speech & language therapy in practice, summer 1999

7/28/2019 Speech & Language Therapy in Practice, Summer 1999

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R ~ D E R O F F E R Win a FREE copy of Earobics!

Step 1 .. Developmental Ages 4 .. 7 Step 2 .. Developmental Ages 7 ..10

Speech & Language Therapy in Practice has a copyof Earobics Pro PLUS Step 1, courtesy of DonJohnston Special Needs and Step 2, courtesy ofSuper Duper Publications. These auditory development and phonics software programs on CD normally retail at 199 each. To enter, all you have todo is find at least seven real words using only theletters of the word 'ear'; you can use all or some ofthe letters and repeat the letters within the wordas often as you like. The winner will be picked randomly from all correct entries. Send your list withyour name (and, if you know it, your subscribernumber) to Avril Nicoll, Speech & LanguageTherapy in Practice, FREEPOST SC02255, STONE-HAVEN AB39 3ZL * or e-mail [email protected] note the winner will also be required toreview Earobics or provide a case study based

around it for the Winter 99 issue.* For readers outside the UK, the address is Lynwood Cottage,High Street, Drumlithie, Stonehaven AB39 3YZ.

Competition rules:1. Entrants must subscribe to Speech & Language Therapy in Practice and

only one entry is allowed per subscriber number.2. Entrants must have access at work to the necessary computer hardware

to run the CD-ROMs.3. Entries must be received by the editor on or before 30th June 1999.4.A person nominated by the editor will randomly select the winner from

all correct entries, but will not know who the entrants are.5. The winner will be notified by 6th July 1999.6. The winner will provide either a review of Earobia or a case study based

around it to Speech & Language Therapy in Practice by an agreed date.Earobics Pro PLUS consists of six interactive games in Step 1 and five inStep 2 to develop phonological awareness, auditory processing, phonics and language comprehension skills.There are two other CDs in the Earobics collection, home practice CDsfor Step 1and Step 2. A Super Duper Publications catalogue is availablefrom http://www.superduperinc.com. e-mail [email protected] UK supplier is Don Johnston Special Needs, tel. 01925241642.

ToPPThe winner of the Test of Pretend Play (Spring 99 reader offer)is Alison Webb. She will review the assessment in a later issue.Thanks to all entrants. The seven three letter words from playare pay, lay, pal, lap, yap, ply and alp.

The photograph shows Laorag Hunter,winner of the Winter 98 competition forReact software, receiving her prize fromPropeller Multimedia's Gordon Russell. A review will appear inthe Autumn 99 issue. The new address for React is 28 QueenMargaret Close, Edinburgh, EH10 7EE, tel/fax 01314452515.
mailto:[email protected]:///reader/full/http://www.superduperinc.comhttp:///reader/full/http://www.superduperinc.comhttp:///reader/full/http://www.superduperinc.commailto:[email protected]:[email protected]:///reader/full/http://www.superduperinc.commailto:[email protected]


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I

Child language, phonological awareness.

22 Further ReadingBrain injury, language development, dementia,

1999

1368-2105by:

[email protected]:

ReidFarmCyrus

Group Ltd7, Edison Road

ParkBN23 6PT

RegMRCSLTand advertising:fa x 01569 740348

Nicoll 1999of Speech & Languagein Practice reflect the viewsthe individual authors and notthe views of the publishPublication of advertisements isan endorsement of the adveror product or service offered.may also appearthe magazine's Internet site.

offo r Dysphasic

See page 18.

ContentsSummer 19992 News I Comment4 Objects of reference"For learners who do not communicate withintent, a communication strategy needs to beidiosyncratic, context-dependent and individuallydirected. In other words,before there are objects of 18 COVER STORYreference, there are objects." t - - - - - - - - ------------------- tKeith Park asks, whoseneeds come first? Training the carers"Communicate 's emphasis throughout ison fostering good practice in7 Rhyme communication. .. such skills are essential to

enable carers to tackle the disablingbarriers associated with communicationtime"It is vitally important impairment. "when teaching rhyme skills Lesley Jordan, Linda Bell, Karen Bryan,to a speech disordered Jane Maxim and Catherine Newman,child that the teacher and reflect on 'Communicate' to date.speech and languagetherapist gettogether to discussand decide uponjoint strategies to aidthis development. "Jill Popple andWendy Wellingtonshare their rhymingideas.

11 Reviews12 Adolescents"For language disordered pupils, making friends isa long process... even the short, positive experienceof the group has been enough to give one pupilthe confidence to join a basketball club, initiallywith support and now on his own."Barbara Paulger on the success of an I CAN socialcommunication group.

15 SpeechmagTop Tips on therapy for children with a voiceproblem.

16 In My Experience"No matter how brilliant you are technically, ifdon't have the capacity to stick it out with theclient then you may never see the end results."Geraldine Wotton introduces our new series witha defence of the therapy process.

AUTUMN 99 will be published on 30th August, 1999IN FUTURE ISSUES stammering new assessments autism dementia head and neck cancer bilingualism Fragile X hearing impairment aphasia outcomes

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 1999

dysphagia, referral .

23 How I usecomputersin therapy"Programs need to be interesting, motivating, easy touse and relevant to therapy. "Computer software forvoice, paediatric and adult

neuro work and a report on BE n 99.

30 My Top Resources"a student on placement with me drew asimplified mid-sagittal view of the head andneck ...1use copies galore in training andinformation for new staff. A laminated version ispinned to a cupboard in my room with blu-tac,easily accessible for explanations at any time."Pippa Wilson on her brain injury rehabilitationwork.
http://www.sol.co.uk/s/speechmagmailto:[email protected]://www.sol.co.uk/s/speechmagmailto:[email protected]


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news

Training advance

Access to a new training method for speech and language therapy students is to be widened. PATSy - Patient Assessment Training System -is web-based and uses video clips to enable students to rehearse and practise their selection of assessments and diagnostic skills before meeting 'live' clients. In addition, PATSy will be used as a research resource and will help standard ise students' experience with different cl ient groups. A student at Queen Margaret University College where PATSy is being developed commented it is "a bit like a simulator - the patient doesn't suffer" . It is envisaged this non-profit community resource will 'go live' in June. http://patsy.cogsci.ed.ac. uk

am what I amlm giving an insight into the lives of people with cerebral palsy will to improve disability awareness.

, I am what I am includes Alan Martin who, at years of limited communication through sign language,

is now enabling him to write poetry is autobiography. A fieldworker for the charity Scope suggested mak

to improve awareness and answer difficult questions about dispeople may want to ask but feel they cannot.

tel. 0171 619 7200, www.scope.org.uk

Therapy shortfallSpeech and language therapy is not provided for over a quarter of young primary school aged children with Down's Syndrome in mainstream education,although at least half have a specific language problem.This disparity in provision is identified in a report from the Down's SyndromeAssociation which explo res the inclusion of children with Down's Syndromeinto mainstream education. By late secondary school stage, the number ofyoung people with Down's Syndrome in the survey not receiving speech andlanguage therapy rises to 71 per cent.Although their survey suggests some progress is being made on inclusion, theDown's Syndrome Association is calling on all Local Education Authorities toallow parents to make a real and informed choice of mainstream or specialschools for their children by ensuring that adequate resources are allocatedand that proper provision is made according to the individual child's needs.Particular problems in accessing mainstream education are identified at secondary level, with staff training and wifh variations in quantity and quality ofprovision also causing concern.One in every thousand children born in the UK has Down's Syndrome.'Experience s of inclusion' from the Down's Syndrome Association, tel. 0181682 4001.

TULIP campaignOnly 20 per cent of people with Parkinson's are referred to a speech and language therapist, according to a survey by the Parkinson's Disease Society.The Society'S TULIP (Towards Understanding, Learning and ImprovingParkinson's) campaign includes a drive to increase referrals to rehabilitationservices . It has produced a checklist for people with Parkinson's to take totheir GP when they are being reviewed to try to encourage partnership inmanagement decision making.Launching the checklist, Mary Baker of the PDS said "A 4 per cent increase in20 years of people with Parkinson'S using occupational therapy, a 13 per centincrease in speech and language therapy and a 7 per cent increase in physiotherapy is just not good enough . Partnership between GPs and other professionals is vital in supporting people with Parkinson's. This checklist highlightsall avenues of help."The PDS has collaborated with the its group for younger people (YAPP&Rs) toproduce a video The UninvitedGuestto illustrate younger people's difficulties with Parkinson's. (From Sharward Services, tel. 01473 212113, price 22 inc p&p.) PDS, tel. 0171 931 8080 .

To wards l inderslaodin g. Lea rning & Im prov ing Par kinson 's

Poor care highlighted A detailed survey of stroke clientsand their carers makes uncomfortable reading fo r health care workers ircludlng speech and languagetherapists .The findings of the report Stro keRehabilitation - Patient and carerviews will be incorporated in thenational evidence-based guidelinesfor stroke care due out later thisyear. Th e organisations Involved*also plan to use the information infuture when producing guidelinesand evaluating st roke services, and

have assured participants that #wewill do our best to make sure yourviews make a difference.Among recommendations are bet-te r training, shared decision making. more information once theclient Is home, improved patientand carer informati on and thedevelopment of links with pa ti ent Ica rer org anisations . Specifically,they advocate adva nce warning ofchanges in service provision. namedcontacts and more written infor mation, and demonstrate t he va lue of

using 'pa tient quotes' to highlightinadequacies in services.The pa rticular problems with therapywere that "help was only availablein the short term, with no follOW-Up,no ongoing assessment of progress,no t ime to digest how far peoplehave got in their recovery and nolong-term help with recovery. Whenhe lp stopped, it often stopped suddenly with little if any warning orexplanation." More flexibility andunderstanding was called for, such asa realisation that people may initial-

Iy refuse therapy for various reasonsbut want to re-access the service at alater date. The quotes also make itclear how often people simply don'ttake in who is visiting them andwhat they are told, particularly Inthe early stages or after the returnhome, and the human impact ofstaff shortages and absences.(* Intercollegiate Working Party forSroke, Research Unit of th e RoyalCollege of Physician s, The Collegeof He alth, The Stroke Association,Dif ferent Strokes)

Stroke Rehabilitation -Patient and carer views is 8.50 inc. p&p (0 if collected in person) from the Royal College of Physicians Publications Department tel. 0171 935 1174 ext 358.

SPEECH & LANGUAGE THERAPY IN PRACTICE SUM M ER 1999
http:///reader/full/http://patsy.cogsci.ed.achttp:///reader/full/http://patsy.cogsci.ed.achttp:///reader/full/http://patsy.cogsci.ed.achttp://www.scope.org.uk/http:///reader/full/http://patsy.cogsci.ed.achttp://www.scope.org.uk/


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news [, comment

rers appreciatedessay competition is encouraging people with

to write about the crucial empowering.

Limbless Association has received funding forThe Prudential Carers Awareness

1000 prize.The Limbless Association, tel. 0181 788 1777,

movethe national educational charity for children

speech and language difficulties, has moved to:

87001040660104067

charity is inviting adventurous cyclists to ride theKenya in the Autumn to raise money

Call Hannah Bence on 0870 0104066 asas possible for a full information pack .

special needscalled for improvements in tra ining of to help children with speech and language

to a government consultation paper meeting the challenge of change, the char

for teachers and speech and lanto train together

to be fully trained, prepared and sup-to provide effective special needs education

to be more aware of special issues

to be rewarded for promoting pupils'

suppor t assistants. to

speech and language difficulty. 01712366487, e-mail [email protected]

now has a web site including lists of publicacourses - http://www.afasic.org.uk

of available voice amplification aidsusers need to be more specific and forceful

their requests so companies can adapt theiralso be seen with

of more money into research andmakes this

The survey identified potentially helpfulincluding a microphone manufacturer

would make adaptations if approached and awho would be able to improve the aesthet

cations and ergonomics of existfor a consultancy fee.

of suppliers and companies willing to consid-fee from Dennis Netcott,Disability Service, South West Region

Assessment Team), tel. 01454848550.

Avril Nicoll,Editor

Lynwood Cottage,

High Street, Drumlithie,

Stonehaven AB393YZ

tel/ansa/ fax: 01569 740348

e-mail: avrilni coll@so l.co.uk

... comment. ..

Makes y o ~ t h i n k . 't et?uoesn I.Who, where, when, how, what, why? All questions we ask - or should beasking - about what we of fer every client. The question of where we providetherapy is as crucial as the tasks we employ. Who we involve is as importantas how we get our message across. When we are best to intervene continuesto exercise the profession. And the fundamental why question is possibly themost interesting.The addition of 'Reflections' to articles and our new series In my experienceseek to explore this in particular. It may be uncomfortable at times, but it isonly by thinking critically about why we do what we do that we can move onas individuals and as a profession . As a crucial partner to research evidencewe must hear and value the voice of experience. In our first example,Geraldine Wotton gives what she sees as a discarding of traditional skills afascinating perspective by relating it to the wider context of changes insoc iety. A reminder perhaps that, while we have to move with the times, wealso have a role in shaping them.But are we, as individuals and team members, flexible enough to do this?I CAN's social communication group at a youth club is surely a step in theright direction. Children with language disorders have a real life too, outwithschool and home. We have a lot to learn about what they want from this lifeand how we can help them achieve it. Barbara Paulger cautions: "I t is veryeasy for us to project potential problems onto pupils and to have objectivesfor them that we think are right, but perhaps they do not."The importance of functional communication is emphasised by Pippa Wilson'sMy Top Resources but, sadly, Keith Park's experience suggests real life is notalways a top priority. He can find little evidence of objects of reference beingused in client's homes and is frustrated by the tendency to standardise ratherthan individualise systems, even for people with very complex needs. Heemphasises the importance of solving such issues by acting on Lenin'sassertion that "theory without practice is barren and practice without theoryis blind". Jill Popple and Wendy Wellington's article on rhyme is one exampleof how motivating therapy games come from a robust theoreticalunderstanding.And the very honest assessment of the progress to date of the Communicatepackage reminds us that training others needs the same rigorous evaluationas our work with individual clients: who, where, when, how, what, why?

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 1999 3
mailto:[email protected]://www.afasic.org.uk/mailto:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]://www.afasic.org.uk/mailto:[email protected]


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The va l. i ia of objects of reference with children and adults with severe and profounddis;abUities raises many questions. Advisory teacher Keith Park challenges us to

learning dlsablUt\ l

ose nee scome irst?ues of inclividualisation, theory and practice, multidisciplinary collaboration and

working iVith p a ~ n t s .

This article is a resume of theauthor's presentation inJanuary1999 co the Royal College ofSpeech & Language Therapists'Special /nterest Group inAugmentative and AlternativeCommunication (S/G MO atthe ACE Centre in Oxford

. . . ._ he term 'objects of reference' refersto the use of objects as a means ofcommunication. Although this mayhave much to offer people with profound and multiple learning disabili ties, there remain important issues of

both theory and practice that have not yet beenaddressed. The apparently ad hoc method of usingobjects of reference, and the apparent lack of evaluation studies, mean that the quality of practice isextremely variable, and there seems to be littleconsideration of the importance of the social context w ithin which objects of reference are intendedto be used (McClarty, 1995; 1997). poses userHow do we knowObjects of reference were first described stands the distance betweenby Jan van Dijk in the mid-1960s as a means what an object vehicle (the object itself) andof communication for people with congen referent (the concept to whichmayor may notital deafblindness. Since then, although it refers). For example, whythe literature is scarce, there have been represent for should a purse represent orsome examples of work in the United someone else? 'stand for' shopping? How doStates, Australia, Denmark, and the UnitedKingdom. A full review of th is literature is in anarticle entitl ed 'How Do Objects Become Objects OfReference' (Park, 1997a) . As the title suggests, thearticle is also concerned with the development of atheoretical model of object use that might shedsome light on some murky subject mat ter ' Most ofthe literature reviewed deals with the use ofobjects of reference with children and adults whoare already communicating intentionally. There isvery litt le, if any, literature on its potential usewith individuals with profound and mult iple learning disabilities who are not communicating withintent.Representational objectsThe literature review (Park, 1997a) identified oneparticular issue in the use of objects of reference

with people with profound and multiple learningdifficulties in that the objects of reference - chosen by teachers or therapists to represent significant activities, objects, or people - may be representational. In other words, the objects maystand for, or represent, something other thanthemselves: a purse or wallet for shopping, apiece of material to indicate the sensory room andso on. Using objects of reference may appeal tous because we think they have a 'common sense 'value: they are permanent, manipulable, andconcrete. Most of the literature reviewed, however, suggests using them in a way that pre-sup

that the under

we know what an object mayor may no t represent for someone else? How canwe validate the assumptions of our practice? Ona theoretical level, we might ask how objectsbecome objects of reference: how does meaningdevelop?Provisional modelThe literature review (Park, 1997a) proposed thata provisional model of object use might bedesigned by using three terms from semiotic theory: index, icon and symbol. These are describedby Elizabeth Bates in her pioneering work onearly communication and language as follows:1. Index"Signs that relate to the things they stand forbecause they participate in or are actually part ofthe event or object for which they stand"*



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If we wish tocomplain aboutacademicsbeing divorcedthat are related to the things theyby virtue of some physical resem from reality, wecannot divorce

ourselves fromthat are related to the things they for by an arbitrary bond agreed upon theory.

who use the

ca n beby two

beas being

Alex, who is 16 and has multihas been observed by his carer, at

to 'flutter' the fingers of his rightwho know him

as meaning "This is nice / Iam comfortable with this." This behav

is, in one sense, unique to Alex, and so it isit only ever occurs at dinner times

so it is context-dependent. It is pre-intenthat Alex is not intenmessage, although the

to interpret it as having a meaning.is a result of their efforts to communicate to

he has been encourto feel the plate and spoon, smell the food,to the carer talk to him and allowed time to

in his own individual way. In this way theis individually-directed in that it

to help him make sense of his environment.final stage of intentional communication

to use words, signs, symbols,any other communication media - can

as conventional, context-indepenFor example, Anna,16, is in a school leavers' group. All of the

in her group have a severe visualThe

shares an objects of reference board thatpe rsonnel, and

. The system of objects of referencebeen d e ~ e l o p e d to be the same for all the

is used across home andol environments (context- independent) andof its aims is communication between the

of the group (socially directed) .seems reasonable to conclude that Alex 's and

be appropriate for eachAlex's objects include a spoon for cookingsame one he is helped to use in stirring the

an armband for swimmingsame one he wears in the hydrotherapy

peers, include anaudio tape casestuck on a pieceof card for'leisure time'(after dinnerwhen the students stay intheir classroom "My granddaughterand play the irown choice of is two and doesn'tmusic) ; a crushed have an establishedcan on a piece of toileting carecard for the current project routine, but she(crushing cans would rather talkfor an ecologyproject); a guide about thecane for 'walking Teletubbies! "/ mobility training'; a purse for shopping (this is also stuck on acard and is not used in the activity); a bus ticketon a piece of card for 'going on the bus.'StandardisationWhat would happen if Alex and Anna attended aschool where a standardised use of objects wasbeing implemented? As has been remarked somemorably, "Is there life afte r toil et and biscuit?"I am not suggesting that standardisation is a priori a wrong decision, but it is important toencourage discussion in this very complex area.For learners who do not communicate withintent, a communication strategy needs to beidiosyncratic, context-dependent and individual ly -directed . In other wo rds, before there areobjects of reference, there are objects. In manycases, people are being given 'objects of reference' before they have been able to develop any

learning disabil i ty

understanding of signification(that is, that one thing can standfor another) . Would Anna'sobjects of reference be appropriate for Alex?Theory and practiceSo how do objects becomeobjects of reference? Objectsmay become objects of referencebecause of their 'canonicality':this refers to the 'canonical, orsoc ially standard, funct ion of theobject' (Sinha, 1988, 105-106).The development of canonicalobject use describes the processof how objects become objectsof reference, and this is an areaof practice and theory that needsmuch attention . Would this investigation

be appropriate for academics or practitioners?

Many of us may feel uncomfortablewhen discussing issues from a theoreticalperspective, but I would argue that it isessential - especially if we do feel uncomfor table about it. Many teachers, andperhaps therapists, may feel that someacademics within their field of work aretoo removed from practice. This may beso, but an academic might justifiablyreply by sayi ng that practitioners are antitheoret ical. Two years ago when I wasinvited to give a presentation on the use of

objects of reference the organ iser to ld me quiteemphatically: "this is a practical workshop thatprovides practical answers to practical questions.We don't want any theory or funny business likethat." I ignored the comment - and, of course,people were quite happy to discuss theory whenit was made clear how it related to our issues ofpractice. If we wish to complain about academicsbeing divorced from reality, we cannot divorceourselves from theory. A famous radical politicianonce said that theory without practice is barrenand practice without theory is blind. Cynics mightreply this was one thing that Lenin got right IIndividualisationWhen con Sdering the use of objects of referencewith someone, it may be helpful to consider the'MMF' prinCiple (Park, 1997b): choosing objectsthat are Meaningful, Motivating and Frequent.These real examples illustrate that objects of reference - and the concepts to which they refer need to be relevant to the individual user and notto the therapist or teacher. In a recent article(Park, 1997b) I asked, jokingly, if anyone knew ofsomeone of school age with severe and profoundlearning disabilities who was using an object ormodern foreign languages. This was evidentlynot a joke. I have subsequently found anecdotalevidence that suggests that many people in thissituation are given a separate object for each ~



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National Curriculum subject with the justifi would like to hear from therapists who havecation of "this is what we teach at schooL" experience of or an opinion on:1. Meaningful 1. individualisation / standardisation ofAngela does not like to sit down and thismade school life very difficult for the class staff.One day, when they had managed to persuadeAngela to sit down, her teacher gave her a stringof beads, and Angela sat at the table with theothers for nearly 15 minutes. This was quite abreakthrough, and so, building on this success,Angela was given the string of beads every timeshe was expected to sit down with a group. Aftera while, Angela was persuaded to leave the beadson the back of the chair and to participate morein the group activity. This strategy has been veryeffective, and the string of beads - for Angela means something like "sitting down with the others and doing things". Angela's teacher can thendifferentiate the activities in her teaching fileaccording to the National Curriculum subjects.When the activity is finished, Angela is encouraged to drop the beads into a small cardboardbox that is presented to her. She then knows thatshe is free to wander around the room for a while.The 'meaning' of the beads from Angela's perspective has been socially constructed, and notarbitra rily imposed.2. MotivatingOne of the highlights of Jill's week is when she hasher hair washed. The bottle of shampoo is herobject of reference for 'hair washing.' One unforgettable day, only six weeks after the weekly hairwashing routine had started, Jill picked up thebottle of shampoo and gave it to a member ofstaff. According to the school staff, this was thefirst time ever in school that Jill, then 18 years old,had made an intentional communication. Herteacher once said to me "Why does everyone haveobjects of reference for toilet? My granddaughter is two and doesn't have an established toileting care routine, but she would rather talk aboutthe Teletubbies!"3. FrequentAbdul loves going to watchrugby matches but can only go oRewice a year. His special hat iskept out of sight until a day or so

display as a frequent and realistic item of choice.More work neededThis article is based on the issues discussed duringmy presentation to the RCSLT SIG in AAC. It wassad to see that among the fifty or so people, therewas just one example of successful home use ofobjects of reference. As one therapist ruefullypointed out, it seems that service users exist tomake professionals feel they are providing a

professional service. Clearly, much more workneeds to be done here.Recently I met a parent of a four year old child

with disabilities who is successfully using objectsof reference at home (without any therapist orteacher being involved!) The school where shestarts later this year has a standardised approachto the use of objects of reference. When I askedthe mother what she thought about this, shereplied that she was going to meet with thespeech and language therapist and the classteacher, discuss the needs of her child, and theywould then draw up a list of communication aimsand methods that would be shared betweenschool and home. She added that this agreementwould then be one of the items discussed at eachannual review. I asked what she thought of stan dardised systems. She said "my daughter's needscome first. " Parent power may sound like acliche, but it is one we should hear more often.Uneven qualitySeveral of the people at the SIG meeting had positive examples of co-operation between therapistsand teachers, and this was encouraging.However, there was a general agreement thatcommunication is far too important to be left toanyone profession or person, and perhaps theuneven quality of practice concerning objects ofreference may point out the need for a much closer collaboration between therapists and teachers,and most importantly parents.CollaborationObjects of reference is just one subject amongmany that are important for multidisciplinary collaboration: eating and drinking difficulties, augmentative communication in general, and of

objects of reference2. successful home use of objects of reference3. working with children with multi-sensoryimpairments.Keith Park is an advisory teacher for Sense (TheNational Deafblind and Rubella Association),based at the Family Centre in Ealing, WestLondon. He is also a teacher for children withvisual impairment and learning disabilities forGreenwich Visual Impairment Service .Address for correspondenceKeith Park, Sense Family Centre, 86 ClevelandRoad, Ealing, London W1 3 OHE, tel. 0181-9910513, email [email protected] AcknowledgementComing to the SIG AAC meeting as a teacher totalk mainly to speech and language therapists, Ilearned that therapists have a positive attitudetowards multidisciplinary collaboration, a readiness to discuss theoretical issues and, perhapsmost importantly, an enthusiasm for their work. Iwould like to thank Gillian Nelms and her colleagues for inviting me.ReferencesBates, E. (1976) Language and Context: TheAcquisition of Pragmatics. London: Academic Press.McLarty, M. (1995) Objects of Reference. InEtheridge, E. (ed) The Education Of Dual SensoryImpaired Children: Recognising and DevelopingAbility. London: David Fulton Publishers.McLarty, M. (1997) Putting Objects of Referencein Context. European Journal of Special NeedsEducation 12 (1) 12-20.Park, K. (1997a) How Do Objects Become ObjectsOf Reference': A review of the literature on

ections: Whose needs come irst? before he goes to a match. Do I give sufficient weight to the needs Of individuals.However, he also enjoys going tothe video shop to hire a video,and this object of reference - the Do I impose meaning on clients. or allow it to developplastic ticket given out by theshop - is kept out on permanent Do I ensure communication systems work in real life?

course involving parents in using communicationsystems at home. The Sense Family Centre atEaling welcomes the opportunity to continue todevelop multidisciplinary collaboration betweenspeech and language therapists and teachers inthe very complex area of augmentative and alternative communication with people who havesevere and profound learning disabilities andmulti-sensory impairments. In particular, we

objects of reference and a proposed model forthe use of objects in communication. BritishJournal of Special Education 24 (3) 108-114.Park, K. (1997b) Choosing and Using Objects ofReference. The SLD Experience 19,16-17.Sinha, C. (1988) Language and Representation:A Socio-naturalistic Approach to HumanDevelopment. Hemel Hempstead: Harvester~ ~ 0

mailto:[email protected]:[email protected]


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t h e r a ~ \ , j . l d e a

hyme is one of the earlier phonological skills that a child shows any overtsigns of learning . But what is "rhyme"exactly? At an auditory level, wordscan be broken up into smaller components, namely syllables and individual

. If we divide a syllable further, we have anor the first part of the syllable which

to the vowel sound and then the secof the syllable consisting of the vowel

ofis called the 'rime'.

that have the same rimes are thereforeto ' rhyme' . The spellings of the 'rime' may be

but the sound of the 'rime' is the sameI fight) .

awarenessto work by Adams (1990)

says the litfollowing order for theof phonological awareness:

Tasks involving monitoring and correctingI sound play

of words for rhyme orion

I syllable splitting (recognition

orphonemes).

has been done into the importance ofto and knowing nursery rhymes at an

ai, 1987; Bryant et ai, 1989)the conclusion that "nursery

I I

Underlying phonological skills are vital for thedevelopment of spoken and written language, sochildren who are struggling need a collaborativeapproach from therapists and teachers.Jill Popple and Wendy Wellington recommend alevels and that, rather than metalinguistic skillsemerging suddenly after six to eight years old, theprocess begins much earlier with a more gradualdevelopment. She feels there are strong indicators that, from two to four years old, there is avery active period of metalinguistic learning andthat "self corrections and sound play can be considered at the border of awareness". Maclean etal (1987) estab lished that " many three year oldchildren had a reasonable knowledge of nurseryrhymes" and that there is "a degree of phonological awareness in children as young as three. Manyof them did well in the rhyme and alliterationtasks, and in rhyme and allitera

sensi- from two to four tion production tasks as well".(rhyme and phoneme detection) They also found an "extraordiin turn enhances years old, there is a narily robust relat ionshipai , 1989). A child between the knowledge that

is able to recall or partially recall very active period children had about nurseryis already showing a rhymes when they were three

to the sounds and sound of metalinguistic years old and their subsequentwithin words and to the fact .

some words have a segment in learntng. This sensitivity in these early

is at a very subconscious level and the childbe able to say why these words go

Chaney concludes that children asas three years old have already started to"the ability to

explicitly about language" - but at varying

phonological development".This ability to rhyme and

detect rhyme and its subsequentlink with developing an improved phonologicalsensitivity has been shown in many studies tohave a significant influence and impact on thech ild's ability to develop their reading andspelling skills. Goswami and Bryant (1990) suggestthat "to recognise that words rhyme is to put

psycholinguistic approachto assessment and sharetherapy ideas for one ofthese skills, rhyme.

them into categories" and, as these categoriesshare a common sound, the child is enabled tostart making the links between words with common sound patterns and common or potentia llycommon spellings.Joint strategiesSo, rhyme is an important measure of a child'sspeech processing skills and develops at a veryyoung age. To apprec iate rhyme a chil d mustrecognise the similarities and differences betwee 'lwords - what is the same about tv'JO wo rds andwhat is different. For example, dog and log aresimilar in that both end in logl but they are dif-ferent in that one starts with Id l and the otherwith II!. Rhyme skills show an understanding ofonset and rime which are the major con- ~



10/32

e r a p ~ ' _ ! < ! e ~ s

of a syllable. This ability to segment wordsa child to read and spell words by analogy

elps to develop a motor programme for sayingnd writing new words. Without this knowledge a

would have to learn each part of a new word3 separate item rather than using existing knowl

of these rhyme families. It is vitally importanten teaching rhyme skills to a speech disordered

-'d that the teacher and speech and languageerapist get together to discuss and decide upon

t strategies to aid this development.evels of difficultyaclean et al (1987) suggest that adults can playa

ficant role in the development of phonologicalwith the help of "informal linguistic rou

nes". Nursery rhymes are one example of inforal ways parents draw the attention of their chilen to the sounds and sound patterns in wordsd thus build on their phonological awareness

s. Knafle (1973; 1974) looked at the comparisonfour categories of difficulty of rhyming words:

of the rime is agle consonant comparison (eg. kill; pill; kiss)

of the rime is aof two different consonants (melt;

in two consolast one of which is the same (silk; milk;

in two consois different (tend;

e children were given a target word and askedhich of two other words rhymed with it, egohich word rhymes with lift - list or gift? Knaflecorrectly identifying rhymes in categories 1 and

- which provided the maximum contrasts - than4. She subsequently found

there were more correct responses in catego3 than in 4. The rhyming words we choose to

with should therefore start with the easiestof discrimination, namely categories 1

2, where there are the maximum contrasts ofTasks can be structured to be easier or hardera) including or excluding the production of

b) minimising or maximising shortinvolvement in performing the task

ai, 1993).At our school we use a psycholinguistic frame

developed by Joy Stackhouse and Bill Wellsto assess phonological skills. This is an

skills, storage system and programming andoutput skills. This approach contains a

of rhyming tasks which "tap diffe rent levelsphonological processing skills in children".

incl udeRhyme judgement - making a decision about

two words rhymeRhyme detection - deciding which of a

of items rhyme and which do not

at

I ( - ' ~~ )( )~ ~cat~ ~

hat

Figure 1 - Posting game

In

~---------]- :'....:::-:::'tin ----

~Figure 2 - 0The aim is to,to identify thThree Pictur1family and 0this level theported by thE

: ~ ~ ~ s o ~The child has two sets of pictures with the words also printed onthem. These are placed face downwards. The post-boxes have thewritten rimes, one on each. As the child turns over the picture theadult says the name of the picture and the child posts it in the correct box. This can be played at all the levels a) - e) mentioned, butit can also be played at just this written word matching level. Theteacher then takes the cards from each set and shows how theyrhyme, ego cat, mat, fat, sat all end in 'at'.

or counter orfamily the we

~[L~ /adults can playasignificant role inthe development ofphonological skillswith the help of"informal linguisticroutines"c) Rhyme production - spoken production of aword or number of words that rhyme with a giventarget.

With the responses to these tests, and lookingat how they integrate with other test responsesfrom the approach, we can hypothesise what processing skills the child can use or what difficultiesthey are having and devise a programme accord

Figure 5 - Rhyme stringsChild generates rhyme strings. Thiscan be done at the level of "I spy"or making words using the rime anddrawing down letters from analphabet arc to make new words. Inthis way, a child learns to synthesisethe two elements of the word toform a new word. This level canalso be worked at by having a complex picture with rhyming wordsaround the side - the child has tofind a rhyming picture from thecomplex picture that corresponds tonamed picture from the edge.

ingly, using their strengths to help their weaknesses. This also leads us to devise our therapyprogrammes at an appropria te level of processingskills and therefore difficulty.Introducing rhymeWe have found it very useful to start this procedure by developing a general awareness of rhymeand then making the concept of rhyme andrhyming explicit. We introduce the word "rhyme"as meaning the "last chunk" of a word. We alsodevelop rhyme corners in the classroom, sing nursery rhymes and carry out cloze procedures withthe adult missing out a rhyme word for the childto supply. Rhyming story books such as Pat the Cat( Hawkins & Hawkins, 1985) can be very useful for

this. When the child becomes familiar with theidea of rhyme it can gradually be brought intomore specific exercises.

At first the child may need to be supported visually when working with rhyme and may need theadult's verbal model to aid their detection ofrhyme. The aim would be eventually for the childto be able to understand the process of rhymeand be able to detect and use rhyme for thedevelopment of both spoken and written language. For the child to do this, a series of steps inthe teaching of rhyme needs to be devised:a) The rhymes are presented auditorily with theteacher supplying the model. The words are represented with pictures and written words (figure 1).

SPEECH &LANGUAGE THERAPY IN PRAalCE SUMMER 1999


11/32

therapy ideas

Outan awareness of rhyme within a set of words and

does not belong to a rhyme family.to the child. Two belong to the same rhyme

The child is to identify the" odd one out". Atis sup

there is no written word. This can be done withbeing very dissimilar ego man, pan, elephant, or with

ego man, pin, pan. The child can put a crossout picture. The child can also say which rimeso making the rhyming element explicit

Figure 3 - Rhyming diceThe ch ild generates the word for comparison, supported by thepicture and written word. A game for this could be a rhymingdice. The words and pictures from two rhyming families are decidedupon and drawn on to a baseboard. The rimes are written on to adice. The dice is thrown and to move forward on the track the childhas to move to the next picture I word from that rime family.~

hat

~/pin ~ 0P

catG~~

tin\:>' ~ ~ in ~ ~

at t~

b) The rhymes are presented with the teacher supplying the auditory model; the words are represented by pictures alone (figure 2). c) The child generates the words fo r comparison the wards are represented by pictures and words (figure 3). d) The child generates the words for comparison the words are represented by pictures a one (figure 4). e) The child generates rhyme strings with or with-out the use of the visual support of letters arranged alphabetically in an arc (figure 5). It is useful to start to deve lop a child's specific awareness of rhyme by choosing rhyming words whose rime is already in their sight vocabulary,

Figure 4 - Rhyme collectionThe child generates the word from a picture card for comparison.A game for this level could be rhyme collection. Rhyming picturesfrom two rhyming sets are dealt out between two players facedownwards Player 1 turns over their card and names it, player 2turns over their card and names i t S/he looks to see if the cardbelongs to the same rime family as player 1; if it does, both cardsare taken. The game continues until all the cards have been used.

ego at and in. Other useful rhymes can then bedeveloped by using a structured approach toteaching letter order and therefore rime ordersuch as described by Broomfield and Combley(1997).

The activities in Figures 1 - 5 can be done at anylevel, but the more unsure the child is the morevisual support s/he will need. We have also foundit is very helpful if these verbal rhyming activitiescan be backed up by the child saying and writingthe words so that the child not only forms a verbal motor programme fo r rhyming words but alsocarries this forward into his written language. Thecase study (page 10) shows how we worked withone child, Donald, to improve his rhyming skills.

Jill Popple and Wendy Wellington are spe ed! alanguage therapists at a special school formunication disordered children in She ffield.

ReferencesBradley, P.E., Bryant, L., McLean, M. and r ~J.(1989) Nursery rhymes, phonological s .reading. Journal of Child Language 16.4 07 - !J :Broomfield, H., and Combley, M _ :+=Overcoming dyslexia. Whurr.Chaney, C. (1992) Language develop ..alinguistic skills and print awareness in 3 .:.e :: :children. Applied Psycholinguis '(513, - - :;' ' ':Dowker, A. (1989) Rhyme and alii E'raNr ' ~

SPEECH & LANGUAGE THERAPY IN PRACTICE SU .1 ER 1% 9


12/32

~ Ideas

.. . poems elicited from young children. Journal of Knafle J. (1974) Children's discrimination ofChild Language 16, 181 - 202. rhyme. Journal of Speech and Hearing ResearchGoswami, U. and Bryant, P. (1990) Phonological 17, 367 - 372.

Freephotocopiablerhyme sheets!For readers interested in pursuingrhyme work with children,Langlearn Communications isoffering a copy of Rhyme Time, aphotocopiable activity book, asthe prize in a free draw. Carefullygraded by 'Metaphon' authors LizDean and Janet Howell, the book(retail price 30.00) can be used tointroduce the concept of rhyme tochildren from 3'1> years.To enter the draw, send your nameand address marked 'Speech &Language Therapy in Practicerhyme prize draw' to Janet Howell,Langlearn Communications, 8

skills and learning to read. Lawrence Erlbaum Associates Ltd. Ha wkins, C. and Hawkins, J. (1985) Pat the Cat: Picture Puffin books. Penguin Group. Kamhi, A. (1987) Metalinguistic abilities in language impaired children. Topics in Language Disorders 7, 1 - 31. Kamhi, A. and Koenig, L. (1985) Meta awareness in normal and language disordered children. Language , Speech and Hearing Services in Schools16,199 - 210. Knafle J. (1973) Auditory perception of rhyming in Kindergarten children. Journal of Speech and Hearing Research 16, 482 - 487.

Marion, M.J., Sussman, H.M. and Marquardt, lP.(1993) The perception and production of rhymein normal and developmentally apraxic children.Journal of Communication Disorders 26, 129 - 160.McLean, M., Bryant, P and Bradley, L. (1987)Rhymes, nursery rhymes and reading in earlychildhood. Merrill-Palmer quarterly 33,255 - 281.Stackhouse, J. and Wells, B. (1997) Children'sSpeech and Literacy Difficulties; A psycholinguisticapproach. Whurr.Van Oosterom, J. and Devereux, K. RebusSymbols. The Symbol Collection (Software for PCand Acorn) Widgit Software, 102 Radford Road,Leamington Spa, CV31 lL F.

Re lections: Rh me time1. Do I use an approach to assessment that helps me workcollaboratively?2. Do I have adequate knowledge of task hierarchies to beflexible when faced with an individual's difficulties?3. Do I provide sufficient visual support when auditory skillsare impaired?

Traquair Park East. Edinburgh, IEH12 7AW, tel. 01313345232. The Idosing date is 30th June. III

OFFERAutismWould you like a FREE copy of Autism:a social skills approach for children andadolescents by Maureen Aarons andTessa Gittens?In celebration of Autism AwarenessWeek, Winslow is giving away co pies ofthis new practical sourcebook, normallypriced 27.50, to five readers of Speech& Language Therapy in Practice.To enter the draw, send your name andaddress marked 'Speec h & LanguageTheragy in Practice autism prize draw'FAO Jane Lindsay, Winslow, TelfordRoad, Bicester, a xon OX6 OTS, [email protected] The closing.date is 30th June.More information about the publicationis in the 1999 Winslow catalogue and athttp://vvww.winslow-press. co. uk_ _ _ _ _ _ _ _ _ _ _ _ _ _ .J

Case study - DonaldDona ld's attention and listening skills have improved but rema in flu ctuating. His copying of rhythmicpatterns is now OK but he still occasionally finds it difficult to hear an un stressed syllable in a word.He has made a significant amount of progress with rhyming skills, particularly when given choices ofwords that rhyme or when he has pictures to help him. He st ill finds i difficult to internalise or work outrhyme for himself, so has a strategy which he can use to help himself when reminded.1. Look at the first word and see what "family" it belongs to2. Look at the "family" of the second word3. See if both words are in the same family: if they are, then they rhymeFor example:

,s A0 at an Look at the first word and see what "family" it belongs toLook at the" family" of the second wordIf both words are in the same family I then they rhyme!

Althoug h this strategy has increased his awareness, rhyme is not a firmly establ ished , spontaneous skill .Overall, the input side of Do nald's profile as compared with the output side suggests he continues tohave difficulties at a repre sen tat ional or storage level as well as some difficulties at an articulatory level.Consequently, it is more difficult for him to Judge word components and patterns automatically.

0 SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 1999
mailto:[email protected]:///reader/full/http://vvww.winslow-press.cohttp:///reader/full/http://vvww.winslow-press.comailto:[email protected]:///reader/full/http://vvww.winslow-press.co


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organisesand C arifies

Children's Speech and LiteracyDifficulties - A PsychologicalFrameworkJoy Stackhouse and Bill WellsWhurrISBN 186 1560303 17.50Many of us are already familiar withthe work of Stackhouse and Wellsthrough their many articles and training courses. This book, based on thosecourses, has become essential readingfor therapists and other professionalsworking with children with speech andliteracy difficulties.

ing a fascinating, longitudinal study ofZoe chronicling her changing profilefrom the age of 3;9 to 9;8 years.One of the strengths of this psycholinguistic approach is that it highlights howchildren presenting with the same diag-

Nothing

READER OFFER100 of Singular books

organises and clarifies assessment andtherapy plans and it is very worthwhileworking your way through all the activities to help you move from theory intopractice. An invaluable book; essentialfor every paediatric department.

Are you hungry for up-to-date speech andguage therapy information? Singular Publishing isoffering 100 worth of books FREE to aSpeech & Language Therapy in Practice reader.PocketGuides, voice, dysphagia, outcome measures- take your pick from the 1999 catalogue.To enter the draw, send your name and addressand subscriber number if known marked 'Speech &Language Therapy in Practice Singular prize draw'to Avril Nicoll, Speech & Language TherapyPractice, FREEPOST SC02255, STONEHAVEN AB393ZL or from outside the UK to Avril NicollLynwood Cottage, High Street, Drumlithie,Stonehaven AB39 3YZ or [email protected] The closing date is 30th June.

Kate Padfield is speech and language therapistfor European Services for People with Autism,South Hills College , 9 The Cedars, Ashbrooke.Sunderland.

reviews

particularly new

Their aim is to produce a practical, sys-tematic, hypothesis-testing approach tothe investigation of speech processingskills. Through carefully structured chap-ters, using thought-provoking activitiesand neat summaries, we are enabled toprofile a child's speech processingdeficits and meaningful, individualisedtargets for teaching and therapy.The first half presents the psycholinguistic model of speech processing interms of input skills, lexical representations and output skills and emphasis isgiven to the development of literacyskills and how this relates to speech .An assessment framework is discussedbased on their speech processingmodel. Questions are posed whichattempt to identify the level at whichbreakdown occurs. Practitioners areencouraged to think critically about thenature of tests used to assess speechprocessing and phonological awarenessas the book clearly states that it doesnot purport to be an assessment battery.The authors offer a developmental perspective in the second half, and hypothesise that various speech disorders canbe explained by failure to progressfrom one phase to another. Detailedclinical case studies are offered includ

Sourcebook of Phonological AwarenessActivities: Children'S Classic LiteratureCandace L. GoldsworthySingularISBN 1-56593-797-XWritten by a speech and language pathologistand based on discussions in a previous text, thisoffers a variety of phonological awarenessactivities based around eight well-knownchildren's stories, fo r example, 'Snow White andthe Seven Dwarves'.It looks at the importance of phonologicalawareness in learning to read and describes thestages of development fo r phonologicalawareness skills. It then describes variousassessments of phonological awareness andexplains how to use the programme.Phonological awareness activities are given fo reach children's book the author has chosen andrecord sheets are included to chart progress.This book may be useful for a teacher whowants to work around a specific project or set ofbooks and needs something she can pick up anduse. Pictures, however, are not provided and, ifa different children's book from thoserecommended is used, the activities have to bealtered to accommodate the differentvocabulary. The activities used in each chapter

nosis may have very different sets ofunderlying deficits which will affecttheir prognosis and efficacy of theirtreatment plan. The careful and rigorousnature of assessing and profiling a child'sstrengths and weaknesses enables thepractitioner to identify more subtle, hidden skill deficits and examine the closerelationship between speech processingskills and literacy development.This is not a book for bedtime; thoughwritten in a clear, careful manner and asjargon-free as possible considering thesubject matter, it is a taxing, thoughtfulread. Stackhouse and Wells do admitthat, initially, profiling a child's speechprocessing skills may take some time butthat, with practice, filling in profilingsheets can be done quite quickly. Myown experience suggests it focuses,

are exactly the same - only the book used andthe vocabulary around it change. They are notparticularly different from phonologicalawareness activities presented in otherpublished books and programmes, although theidea of using familiar books may make theactivities more interesting for the child.The author suggests that a child should masterone level before progressing to the next andthat activities should be repeated using differentchildren's books until the child can cope withthat level. As children tend to developphonological awareness skills in dif ferent ways,this may lead to a child being "stuck" on one setof activities when they may be able to copewith higher or lower level tasks. It may havebeen more useful to suggest a varie ty of tasksat different levels to prevent the child frombecoming frustrated.While this book may be useful for people whowant something they can pick up and use, foranyone who has experience of working withchildren with phonological awarenessdifficulties, it does not offer any particularlynew ideas.Lynne A. Kemp is a senior speech andlanguage therapist with Tayside Primary Care(NHS) Trust.

--,

lanlucky

inat



14/32

Helps Children Communicate

For pupils with languagedisorders, making friends. or even coping in social

situations - can be a long,challenging process.

Barbara Pau/ger reportson a pi lot project where a

group of 11 to 13 yearolds with poor socialcommunication skills

"were given strategiesand opportunities for

integration at a youth club.

CAN, the national educational charity forchildren with speech and language impairments, opened its first of four secondaryschool language Resources in 1995 with theaim of offering a unique combination ofspecialist support and opportunities for

inclusion within the main school. However, eventhese cannot address the pupils' difficulties withcommunicating in other situations. We thereforedecided to run a Social CommunicationCommunity Group as a pilot project over nine ses-sions from January to April 1998 to focus on theapplication of social communication skills outsideof school and home. The success of the pilot hasled to a family support worker being appointed.She is continuing support to Resource pupils whoare participating in local community groups.

Eight pupils from I CAN secondary school language Resources in Surrey took part in the group;five from I CAN at The Park (a resource for pupilswith speech and language impairment in additionto moderate learning difficulties) and three fromI CAN at Broadwater (a mainstream secondaryschool language resource). The pupils were eithe rin Year 7 or Year 8 (ages 11 - 13 years).Difficulty making friendsThe pupils who attended the group had difficulties making friends due to social communicationproblems including:1. poor eye contact2. poor listening and turn taking

3. a lack of awareness of the needs of others4. poor understanding of what constitutes afriend5. difficulties expressing feelings or intentions6. lack of confidence in talking to others7. inappropriate touching8. poor awareness of when to stop / say no / compromise9. inability to talk through a problem with others.The pupils themselves were asked during theirfirst session at the youth club to suggest reasonsfor the group's existence and their attendance.Having picked up on clues such as who was running the group, the pupils who were attending itand where it was being held, they cited:1. so can tell friends at school about new friends2. play games3. have fun4. to know each others' names5. to make new friends6. to hang out with your school mates7. to be friendly with others8. to calm your nerves9. help with speech10 . play sport11. learn language skills12. to talk to people with same problem as us13. to make new friends from different schools14. to learn how to listen.The group was in tw o parts, structured activitiesfollowed by less structured activities, each lastingone hour. The group was run by two speech and



15/32

g r o ~ p s

In addition to I CAN's Mainstream Support Programme , the charity's services include : a, An Early Years Programme: a national network of specialist speech and language nurseries, b,Three Special Schools : Dawn House in Nottinghamshire, John Horniman School in Sussex and Meath in Surrey, c. A Training & Information Programme : sharing I CAN skills and expertise with professionals, parents and the general public. For further information please conta ct I CAN 'sCentral Office on 08700104066, Below: Barbara Paulger with social communication group members from I CAN at The Park.

Resources, Youthfo r organising activitiesof the evening and these were

with the therapists,and support

to develop friendto identify, discuss and solve

toin experiencing new and chal

We found the Social Use of2) and Games for Social

by Tim Bond useful fo r ideas,pens were the

as we used mainly brainin

session, The subjects discussedto introduce yourself to someone,to do if someone is rude to you,no, '

,some people always play on

is this fair, what could we do 'have not made many friends at the youth

of the second part of the evening was forto use the skills and strategies they hadin the first part in their

with the youth club members, The less

structured activities included football, basketball,pool, table tennis, trampolining, team games,quizzes, cooking pancakes, computer photo scan-ning, use of a camera fo r developing stories andan outing to Laser Quest in Guildford,

Initially all the pupils found it hard to settle inthe group, their eagerness to sample the facilitiesof the club obvious, However, they all respondedpositively to discussions and to targets set, andthe group gelled well ,Recognising problemsThe nature of the pupils' communication difficulties often made it hard for them to recognisewhen a problem situation had arisen or to puttheir difficulties into words, They tended to walkaway and then miss out on activities, so theybecame unhappy and had negative experiences.However, when a problem was presented to themthat had been observed by one of the speech andlanguage therapists they were excellent at t alkingabout the situat ion and then problem solving, It istherefore crucial that therapy is not just confinedto made-up situations in a clinic / therapy room /classroom, It must involve real life situations and,while discussion and problem-solving is invaluable, it needs to be put into practice over andover again, Videoing is also a powerful tool forfeeding back and, the more the pupils are able tosee what led up to the problem and discuss it , thebetter they should become at recognising it at thetime it happens, ~

a flip chart,paper and penswere the mostessential items aswe used mainlybrainstorms,discussion androle play



16/32

The natureof the pupils'

communicationdifficulties oftenmade it hard for

them to recognisewhen a problem

situation hadarisen or to

put theirdifficulties into

words.

ections: Thera

.... For the first few sessions there were very fewpupils from the youth club available to integratewith the Resource pupils, so they were able toconcentrate on becoming familiar with the cluband its facilities . They were very keen on thesports activities but did not get involved with themore verbal activities - video, chat, story boardsand quiz sessions. The Resource pupils were initially reluctant to try some of the new experiencesoffered at the club, but with support they eventually joined all of these exciting activities.IntegrationThe Resource pupils had an initial target of finding out the name of a pupil from the youth club,which they achieved, but they were unable toreally sustain a friendship. However, towards theend of the sessions there was a core group ofpupils who knew the names of all the Resourcepupils and vice versa. They interacted well andthe youth club pupils often encouraged theResource pupils to join in activities with them.The youth club pupils also approached the speechand language therapists and asked questionsabout the Resource pupils in an interested andpositive way. If we were running another similargroup, we would talk to the youth club pupilsbefore it started to explain what it was all about.We would also consider inviting some of theyouth club pupils to the structured part of theevening to facilitate better integration.

We asked the Resource pupils to think about:"Why didn't we make more friends?" Theyresponded: "Keep forgetting, other things on mind." "Talking to friends is wasting time, having fun

doing other things." "We were making friends with people from the

group." "Not enough time, only one hour." "Because we are not in the same group as them,

so don't get to meet them." "Not many people here."

or real li e

exciting than making friends! In addition, few ofthe Resource pupils had previously had the opportunity to socialise with their classmates outsideschool, so it is not surprising that cementing existing friendships was more of a priority than making new ones. For language disordered pupils,making friends is a long process. This is especiallytrue for some of the project pupils who had hadnegative experiences in the past. They appearedto be happy just to be accepted in the club with-out any negative reactions such as teasing. I amconfident that some of them would have madereal friendships had the project been longer buteven the short, positive experience of the grouphas been enough to give one pupil the confidenceto join a basketball club, initial ly with support andnow on his own.

The Social Communication Community Groupwas a success for those pupils who attended. Theywere able both to explore strategies for coping insocial situations and to participate in communityyouth activities. Staff were however aware of theless than ideal circumstances, with school staffused to run after-school activities and childrentaken outside their own localities to integrateinto community activities.Local supportI CAN has now recruited a family support workerwhose role includes the support of Resourcepupils participating in appropriate local groups.She is using the findings of the SocialCommunication Community Group to guide herpractice. She gets to know the pupils, finds outtheir main interests and liaises with school staff inthe first instance, then meets with the staff andyoung people at the out of school activity theResource pupil is going into before they start. Themost valuable advice we have been able to passon to her from our group is that the pupils have arange of needs, but all need support, even if it isjust an initial presence.

Barbara Paulger is a specialist speechand language therapist, I CAN at ThePark, The Park School, OnslowCrescent, Woking, Surrey GUl2 7AT,tel: 01483 726913.dress a client's communication needs in real life situations?

beyond my own aims for a client to what they want from therapy?exploit the problem-solving and motivating potential of groups?

Solutions that they offered were: Make the unstructured part longer. Invite some of the youth club pupils to join in

the group.It is very easy for us to project potential problemsonto pupils and to have objectives for them thatwe think are right, but perhaps they do not. Wemust bear in mind that some of the pupils in theproject were experiencing a youth club environment for the first time which was exciting - more

14 SPEECH &LANGUAGE THERAPY IN PRACTICE SUMMER 1999

AcknowledgementFunding for the social communicationcommunity group was generously provided by the Joint Commissioning

Panel of Surrey Education and Social Services.

ResourcesSocial Use of Language Programme by Wendy Rinaldi, 77.25 + VAT from NFER Nelson, tel. 01753858961 Games for Social and Life Skills by Tim Bond, 13, Stanley Thornes, tel. 01242 228888. 0


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Internet

http://www.sol.co.uk/s/speechmag The Winter 1998 speechmag asked for top tips for therapy forchildren with a voice problem. We are indebted to ColletteMcCallum and Claire Hood of Lanarkshire Healthcare NHS Trustfor this collection of ideas and resources:1. Ideally, a dysphonic child should not be placed on a waitinglist. They should be viewed as a priority and treated as soon aspossible.2. Therapy can be individual and / or in a group.3. Individual therapy can focus on relaxation, posture, movement, breathing, phonation, resonance. The area(s) focusedon depends on assessment results.4. Therapy will involve working through a series of steps.5. Paren ts and teachers are extremely important in helpingthe child deal with therapy. Therapy may involve majorlifestyle changes and dealing with feelings.6. Intensive therapy w ith a contract is best.7. Treatment of dysphonic children is difficult and challenging- but rewarding.8. Relaxation: tin soldiers v raggy dolls; puppets on a string;flowers opening; giraffes and monkeys; imagery.9. Posture: explain and show the benefits of good posture.10. Movement: we base this on "Move and Rela x with Music".11. Breathing: Mr Big Breath; blowing out birthday candles;silly putty; blow football/ fish.12. Phonation: puppets - hard and soft; describe their voice ingeneral terms, eg loud / quiet, soft / hard, dancing / marching.13 . Pitch: ladder; high and low sentences.14. Give clear and concise aims. A chart is exce llent as a visual aid.15 . It's a good idea to use a tape recorder and / or video camera for feedback. Keep the child informed of what is expectedof them.16. Dysphonia groups can be varied according to need. Wehave run a pre-school, older children and an adolescents'group. The younger group incorporated Mr Men characters,Mr Noisy and Mr Quiet.17. Group aims were: to improve awareness of voice; to promote voice care and therefore eliminate vocally abusivebehaviours; to develop sel f-monitoring.18. Each session included: topic and associated vocabulary;individual and group activities; relaxat ion; homewo rk .19 . Weekly plan: Week 1 - general awareness of sounds (environmental); concept of noisy and quiet; introduce relaxation. Week 2 - recogni sing voice as a special sound; developingunderstanding of relationship between sounds and feelings;unique characteristics of voice - loud/ quieti rough/ smooth/nice/unp leasant. Week 3 - learning about voice production and voice care;introduce relaxation through imagery. Week 4 - good vocal habits - introduce alternative means ofcommunication (non-verbal, facial expression, body la nguage); discuss pitch/hard/soft attack.20. ENT consultants are extremely reluctant to operate on children. Full pre-operative counselling is essential. The decisionwill take into account the length of the dysphonia and thedegree of handicap caused (eg. children studying music). The

optimum age is 9 - 11 years. The outcome is still dependent onthe child's abilities to change behaviours with speech and language therapy help. Therapy should always be tried beforesurgery.21. Voice advice sheet for parents:Your child is experiencing some voice difficulties and needsyour help to improve their voice. Here are some ideas to try:Encourage your child to speak quietly and try to reduce background noise, ego TV, washing machineEncourage your child not to throat clear or cough and insteadoffer them a glass of water or ask them to swallovil hardEncourage your child not to singEncourage your child to drink lots of water or suck blackcurrant pastilles to keep their throat moistEncourage your child to have quiet timesEncourage your child to have good vocal habits by trying tohave these good vocal habits yourselfIf you are worried in any way about your child's voice pleasecontact your speech and language therapist.22. (With picture of frog) Mr Croaky says:

Don't croak like me,Try the tips below and makeyour voice croak free.1. Do not shout.2. Do not clear your throat.3. Do no t sing.4. Drink lots of water.

23. Useful resources Andrews, M. (1986) Voice Therapy for Children. Longman. Fawcus, M.F. (ed) (1986) Voice Disorders and their Management. Chapman & Hall. Greene, M. and Mathieson, L. (1989) The Voice an its Disorders. Whurr. Martin, S. (1987) Working with Dysphonics . Winslo . Prater, R.J. and Swift, R.W. (1984) Manual of Vo ice Therapy. Little, Brown and co . O'Neill, C. (1993) Relax. Child's Play. Wilson, D.K . (1972) Voice Problems in Children. Wil liams and Wilkins.

SPEECH &LANGUAGE THERAPY IN PRACTICE SUMMER 1999 15
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In my experience '

IIsp.0sab eor dsp saIn the first of a new series giving therapists

the opportunity to reflect on what they havelearned from experience, Geraldine Wotton

urges us to recognise and value theemotional and technical skills involved in thetherapeutic process and considers the

r - - ~ implications if we do not.

comment so well; I would rather he had beenimpressed by my in-depth knowledge of psy-cholinguistics. I now realise that 'old fashioned'qualities such as patience are absolutely crucial ifwe are to have a chance of effecting change. Nomatter how brilliant you are technically, if youdon't have the capacity to stick it out with theclient then you may never see the end results. It isoften the client knowing that you can indeed stickit out with them in spite of the grave problemsthey encounter that provides and maintains theirmotivation to continue and move forward .

I love my job as a speech and language therapist. It challenges me at all levels intellectually andemotionally as it is not about teaching language /speech / communication skills as if the client issome passive container into which I pour my endless wisdom. The 'work' of a therapist is a 'process'.This process involves the therapist using intellectual and emotional skills to understand the client'scurrent impairments and strengths, from whichfollows an interaction between this understand

...7 ollowing a particularly stressful sessionwith a very disabled dysphasic gentleman recently, his son said "I can ' t getover the extent of your patience withmy father", Early on in my career Iwould perhaps not have taken this

16 SPEECH & LANGUAGE THERAPY IN PRAOICE SUMMER 1999


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. Not doing so cuts us Re ections: The thera rocessvery essence of our raiand, if it continues, I feel Do I truly appreCiate what I do?long-term

as an autonomous thera Do I value my relationships with clients?profession.lack of recognition of those Do I have the emotional capaCity to see my work through? reflects a wider shift seen

society as a whole . This includes a devalu- Geraldine Wotton is an Independent Speech & traditional skills of wisdom, experience and Language Practitioner in Walthamstow, London El7.


appreciation of their ownand the therapist's insights. Ultimate inte

of these will depend upon the level of the

ly - the therapist's emotional capacity tothat is sopart of the work. The relationship

is therefore the corof the process.

depthfor the work we do devel

gut instincts hadbut this involvement

me to appreciate theof the work we undertake.

of this I feel ardently that

is something to besomething that should be sopassed over or - perhaps even

versially - handed overuntrained person. This is a

which takes skill, experiand courage and cannot be

after one,three, four, five or however many years.

my appreciation grows, I am concerned atto be an increasing lack of appreci

for these skills by others. Like so much elsetreated as if they are easily acquired and

of . This indifference is alsowithin our profession,

recent debates have highlighted conabout the consultative models adopted by

moves which involveto others who do not have

or training.d'etreis the reason used to explain such a state

is a false economy. Matu rat ion ofcan only come through an under

and recogni tion of the skill of experi, with this,

. This is

I love my job asa speech andlanguage therapist.It challenges meat all levelsintellectually andemotionally

nurturing . Women have largely been viewed as guardians of these skills and values. However - to borrow a phrase from one of my colleagues - 'in pursuit of professional careers' we women have also colluded with this devaluation. I was sharply reminded of this recently by a mother who, when I asked if she went out to work, retorted "I work at home raising my kids". Pursuit of machismo This apartheid is also seen within the work place. The discrepancy in pay scales in jobs for those who opt to work in areas of hands-on child care,

Sadly, the current NHS philosophy has forcedmany of us to adopt ways and methods of working which we feel instinctively are not offering usor our client group the way forward. In our bid tocompete and prove ourselves we are throwingout the ba by with the bath water.

Timing and level of input, environmental I institutional I organisational support for the therapeutic process and financial and political supportfor the therapeutic relationship are vital and, ifnot present, must be fought for. The longer I workthe more I realise that the process we engage in isindeed complex and rarely straightforward. Itdoes not easily sit or fi t with the constraints anddemands most of us professionally face. Yes,these constraints are a reality that inevitablyinvades the therapeutic process and are thereforenot easily ignored. It is down to us to make thosewho insist on them aware of the impact of theirdemands on our work. We really cannot make asilk purse when only offered a sow's ear - andthey, not just us, have responsibility for that.Particularly when it comes to assessing outcomes.

for instance, is considerable whencompared with the less hands-on professionals involved in the same field.There seems to be increasing respectfor the machismo, the intellectual, thepackage, the short term objective andthe quick-fix, easy answer. Good oldfashioned values such as patience are- in spite of what is said - becomingless respected and valued . They arejust not fast-track or sexy enough. It isthe pursuit of the machismo that really underlies the current cultural trendsand is also influencing how we as aprofession are viewing the way forward.

the current NHSphilosophy hasforced many of us toadopt ways andmethods of worki ngwhich we feelinstinctively are notoffering us or ourclient group the wayforward.


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t ra ln lnQ

_earnln I

ommunicate'There is an expectancy in

speech and languagetherapy that priority should

shift from working onimpairments with individualsto improving communication

environments by trainingcarers, but how often has

such training beensystematically marketed and

evaluated? Lesley Jordan,Linda Bell, Karen Bryan, Jane

Maxim and catherinel)Iewman reflect on the firstthree years of Communicate

training and ask what we canall learn from the experience.

n Autumn 1995, Action for Dysphasic Adults(ADA) launched its training programme forcarers of older people with communicationimpairments. Communicate's emphasisthroughout is on fostering good practice incommunication: listening skills; carers' ways

of expressing themselves; and use of differentmodes of communication including facial expression, body language and gesture as well as language. These are general skills which are relevant whatever the cause of the communicationimpairment, in relation to clients without anyspecific communication impairment and for interaction with cl ients' relatives and, indeed, in otherworking relationships. Above all, such skills areessential to enable carers to tackle the disablingbarriers associated with communication impairment (Kagan, 1995; Jordan and Kaiser, 1996).

The programme has been described in somedetail elsewhere (Bryan et aI., 1996), so, afterbriefly explaining its background and aims, thefocus here will be on administrative issues, takeup and effectiveness, the purpose being to reflecton experience to date of ADA's first venture intothe health and welfare training market. Theauthors are engaged in a Middlesex University /University College London research project to conduct an evaluation of Communicate, funded bythe NHS Executive North Thames Health of OlderPeople Research & Development Programme.Need identifiedThe impetus to develop the Communicate training came from two sources. ADA's Director, RuthColes, became increasingly aware of the numberof requests for advice being received from careworkers in residential homes, and from relativesconcerned about these care workers' inability tocommunicate with a dysphasic person. At thesame time two of us, Karen Bryan and Jane Maximof the Department of Human CommunicationScience, University College London (UCL), identi

fied the need for a short, inexpensive trainingcourse for care workers . This stemmed from workover many years with older people in residentialcare. Several approaches to charities for fundingto develop such training proved fruitless. OnceADA and the UCL therapists discovered that theywere thinking along similar lines they workedtogether, with colleagues, to obtain a year's funding from the Department of Health (DoH) todevelop and pilot what became the Communicatetraining package.It was decided to focus on carers working in res-idential accommodation for older people becausethis is where communication impairment is mostconcentrated. There are an estimated 165,000communication-impaired people aged 60 andover living in institutions (hospitals, nursinghomes, residential care) in Great Britain. Studiesof older people in residential settings in two areasfound that over 50 per cent had communicationlimitations (Bryan and Drew, 1989; Lester, Soordand Trewhitt, 1994).Paucity of servicesEvidence also suggests considerable unmet needin relation to communication impairment. In particular, work on ADA's National Directory ofLanguage Opportunities (1995) revealed thepaucity, in many parts of the UK, of speech andlanguage therapy services for people needing theservice to be brought to them in residential careor in their own homes (see also Bryan and Maxim,1996). Current resourcing for statutory speech andlanguage therapy services would be most unlikelyto extend to the provision of staff training inmore than a small percentage of residentialhomes.

Communicate is designed as a workshop for 8-16 participants, aiming: to increase communication awareness; to provide knowledge about communicationimpairment;



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tra in ing ..

of practical commun ifor use with communication-impaired

.of Communicate's two half-day ses

draws on the NHS Trust Community Healthion disability awareness

(Lester, Boddy et ai , 1994). Whilst the mainof Communicate is on dysphasia, the second

s 'options' on Parkinson's anddiseases and the accompanying book

to all participants, gives informaof Communicate is

and language therapists inducted by ADAof Communicate .

Communicate's first year ADA received ato employ a marketing and

but since September 1996has been funded primarily by receipts,

as necessary by ADA. The price hasas low as possible and is calculated to

costs rather than to make a profit.now employs a part-time project manag

o is a registered speech and language therShe is responsible for:and language therapists as accredited

tutors;with potential purchasers of

in the statutory, voluntary and comsectors;

of the train ing package purchaser satisfaction.

liaisontutors are employed by ADA on a

basis. The 30 tutors cover most parts ofThey are expected to liaise with thech and language therapy service nearest

is to take place, to enable accu-

Table 1: Characteristics of Communicate purchasers to Sept. 1998Type of Agency Number of Agencies Number of WorkshopsIndependent Care Sector Agencieslocal Authority Social Services DepartmentsNational Health Service (NHS) TrustsOtherTOTAL

rate and appropriate information to be providedabout local services .

By the end of September 1998, 98 Communicateworkshops had been provided fo r 49 health andsocial care organisations. Table 1 shows the typesof organisation that have purchasedCommunicate. Three things are clear:1. Communicate has been purchased by awide range of agenciesIt has been taken up by agencies in statutory, voluntary and private health and social care. Theindependent care sector agencies comprise mainly providers of residential and nursing homes pur

24 3712 369 194 649 98

chasing either individually or as consortia. Theyalso include a small number of domiciliary andday care providers and a Housing Trust that hastaken on home care responsibilities. The NHSTrusts are mostly community Trusts but includealso two hospital Trusts and a mental health Tru st .'Other' purchasers are mainly voluntary organisations concerned with disabled people.2. Take-up in the residential care sector hasbeen disappointingThe training was initially designed for the residential care sector but only a very small percentage of approximately 15,000 residential and ~



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ursing homes fo r elderly people in England havesent any staff to a Communicate workshop.Some, bu t by no means all, participants in theworkshops purchased by Local Authority SocialServices Departments (SSDs) have been residentialcare staff.3. Communicate has been purchased for a farwider range of participants than anticipatedThe majority of participants' occupations areavailable from evaluation forms completed at theend of each workshop. These include over seventy different job titles. Care assistants are thelargest group, comprising over 20 per cent of allparticipants. SSD employees have included stafffrom day care and domici liary settings and, in oneinstance, informal carers. A number of managersand professionally qualified staff have attended,the lat ter inc luding nurses, social workers, andoccupational therapists.Take-up patternsTable 2 gives the geographical distribution oftake-up by NHS region. It shows a wide butuneven spread.

There has been no take up yet in Wales andNorthern Ireland, and only minimal take up inScotland . Communicate has not yet 'taken off' .The largest number of workshops so far fo r anyone organisation is six, purchased by a social services department in the Northern and Yorkshireregion.

Figure 1 shows the distribution of bookingsamong purchasers. Nearly half the purchasershave booked at least two workshops. Take-uppatterns vary, with some purchasers making aninitial booking for more than one workshop .Fourteen agencies have re-booked after experiencing a workshop, two of these having rebookedtwice and one three times. This suggests that asmall number of agencies have become regularcustomers. Most bookings are made three to sixmonths in advance. ADA clearly has much 'sparecapacity' since, during the fir st three years, only18 of the 30 accredited Communicate tutors delivered any workshops.

complementary service!ADA sees Communicate as complementary totatutory services. How do speech and languageherapists view it?

One factor affecting demand might be assumpions about Communicate among NHS speech andlanguage therapists and care providers. Do theormer see Communicate as a potentially usefulesource? Could one reason for low take-up behat Communicate is identified too strongly with

dysphasia, and wrongly perceived as less relevanto other

speech & language therapy in practice, summer 1999

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