time all she did was col- and teaching storytelling skills?
recounting and storying lect the nettles that grew in
•really listening to what our
clients have to tell the churchyard and she Personal events
•developing your work with soaked them and retted I was particularly interested in conversational sto-
groups them, and spun them into flax and from that flax rytelling (Norrick, 2000) about personal events. I
she made....... wanted to see what kind of stories people told
This is part of a much longer story that I haven’t about their lives, and whether they could share
“Do you remember the the time to tell you here. these stories effectively with others.
time...?” “I couldn’t believe Once there was a lecturer who was given a year Some clear differences emerged between the
and a day to go out and collect stories from people people I was working with, depending on their
it when...” “And then she who don’t find it easy to tell ... ability to communicate. The first group of adult
said...” “A friend of mine Actually it was a year, but this is poetic licence. I storytellers all had effective verbal communica-
tion: only three of the nine could be said to have
did that once and...” was lucky enough to receive a mid career award
from the Health Foundation in 2002-2003, and I significant difficulties in expressing themselves.
We are all working to spent it exploring some different ways of story- They told stories about themselves, stories based
on television programmes (EastEnders and Dad’s
ensure our clients can telling with adults and children who have learn-
Army being the favourites) and traditional stories
ing disabilities. Silence for a year and a day is a
make choices and good plan. When you are in the middle of the such as The Wizard of Oz. Falling off a horse, told
decisions, but what of that forest and feeling your way, it’s quite hard to by Terry, is a typical example from the data of an
anecdotal third person narrative:
explain to other people why you are there and
most basic of human how to get where you are going. Now I’m emerg-
Falling off a horse
needs, the sharing of ing out of the wood, the year is nearing its end “I have a friend who fell off a horse. She tried to mount it from
and I’m beginning to be able to see where I’ve
conversational stories? been and what it all meant.
a stool. She got on the horse, it jumped and she fell back-
wards. She never went riding again! Gave up the same day!”
Nicola Grove reflects on I worked with two groups of adults - nine people
with mild to moderate learning difficulties, and This short story meets the criteria for conversa-
a year spent exploring six people with severe and profound disabilities - tional stories suggested by Norrick (2000). It is
different ways of and two families of children with special needs. I told partly to convey information, but also to
storytelling with people also spent seven days working in special schools,
one for children with autistic spectrum disorders and
build rapport, being a classic “response story”,
told after Sally had volunteered that she used to
who have learning one for children with severe learning difficulties. ride and that she had never fallen off. I then
disabilities. The main questions which drove my research related an accident falling off a galloping horse,
were: and Terry then contributed his story. Sometimes,
• What kinds of stories are generated by people however, narratives were what Norrick characterises
with severe communication difficulties? as diffuse (that is, the bones of the story emerge
• How can people with disabilities and their families gradually during the course of a conversation) 

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2004 <

 cover story

 and potential (where only one or two narrative

Figure 2 Storytelling analysis
elements are present). Children with autism who
(a) My Hamster (by Ed) were verbal were also able to tell stories, both real
A. She is called Naughty, because once she escaped from the house. and imaginary (see for example Wolves in figure 2).
B. I didn’t put the tubes together properly.
C. It was where I lived before.
D.I kept the door shut all the time.
Reliant on others
E. When I came home one day, I found her missing. By contrast, the nonverbal pupils in the two
F. I said, “Where’s she gone?” schools and the adults with profound disabilities
G. I put a board at each end of the sideboard so she could not keep running up and down. were reliant on others to construct the narratives,
H. She never escaped again. and here there seemed to be a real difficulty in
storying, as opposed to recounting, experience. I
Structure: elicited stories from primary carers of the six
Ed introduces the story with an abstract, summarising the story and explaining the name of the pet (A). He provides
background information (C, D), and then launches into the event sequence (E, F, G) finishing with a resolution (G) and adults with profound disabilities in the story-
a coda (H) which rounds the story off. The sequencing shows Ed veering from one time frame (general past) to anoth- telling group, and from teachers and parents of
er (local past), but this is not enough to derail the story from the listener’s point of view. It’s a rather bare narrative, children in the special schools. What emerged
which Ed could be encouraged to elaborate - for example by including more events such as his search round the room. was a strong bias towards recounts - description
He leaves implicit the finding of the hamster, so that the high point is actually at F, and the narrative is left hanging. of a routine rather than a story about a meaningful
experience. It was common in the interviews for
Affect:
events from the past to be placed in the context
There are a number of evaluations here. At A he says explicitly that the hamster is naughty. At B he explains his own
role in her escape - the inclusion of properly signalling that he was at fault. Ed uses his voice very effectively to main- of the present. Most informants used either the
tain listener attention, stressing “missing” and saying, “Where’s she gone?” with an exaggerated questioning intona- present tense, so that questions originally
tion and a half laugh at the antics of the hamster. He shakes his head as he says the coda (H). designed to focus on the past drifted into the
here and now; or the past continuous, describing
Form: habitual rather than unique events, as in the fol-
Ed uses relatively few rhetorical devices, but here there is patterning in the repetition of “escaped” from the first line
lowing example (N is me, M is the mother of the
in the final line, and the formulaic “running up and down”.
service user concerned):
Audience awareness:
N. And just thinking about the year - what would you say
Ed is extremely aware of the listener. He checks and monitors attention, uses stress, cues the listener into the context
are the key events for Shahela in the year?
(C, D) and provides explanations (A, B).
M. Christmas.
Figure 1 Analysing stories N. Right, what happens at Christmas.
(b) Wolves (by Izzy)
M. Because she has the Christmas tree and the carols.
A. I like the safari park.
She loves listening to the carols. So come around the
B. I see lots of animals.
beginning of December, you know, I start playing the
C. I saw some wolves.
carols at home, and she enjoys that. (.) And she likes
D. They look like me.
summer as well, the sunny days. She enjoys that.
E. They eat bones, your bones!
Those are her highlights of the year.
F. If we were out there, getting out, the wolves would eat our bones.
N. Can you remember any special Christmas - any time
G. They would hunt, they’d crunch and rip your top.
that stands out?
H. I can smell the bones.
M. The opening of the presents she likes, around the
I. I can smell wolves.
tree you know?
J. I hear the howls (makes loud wolf howl).
N. But there isn’t one that stands out?
M. There is one. On Christmas Eve I take her to (shop-
Structure:
ping centre), for many years we have been doing that.
This story, dictated to a teacher, counts as a potential fantasy narrative, because of the tense switches, the hypothetical
We take her there and we have lunch there and we look at
actions, and the lack of climactic event or resolution. There is some confusion in the referent of “getting out” (F), and
the decorations. And she likes that.
there is no logical event sequence as such: eating is mentioned first, followed by the events which would precede it
(hunting, then crunching and ripping).
There were some tantalising clues about why
Affect: this might be so - the impoverishment of many
There is powerful emotive content here, and Izzy leaves us in no doubt how we should be feeling. At (E) he switches people’s lives making reportable events the
from the generalised “bones” to “your bones”, then to “our bones”, including himself as victim with the listener. The exception rather than the rule, and assumptions
exclamation mark suggests he marked the phrase in some way with stress or pitch. He ends with a scarey sound. He that only simple accounts rather than stories will
chooses strong, specific verbs: crunch, rip. He does not, however, make any explicit references to feelings, so that the be understood. The answer may lie in the role of
evaluations are descriptive and evocative rather than personal in character.
the respondent in conversational storytelling.
Form: Where we receive no feedback from the listener,
The story may not be entirely coherent, but it is extremely satisfying, largely because of Izzy’s mastery of rhetorical and where the key person does not initiate a story
devices. He links ideas through patterned sentences and repetition (I like (A) / They look like me (D); I see (B) / I saw (C); by indicating that an event is significant to them,
They eat (E) / They would eat (F); I can smell (H) / I can smell (I)). The repeated phrases with “bones” are particularly we are unlikely to engage in extended storied
chilling, bringing the threat nearer and nearer. He also uses poetic forms: assonance (hunt/crunch) alliteration dialogue. Moreover, the current policy emphasis
(hear/howls) and internal rhymes (rip/top). The short sentences add to the sense of contained menace, with longer pat- on choicemaking (Department of Health, 2001)
terned sentences acting as the climax at F and G. The high point is thus rhetorical and formal, rather than structural.
may privilege some kinds of talk - notably the
Audience awareness: negotiation of wants and needs and decision-
As this is dictated, it is not clear whether the story was in fact constructed for a listener, or as a private fantasy. However, making - over the sharing of experience which lies
the shift in pronouns suggests that Izzy is in fact aware of his listener. at the root of storytelling.
I like this story just as it is, and wouldn’t change a word of it, but I would want to check out Izzy’s ability to structure
event sequences, and to use the language of feeling as well as description. Different approaches
Various different approaches were explored in

I SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2004

 cover story

the course of the project - working with groups,

working with individuals using PowerPoint soft-
Analytical framework (Adapted from ‘The Three Gifts’ by Helen
Broadbent in Fairy Tales for the Schoolroom,
Analytical frameworks need to fit the available
ware or tactile sensory books, and recording sto- data: in this case, stories which are diffuse, partial Gresham Publishing Co Ltd.)
ries in scrapbook form, used with the families. I and co-narrated. I have drawn principally on the
will focus here on the value of a storytelling social constructionist approach, deriving from the Dr Nicola Grove is Senior Lecturer at the Department
group for the individuals concerned, the use of work of Labov & Waletzky (1967) and developed of Language and Communication Science, City
co-narration, and interactive storytelling. by McCabe & Peterson (1991). As well University, e-mail [email protected].
The setting up of groups dedicated to story- as the structural or referential compo-
telling definitely contributed to a sense of identi- nents of narrative - event sequence, Note: Keith Park and I have now
ty and to foregrounding the activity, as was evi- setting information, climax and resolu- As storytellers set up an organisation to coordi-
dent in the following field note: nate all the work we do around
tion - Labov emphasises the affective mature, they storytelling - ‘Storytracks’. Further
aspect. The teller needs to convey why
In a discussion about the party invitations, I asked what we
called ourselves - and Jim immediately said “storytellers!” the story is significant and worthy of become more information and free resources
with an inflection that suggested this should be obvious. attention, and does this typically able to take can be found on our website
www.storytracks.com, or from 41
through affective signals and devices,
As found previously (Grove, 2002) it seems very
termed evaluations. These are both
account of the St Pancras Court, London N2 9AE.
hard for people with learning difficulties to have
the confidence and the skills initially to “take the
verbal (for example, references to needs of their Acknowledgements
floor” and relate a story as monologue. What
emotional state) and nonverbal (ges-
ture, intonation, stress). Norrick (2000)
listeners. The projects were supported by a
works much better is a style of co-narration, where mid-career award from the PPP
identifies a third aspect, which is
a familiar story is constructed jointly, with partici- Foundation, and would not have
rhetorical: formal devices used to cue
pants invited to provide specific contributions. been possible without the help and cooperation
the genre and thus expected response, to secure
attention, and to give a pattern to the narrative. of service users, staff and families from Fieldways
Jim shows a picture of himself in fireman’s uniform. He is
As storytellers mature, they become more able to Centre and Rosa Morison Centre; pupils and staff
unable to say much here, but the others help out - “He vol-
unteered”; “It’s a fireman”; “It was at the flower show”. take account of the needs of their listeners. This is at Sunfield and Reynalds Cross Schools; and Karen
apparent in each of the three dimensions Powell, Martin Samuel, Rachel Clifford and
Once the group has supplied Brenda McConville, student speech and language
(structure / reference; affect; form /
the relevant details, they can Where we rhetoric), and is represented in the model therapists.
collaborate in the telling of a
story. Jim, Terry and Ed, who all receive no by a shift from the centre (self awareness)
References
to the outer perimeter (awareness of oth-
remembered the war vividly, feedback from ers). Figure 1 shows a diagrammatic repre- Department of Health (2001) Valuing people: a
did a storytelling performance
in which I provided the skeleton the listener... sentation of the model, and Figure 2 new strategy for the 21st Century. London:
HMSO.
shows how the model can be applied to
narrative, and they contributed we are unlikely the two stories, ‘My Hamster’ (told by Ed, Grove, N. (2002) Storytellers in the SLD school.
sound effects, gestures to show
the doodlebug overhead, and
to engage in who has mild learning difficulties) and Paper presented to the Inaugural Conference of
IASSID Europe, Dublin, 12-15th June.
key lines of dialogue. extended ‘Wolves’ (told by Izzy, a child with autistic
spectrum disorder). Labov, W. & Waletzky, I. (1967) Narrative analysis:
Interactive call and response
has proved highly successful in
storied Listening to stories - really listening to oral versions of personal experience. In J. Helm
(ed) Essays on the verbal and visual arts. Seattle:
other contexts (Park, 1999) but dialogue. what people who have severe communi-
cation difficulties want to tell - and find- University of Washington Press (pp. 12-44).
is usually associated with tradi- McCabe, A., & Peterson, C. (Eds.) (1991)
ing a register that feels comfortable for
tional stories, literary stories and poetry. In this Developing narrative structure. Hillsdale, NJ:
telling - is extremely hard work. I feel I have only
project we used a similar style to construct quick Lawrence Erlbaum.
been able to scratch the surface in my year of story-
spontaneous storytelling about everyday events Norrick, N. (2000) Conversational narrative in
telling, but I’m encouraged by the enthusiasm and
after lunch in the day centre for people with pro- everyday talk. Amsterdam: John Benjamin.
interest of the many people I have worked with -
found disabilities. The high level of rhetorical Park, K. (1999) Storytelling with people with sen-
day centre staff, school staff, parents, students
devices - repetition, exaggerated prosody, use of sory impairments and additional disabilities. SLD
from City University and people with learning dif-
formulae often programmed onto switches - Experience 23: 17-20.
ficulties themselves.
seems to work effectively to engage the attention
of people with limited understanding of content. A King had three daughters, all born on the same
Although this approach has the effect of ritualis-
ing what is normally a very natural and unaffect-
day, and he decided to send them out into the
world and give his throne to the one who brought Reflections
ed process, the difference between performance home the best gift. The first girl returned after a • Do I value opportunities for
storytelling and conversational storytelling is rela- week with a pearl of great price which bestowed silenceA listening and
tive rather than absolute. Norrick (2000) provides eternal youth and beauty on its owner. The second
several examples of patterned language and for- returned after a month with a dagger which granted
reflection?
mulaic speech in his examples of anecdotes told certain victory over foes. But the summer slipped
by adults to each other. There were signs that the away and still the third daughter had not returned. • Do I help clients share
inclusion of a regular shared storytelling activity One day in early autumn she was resting in a wood experiences and build
could lead to genuine mutual affirmation, and we when suddenly a quaint little figure appeared, conversational stories?
saw service users beginning to take part and dressed in motley. “Your sisters have brought home
respond to what was happening. It is, however, great and wonderful gifts”, he said. ‘But what • Do I try to see the wood as
challenging for staff, requiring a high level of self- have you been doing all this time?” “Oh,” said well as the trees?
confidence and disinhibition. she, “I’ve been listening to stories....”

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2004 J

 early intervention

Read this
Sure Start:
the final fron
if you
•have the opportunity to be innovative
•want to provide a community based,
inclusive service
•plan at a strategic or operational level

Alison Cooke & Dana learnt of many tales of woe, as well as wishes.
Actively seeking out and listening to their com-
We subsequently spent approximately three
months ‘loitering with intent’ - visiting community
Taylor report back on munity enabled them to develop a plan of action settings, being seen and talking to staff and families
at both a strategic and operational level. about current opportunities to promote language
their joint mission to The two chosen ones felt honoured to work in development and potential future partnerships.
bring specialist partnership and be given the opportunity to take
on this challenge. However, they felt understand-
During this time we got to know various members
of the community quite well and vice versa.
knowledge of early ably apprehensive about taking on such a diverse During visits to local nurseries we discovered
speech and language role. They felt that a united front was a stronger
force than a divided one.
their concerns about the lack of verbal communi-
cation skills that children were displaying and
development to two During Sure Start team meetings it quickly their lack of readiness for reading and writing.

culturally diverse Sure became apparent that they appeared alien to the
other chosen ones from around the galaxy. They
This is consistent with the findings of Locke et al
(2002) in their study based in the local area. They
Start locations in Sheffield. had to work at being accepted. Rather than orbiting reported a link between poor verbal skills and a
around the planet, they had to land on site regu- difficulty acquiring academic skills. Teachers

W
e were asked recently what larly, especially in a social capacity (lunch-time). reported a number of difficulties to us, namely:
our recommendations would Their title as speech and language therapists limited vocabulary, sentence formulation skills,
be for up-and-coming Sure merely functioned to isolate them from the team attention and listening skills, turn taking skills,
Start speech and language and hence they came to be known as Sure Start knowledge of nursery rhymes and lack of ability
therapy posts. Following a speech and language workers. Their apparel was to participate in group times. They felt that a
year of joint targeting of another obvious issue. They appeared very clinical in potential contributory factor was a lack of verbal
early language promotion in community settings, their dress code, which affected their rapport with interaction in the pre-school years and a lack of
our answer was: two speech and language thera- the community. Fabrics such as cotton and wool attendance at or active involvement in parent and
pists working in a skill mix partnership. So, why do were replaced with denim. They worked together toddler groups.
we feel this is so crucial? to establish an allegiance with the entire commu- From here we decided to investigate the local
Just as the medical profession heard of The nity, so that the success of their mission became preschool provision. Again, this involved loitering
Gatekeeper and the Wizard (Mathers et al 1989), even more tangible and so the story continues... with intent and talking to the children and carers,
we thought a galactic perspective would be an ............ as well as observing. The environments varied.
appropriate analogy to reflect our experiences However, there appeared to be a number of carers
initially, before we give a more mainstream Play & Say is a six week workshop devised to viewing the group as support for themselves,
account. So here goes... promote speech and language development pre- whilst they sat quite separately from the children,
A long, long time ago, in a galaxy far, far away dominantly with children under four. It is aimed who were left to play with little supervision and
(Sheffield), a chosen one....no, actually two chosen at showing carers how they can help their child’s minimal adult interaction.
ones, were brought forth to fulfil their destiny as speech and language development by having fun From our observations it seemed that many of
speech and language therapists (well, speech and together and playing. At present, we are targeting the children showed restricted symbolic play skills
language workers, but that comes later) within the local parent and toddler groups. The workshop even at three to four years of age, with difficulties
Sure Start. The future had yet to unfold. Sure was piloted with successful results in January to not dissimilar to those noted by the nursery staff.
Start, a new entity within the galaxy, remained February 2002 and we have subsequently completed Snack time often had no set routine. In general,
formidable and their task was to promote early a further four Play & Say workshops within the children were given food and drink and left to sit
language development and early identification, two Sure Start areas. These were five very different or wander around, whilst carers sat together.
and to empower the community. The challenge groups and we therefore adapted Play & Say to When discussed with fellow Sure Start Workers
was indeed a great one but, together in partner- suit individual needs. they reported the same findings and noted a lack
ship, they knew they could rise to it. of motivation to be more active on the carers’
In the early stages of their allegiance, the plan Loitering with intent part. This was consistent with our discussions with
was a simple one...to loiter with intent and let We started co-working in Sure Start in July 2001. carers, which indicated that the carers needed
themselves be known to the community. The aim We were excited to have been offered such a chal- support from each other and adult conversation.
was to dispel the myths around speech and language lenging role, but at the same time a little apprehen- They did however show interest in our ideas for
therapy and to ensure they were approachable. sive. The Sure Start areas we work in are culturally activities to promote language, and responded
Armed with little more than a packet of plasters, diverse, one having over 42 languages spoken in with positive comments.
they set out on foot (trainers at the ready) wher- one community. We therefore felt it was essential As early intervention has been shown to have a
ever possible to drop in at community venues and to find out what the community really needed in positive effect on children with general develop-
put names to faces. During their travels they terms of communication before setting an agenda. mental delay or more specific speech and lan-

- SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2004

 early intervention

ontier
guage difficulties (Glascoe & Sturner 2000), we
decided to take action and Play & Say evolved.
Dana’s son Dominik helps Alison perfect her technique!

Figure 1 A typical Play & Say workshop

Week One: Introduction
Carers are introduced to the idea of “playing & saying” in this week. They are given verbal and
written information about the aims and practicalities of the workshop. Carers fill in a consent
Inclusive form, a snack time information sheet and a Starter Vocabulary Checklist (Locke, 1985) (with help
Our initial criteria were to run a workshop that from us as necessary). Filling in the vocabulary checklist enables us and carers to monitor progress
was community based and inclusive. We wanted of individual children. Additionally, it helps us determine what level to pitch language activities at.
carers to have the choice of opting in or out. We
Week Two: Nursery Rhymes
did not want to offer a ‘speech and language
Each carer sits with their child and the “hello” song is sung to all the children. We then sing
therapy’ group. Following the ethos of Sure Start, “have a turn and pass it on” and the children are given a choice of two action nursery rhymes.
we wanted all children, regardless of their lan- This is presented visually in the form of symbol cards for each rhyme. The children choose a card
guage abilities, to be included. (with / without naming the rhyme, depending on verbal ability) and place it on the choice board
As carers had shown an interest in our ideas to (attached by Velcro). We model the key vocabulary for the children and sing each rhyme together
(with words available for those who don’t know them). We then sing “bye bye” to each child and
promote language development, we wanted to give them a reward sticker and a home activity pack.
give them something that would benefit both
themselves and their child. We knew it had to be Week Three: Listening & Attention / Animal Theme
realistic, so that they could take it on board and Again, the “hello” song is sung. After singing the “have a turn” song, each child selects a small animal
picture from a bag and matches it to the appropriate larger picture (again, with / without naming the
generalise it to their own environments. We were
animal). The animal words and noises are modelled for the children. We then sing the “have a turn”
already aware that many of the carers we talked song and each child selects an animal picture, which they wave in the air during ‘Old MacDonald’. We
to saw Parent Toddler Groups as a support system finish the session by singing “bye bye” giving a reward sticker and a home activity pack.
for themselves, plus a chance for their child to
play with others. We therefore needed a way to Week Four: Snack Time Choices
A structured snack time is demonstrated, using a choice of two items of food and drink. These are
show carers activities that they could continue in food / drinks that the group would normally have. Symbols for each choice are used to reinforce
the group and at home, as well as continuing to these visually and to involve non-verbal children in making choices. The “have a turn” song is
have adult conversation and some time out. sung and carers are encouraged to partake in this activity, supervising and interacting with the
The aim is to demonstrate hands on strategies to children. This demonstrates how they can promote language by giving the children choices. The
symbols are exchanged for the requested item. The session is ended with the “bye bye” song,
enable and empower carers to promote language
giving of reward stickers and home activity packs.
development and feel confident transferring
these skills to any environment. For example, Week Five: Body Parts
singing “hello” and “bye-bye” to the children and Fun with water week! Again, “hello” is sung. Children and carers are encouraged to bath dolly
“have a turn and pass it on” encourages social use together, the adult reinforcing body parts vocabulary and concepts. We then look at the body
parts lotto and sing “Heads, Shoulders...” and “bye bye”. Reward stickers and a home activity
of language and makes them feel like a special pack are given.
member of the group. Carers can then continue to
sing these at home, singing hello in the morning, Week Six: Evaluation (Play & Say Toys)
bye-bye to toys as they are tidied away or “have a Evaluation forms are given to carers. Help is given as necessary to ensure that everyone is able to
express their opinion. There are opportunities to discuss follow up workshops and time for carers to
turn” while playing a family game. This promotes
talk privately about any concerns they may have about their child’s speech and / or language. We
interaction and the essential precursors to effective also talk about toys that help you to Play & Say with your child, and provide written information.
everyday social communication. It also encourages Favourite activities are repeated. Certificates are given to both carer and child.
the acquisition of social tools that prepare a child
for their entry to nursery and make active partici- Play & Say songs
pation less daunting. Hello (made up tune)
Groups of approximately four to six children Hello Meena, Hello Meena, Hello Meena,
(depending on ages) and their carers are taken on We’re glad you came to play.
a rotational basis. They are taken to a quiet area
Have A Turn (“London Bridge Is Falling Down”)
within the setting. The carers are encouraged to
Have a turn and pass it on,
be with their child throughout the activities and pass it on, pass it on,
to Play & Say together. After each session the carers Have a turn and pass it on,
are given a Play & Say home activity pack. This Pass it on to Jamie.
contains ideas and games related to the theme of
Bye Bye (made up tune)
that particular session, for example a nursery Bye bye Max, Bye bye Max, Bye bye Max,
rhyme activity booklet. We’re glad you came to play.
A typical workshop, including songs used, is
described in figure 1. 

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2004 --

 early intervention

REVIEWS
 CHILD VOICE
Well-known phrase AN EXCELLENT OVERVIEW
Play & Say has been successful. It is now a well-known phrase within the Working With Children’s Voice Disorders
community - in many different languages. We have been evaluating Jenny Hunt and Alyson Slater
Play & Say in a number of ways, namely through feedback forms, vocab- Speechmark
ulary checklists, informal interviews and keeping field notes. By collat- ISBN 0 86388 279 X £34.95
ing this information, we have been able to conclude that it has been a This book provides an excellent overview of child voice development and disorder
productive initiative. We have used feedback in a positive way to adapt and should appeal to both the generalist and specialist therapist for its accessible
the workshop to make it as effective as possible. Sure Start has received and practical format. It gives an overview of the development of the infant and
a number of phone calls from carers requesting further information juvenile larynges and the contributory and maintaining factors of voice problems,
and when / where they could attend. A waiting list has developed. and practical advice is included for case history details, the assessment and evalu-
Monitoring suggests that word of mouth appears to be the main source ation of the child’s voice and subsequent management strategies.
of community information regarding Play & Say. This indicates the impact Layout is good with subheadings and bullet points to help the busy therapist. A
it has had on the community and the encouraging reviews we are getting series of photocopiable handouts covering information about voice, exercises,
from local people. record sheets and letters provides a timesaving resource.
In one area we are compiling Play & Say toy packs, consisting of sym- Recommended in terms of content and value to therapists who have infrequent
bolic play items such as a doll and tea-set, that children will receive after contact with paediatric voice problems. It should prove to be a very practical
completing the six week Play & Say workshops. Workshops are continu- resource in any clinic.
ing to be run on a regular basis. Additionally, Play & Say is being piloted Karen Shuttleworth and Alison Taylor are Speech and Language Therapists work-
in a nursery environment, with so far positive results. However, with ing for Morecambe Bay Primary Care Trust.
increased demands on our time, we are looking to train other people to
take on this enabling role. We have initiated a City wide training pro- LANGUAGE
gramme. This includes initial training on Play & Say, which will be followed CLEAR AND RELEVANT
by participants shadowing a workshop in order to be able to run them Basic Verbs
independently. As we become involved with new Sure Start pro- ColorCards®
grammes, we are constantly extending the opportunities to Play & Say Speechmark
and hope the momentum and success will long continue. ISBN 0 86388 476 8 £25.95 + VAT
Working in partnership has been highly rewarding. Being able to This pack contains 48 large format colour photocards presented in a sturdy box.
work in such an exciting and innovative area together has enabled us The photographs are clear with relevant subject matter and should encourage
to be more creative and effective than if we had been working alone. vocabulary expansion in clients of all ages.
It has facilitated the targeting of a larger population size and allowed us The background colour enhances rather than detracts from the target verb thus
to deliver speech and language information to a wide range of settings. reducing visual perceptual problems for some clients.
We have learnt a lot during this past year. We have learnt about trans- This resource would be beneficial to all therapists working with both individuals
disciplinary, interdisciplinary and multidisciplinary ways of working. We and groups and it will help to encompass many therapy aims in areas such as verbal
have gained an insight and developed skills around working in a comprehension, expressive language, sentence formulation and indeed general
diverse cultural environment. Tackling problems together has been far communication skills. Children enjoy and respond well to the colour photographs
easier than facing them in isolation and we have been able to reflect and we would recommend this set as a valuable asset to any therapist requiring a
on our experiences. This has enabled us to continually develop ways of set of action pictures.
working that promote good evidence based practice and mean we Alison Taylor and Karen Shuttleworth are Speech and Language Therapists working
work with the community for the community. for Morecambe Bay Primary Care Trust.
May the force be with you!
Dana Taylor is a Specialist Sure Start Speech & Language Worker / Therapist EDUCATION
and Alison Cooke a Senior Sure Start Speech & Language Worker / Therapist STRAIGHTFORWARD GUIDE
with Sheffield Speech & Language Therapy Agency Sure Start Team. How to ... Identify & Support Children with Speech and Language
Difficulties
References Jane Speake
Glascoe & Sturner (2000) Surveillance and Screening: In Law, J.,
LDA
Parkinson, A. & Tamhne, R. (Eds) (2000) Communication Difficulties In
ISBN 1 85503 361 5 £9.95
Childhood - A Practical Guide. Radcliffe Medical Press.
This straightforward guide for teachers, SENCOs and teaching assistants will help
Locke, A. (1985) Living Language. Putting Words Together. NFER-Nelson.
them identify primary aged children who have speech and language difficulties.
Locke, A., Ginsborg, J. & Peers, I. (2002) Development and disadvan-
Terminology is covered. There is an overview of the roles of education and speech
tage: implications for the early years and beyond. International Journal
and language therapy plus a discussion of collaborative working. Inclusion of AFASIC
of Language and Communication Disorders 37 (1): 3-15.
checklists provides a structured approach to observation and a basis for referrals.
Mathers, N.J. & Hodgkin, P. (1989) The Gatekeeper and the Wizard - a
The most useful section identifies strategies for support and gives specific ideas on
fairytale. BMJ 298:172-4.
helping the child to manage in the classroom. Ideas on multi-sensory materials

Reflections and experiences are given and difficulties are linked to the curriculum. There is an
excellent section on ideas to underpin semantic development.
•Do I get out and networkA or do I expect Well written and inexpensive, this is good on basic ideas but limited in follow-up;
people to come to me? speech and language therapy extension would be advisable. More resources and
•Do I take advantage of opportunities to work more on IEP targets would improve it. A resource for therapists working in main-
with colleagues? stream schools to recommend if opportunities for training are limited.
•Do I work with the community for the Noreen Marks is a speech and language therapist in Essex.
community?

- SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2004

 reviews

LANGUAGE DEVELOPMENT COLLABORATION

A USEFUL REFRESHER OFF-THE-SHELF PACKAGE
Child Language Development - Learning to Talk 2nd Ed. Speaking, Listening & Understanding
Sandra Bochner & Jane Jones Catherine Delamain & Jill Spring
Whurr Speechmark
ISBN 1 86156 379 5 £25.00 ISBN 0-86388-433-4 £32.95
This is a comprehensive handbook for those working across the range of This book contains a collection of activities, games and photocopiable work-
early years settings, especially speech and language therapy assistants / sheets for use with children in Key Stage 1 of the National Curriculum for
workers. It would also be a useful refresher for those returning to practice. England and Wales. The three main sections are: ‘Understanding Spoken
Every part of the programme rationale is supported by up-to-date and Language’, ‘Using Spoken Language’ and ‘Activity Resources’.
referenced research, yet the authors manage to maintain an enjoyable, Games and activities are designed for whole class use and are intended to fit
readable style. into the existing curriculum.
The book has three parts: Each activity includes a clear aim, graded for difficulty, equipment and preparation
• the background theories upon which the authors based their required, as well as instructions and additional ideas for extension.
language programme A relevant resource for therapists covering busy mainstream schools, providing
• the language programme, including a chapter on how to organise a an off-the-shelf package for teachers to support existing language therapy
programme programmes.
• phonology, AAC, working with non-English speaking families, One small criticism - the illustrations and texts provided in the teaching resource
working in groups and with families. section could be more attractive.
An excellent resource for any early years practitioner, and good value for However, good value for money and a useful tool to develop collaborative working
money. between teachers and therapists.
Debbie Wheeler is a speech and language therapist with Sure Start Barrow. Ann-Marie Thompson is a specialist speech and language therapist for mainstream
schools with Homefirst Community Trust, Northern Ireland.
ADULT STAMMERING
A CHALLENGING OPTION LIFE SKILLS
Beyond Stammering: The McGuire Programme for Getting
Good at the Sport of Speaking
KEY REMINDERS
ColorCard® Simple Sequences
David McGuire
Vanessa Harrison
Souvenir Press
Speechmark
ISBN 0285636731 £12.99
ISBN 0 86388 475 X £25.95
This easy-reading user guide provides an understanding into the ethos
This resource can be used in schools for children at key stages 1 and 2 for a variety
and method of the David McGuire Programme. Based on using costal
of purposes in assessment and management of communication difficulties. The
diaphragmatic breathing to control stammering, it emphasises drilling
pack comprises 48 large colour format photographs depicting familiar situations
this technique in a manner analogous to championship tennis. No compro-
with varying age groups participating.
mises are offered on the path to eloquence, its ultimate goal! It discusses a
Activities involving sequencing and extending ideas / possibilities as a basis for
holistic approach to dealing with the complexity of stammering, tackling
discussion in a group are possible as well as using the pictures to address tenses,
fear, avoidance and self-actualisation. Achieving its goal is by no means
opinions and use of language in descriptions. They could be useful as key
an easy road and may well be beyond the scope of many. A worthy
reminders for pupils learning familiar sequences in daily living events.
resource and a challenging option!
Janet V. Graves is a senior speech and language therapist with Conisbrough and
Nicola Godfrey is a speech and language therapist for Brent PCT, London.
Denaby Main Education Action Zone in Doncaster.
MANAGEMENT
EMINENTLY READABLE HEARING IMPAIRMENT
Healthcare Management Directory BASIC AND PRACTICAL
Annie Phillips Working with Children with Cochlear Implants
Radcliffe Medical Press Ltd Published as part of a series of RNID Education Guidelines titles
ISBN 1 85775 802 1 £21-95 Updated ICTOD guidelines included
Somewhat daunted at having to review a healthcare management dic- RNID (tel 0808 808 0123)
tionary I actually found it eminently readable and extremely useful. ISBN 0 900 634 987 £5.99
The author is a qualified speech and language therapist with extensive Intended to support teachers of the deaf, this would be a useful resource for
NHS management experience. The communicative style is very clear pro- speech and language therapists as well as mainstream teachers and parents. It
viding hundreds of plain English definitions of clinical management provides easily accessible guidelines including useful background information
terms, acronyms and jargon currently in use within Primary Care. for anyone new to cochlear implants. Discussing implants with the parents of
As this type of text can date quickly, websites have been provided very young children and with teenagers are among the issues covered.
throughout as a useful source of further information. The main section deals with supporting children after implantation with the
This very comprehensive reference book would be a valuable resource emphasis on practical help. Advice sheets of ideas for parents and children from
for any department and in particular for newly appointed managers or Foundation Stage to Key Stage 4 can be photocopied. At the end of the book is
clinicians in leadership roles. a particularly useful resource section containing addresses and lists of publications.
Good value for money, but will probably need updating / revision within The Implant Centre Teacher of the Deaf (ICTOD) guidelines will make speech
two years if the current rate of change within the NHS continues. and language therapists aware of the remit of teachers of the deaf.
Angela Grant is Head of Speech & Language Therapy for North Devon Shirley Down is a speech and language therapist with the Conwy &
Primary Care Trust. Denbighshire NHS Trust in North Wales.

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2004 -5

 winning ways series ()

Enjoying
the ride
“ He has half the deed done,
Who has made a beginning.” As the wheel of life Jean arrived from Glasgow with some trepida-
tion. She spoke incredibly well thanks to her own
Horace
I never make any secret of goes round, it’s easy to determination and she taught me how to speak
to her in a relaxed yet focussed way. We also used
the fact that I believe my
work to be vocational and lose our balance. Life a flip chart for illustration and word clarification.
I had to set up the room differently, use signs and
spiritual. That is not to say
that religion usually comes coach Jo Middlemiss actions and pay even closer attention to my client
than usual. However the story was really no dif-
into coaching unless it is specifically part of the
work that my client wants to do. No, the spiritual encourages us to find ferent to many I had worked with. Dealing with
others’ insensitivity was the presenting problem
element of the coaching is just the acknowledge-
ment that we are all made up of mind, body and ways of getting things but the real issue was that my client was looking
outside herself for solutions. She wanted to
spirit, and that each of these elements is hugely
important and simply cannot be ignored. back on an even keel. develop skills leading to a new and interesting job
but the work would involve speaking in public
However, many people believe that we are get- and she carried with her the memory of being
ting into slightly boggy ground when the spiritu- laughed at in school, and one or two insensitive
al dimension is mentioned, and are inclined to teachers who had treated her as though she was
leave all that stuff to mystics, and off-the-wall stupid.
incense burning, tree-hugging wackos. In her adult life she was a successful wife and
But close your eyes for a moment and ponder mother not to mention a gifted sportswoman at
the following scenarios: both riding and tennis. She did not rate these
1. The person who is your immediate superior talents as successes because they came fairly easily
calls you into his or her office. They tell you that to her. The coaching work was to take the confi-
your work is outstanding and that your profes- dence she experiences when she feels powerfully
sionalism and efficiency are an example to all. in charge of a horse and transfer that confidence
What is your reaction? How do you feel? What to speaking in public. She imagined each session
emotions are around for you? as a hurdle to be leapt over. Another challenge,
2. Now - imagine that you are on top of a high hill which faced her was that she was by nature a fun
or mountain, that you have spent most of the loving and gregarious person. She imagined that
morning climbing. It is a glorious day, the sun is it was her deafness that got in the way of her
shining, the sky is blue, and the temperature is expressing her natural instincts. Jean accepts that
perfect. You sit down to rest and gaze around, nothing can be done about her deafness but the
when suddenly and unexpectedly an eagle soars coaching has been useful in as much as she has
beside you, unaware of your presence.
Now, can you describe the difference between if you
Read this been able to address her attitude to herself and
other people. When she decided to put fear to
these two experiences? I would argue that the • have already broken New Year resolutions one side and actually ask people to slow down or
first gives you mind and possibly body pleasure. It • feel mindA body and spirit are out of to say something again she was amazed to find
is ego driven, however, and the mood change was balance that they welcomed her interruptions and altered
brought about by another’s opinion. The second • have a tendency to procrastinate their behaviours accordingly. Her fear of being
is experienced at a spiritual level, and conse- thought stupid made her critical and judgemental
quently touches us in a completely different way. language therapy was limited but, within days of of them. The truth was something very much
The first experience was earned, whereas the second agreeing to do it, I was asked to take on a deaf simpler.
was given freely by nature and is available to all. lady as a client. Serendipity! Jean had some chal- Jennifer is a part time speech and language
I start in this way because the main thrust of this lenges in her life relating to confidence. I have no therapist. She is a member of a newly created
column is balance and, as you can see from figure signing skills at all but I do know about confi- out-reach team. She is a portfolio worker with
1, a life out of balance is an uncomfortable dence building so I wasn’t going to let a little other part-time jobs plus time consuming family
experience, no matter how good some elements thing like ignorance get in my way. Also, there is commitments. Skilful balancing of all these
of it are. a statistic going around that says only seven per aspects of her life was Jennifer’s main challenge.
cent of communication depends on words so I After filling in the Wheel of Life diagram (figure
thought I would have a go. Another element of 1) Jennifer was able to pinpoint the areas of her
Symbiotic relationship coaching is the sure knowledge that both coach life that she needed to smooth out in order for
When I was approached to write for this maga- and coachee are helping each other and that the her to be as effective a speech and language ther-
zine my experience with the world of speech and relationship is entirely symbiotic. apist as she wanted to be. Use of time and space

-
SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2004
 winning ways series ()

Figure 1 (see, for example, Whitworth et al, 1998)

Would you like to: Physical Environment Career
• Identify and achieve your dreams
Fun and Money
• Unlock your potential recreation

• Confront difficult decisions

• Shake off restrictive behaviours
and limiting beliefs Personal Health
growth
• Gain and maintain mental and
spiritual balance Significant other/
Romance Friends and family
plus developing good relationships with her new
colleagues was Jennifer’s main concern. • Be aware of and use your talent? The eight sections represent balance.
The centre is 0, the outer edge is 10.
One of the seemingly innocuous questions in my Our series ‘Winning Ways’ with Rate your level of satisfaction with each section, then draw
first session form is: “What unfinished jobs and Personal Life Coach Jo Middlemiss a new outer edge (example below).
unused items do you have using up your energy How bumpy is your ‘Wheel of Life’ now?
aims to help you find out how you
and space?” Initially this had not been Jennifer’s can be better at what you do, and
focus but when she realised that she could hardly better at being you.
get into her study to get going on her plans and
make her decisions, she decided that she would To gather material to make the
like to tackle that first. issues - and their potential solutions
- as realistic and relevant as possible
for readers, Jo offers readers a
Calm and productive confidential and complimentary
She was honest enough to acknowledge that half-hour telephone coaching
although she was always busy she was also a bit of session (for the cost only of your
a procrastinator. Procrastinators are rarely lazy call). Although Winning Ways will always choices, because there is always more than
people; they are just people who do not differen- be based on what is raised in the one way to look at anything and there is always a
tiate between ‘urgent’ and ‘important’. They tend calls, you can be reassured that choice of attitude. And after everything else
to do the jobs as they come at them so life tends details will be altered so that it will there is a call to action. What am I willing to do to
to be like driving through a snowstorm with inef- not be possible to identify individuals. change this situation and what am I willing to
ficient wipers. It’s exciting and absorbing but you stop doing to make this situation better? So let
never seem to be getting anywhere. There was so
CALL JO ON 01356 648329
this year be about solutions rather than resolu-
much stuff in Jennifer’s office that she was con-
(www.dreamzwork.co.uk).
tions and then, rather than desperately worrying
tinuously searching for and stepping over things. about punctures or falling off, you will enjoy the
So, somewhere that she would like to have as a ride.
calm and productive place had become a place There was a good outcome for me too as I reor-
she just wanted to close the door on. ganised all my books after my session with Jo Middlemiss is a qualified Life Coach with a back-
I asked her to imagine her room with absolutely Jennifer. ground in education and relationship counselling,
nothing in it. How does that feel? Fantastic? Balance is important, and we all seek it. But tel. 01356 648329, www.dreamzwork.co.uk.
Jo: “Is it in decorative order that appeals to you?” why? Firstly, balance is not a static state. You
Jen: “Yes.” know that the minute you try to stay still on a Reference
Jo: “Now, in your imagination, start putting bicycle you will probably fall off. No, we need Whitworth, L., Kimsey-House, H. & Sandahl, P.
things back in the order you need and want constant small adjustments and corrections to stay (1998) Co-Active Coaching: New Skills for
them...” on the bike and on the path. ‘Out of balance’ is Coaching People Toward Success in Work and Life.
Now followed a process of replacing only essen- that awful feeling that one is being driven by cir- Davies-Black Publishing.
tial items. Computer table and computer, desk, cumstances. When I see hearty people riding a
comfortable chair, bookcase and only half the tandem it gives me the collywobbles - I wouldn’t
books from the bookcase.
Once Jennifer had a mental picture of a clear
want someone else riding my bike!
When you feel as if you have no choices in any
Reflections
and peaceful space to work she felt motivated to situation - know that the bike is beginning to
clear that space and to get the work done that wobble. When you hear yourself saying things •Do I recognise and face up
she had been putting off. Unnecessary piles of like “I can’t.....I have to.... I need to......That won’t to my fears?
paper and unread articles were discarded, books work because she would never...” - know then
taken to a central base where they could be used that your ego, gremlin, lower self, call it what you
by others, and borrowed equipment returned. will, has taken over the steering of your life. •Do I know where I could
Once she had a plan and had committed herself FEAR is its usual guise but, when your awareness release energy and space?
to the job nothing could hold her back. The spin notices, then it’s time to stop, think and look for
off was that clutter in other parts of the house options and to call on that part of you which is •Do I see what I need to
was tackled also. Her children were enlisted to not hindered by past failures, fears or limiting
help and her mood lightened when she realised beliefs.
start 2 and what I need to
how oppressive all the excess stuff was. The sense That is where your spiritual self comes in and
stop 2 doing?
of satisfaction and success in this area encouraged gets you back into balance. No one can do that
Jennifer to start tackling other areas of her life. for you, and no one makes it happen. There are

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2004 -E

 guidelines

You talk -
but what does
O
ver the past 50 years, computer technology for automatic
speech recognition has advanced significantly. Low cost com-
mercial products are now available with good performance
in continuous speech recognition for people without speech
difficulties. Such software can give a new dimension to the
ability to use computers, including office tools, internet
access and even games.
We have been investigating the viability of automatic speech recognition use
by people with dysarthric speech difficulties. The key issues are the capability
of the software to adapt to the particular characteristics of the dysarthric

Read this
if you want to find out how
speech, and the degree to which the recognition can tolerate an increased
variability of certain characteristics of the dysarthric speech (Thomas-Stonell
et al, 1998; Blaney & Wilson, 2000).
•clients can benefit from new From limited recognition of a small vocabulary of single words or digits in
communication tools
•technology can be adapted to the 1950s, speech research moved to new concepts in the matching of input
enable wider access speech with stored speech databases in the 90s. Statistical modelling and
left to right: Malcolm Joyce,
•to choose software with matching methods enabled the development of a series of viable products,
Claire Philpott, Peter Roberts appropriate features
which gave continuous speech recognition with progressively increasing
vocabularies. Newer product technologies with what are called Hidden
Markov models, together with neural nets, allow effective and rapid ‘user
training’ of the inbuilt speech databases. This personalisation gives a high
level of recognition accuracy (95 per cent) across many speakers.
Earlier research with people with dysarthria was restricted by technology in
terms of both cost and performance. However, even with the early template-
based solutions, successful recognition of dysarthric speech could be achieved,
with closely limited vocabulary and tailoring of the speech model (Ahmed, 1985).
Ferrier et al (1975) showed good recognition in trials with one, and then
ten, dysarthric speakers, using early software. A panel of listeners also scored
the intelligibility of the speakers. The work demonstrated the value and
effectiveness of the Hidden Markov models learning/training process where
recognition accuracy increased from 30 per cent to 90 per cent over three sessions.
The poorer speakers displayed more variability in their speech, including that
caused by fatigue. This demanded longer automatic speech recognition
‘training’ sessions but, ultimately, similar levels of recognition were achieved
to the moderate or mild dysarthria. Further investigation of the causes and
characteristics of this variability would be useful, especially with larger numbers
of speakers.
Doyle et al (1997) also endorsed the effectiveness of the automatic speech recog-
nition learning with the newer software products (six speakers: two mild, two
moderate, two severe), especially for severe dysarthria where, after six sessions, the
automatic speech recognition was still displaying learning improvements.

Increasing viability
In the UK research continues with ‘STARDUST’ at Sheffield University and various
projects at Frenchay Hospital, Bristol. Our current work (Roberts, 2002) has
endorsed further the increasing viability of these software packages, certainly for
mild and some moderate dysarthria, and we have developed specific guidelines
to help the dysarthric user and their carers in the most effective configuration and
use of the facilities.
The computers and operating systems now available are well established
and give good value for money. As they are being marketed in a competitive

-0 SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2004

 guidelines

es it type?
situation, designers are continually looking to give equivalent and improved
Most people are familiar with the idea
of using a keyboard to type up a
document, send an e-mail or play games
on a computer. Automatic speech
recognition software can also be used to
facilities. This means there is considerable ongoing change and update to the do these tasks; as the adverts say, “you
products, with the risk of compatibility problems and change to appearance
and procedures. Different versions, or releases, of software do change aspects talk, it types”. But can this work when
that are of particular relevance to the dysarthric user. A good example is the
improvement in flexibility of the IBM speech training/enrolment process in
the user has a speech difficulty such as
release 10, from release 8. Further software releases may include changes to dysarthria? Peter Roberts, Malcolm Joyce
the advantage of people with dysarthria. However, a progressively increasing
capability has a down side of potentially increased complexity of use or com-
and Claire Philpott find out...
patability problems that may be a particular disadvantage for disabled users.
the remaining moderates and the severes could not use the systems because
Users need to maintain an awareness and alertness to these possibilities
they were not able to ‘enrol’ (the initial process to enable the systems to
when acquiring particular systems and ensure the use of appropriate profes-
recognise the specific voice). However, as you will see, we were able to follow
sional advice as necessary.
a series of procedures that improved on this initial recognition performance.
It is especially important that users and carers avoid the frustration and
errors of an impatient, unprepared start, and build up an understanding of Figure 1 Initial recognition performance
the features of automatic speech recognition systems. A range of self-train-
ing tools is included with the software and specialist training is also available.
In our research we used proprietary software packages from IBM (ViaVoice)
and ScanSoft (Dragon; Naturally Speaking) with Pentium 3 and 4 computer
processors, and Microsoft Windows 98SE, 2000, and XP. The conditions of the
Initial
various speakers involved in the research are in table 1. enrolment
cannot
Table 1 Speakers involved in the research enrol

patient ID severity M/F condition

mild1 mild male kennedy syndrome, slowly
progressive
mild2 mild male cerebellar ataxia, slowly
progressive
moderate1 mod male cerebellar ataxia, slowly progressive
moderate2 mod male stroke, static Satisfactory user speech input was achieved with the small headset and
moderate3 mod male multiple systems atrophy, slowly microphone supplied with the packages. The instructions included in the
progressive package guide the fitting and positioning of the headset. The use of these
moderate4 mod male kennedy syndrome, slowly microphones gave a good tolerance to the effects of ambient noise and
progressive acoustic characteristics of the surroundings. Some trials with hand-held or
moderate5 mod male cerebellar ataxia, slowly progressive desk-mounted microphones were less successful, as potentially improved
moderate6 mod female stroke, static quality of the microphone was offset by increased susceptibility to the effects
moderate7 mod male cerebellar ataxia, slowly progressive of surroundings. We therefore recommend use of the supplied microphones.
Once the software is installed, an initial set-up process is carried out. This
moderate8 mod male stroke, improving
enables the adjustment, usually automatic, of microphone loudness levels,
severe1 severe male cerebral palsy, static according to particular users.
severe2 severe male head injury, static Unique user set
severe3 severe male stroke, static At this stage a unique user set of information is initiated. A name is chosen
for this user, then subsequently re-selected as required in the future. The
control1 male
variability of some dysarthric speakers can usefully be managed and accom-
control2 female
modated by the user identification, as there is nothing stopping one user
control3 male progressively establishing him/herself with more than one user information
set. For example, if the person’s voice has differences between early morning
In the initial analysis (figure 1) people with mild and some with moderate and later in the day, with fatigue affecting loudness or pitch, then two user
conditions were able to make some use of the software. However, all of names would be set up. Careful choice of names for each user set helps man-
these moderates had recognition performances of less than 50 per cent. Also agement and avoids later confusion. 

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2004 -<

 guidelines


As initial set-up proceeds, the user is requested to progressively introduce matically. Alternatively ‘contact1’ could generate all the text concerning a
‘samples’ of their voice to ‘train’ the software in the particular characteristics wish to meet or contact at a particular address and time.
of their voice. This is usually called the enrolment process. You will need to examine closely specific details of all these features in the
This area of set-up gave difficulty to some dysarthric users. Early versions specifications or manuals for the package in question.
(such as release 8 of IBM ViaVoice) demanded complete and correct reading of
the prompting texts on the screen, but some versions (including release 10, and Ongoing improvement
all versions of Naturally Speaking that we examined) allowed the user to skip All the systems have a range of features to enable ongoing improvement of
sections that were proving difficult, and progressed to a point where sufficient the vocabulary databases as the system is being used. As more recognition is
data was achieved. We therefore recommend the more flexible enrolment. being carried out, especially in the creation of letters and documents, the
Where enrolment was still proving difficult (even after trying the various correction of mistakes / misrecognitions can be set to build up improvement
alternative texts provided) we had the possibility of changing the actual text to recognition. Documents being produced can also be used to build up better
to be read. Figure 2 provides an indication of where this helped as shown by automatic speech recognition knowledge of the speaker.
the data labelled ‘tailored enrol’. In general, you have to deliberately activate the above features, and cor-
rections to recognition mistakes have to be carried out in a particular way.
Figure 2 Enhanced recognition performance
Specific documents have to be triggered to contribute to vocabulary update.
We recommend the use of these features where practical for the users.
Also, as users become more familiar with the speech input capability, they can
standard
use progressively integrate the automatic speech recognition with other applications
on their computer. Spreadsheets, internet browsers, and even graphics packages
tailored
enrol can be ‘speech enabled’ to give facilities especially valuable to a disabled user.
reduced If you have a significant level of technical competence with computers, you
vocab
can make further changes and tailoring to enrolment and vocabulary. Be
cannot warned, though, that incorrect changes at this level could disrupt the operation
enrol
of the software and the computer system as a whole, and can cause consid-
erable difficulty and frustration.

1. Changes to enrolment
For some dysarthric users, the available enrolment texts were not usable.
There was difficulty with certain words, or difficulty maintaining concentration
When the speech recognition system is being used, the software is continually and interest in an enrolment process that was potentially very tiring. This
referring back to a vocabulary database held in the system. This database is meant that enrolment was difficult, and in some cases not possible.
generally a large and reasonably complete vocabulary as supplied with the As an extreme test of this issue, we changed the enrolment text to a series
system and is adequate for typical use. Associated features that can be of of much simpler texts used by speech and language therapists in the course
value to dysarthric users are: of their work. Figure 2 shows how this enabled successful enrolment for
1. Different variants such as US or UK English can be selected. speakers designated moderate5 and moderate6. The simplified enrolment
2. Different supplementary databases such as legal or medical can be invoked, text also gave a better recognition performance for moderates 1, 2, 3 and 8,
according to the application area of the users. although there was probably a limiting of the range of trained speech.
3. It is straightforward to add vocabulary. Words and phrases, specific to users, In another test, the text was changed to a passage more familiar to the
are added either by specifying (and speaking) particular items, or by letting user, enabling a more relaxed and representative enrolment. Speaker desig-
the software analyse typical documents relevant to the user. nated mild2 in figure 2 shows the improvement in this case.
4. As the system is being used, the opportunity is available for correcting mistakes The change to enrolment text was carried out on the Scansoft/Dragon
in recognition. When this is done as instructed, it has the effect of improving Naturally Speaking packages versions 5 and 6. Initial searching is required to
accuracy of subsequent recognition. find the file containing an existing enrol text (a datan.bin file) and carrying
However, where dysarthria is significantly affecting the ability of the software out a series of cut and paste then re-save operations in the Microsoft
to recognise the speech, an alternative strategy may be of value. If the vocab- Notepad editor to replace with alternative text.
ulary database is deliberately reduced to a minimum set of words used by the When these changes to enrolment are used, it is also important to watch for
speaker in particular restricted circumstances, it can give the automatic any potential omissions in the vocabulary and to use the automatic speech
speech recognition a better chance of selecting appropriate matches to the recognition vocabulary editor to fill any omissions relevant for the typical usage.
spoken word. Figure 2 indicates where this helped, as shown by the data
labelled ‘reduced vocab’, but it does place an equivalent constraint on the 2. Changes to vocabulary
use to which the software can be effectively applied. Automatic speech recognition systems come with various editors to enable
All the systems examined are supplied with a series of ‘commands’ built in basic and more involved adjustment to vocabulary. You should consult the rel-
to the vocabulary, which carry out specific actions rather than just counting evant instruction manuals for more information.
as dictation words. The obvious needs are for commands for the speech dic- To evaluate potential benefit of reducing vocabulary, we re-established the
tation, such as ‘newline’, ‘uppercase’, ‘fullstop’ and so on. Further commands speakers designated moderate 6,7 and 8 with a vocabulary limited to the simple
are especially useful for navigation, including on Internet pages when using texts. This meant that, when using the software, the choices of vocabulary and
a web browser, like ‘back’, ‘forward’, ‘move down items’ or ‘close’. These fea- phrases likely to be spoken by that speaker were deliberately bounded. The
tures are of potential value to disabled users, especially if keyboard ability is recognition tests were then also limited to those words and phrases.
difficult or limited. Figure 2 shows the improvements in recognition accuracy achieved, but at
With certain versions of the automatic speech recognition packages (usually the cost of the heavily reduced scope of usage that is a consequence of the
the higher specification / cost variants) it is possible for the user to add their limited vocabulary. For some dysarthric users, this situation may be regarded
own commands and macros / shortcuts. These can be especially valuable to as a benefit and improvement.
disabled users, where a command can save considerable effort and time. For The vocabulary reduction in this test instance was achieved by using an
example ‘myaddress1’ could insert the speaker’s full name and address auto- enrolment option with ‘empty’ vocabulary, for example in Naturally

-I SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2004

 guidelines

...resources...resources..
Step by Step
Speaking, which is intended for specialist users to add specific vocabularies. Work on the StepByStep software for people with aphasia is
Some items of basic vocabulary are defined in the system so that they cannot progressing. The developers welcome contact from anyone interested
be deleted. We then had to ensure that the words of vocabulary needed for in becoming a beta tester.
the targeted use were added by analysing the relevant text documents. Jane Mortley, Steps Consulting Limited, e-mail
We have summarised guidelines for the use of automatic speech recognition [email protected].
by dysarthric speakers in figure 3. Our work suggests that current commer-
cially available automatic speech recognition products can be viable for mild Get animated
or moderate dysarthric users. This applies, to a reasonable extent, to even the New items in the 2004 Don Johnston Special Needs sourcebook
basic lowest cost options of the software (around £30). include PCS Animations, aimed at helping pupils to learn about verb
meanings and tenses.
Figure 3 Guideline summary The animated Picture Communication Symbols include washing dishes
Key points and brushing your teeth. They can be imported into other programs
• use the microphones provided, and follow set-up procedures carefully such as Speaking Dynamically Pro, Clicker 4 and BuildAbility.
• ensure adequate preparation and understanding of the features
before starting PCS Animations is £78+VAT, tel. 01925 256500.
• take particular care and patience with enrolment
• set up more than one ‘user’ per person to manage variability
• improve the vocabulary database
Stammering Research
• balance features and changes against potential complexity of use. The British Stammering Association is to publish an on-line
international journal, dedicated to the furtherance of research into
Specialist adaptations
• try simplified enrolment to aid initial set up stammering. The editor is Peter Howell of the Department of
• modify the vocabulary database in a way appropriate to the user. Psychology at University College London.
Stammering Research, see www.stammering.org/research.html.
Peter Roberts and Malcolm Joyce are based at Lancaster University, Lancaster
LA1 4YR. Claire Philpott is a speech and language therapist with Morecambe 2004 Directory
Bay NHS Primary Care Trust, Lancaster LA1 4JT. The Contact a Family Directory of Specific Conditions and Rare
Disorders 2004 includes 30 new entries. Every entry contains a
Please note that we give guidelines in the context of the software examined, medical description of the condition with details of inheritance
and to a level of features considered appropriate. This should not be taken patterns and pre-natal diagnosis, and relevant support organisations.
as a definitive recommendation, or a criticism, of any specific manufacturer’s Print edition £35, tel. 0207 608 8700, CD-ROM £88.13 (single user),
package. The manufacturers and distributors involved are very willing to give www.cafamily.org.uk.
help and advice to disabled users, in order to assist their use of the products.
To get easiest responses you should contact them by email rather than telephone. Afasic Helpline
A leaflet outlining the services offered by the Afasic Helpline includes
References the opening times, recruitment of volunteers and the helpline
Ahmed, W.W. (1985) Computer recognition of cerebral palsy speech. Proc complaints procedure.
speech tech conf, 205-209. The confidential service provides support and information to everyone,
Blaney, B. & Wilson, J. (2000) Acoustic variability in dysarthria and computer particularly parents, to enable them to secure appropriate help for
speech recognition. Clinical Linguistics & Phonetics, 14(40): 307-327. their children with speech, language and communication needs.
Doyle, P.C., Lepper, H.A., Kotler, A., Thomas-Stonell, N. Oneil, C., Dylke, M. & Rolls, Copies from Afasic, tel. 020 7490 9410.
K. (1997) Dysarthric speech: a comparison of computerised speech recognition
and listener intelligibility. Jour rehabilitation research & dev 34(3): 309-316. BSL software
Ferrier, L.J., Shane, H.C., Ballard, H.F., Carpenter, T. & Benoit, A. (1975)
‘Let’s Sign & Write’ is a new development to support British Sign
Dysarthric speakers intelligibility and speech characteristics in relation to computer Language (BSL) in education as a separate and equal language.
speech recognition. Augmentative & Alternative Communication 11: 165-174. Over 700 BSL graphics, in both plain line drawings and full colour, can
Holmes, J. & Holmes, W. (2001) Speech Synthesis and Recognition. Taylor & be used with Widgit’s Writing with Symbols software, or in other
Francis, ISBN 0 748 408576. programs such as Microsoft Word and desk top publishing programs.
Roberts, P.E. (2002) Speech Recognition Technology for Dysarthric Speech You can use them to create individualised materials, either with signs
(pp243-248). In: Advances in Communications and Software Technologies, alone, or with symbols, finger spelling and text.
WSEAS, ISBN 960 8052 71 8. A guide book includes information on supporting signers, a glossary
Thomas-Stonell, N., Kotler, A-L., Lepper, H.A. & Doyle, P.C. (1998) Computerised of the signs and ideas for creating resources.
speech recognition: influence of intelligibility and perceptual consistency on Let’s Sign & Write by Cath Smith is published by Widgit Software, tel. 01223
recognition accuracy, Augmentative & Alternative Communication 14: 51-56. 425558, www.widgit.com, £35 single user, £45 single geographical site.

Resources Understanding Asperger’s syndrome

• AbilityNet at Warwick UK, tel 01926 312847 (http://www.abilitynet.co.uk)
The author of ‘Autism and Creativity: Is there is a link between
• Lancaster University, contact [email protected]
autism in men and exceptional ability?’ hopes his book will help

Reflections people with autism be more understood and included in a society in

which everyone has strengths and weaknesses.
• Do I consider both positive and negative effects when Michael Fitzgerald (Henry Marsh Profession of Child and Adolescent
planning change? Psychiatry at Trinity College Dublin) suggests that several high profile
• Do I read instructions to ensure I make the best use of men, including Socrates, Lewis Carroll, Keith Joseph and Eamon de
a product? Valera, could have had Asperger’s syndrome.
• Do I access help in the voluntary and academic sectors? Pub. Brunner-Routledge, £29.99.

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2004 -J

 collaboration

Skills for
How can therapists and teachers provide effective
support for secondary aged pupils with specific
language impairment? Barbara Clarkson and
Angela Peel join forces with their Year 8 and
Year 10 pupils to offer some ideas.

O
ur secondary speech and lan- celebration of who I am, feelings and their
Read this guage resource, based at a High
School which also has a 6th form
expression, teamwork and so on).
Read this if you are
interested in and language college status, Role as facilitators
opened in September 1999, aiming We believe it is the HOW of our lessons rather
• metacognition to provide successful inclusive than the content that makes the difference. All
education for pupils aged 11 years and over who pupils are supported in developing their own
• promoting inclusion have severe specific language impairment. The thinking and evaluation skills right from the start
model of provision which has developed is based - we give them the responsibility for working out
• improving social skills
collaboration on pupils with specific language impairment solutions and see our role very much as facilitators
Angela & Barbara receiving their education within their peer group rather than teachers or therapists. We set the task
in mainstream lessons for all subject areas except and then ask key prompt questions, constantly
modern foreign languages, supported by specific feeding back the problem to the pupils so that
specialist lessons within the resource focusing on they make their own discoveries. We often find
‘Learning Skills’ and ‘Challenger - Social Skills’. We that the lesson explodes in new and powerful
are now finding real evidence of this being a suc- directions, ignited by the pupils’ own need to
cessful practice. Our model is based on an 11 year learn and change. But what do our pupils think
collaborative relationship as a specialist teacher Challenger is all about? We decided to take the
and a specialist speech and language therapist. plunge and ask our Year 8 and Year 10 pupils to
Our model is Our way of ‘doing’ social skills work with such brainstorm what they thought we were learning
pupils through Challenger groups was our first in Challenger. Quotes following on from the
based on an 11 collaborative venture all those years ago, and brainstorm are reproduced with pupils’ own styles
year collaborative now provides the foundation for all the other and spellings.
relationship as a specialist support we provide for our current
pupils. Barbara Clarkson is a specialist speech and lan-
specialist teacher We believe that we are providing an opportunity guage therapist with Eastern Wakefield Primary
and a specialist for pupils to develop a clear picture of themselves Care Trust and Angela Peel the specialist teaching
speech and ‘warts and all’ and to be proud of who they are, head of Wakefield secondary speech and language
to develop awareness of positive interaction within resource at St Wilfrid’s Catholic High School, 6th
language school with teachers and peers and the skills that Form and Language College. This article was writ-
therapist. make it work, and to extend their metacognitive ten with the resource pupils from Years 8 and 10.
ability to think about their actions in situations
and problem solve effectively. We started our References
Challenger work following the outline provided Rinaldi, W. (2001) SULP-R. Windsor: NFER-Nelson.*
within the Social Use of Language Programme
developed by Wendy Rinaldi (see Rinaldi, 2001),
but found that we needed an ongoing curriculum
of social development which went beyond the
excellent foundation it provided. For pupils in our
Reflections
• Do I recognise that how I give
resource, Challenger holds a permanent place on my input can be more
their timetable, once every week throughout important than the content?
their time with us. We cover basic skills of interaction • Do I tap into a client’s own
along with introducing self / other awareness in need to learn and change?
Year 7 (a year of Social Use of Language • Do I give clients the
Programme work), and then extend these themes opportunity to say what they
through a more topic based approach in later
think they are learning?
years (for example, bullying, rules and discipline,
friendship, repairing breakdown in relationships,

 SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2004

 collaboration

r life THINKIN
G
FRIE
NDS
HIP RESPEC
T CONCE
NTRATI
ON
“The games are there to improve our skills and to
“Challenger has a lot of activities that give us more confidence...The games also helps us “We play communicating games
well help you to make a lot of to concentrate and to be patient and different because it helps us better when
improvement to how you work in a ways to think. Also to use the right body language. were in conversations and other
classroom and at home. In most of the We also do brainstorms and the teachers do role- things.” (Year 8)
challengers lessons we work as a group play so we will know what to do and what not to
to improve each other. In challenger we do and to see if we can spot the mistakes what we
play a game at the start of the lesson might do.” (Year 10) CONFID
to get us to start think.” (Year 10) ENCE
WORK
T “The way I’ve think Challengers help GROUP
ONTAC is me is I’ve become more & more
C
EYE confident....I can having a “The skill in this activity teaches me how to
conversation where as 4 years I didn’t do eye contact better and it helps my
want to have conversation as much I memory remember things.” (Year 10)
E
ENC
show people what I know orally.
Another way Challenger has helped PATI
my is I’ve learnt to work as a group EXPRES
INCLUS SION
ION where as 4 years I use work on my
own as much as possible.” (Year 10)
“Social skills mean’s working with people not
“We learn about teamwork, to believe in alone all the time and we learn things when
each other, express our thoughts and to share “You can learn things by listen to we work together we take turns in listening
other peoples ideas...Learn to be patient so people and talking to people so to people and talk to people.” (Year 8)
we can wait for people to finish what they you can understand what they are
have to say so you don’t think that your ideas saying.” (Year 8)
are the most important. We also have to
“In all the challenger lessons we have this thing
respect each other.” (Year 10) ROLE-P
called a brainstorm. This helps us to write things LAY
down so we don’t forget them.” (Year 10)
GE
“You share feelings so that you
ANGUA
can have fiends to share with YL “We make new friends Because
you.” (Year 8) BOD we want to be mate and be
“...help each other as a
team because we are
nice to each other.” (Year 8)
REMEM honest, trusting and
TURN T BERING all friends.” (Year 8)
AKING “The challenger has leant us a lot of skills like
trying to us use eye contact...The activities teach
to us will help us to think about what we will
“I think that challenger has help me to think have to face in life and to get us to use them in
before I do something. In some of the lessons the lessons and when you are out with friend. “We learn things from Challenger by
we get to work in a group so it gets us used to The skills that we have learnt is eye contact and using it anywhere if someone in troble or
working as a team.....I think that challenger to use it when someone is talking to us. The got problems.” (Year 8)
will help people that have some problems to activities we have learnt is to help people how
think and to get them to work more if they have to get the help of people to get their ideas
NG
LISTENI
will play the game challenger.” (Year 10) across in a group so it lets us now what they are
thinking. When someone is feeling left out we
G
TORMIN try to get them to work as a group with us and
BRAINS to get them to get their ideas across if they
“We play games because it is to get us
want to help and work in a group.” (Year 10)
“Social skills help us with reading, writing, thinking about are lesson and get are
thinking and doing and the way people live brains started.” (Year 8)
and work together in groups.” (Year 8) PRACTI
CE

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2004 -

 further reading

COCHLEAR IMPLANTS AUTISM

FURTHER
further reading further reading further reading further reading

Vermeire, K., Brokx, J.P.L., Van de Heyning, P.H., Charman, T. (2003) Why is joint attention a pivotal skill in
READING Cochet, E. & Carpentier, H. (2003) Bilateral
cochlear implantation in children. Int J Pediatr
autism? Philos Trans R Soc Lond B Biol Sci 358 (1430): 315-24.
Joint attention abilities play a crucial role in the development of autism.
Otorhinolaryngol 67 (1): 67-70. Impairments in joint attention are among the earliest signs of the disorder
This regular feature AIMS: to determine the benefit of bilateral cochlear and joint attention skills relate to outcome, both in the ‘natural course’
aims to provide implantation in a child on speech and language of autism and through being targeted in early intervention programmes.
information about development. METHOD: This child got her first In the current study, concurrent and longitudinal associations between
implant, a Nucleus 24-system, on the right side at the joint attention and other social communication abilities measured in a
articles in other
age of 2.5 years. The left side was implanted at the sample of infants with autism and related pervasive developmental dis-
journals which age of 4.4 years with a Nucleus 24Contour-system. On orders at age 20 months, and language and symptom severity at age 42
may be of interest the right side she’s now wearing an Esprit 24-speech- months, were examined. Extending the findings from previous studies,
to readers processor (SPR). On the left side she has a Sprint-SPR. joint attention ability was positively associated with language gains
The Editor has M. goes to a mainstream school and receives Speech and (lower) social and communication symptoms, and imitation ability
and Language therapy in a Speech and Hearing was also positively associated with later language. Some specificity in
selected these
Rehab Centre. The etiology of her deafness was the association between different aspects of joint attention behaviours
summaries from a hyperbilirubinemia. Auditory capacity and speech and outcome was found: declarative, triadic gaze switching predicted
Speech & Language recognition tests were performed for both ears sepa- language and symptom severity but imperative, dyadic eye contact
Database compiled rately and together. RESULTS: Aided thresholds give a behaviours did not. Further, although joint attention was associated
by Biomedical PTA of 28 dBA with the first implant, 22 dBA with the with later social and language symptoms it was unrelated to repetitive
second implant and with both implants we get a PTA and stereotyped symptoms, suggesting the latter may have a separate
Research Indexing
of 23 dBA. Results for speech identification and developmental trajectory. Possible deficits in psychological and neuro-
Every article in recognition demonstrated an increased performance logical processes that might underlie the impaired development of
over thirty journals when both implants are used together. Speech and joint attention in autism are discussed.
is abstracted for language development was equivalent to the mean
this databaseA of age 4.5. At the time of testing M. was 4.8 years. At ADHD
this time the speech and language development Friedman, S. R., Rapport, L. J., Lumley, M., Tzelepis, A.,
supplemented by a VanVoorhis, A., Stettner, L. & Kakaati, L. (2003) Aspects of social
show no delays with normal hearing children. CONCLU-
monthly scan of SIONS: bilateral cochlear implantation in children may and emotional competence in adult attention-deficit/hyperac-
Medline to pick have additional value for their speech and language tivity disorder. Neuropsychology 17 (1): 50-8.
out relevant development. Also, implantation may be considered Social and emotional competence were evaluated using self-report and
when auditory neuropathy is likely. behavioral measures in adults with attention-deficit/hyperactivity disorder
articles from others
(ADHD) and controls. Adults with ADHD viewed themselves as less socially
competent but more sensitive toward violations of social norms than con-
To subscribe to the VOICE trols. Films depicting emotional interactions were used to assess linguistic
Index to Recent de Jong, F.I.C.R.S., Cornelis, B.E., Wuyts, F.L., properties of free recall and perceived emotional intensity. Although
Literature on Kooijman, P.G.C., Schutte, H.K., Oudes, M.J. & adults with ADHD used more words to describe the scenes, they used
Graamans, K. (2003) A psychological cascade fewer emotion-related words, despite rating the emotions depicted as
Speech & Language model for persisting voice problems in teach- more intense than did controls. In contrast, no group differences for
contact ers. Folia Phoniatr Logopaed 55 (2): 91-101. words depicting social or cognitive processes were observed. Overall,
Christopher NorrisA Maintaining factors and coping strategies were adults with ADHD appear more aware of their problems in social versus
DowneA BaldersbyA examined in 76 teachers with persisting voice prob- emotional skills. Findings may have implications for improving the psy-
lems, and physical, functional, psychological and chosocial functioning of these adults.
ThirskA North
socioeconomic factors were assessed. A parallel with
Yorkshire YO<
PPA a psychological cascade model designed for patients STAMMERING
tel -<0E 0
I5A with chronic back pain was demonstrated. The major- Kalinowski, J. (2003) Self-reported efficacy of an all in-the-ear-
fax -<0E 0
EE0 ity of the patients were in a deadlocked situation canal prosthetic device to inhibit stuttering during one hundred
(phase 1 of the cascade model), for which the combi- hours of university teaching: an autobiographical clinical com-
nation of externalization and unawareness of the sit- mentary. Disabil Rehabil 25 (2): 107-11.
Annual rates are
uation is the main risk factor. Subjective rating of the This manuscript outlines the lifelong battle with severe stuttering and
CDs (for Windows voice problem was assessed by the Voice Handicap describes a new modality of effective amelioration of the disorder from the
JE): Index (VHI) and a visual analogue scale (VAS). standpoint of a university professor and researcher in the field of stuttering.
Institution LJ Patients in phase 1 of the cascade model showed Childhood reactions to stuttering are discussed, along with the educational
Individual L< higher VHI and VAS scores compared with the other and vocational impact of stuttering. Ongoing therapy was received
patients. For a high VHI score, the combination of throughout the formative years and into adulthood, emphasizing reduced
Printed version:
socioeconomic factors and being in phase 1 was the rates of speech. The use of Delayed Auditory Feedback (DAF) was found to
Institution L< most important risk factor. Socioeconomic factors induce fluent speech, but was considered only as a tool for decreasing the
Individual LE  were the most important risk factors for a high VAS speech rate to achieve fluency. When fluency under DAF was discovered to
score. The term ‘chronicity’ is introduced, meaning be possible at faster speech rates, the possibility that the use of DAF and
Cheques are that the problems are maintained, the patient finds other forms of altered auditory feedback could themselves have an inhibito-
himself in a deadlocked situation, and is sliding down ry effect on stuttering, without concomitant rate reduction was investigated.
payable to
into a chronic disease. ‘Chronicity’ is essentially dif- An In-The-Canal (ITC) fluency-enhancing device was used that provided DAF
Biomedical ferent from ‘chronic’, which refers only to the dura- and Frequency Altered Feedback (FAF) to produce more fluent speech.
Research tion of the disease. Maintaining factors and (inade- After 10 months of use, the author was relatively free from stuttering.
Indexing. quate) coping factors, consisting of emotional/psy- Speech was natural sounding, relatively spontaneous and unlaboured with
chological, physical and socioeconomic aspects, are an absence of fear. However, further testing (that is currently underway at
considered as indicators for chronicity. various centres) is necessary before generalizations can be made.

 SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2004

 here’s one I made earlier

Alison Roberts with some more

low-cost, flexible therapy suggestions.

“Here’s one I
made earlier...”
Emotions / Facial
Expressions Dice
“
This is a useful and fun activity for a group
of students with autistic spectrum disorder.
You can use it as a 5-minute ‘filler’ or extend it
into two 20-minute exercises.”
Materials
• mirror
• wooden, sponge, or polystyrene cubes Road sign Dominoes
approx 4 cms, either from a toyshop, or
made yourself “This game promotes careful observation,
• simple images of facial expressions road safety, and conversation about road
depicted on sticky labels manners (a form of self / other awareness!)
It is useful for clients who have grown out of
Brawn picture dominoes, but who find the traditional
You may need to saw off the cubes from a black & white dots game boring. Also useful
length of timber. Take care over the for those who are current or potential drivers.” Eye Instruct You
sanding, so that there are no splinters.
Materials “This is a game to encourage eye contact,
Artistry • You need to buy at least two Highway
and can be stretched to become a memory
You can copy the images of facial expressions Codes. In fact four would be
from various books on body language; or better, as then you can use both game too.”
from Asperger’s Syndrome: A Guide for sides of each page. You need
Parents and Professionals (Tony Attwood, two of each picture. Materials
• Good quality card, or Taskmaster blank • 1 pair of spectacle frames (old sunglasses
1997, Jessica Kingsley Publishers), on the
cards (£5.75 for 200, with the lenses pushed out are fine), or
page headed ‘How are You Feeling Today?’;
see www.taskmasteronline.co.uk). My you can use your hands
or you can do your own artwork; or simply
advice is not to scrimp on this, as you • 1 foam or Koosh ball (or scrunched up
write the emotions on the sides of the cubes.
need to present your (quite expensive) paper if you’re really skint)
It’s good to have two cubes, one with the
easier expressions (happy, sad, angry, pictures in the best possible way.
surprised, disgusted, scared), and one with
In Practice (I)
more subtle ones (confused, worried, Brawn 1. One person (any of the clients, or the
therapist) wears the glasses. Another
shocked, unsure, tired, disappointed). Cut out the signs and keep together in their
pairs. Bear in mind that each card will need person has the ball.
2. The person wearing the glasses indicates,
In Practice (I) to show two different signs. You will need
with their eyes only, another person in
1. Each member of the group rolls the cube to line up the cards and stick one of each
pair of signs on the touching sides of the group to whom the ball must be
with the simple expressions. Just copy the
adjacent cards. The first half of the first thrown.
one you roll. Check in a mirror.
card will match up with the last 3. Now a new person has the glasses, and
2. Repeat using the more complicated
half of the last card. you start again.
expressions.
3. Roll both dice; make one ‘face’, then the
other one. In Practice (I) In Practice (II)
Play as for other forms of dominoes. You can extend this by looking at two
people, so the catcher throws to one person,
In practice (II)
Two people each have a cube; they roll, and In practice (II) who then throws to the second one. This
involves everyone in close watching and
make the face, then, by looking at each Stick pairs of pictures on different cards,
and use for a Snap game. memory.
other (not the dice), swap facial expressions.

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2004 5

 how I

Louise K. Frazer left Scotland for

Barbados five years ago and works on a
How I
am keeping
private basis as a paediatric speech and
language therapist.

Further information on Johansen Sound

Therapy from Camilla Leslie, 10
Kingsburgh Road, Edinburgh EH12 6DZ,
tel/fax 0131 337 5427, e-mail
[email protected],
www.johansensoundtherapy.com.

For details of the North Eastern Speech

Readers have asked for more feedback
& Language Therapists Association see
www.nesta25.com. The Silver Jubilee days. Here, we travel to Las Vegas, Edin
Conference ‘From Training to Practice’
was held on 12th November 2003 about a toolbox for school-aged childr
near Newcastle.
Therapy and a variety of projects in the

The tools of the trade

For Louise Frazer, working

W
hen you are working on an Island (direct, indirect), reinforcement (immediate,
with only a few other therapists, it with school aged children delayed, occasional, self), location (where is
is important professionally and therapy taking place), listener (who is present).
personally to attend gatherings of
who stammer was a particular Talk about stammering with your client. Do
other like-minded people. In July 2003 I was lucky challenge - until she found some stammering together. We need to be able
enough to go to the 20th National Lingui Systems to stammer with our clients so that we can explain
Conference in Las Vegas, along with a large num-
the right tools for the job. to them how to do things either without stam-
ber of paediatric speech and language therapists mering or when you are stammering. Try out
from all over the United States and Canada. The clients is to be their own therapist. During the some repetitions, prolongations and blocks. Play
seminar that had most impact on my practice was process of intervention it is important for speech with stammering and the level of tensions.
A balanced approach to school-age stuttering and language therapists to create opportunities Secondary behaviors tend to disappear as the
therapy by Nina Reardon, a stammering specialist. for long-term success from the very first moment child begins to ‘ease’ instead of ‘push’ (see page
I am often at a loss over where to go with some of of therapy. So there is really no such thing as 26).
the school age stammerers. Their therapy is usually transfer and maintenance activity - all the things We should not be telling our clients that some
a long haul - they have sometimes had therapy we do from the first moments of therapy are sounds are harder than others to produce. It is not
from an earlier age and no change has been noted. transfer and maintenance activities (figure 1). about the specific sounds - more about the per-
Since attending Nina’s seminar, I have used the Before we start, we need to discuss our therapy ception. Instead of saying which sound is hard to
‘tools’ she outlined with three different clients. with the client, parents, teachers and others. produce, ask the child where in their speech
All three boys are aged from 8-10 years and have We do not need to count stammers - this is too machine does it feel hard - lips, tongue and so on.
not had any intensive stammering therapy before. variable. It can be done on entry and exit to the Nina introduced the idea of the Speech Triad. I
They have enjoyed discovering new things about therapy programme but not on a weekly or daily found this particularly useful when remembering
their stammers and have become experts about basis. Changes can be documented in a speech note- all of the goals that we should be working on. The
stammering difficulties. They feel much more con- book. Ratings can be given by therapist and client at three sides are communication, beliefs and feelings
fident about stuttering and within therapy sessions the end of each session: “On a scale of one to ten, and speech management.
there has been a noticeable decrease in their where do you think your talking was today?”
stammers. The parents have also commented on The underlying concepts of therapy are: 1. Communication
how much better their speech is at home. • Hierarchies - discuss what is least difficult / most • Discuss turn taking, and make your client aware
We know that our goal is not for perfect fluency. difficult. Draw ladders or stairs to represent this. that they have time to think about what they
We should be aiming for more fluency. Do we tell • Desensitisation - the fear of stammering want to say.
our clients and families this? Are they expecting that needs to be decreased. • Always introduce eye contact into therapy sessions.
miracle from us? We should be aiming to give our • Self-monitoring, analysing and reinforcement Eye contact increases the speaker’s feelings of
clients effective communication. The child needs to (Did I stutter then? Was that a hard stutter?) The confidence, as well as demonstrating that the
accept that they stammer and know that both stam- child is becoming their own speech and language speaker is comfortable communicating. Try
mering and managed speech are OK. Therapy needs therapist, and monitoring their own speech. activities during role-play. The children I work
to activate the child’s ownership of stuttering. • Variables to be manipulated, for example: with often have poor eye contact - especially at
Therapy needs also to be meaningful to the child. length and complexity of utterances, formulation the moment of the stammer. More eye contact
As therapists, one of the tools we can give our (imitation, picture naming, reading), model leads to more confidence and more confidence


SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2004
 how I

ng up-to-date
ck from conferences, courses and study
dinburgh and Newcastle to hear more
dren who stammer, Johansen Sound
the North East of England.
Figure 1 Checkpoints for success in transfer and maintenance
As a therapist, ask yourself at various stages of therapy:
• Have we established an awareness of fluency?
• Have we begun the process of acceptance of stammering?
leads to more eye contact. • Have we activated the child’s ownership of stammering and the therapy process?
• Teach the child how to resist time pressures - if • Have we given the message to the child that both stammering and managed speech are OK?
they are encouraged to use ‘wait-time’ prior to • Have we used a conversational context as much as possible?
commenting or answering a question, it will • Have we made therapy meaningful to the child?
decrease the rate of communication, increase • Have we got out of the clinic setting as much as possible?
formulation time, increase the time the child • Have we worked through the variables that can be manipulated?
has to use the ‘tools’ you are teaching them • Have we involved the client’s parents, teachers and others?
and, importantly, decrease the tension in the • Have we helped the child to self-monitor?
speech muscles. Encourage the client to count • Have we developed resistance to fluency disruptors?
to two in their heads - slowly! • Have we prepared the child for possible relapse and told them that this is part of
• Reflective listening is not a skill we are born stammering - it is not a failure?
with. Repeating or rephrasing the message
delivered to you as the conversational partner 3. Speech management sounds. Get them to say “ahla” then ask, “What
lets the client know that you have got the idea Speech management includes fluency enhancing did you feel moving?” then get them to say,
but also that, if the message did not come techniques, stuttering modifications and the inte- “Papa” and ask, “What is moving now?” Talk
through correctly, they can repair it. Use reflective gration of both. about the normal flow of speech and then talk
language to your client like, “So what I heard Before we start on techniques, we have to think if about what happens when this breaks down. Talk
you say was...” or “You are telling me that...” the particular child needs every tool. Nina suggests about the tension in the muscles.
packing a toolbox with the client - draw one in the Techniques for easier speaking include:
2. Beliefs and feelings speech book so you can add new tools as they 1. Light contacts
Beliefs and feelings need to be addressed. We come up. A child needs many tools but, once they This helps keep the tension away by utilising softer or
need to have a good rapport with our clients so have them, they can adapt and change them when lighter contacts between articulators. Demonstrate
they will tell us how they feel about their speech necessary. Try and make therapy meaningful by tight / loose so the client can see and feel the difference.
and their communication in general. The children thinking about the child’s interests, curriculum rel- 2. Easy starts
will experience more long-term success in dealing evancy (use classroom topics) and communication Encourages tension to decrease. You are not
with stuttering if we help them understand that environments. Always ‘check-in’ with your client encouraging the child to slow talk. Easy starts
they can be great communicators whether or not by asking questions like, “How did you feel about decrease tension, increase sense of control over
they stammer. that?” or “Do you like easy starts?’ speech mechanisms at the start of speaking and
Let your client do some stammering research. We need to help our clients develop an under- indirectly decrease the rate of speech and commu-
Tell them some internet addresses related to standing of the process of producing speech. They nication. Demonstrate with a ball - throw it with a
stammering and ask them to find out ten things should be aware of how speech is made and what lot of tension in your arm, now do it relaxed.
about stammering. (Some good sites, along with can cause it to break down. They need to understand 3. Pausing / Phrasing
the British Stammering Association - www.stam- speech before they can change it. To help with This is normal for all of us to do when we talk. Make
mering.org - are these American ones:www.stut- this you can draw a man and label the parts needed sure your clients know that we all do it. Using
teringhomepage.com, for speech. Talk about the whole process - from longer pauses between phrases helps decrease the
www.WeStutter.org, www.friendswhostutter.org, lungs and vocal folds up. Let the child touch their rate of communication, increases the time to use the
www.stutteringhelp.org.) throat when they make voiced and un-voiced tools and decreases tension in the speech muscles.


SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2004 E

 how I

 This is appropriate whatever the tool. 2. Blockouts them to moments when they do stammer. You can
We sometimes think as therapists that we will A variation of cancellations. The child needs to then ask the child how it felt to stammer.
eliminate all stammers. We have to rethink this take control during the moment of the stammer, So, you now have the tools and ideas. Adapt your
and remember that the child will still stammer, to learn to stop in the moment of the stammer, own techniques, add some of these - and good luck!
especially once he leaves the therapy room, so pause (analyse, relax) then start again.
let’s give him some techniques to help him be 3. Pull-Out Suggested reading
more fluent and stammer more easily. These are Taking control during a moment of stammering. Chmela, K. & Reardon, N. (2001) The school-age child
techniques to ease out of a stammer, rather than This makes the stammer turn from something who stutters: Working effectively with attitudes and
push through with it. The client needs to be involuntary into something voluntary. We can emotions. Stuttering Foundation of America.
aware that they can fix it and they have a choice imagine this to be like a slide. The stammer starts Manning, W. (2001) Clinical Decision Making in
- to ease out instead of pushing through: at the top of the slide, and as we think of going Fluency Disorders. (2nd Ed) San Diego, CA:
1. Cancellations down the slide, we slide out of the stammer. Singular Thompson Learning.
This happens after the stammer has occurred. 4. Voluntary Stuttering Shapiro, D.A. (1999) Stuttering Intervention: A collab-
Once they stammer, the child will pause long Involves using purposeful, under-control stam- orative journey to fluency freedom. Austin, Tx: Pro Ed.
enough to analyse the moment of stuttering, mering to decrease fear, involuntary tension and Zebrowski, P.M. & Schum, R.L. (1993) Counselling
release tension, and return to the word to produce avoidance of stuttering. It also helps the client to parents of children who stutter. American Journal
it in a modified way (such as with an easy start). be more open about stammering and desensitises of Speech-Language Pathology 2:65 - 73.

A sound therapy?
Can CDs of music with certain

I
ntuitively it makes sense that auditory deficits - The profile of the curve is considered more important
not picked up through an ordinary hearing test frequencies dampened or than the level of hearing, although referral to audi-
- could underlie at least some speech and lan- amplified to stimulate an ology would be made for a child showing a hearing
guage impairment. Readers have been asking loss. The aim of the therapy is to bring the audio-
for more information about auditory processing
individual’s listening skills gram as close to the ideal profile as possible and the
and sound therapy and, having featured it in the lead to improvements in their effect of these improvements should be seen in lis-
magazine (Robinson & Leslie, 2001; Treharne et al, speech and language? Avril tening and language skills, but may also be seen in
2002), I was sufficiently intrigued to sign up for a four Nicoll sounds out Johansen other areas such as motor skills and concentration.
day Johansen Sound Therapy course with its founder, Questionnaires for parents probe the current
Dr Kjeld Johansen, the Director of the Baltic Dyslexia Sound Therapy. attention, behaviour, coordination and language of
Research Laboratory in Denmark. tones. This imbalance is often found in children the child. Laterality of hands, feet, eyes and ears is
There are many different types of sound therapy and adults after recurrent middle ear infections in checked. Audiometry is used to establish a hearing
making a variety of claims, so consumers and the early years, and in people with reading and profile through monaural thresholds followed by
therapists can be excused for feeling a little con- spelling problems with a diagnosis of dyslexia. ear advantage through binaural pure tone
fused. The field suffers from two credibility problems. Dyslexia is Kjeld Johansen’s main area of interest audiometry. This is followed by dichotic listening
Firstly, it is not generally accepted within the but both he and speech and language therapist tasks, where CVC combinations are played
mainstream academic community, so research has Camilla Leslie (who oversees Johansen Sound through headphones into one or both ears. These
been somewhat idiosyncratic. Secondly, because it Therapy in the UK) believe it can bring at least tasks include listening to and repeating a CVC
operates outwith the mainstream, it is usually only an some benefit to all children assessed as requiring combination played into one ear without becoming
option if clients are willing to pay. Kjeld is however speech and language therapy. distracted by a different CVC combination played
unequivocal about the ethos of the Johansen approach: Audiometry is an essential part of Johansen into the other ear.
“We want to help kids, not become millionaires.” Sound Therapy assessment, so anyone following Johansen Sound Therapy normally takes nine to
Kjeld’s rationale is based on the concept of central through their attendance at the course will need eleven months to complete as, although short-
auditory processing. While audiologists are interest- to purchase an audiometer (cost around £800). It term, intensive training has an immediate effect,
ed in the ear and neurologists are interested in the is unlikely that audiologists would be in a position this diminishes quickly and is not maintained. It aims
brain, sound therapy proponents are interested in to do the audiometric assessment, as what to “change the architecture of the auditory cortex”,
the system leading from the inner ear to the brain. Johansen Sound Therapy regards as signs of prob- moving the hearing profile as close as possible
Right ear dominance is considered crucial to the lems with listening often fall Figure 1 The optimum hearing reference curve
efficiency of input to language centres which, even within the ‘normal’ range of (See Tomatis, A.A. (1991) The Conscious Ear. New York: The Talman Company.)
for the majority of left handed people, are located hearing.
in the left hemisphere of the brain. Optimum hearing reference curve......
If the balance between the right and left ear is Ideal hearing curve
not correct, symptoms can include sensitivity to Thorough testing produces a
background noise, difficulties discriminating listening profile. This is con-
language sounds, hyper-sensitivity in the low sidered against the ideal
frequency range, too little sensitivity in the high hearing curve (figure 1) and,
frequency range, fairly large differences in thresh- if there are any deviations,
olds between left and right ears, and left ear the child is a candidate for
advantage for language sounds and / or pure Johansen Sound Therapy.

0 SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2004

 how I

towards the ideal curve. This is done incremental- anomalies which can contribute to reading failure, The other therapist there, Alison Taylor, is keen
ly by listening for 10 minutes a day through head- and how these can be ameliorated. to discover ways of helping her third child Emily
phones to a music CD which has had certain fre- cope better with learning. She had been trying
quencies dampened or amplified by a certain Research encouraged another sound therapy with inconclusive results,
amount according to the client’s individual profile. The American Speech-Language-Hearing and I caught up with her recently to find out how
Usually the right ear is stimulated more than the Association has put out a position statement Johansen Sound Therapy is going:
left ear. Initially, and in other instances where a (2004) on what it refers to as Auditory Integration “I must admit this must be the easiest and most
reliable audiogram cannot be achieved due to age Training (specifically including the Berard method, enjoyable form of therapy I have participated in.
or hearing problems resulting from a cold or glue Samonas Sound Therapy and Tomatis method). It Emily doesn’t need much prompting to go and listen
ear, standard rather than customised CDs are used. concludes that it “has not met scientific standards and is getting much better with left and right -
Neutralised CDs are used for a few left handers for efficacy that would justify its practice by audi- probably a result of putting the headphones on.
where you suspect language may be processed in ologists and speech-language pathologists.” It After listening to Waves 4LFR for 7 weeks I thought
the right hemisphere. Children are reviewed every adds, “However, well-designed, institutionally her comprehension when reading to herself and
six to eight weeks, with CDs changed as required. approved, research protocols designed to assess when I read to her had improved. This was con-
A good quality CD player (personal or other) and the efficacy of AIT are encouraged. It is recom- firmed by the audiogram. Initially there was a big
headphones are essential. The CDs cost from £13 - mended that this position be re-examined should dip at 3000Hz but now the right ear is on the correct
£26 each, with the average number required scientific, controlled studies supporting AIT’s effec- line. Spelling has improved in tests. She used to be
around four. tiveness and safety become available.” in the bottom three in her year but actually won
Caution is required in some circumstances, for It would be disingenuous to say that everything a prize for the best term’s learnt spelling in her
example with children who are left handed or suf- we ever do with our clients is evidence-based. For group. She has made 12 months progress in 8
fer from epilepsy, or when combining sound thera- one thing the evidence we have access to and use months, but still has a long way to go. Emily
py simultaneously with other treatments that could depends on many things - experience, training, appears now to be working things out more for
overstimulate a child. When listening to the CDs environment, beliefs, interpretation, peer pressure, herself, as in jokes. It will be interesting to see
children should not be eating, have background even (as Lord Hutton might say) the subconscious. what happens after listening to a customised CD.”
noise or be doing any language-based activity. Kjeld However, three speech and language therapists
says Johansen Sound Therapy has the best chance were among the individuals attending the course, References
of stimulating the brain when clients are aged from and they had an open-minded but questioning American Speech-Language-Hearing Association
31/2 to 9 years. It has, however, been used with chil- approach, constantly looking for verification of (2004) Auditory Integration Training. ASHA
dren of all ages, adolescents and even adults up to effectiveness. Anecdotal evidence from people Supplement 24 (in press).
around 70 years of age, although with adults it who have extensive experience of Johansen Sound Robinson, N. & Leslie, C. (2001) My Top Resources.
takes longer for the effects to become apparent. Therapy - such as emerging sub-groups of hearing Speech & Language Therapy in Practice. Winter.
Kjeld does not claim that Johansen Sound Therapy profiles which match presenting features like autis- Treharne, D. (2002) From sceptic to convert, the objec-
is a panacea. The many factors which can contribute tic spectrum disorder and specific language impair- tive way; Lane, C. (2002) A.R.R.O.W. hits the bull’s-ear;
to children’s difficulties - genetics, the perinatal peri- ment - is promising, but more specific research by O’Connor, K. (2002) Enthusiasm, knowledge - and a set
od, health, socio-economic status, family, critical life the speech and language therapy community is of headphones. All in ‘How I use therapeutic listening’.
events, behaviour / personality and education - needed. The changing audiogram is clearly useful Speech & Language Therapy in Practice. Winter.
mean that for each child a different balance of inter- as an outcome measure and, because this approach
vention will be needed. An unexpected bonus of the is so different from traditional therapy, one of the Resources
course was a fascinating presentation by orthoptist therapists attending is planning to set up a control Dr Alison S. Hood, Orthoptist, Eyescan (UK), tel. 0141 637
Dr Alison Hood on the signs and symptoms of visual group alongside her treatment group. 7503, e-mail [email protected].

Past meets present

The North Eastern Speech &
“PLEASE STAND BACK TO LET OTHER PASSENGERS practice were among the hot topics, with recruit-
DETRAIN” Language Therapists ment and retention a strong sub-text.
(notice at Newcastle Station, 2003) Association was formed 25 Morag Horseman, one of NESTA’s founder mem-
years ago to provide low cost bers, recalled the early days of her career. A
“Girls, girls, always wear your earrings - your face profession split between health and education
comes alive, and people will talk to you.”
training for speech and language and isolated by the medical officer’s policy of
(Kay Morrison, Edinburgh lecturer, recalled by therapists in the north east of keeping speech therapists apart. Taking the bus
Morag Horseman) England. Avril Nicoll finds the with a Grundig reel-to-reel tape recorder and
energy, drive and vision of the heavy bags, and fellow passengers - miners on
In 1978, the North East Speech Therapists their way to work - carrying her bags along to one
Association (NESTA) was formed to provide low
founder members mirrored by of her schools. Her department’s policy in 1954
cost training in the north east of England and to the current cohort. ‘not to employ married women’ or, if they did, to
support newly qualified therapists, especially underlying issues they address remain the same. keep them on without any rights. No incentives
those working single-handedly. As the examples And at the conference celebrating NESTA’s Silver for married women with children to return to
above also show, while our language and our Jubilee, training, support, skills, research and work, and no refresher courses when they did. 
profession continue to evolve, sometimes the development, collaboration and evidence-based Going into a new post, and being handed equip-

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2004 <

 how I

 ment including a home-made metronome. The Sometimes we don’t know what a client is capable development module run by specialists which
excitement of the arrival of the Reynell of because we lack appropriate assessments, training aims to build a portfolio of skills and emphasises
Developmental Language Scales, a revolution at and multidisciplinary teams. Selena Mathie praised practical activities. Eight areas across the north
the time. the Sensory Modality Assessment and Rehabilitation east of England are involved. In future, the SIG is
Morag says that, “The older you get, the more Technique (SMART) as a consistent and in-depth tool planning to get accreditation for the module, to
important your past becomes.” This is as true for for establishing whether or not a client is in a persis- develop modules for older children and adults,
the profession as it is for us as individuals. By tent vegetative state. Her use of television material and to run cross-district groups for people who
recording what we are doing, and sharing our featuring a young woman was a poignant reminder stammer.
experience, we pay due respect to the pioneers not to make assumptions based on single visits, assess- Sometimes we have an idea but we can’t do it on
and pave the way for the speech and language ments or reports. It also showed clearly the tremen- our own. Karen Dixon, Barbara Storey & Colin
therapists of the future. dous value of music therapy, as music can ‘reach’ Sawyer (a speech and language therapist, artist and
Sometimes, even now, members of our profes- someone in the way other communication cannot. computer programmer) have developed a multime-
sion are pioneers. Sarah Glenwright has been set- dia resource which they hope will be the first of
ting up a speech and language therapy service in many. My own kids and their friends are computer
mental health. She says that, for a new service, you Passion and determination junkies used to games which involve television char-
need at least a month in post with no therapy Sometimes the difference between success and acters and sell in their thousands. They have tried
appointments. You need to find out from other failure is down to our own passion and determi- out ‘Listening and Rhyming’ and really enjoyed it,
people what services already exist, and how nation. This was the case for Mary Greetham & both on-screen and in printed-out worksheets.
speech and language therapy might fit in, Rachel Baker when they successfully introduced There was a relaxed, informal, supportive
although people are not always clear on this. She the Picture Exchange Communication System atmosphere at this conference, with speakers
suggests shadowing therapists in other areas who (PECS™) to secondary school aged children. Their given time to explore their topic and the audience
are working with a similar client group, and con- service delivery model can be applied to any sys- given time to ask questions about subjects of
sidering a job share arrangement for this kind of tem not just PECS™. The speech and language interest. This was best in the adult-orientated ses-
development rather than a single person. A specif- therapists initiated the idea with the head sion I attended, where there were smaller numbers
ic interest group can also provide much needed teacher, who arranged the first meeting with of delegates. Poster presentations added to
support and guidance. In Sarah’s case, the mental staff. Therapists showed the PECS™ video and knowledge of the area and the services it is devel-
health SIG is looking at organising a ‘buddy’ sys- related it to children in the school. Targets were oping, and exhibitors gave delegates hands-on
tem, and putting together a pack which will cover set for staff, including having a PECS™ coordina- time with their products.
funding, references and clinical issues. tor in the school, and at the second meeting staff Sometimes a conference really works.
Sarah has had to be very focused as it would identified four children aged from 14-18 years.
have been impossible to do everything at once. The therapists sent a letter to the head and the Resources
Now that her service is up and running, she wants class teachers giving the times of nine sessions • Leaps and Bounds Multimedia Ltd: Phonological
to consider research into what it is that speech and over six weeks with named therapists, the need Awareness Series Disc 1: Listening and Rhyming
language therapists do that is different from other for a member of staff from the class, the room is available for £45 tel. 0191 413 1818, e-mail
members of the team. She also wants to look into size and a questionnaire regarding motivators for [email protected]. Disc 2: Syllabification
quality of life outcome measures which will show that child. Staff took on board the need to make will be available in Summer 2004.
where we have been able to be effective. As an resources and symbols for their own classes, and • PECS™ (including courses): Pyramid Educational
example, she quotes a 76 year old lady with mem- the school have ordered PECS™ resources. Consultants UK Ltd, Pavilion House, 6 Old
ory and word finding problems who, following Sometimes a client group is significant, but thin Steine, Brighton BN1 1EJ, tel 01273 609555,
her involvement, has the same problems but is no on the ground, and therapists with specialist knowl- www.pecs.org.uk.
longer avoiding situations such as going to the edge even more so, particularly in rural or less heav- • Reynell Developmental Language Scales: Now
hairdresser and using the phone. ily populated areas. The North East Regional on their third version, completely revised by
Sometimes, whatever we try, we feel frustrated Dysfluency SIG (known as NERDS) provides support Susan Edwards, Paul Fletcher, Michael Garman,
and unhappy, and unable to see a way through for therapists at any level of experience who are Arthur Hughes, Carolyn Letts & Indra Sinka, from
with particular clients. One of Jo Borrelli’s clients working with people who stammer. They meet NFER-Nelson, £451.75, see www.nfer-nelson.co.uk.
would say, “I want to do _____, and do it now, and every two months, with the focus rotated between • SMART: Sensory Modality and Rehabilitation
this isn’t helping me.” She found they were both paediatric, adult and joint issues. This SIG grew out Technique by Gill-Thwaites (1997). Details from
battling to set aims and to be in charge. The of a recognition that ongoing support was needed Royal Hospital for Neurodisability, London,
solution was transactional analysis, a counselling and that, while specialist skills are not available in tel. 020 8780 4568.
technique which has concepts consistent with the every trust, access to such support is essential. • Transactional Analysis: Eric Berne’s Games
rehabilitation concepts of progression from So far, the SIG has developed a telephone support People Play (1970), published by Penguin
dependence to independence. network and a fluency continuing professional ISBN 0140027688.

My Top Resources (back page): references • Kay Elemetrics (1986) Nasometer manual, and its Disorders. Whurr. 5. Vocal Profile Analysis Training
Kay Elemetrics Corp. USA. • Andrews, M. (1986) Voice Therapy for • Laver, J., Wirz, S., Mackenzie-Beck, J. & Hiller,
1. Access to the joint voice clinic Children. San Diego: Singular Publishing. S. (1988) Vocal Profiles of Speech Disorders.
• Laryngograph Ltd, tel 020 7387 7793, 3. Normative voice measures • Andrews, M. (1995) Manual of Voice Research Project. Phonetics Laboratory,
[email protected] • Aronson, A.E. (1990) Clinical voice Treatment: Paediatrics through Geriatrics. Dept of Linguistics, University of Edinburgh.
disorders: an interdisciplinary San Diego: Singular.
6. Access to the internet and library resources
2. Instrumental voice analysis systems approach (3rd Ed) New York: Thieme.
• KA24: http://stlis.thenhs.com/hln/ka24/
• Fourcin, A. (1986) Electrolaryngographic • Baken, R.J. (1996) Clinical Measurement 4. Voice therapy concept cards
• UCL library: http://library.hcs.ucl.ac.uk/
assessment of vocal fold function. of Speech and Voice. Singular Publishing. • Dean, E.C., Howell, J., Waters, D. & Reid, J.
• ICH library: http://www.ich.ucl.ac.uk/library/
Journal of Phonetics 14: 435-442. • Wilson, D. (1987) Voice problems of (1995) Metaphon: A metalinguistic
• Laryngograph Ltd, tel 020 7387 7793, children. (3rd ed) Baltimore: Williams approach to the treatment of phonological 10. Augmentative communication systems
[email protected] and Wilkins. disorder in children. Clinical Linguistics • www.makaton.org
• Speechviewer from PAS UK Ltd, tel • Mathieson, L. (2001) (6th Edition) and Phonetics 9 (1). (This forms part of • Kapitex Healthcare Ltd, tel 01937
01635 247724. Greene and Mathieson’s The Voice a clinical forum on Metaphon, pages 1-58.) 580211, www.kapitex.com

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MY TOP RESOURCES
1. Access to the joint voice clinic 3. Normative voice measures 7. Supervision and clinical
Laryngeal examination of dysphonic I constantly need to refer to normative support networks
children is challenging and yet essential to measures for pitch, maximum phonation Many of the dysphonic children I see have
rule out airway disease and to confirm the time, s/z ratios, across the age groups and a history of prematurity and a significant
dynamics of voice production. I am fortu- sexes. Relevant measures can be difficult population have a co-occurring diagnosis
nate to work in a dedicated Voice Clinic to come by and will need to be considered of speech and language delay, behaviour
with an ENT Consultant who specialises in against the child’s growth measures if they or attention difficulties, dysfluency, dys-
the medical and surgical management of are to be interpreted meaningfully. See praxia and so on. I have had to develop
children’s voices. We see five children per reference list for useful texts. skills in screening for co-occurring speech
clinic, aged from three years old. Our joint and language and cognitive problems to
opinion results in a coordinated diagnosis 4. Voice therapy concept cards ensure that my assessment of a child’s
Lesley Cavalli works as a and management plan. Keeping the clinic Voice can be quite an abstract concept, voice is based on knowledge of the ‘whole
member of the speech list limited to only five children allows us particularly for young children. Children child’. I regularly call on the skills of team
to provide the necessary preparation time can find it hard to tune in to their own members to assist in complex assessments
and language therapy for successful examination. We aim to use sensory feedback systems and thus master and / or seek their advice through supervision
team at Great Ormond a rigid laryngoscope, which provides control of a specific aspect of their voice. I systems. Speech and language therapists
excellent views of the larynx and tends to have found using paired pictorial concept working with a child at a primary care
Street Hospital in be tolerated well. This is linked to the cue cards very useful in developing chil- level are also an invaluable source of
London She specialises LaryngoStrobe 2 System (Laryngograph dren’s awareness and control of a specific support and information. By working
Ltd). Some children will require flexible vocal parameter or skill such as ‘soft onset collaboratively and sharing assessment
in the assessment and nasal fiberoptic laryngoscopy. Whilst the phonation’ vs ‘hard glottal attack’ or findings we can arrive at a robust diagnosis
management of voice majority of speech and language thera- ‘loud’ vs ‘quiet’ voice. and realistic treatment plan.
pists working with dysphonic children will Drawing is not my forte and I have thus
disorders in children and not have immediate access to a Voice tended to develop my set of contrastive 8. Developmentally appropriate
adolescentsA as well as Clinic I would recommend that, whether picture concept cards for voice therapy toys and reward systems
head and neck surgery they work in mainstream, special schools from systems marketed at phonology like My toy cupboard is finely tuned! Favourite
or community clinics, they identify the Metaphon. toys for eliciting a voice sample from the
Children attend Great location of their nearest Voice Clinic and younger children include dolls and a tea
Ormond Street for ascertain whether the team will accept 5. Vocal Profile Analysis Training set, cars and miniature farm and zoo ani-
paediatric cases. I have found the Vocal Profile Analysis mals. Older children respond well to being
second opinions and for Scheme (Laver et al, 1988), the most com- involved in the interview process and
management of both prehensive perceptual assessment tool to those that are more easily distracted tend
2. Instrumental voice analysis use with children’s voice, despite the fact to enjoy drawing. Toys for blowing such as
common and more systems that the training and the assessment form bubbles and whistles are really helpful for
unusual voice problems Many of the children I see have very disor- are based on analysis of post pubertal looking at breathing and for developing
dered voices. Identifying the affected voices. The system considers voice as a breath control in children post airway
Lesley also lectures in components of the voice (pitch, quality product of the entire vocal tract and is reconstruction. Reward systems tend to be
voice at University and so on) using perceptual skills alone is really helpful in treatment planning. I basic. Children love choosing stickers at
tricky. A good tape recorder is essential. I don’t use the entire form with every child the end of a session and marble runs and
College London use a Digital Audio Tape (DAT) recorder as appointment scheduling does not allow posting boxes are effective in building
for collecting voice samples as this this and neither is it necessary unless we voice therapy skills through structured
maintains a good recording frequency are collecting research data. I have had to behavioural reward systems. Time spent
range and allows for dual channel modify it a little to include some more researching voice on the internet or working
data collection. I use the electro- unusual voice characteristics that we see as through a simple project on voice can be
laryngograph (Fourcin, 1986) a bi-product of airway reconstruction, for fun and educational for older children.
with the majority of my example ventricular band voice or other
patients, mainly as an supraglottic type voices. 9. A quiet clinical room
assessment tool, for con- This can be difficult to come by with all the
firming measures such as 6. Access to the internet and building works going on around us at the
fundamental frequency, library resources moment, but is essential to obtaining
but also as a biofeed- I try to keep up-to-date with new books good recordings for reliable perceptual
back tool, for example and relevant papers as they come up. I analysis.
when working to re- find the libraries at University College
establish voice with London and the Institute of Child Health 10. Augmentative communication
children with psy- very helpful in refining searches on partic- systems
chogenic voice loss. ular topics. When more unusual cases are Children who have no voice or a severely
The Speechviewer pro- referred I try and prioritise the time to disordered voice may be at risk of devel-
grammes can also be search the internet for an article that opmental speech and language delay as
very helpful in providing might guide my management. I would well as communicative frustration. It is
the necessary encourage- access a system such as KA24 (a round the important to consider mechanisms that
ment to very young children clock service for local NHS employees) to will assist their communication and its
to provide any voice sample assist my search. I usually find the time to development. Very young children may
Detail from Edmund Caswell’s Peter Pan at all! Some of the children I read articles on the bus to and from work. need to develop skills in a signing system
mural at Great Ormond Street Hospital. see may also need assessment of The speech and language therapy students such as Makaton. Many children with
Reproduced by kind permission
of Henny King. their nasal airflow, for example with who work with me on research projects tracheostomies are now routinely fitted
nasometry. Video recording can also be and clinical placements frequently direct with speaking valves. Older children may
helpful for raising children’s awareness of me to new information and keep me on need to learn to use an electrolarynx and
their posture and for skills training with my toes! children with pathologically quiet voices may
the electrolarynx and so on. benefit from a voice amplification system.
Many voice aids have been developed for
adults and their use with children will
require careful consideration. Individual
assessment is always required to ensure that
an aid can be used successfully by the specific
child. Supply companies such as Kapitex
Healthcare are usually very helpful in attend-
ing assessment sessions with the child and
their family before a product is purchased.

References are listed on p28.