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Transcript of Speech & Language Therapy in Practice, Winter 2001
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7/28/2019 Speech & Language Therapy in Practice, Winter 2001
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EvaluationReflective diaries
User involvementSeeking the whole truth
Objective assessmentResearch report
CollaborationJoint training
In myexperienceMaking learningmeaningful
Expressive artsA P O T E N T C O M B I N A T I O N
ISSN 136
WINTER
http://wwwspeechmagcom
How I usemusic intherapy
My topresourcesSchool aged
children
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Winter 2001 speechmag
Reprinted articles to complement theWinter 2001 issue of Speech & LanguageTherapy in Practice
Putting parents perceptions first.(October 1989, 5 (5))*Linda Banks explains how the therapist-parent relationshipcan get off to a good - or bad - start. She argues thatthe first visit is a momentous occasion and deserves ourfullest consideration.
New skills are needed in adult mentalhandicap. (January 1989, 4 (5))*With the return of adults with learning difficulties intothe community, Susan Dobson found that skills neededin this field had to be re-assessed.
Drake music project strikes the right notefor communication. (Nov/Dec 1995, 5 (1))**The Drake Music Project aims to enable disabled people to
make music through technology. Adele Drake, DianePaterson and Leon Clowes describe their work.
Also on the site - contents of back issues and news aboutthe next one, links to other sites of practical value andinformation about writing for the magazine. Pay us avisit soon and try out our search facility.
Remember - you can alsosubscribe or renew onlinevia a secure server!From Speech Therapy in Practice*/HumanCommunication**, courtesy of Hexagon Publishing, orfrom Speech & Language Therapy in Practice*** w
ww.spe
echmag.c
om
READER OFFERS
Win Workingwith DysphagiaThe caseloads of speech
and language therapists
are increasingly includ-
ing work with clients
with dysphagia. This
practical text by Lizzy
Marks and DeirdreRainbow is suitable for
a range of client
groups including those
with acquired neuro-
logical disorders and
those with learning
difficulties.
Reflecting current practice in the UK, the contents
include subjective and objective assessment, tra-
cheostomies and ventilators, and legal, health and
safety and ethical issues. Multidisciplinary working is
discussed, as is training other professionals.
Working with Dysphagia normally retails at 35.00
but Speechmark Publishing Ltd (formerly Winslow
Press) is making FIVE copies available FREE to luckyreaders of Speech & Language Therapy in Practice.
To enter, simply send your name and address marked
Speech & Language Therapy in Practice - WWD offer to
Su Underhill, Speechmark, Telford Road, Bicester, OX26
4LQ. The closing date for receipt of entries is 25th January
and the winners will be notified by 31st January.
Working with Dysphagia is available, along with a
free catalogue, from Speechmark, tel. 01869 244644.
Congratulations to Angela Abell, K. McGuigan, Miss
R. Surridge and Ellen Hesketh who won
Speechmarks The Selective Mutism Resource
Manual in an Autumn 2001 reader offer.
Also to Mrs Linda Robinson, Helen E. Bruce and K.McGuigan (again!) who won Music Factory, courtesy
of Widgit Software, an offer in the same issue.
READEROFF
ERREADEROFFERREADEROF
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Speech & Language Therapy in Practice is pleased to report that, in spite of increasing productioncosts and minimal advertising revenue, subscription prices are being held yet again for 2002.
This means that: for only 25, you have all the advantages of a personal UK subscription UK part-timers (5 or fewer sessions) will continue to enjoy these advantages for 16 per cent less UK students and those on a career break will continue to enjoy these advantages for 28 per cent less UK departments and other groups, including those outside the UK, will continue to benefit from our exceptional bulk rates everyone can continue to access our regularly updated website with online payment facility.
We work to drive up standards and keep costs low so that you benefit in every way.
Remember, the more people who subscribe to the magazine, the longer we will be able to keep subscription rates at their present low level - so why not recommendit to a friend? They will benefit from 5 issues for the price of 4 in their first year of subscribing, and you will get an extra 3 months FREE (see back inside cover for details.)
- every ones a winner!
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Inside coverWinter 01 speechmagReader offerA chance to win Working with Dysphagia from Speechmark.
2 News / Comment
4 EvaluationWithout the reflective diary and contemporaneousrecords of discussions, the speech and languagetherapist and the group leader would have only hadthe option of feeling, Havent we done well?(which could have occurred just because the verylarge project had finally finished).The shift away from one-to-one direct interventionpresents extra challenges when we try todemonstrate effectiveness. Sue Dobson reports onthe value of a reflective diary for a feelings projectwith adults with learning disabilities.
7 Further readingUser involvement, stroke, stammering / Parkinsonsdisease, mutism, aphasia.
8 User involvement... use of this method [a questionnaire] has the
potential to explain why some services are acceptedwhile others are declined, and by whom. In thesedays of limited resources, it is hard to overestimatethe importance of maximising the uptake of services
provided and cooperation with therapy.Evidence-based practice shouldinclude evidence of the acceptabili-
ty as well as the effectiveness ofhealth care services. MargaretGlogowska and colleagues foundout what parents thought of theirchilds speech and language thera-py, and how services could improveas a result.
11 ResearchreportThere is clearly a need for a noninvasive, easily transportable systemwhich will be both well tolerated byinfants and allow objective and
simultaneous assessment of several
aspects of infant feeding.Anthea Masarei and colleagues detailthe progress of the Great OrmondStreet Measurement of Infant Feeding (GOSMIF) whichprovides objective assessment of babies fed via a bottle.
19 Reviews (cont. p24)Voice, stammering, acquired disorders, semantics,paediatric dysphagia, multiple sclerosis, child language,language and literacy.
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2001 1
20 In my experience:Making learning meaningfulThe first time a teaching colleague asked me to getinvolved in a maths lesson, I replied, Me? Me, who
struggled endlessly with maths at school? OK, so I gota B grade at O level, but I never really totallyunderstood what I was doing! Now...I realise it is thecomprehension of mathematical language conceptsthat gives meaning to the subject.In a discussion which has relevance to our role whateverthe client group, Wendy Rinaldi shows how a language-based approach to school curriculum subjects improvescollaboration with education staff and gives moremeaningful learning opportunities to children withlanguage impairment.
22CollaborationBy studying together with teachers, speech and languagetherapists will be enabled to understand differentapproaches to teaching methods and will also develop agreater awareness of how children think and learn, whileteachers will gain a better understanding of speech, lan-guage and communication needs and how interventioncan be used to help children overcome their difficulties.Ruth Paradice explains what a new Joint ProfessionalDevelopment Framework should mean for speech andlanguage therapists, teachers and children withspeech, language and communication needs.
25 How I use music in therapyUsing music in this way feels genuinely therapeutic asit involves creating opportunities and offering time,
support and feedback. It demandsof the therapist the verybasic skill of really tuning
in and of beingfundamentallyfacilitative...Claire Finlay, HelenBruce and WendyMagee with SusanFarrelly & SophieMacKenzie inspire us toturn on, tune in and singout with all client groups.
Back coverMy TopResourcesAudited benefits ofJohansen Sound Therapyinclude improvements in
concentration, comprehension, reading and spelling,and, in particular, in maximising the benefits of theteaching and therapy they are already receiving.Nicola Robinson and Camilla Leslie work withchildren at primary and secondary school stages whopresent with specific speech and language /communication difficulties, with or without associateddifficulties with reading and spelling.
WINTER 2001(publication date 26th November)
ISSN 1368-2105
Published by:Avril Nicoll33 Kinnear SquareLaurencekirkAB30 1ULTel/fax 01561 377415e-mail: [email protected]
Production:Fiona Reid
Fiona Reid DesignStraitbraes FarmSt. CyrusMontrose
Website design and maintenance:Nick BowlesWebcraft UK Ltdwww.webcraft.co.uk
Printing:Manor Creative7 & 8, Edison RoadEastbourneEast SussexBN23 6PT
Editor:
Avril Nicoll RegMRCSLT
Subscriptions and advertising:Tel / fax 01561 377415
Avril Nicoll 2001Contents of Speech & LanguageTherapy in Practice reflect the viewsof the individual authors and notnecessarily the views of the publish-er. Publication of advertisements isnot an endorsement of the adver-tiser or product or service offered.
Any contributions may also appearon the magazines internet site.
ContentsWINTER 2001
Cover picture by Paul Reid.Thanks to Helen Gowland andDuncan of Jordanstone College of Artand Design.See page 11.
www.speechmag.com
IN FUTURE ISSUESPAEDIATRIC FEEDING AAC ETHICS IN DYSPHAGIA
AUTISM HEARING IMPAIRMENT CLINICAL EDUCATION
14 Expressive artsSame people altogether - similar but different,
like being pals. The people helping too were
awfully good. That first year I wouldnt have
gone because at that time I was thinking I
would still be alright - doing a lot to try to help
myself. The worst thing was coming to, youre
not going to be the way you want - youve got
to change your heads way. Even now, its hard.
Avril Nicoll meets participants in the
Expression project, a collaborative venture in
printmaking involving people with aphasia.
She hears their unique and often surprising
stories about life, change, services, aphasia -and speech and language therapy.
COVER STORY
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BenefitpleaA charity which supports familieswho care for children with disabili-
ties and special needs is calling on
community health professionals to
help increase the uptake of benefits.
Contact a Family has found that
nearly half of all children and young
people with disabilities in the UK are
not receiving Disability Living
Allowance. The purpose of this bene-
fit - which can mean as much as
93.95 extra income a week - is to
meet the extra costs which arise
from having a disability. It is not
affected by savings and can be paid
on top of any other benefits orincome. The charity wants health
professionals in the community to
encourage parents to ring its new
helpline number to see if they are
eligible and to get a free informa-
tion pack.
Contact a Family Helpline,
freephone 0808 808 3555
(Mon-Fri, 10am-4pm);
www.cafamily.org.uk.
Conductive educationpioneerThe director of the birthplace and world centre of conductive education has died at home in Budapest.
In the late eighties, following the the BBC TV documentary Standing up for Joe, Mria Hri opened the doors
of the Peto Institute to foreign children and their families. She became a Trustee of the Foundation for
Conductive Education, the Birmingham-based national charity created specifically to bring ConductiveEducation to the UK.
Conductive Education, an approach to managing children and adults with motor disorders such as cerebral
palsy, was developed in Budapest after the Second World War by Andrs Peto. Mria Hri was a medical student
who worked with Peto as an unpaid volunteer, and devoted her life to this work, increasingly as an educator
rather than a physician. After Peto died in 1967, she succeeded him as director and was chiefly responsible for
developing the role of conductors.
Andrew Sutton, Director of the Foundation for Conductive Education, said, Mria Hri grew up under
Fascism, qualified as a doctor under Socalism and steered the Institute
right through into Capitalism. She was a pragmatist and survivor. She
never married and leaves no surviving relatives. But there are now
nearly two hundred places around the world where conductors prac-
tise their craft and professional training courses in the UK, Israel,
Germany, Austria and the United States. That is her living memorial.
news
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 20012
Black Sheep Press - anapology from the editorBlack Sheep Press made two more
great Reader Offers in the Autumn
01 issue of Speech & Language
Therapy in Practice, for the CD Time
to Sing and Concepts in Pictures
material. Unfortunately, I printed the
companys old address. Mail re-direc-
tion ensured all entries arrived, but I
would like to apologise for my error
and to advise you of the new
address:
Black Sheep Press, 67 Middleton,
Cowling, Keighley, W.Yorks BD22
0DQ, tel. 01535 631346,
www.blacksheep-epress.com.
Society movesThe British Geriatric Society (specialist
medical society for health in old age) has
moved to Marjory Warren House, 31 St
Johns Square, London EC1M 4DN, tel. 020
7608 1369, www.bgs.org.uk.
Older peoplemisplaced andforgottenOlder people with learning disabilities
are too frequently misplaced in nurs-
ing and residential homes for older
people which do not meet their needs.
According to research from theFoundation for People with Learning
Disabilities, people with learning dis-
abilities are around 20 years younger
than other residents, staff have little or
no training in supporting them, and
there are few opportunities for daytime
activities, particularly outside the home.
David Thompson, GOLD (Growing
Older with Learning Disabilities) pro-
ject manager, said, Fifty per cent of
people with learning disabilities now
have the same life expectancy as the
general population, but services just
arent meeting their needs. Instead,
people find themselves cut off from
day services, with little opportunity to
maintain friendships and relationships
outside the residential home, which we
know to be a safeguard against abuse,
and often overlooked by specialist
learning disabilities services.
The research report recom-
mends a review of all place-
ments of people with learn-
ing disabilities in older peo-
ples homes by learning dis-
ability care management. It
also calls on local authorities
to hold registers of people withlearning disabilities, and services
to pay more attention to helping
maintain older peoples social net-
works and family relationships.
Misplaced and Forgotten, 10 + p&p,
Foundation for People with Learning
Disabilities, tel. 020 7535 7441, or
download it free from www.learning
disabilities.org.uk.
Disabled young people face social exclusion
Action for autismThe UKs leading autism charity intends to mark
its 40th anniversary in 2002 with its biggest cam-
paign to date.
Action for Autism will see the National Autistic
Society working to raise public awareness, taking
a lead role in encouraging integrated workingacross agencies, and raising 4 million to support chil-
dren and adults with autism. Initially established in 1962 by
a small group of parents frustrated by the lack of appropriate
provision for their children, the Society provides education, care and sup-
port services for those with the disability and their families.
www.nas.org.uk
Not being listened to, having no friends, and finding
it difficult to go shopping, to the cinema or out club-
bing are some of the problems faced by disabled 15-
20 year olds.
Young disabled people interviewed for a leading dis-
ability charity also identified a lack of control over money,
feeling a burden and being harrassed and bullied as part
of their social exclusion. In a new report, Scope calls onservice providers and policy makers to tackle the issue as,
despite social exclusion being on the mainstream policy
agenda, the experience of young disabled people with
high level support needs is not generally addressed.
Richard Parnell, Head of Research and Public Policy at
Scope says, Scope wants policy and service providers
to look again at their policy and service objectives. We
want them to ensure that they go beyond the physical
and basic needs of these young people and take into
account their views and opinions on how they wish to lead
their lives if they are ever to achieve true equality.That kind of life is 3 to individuals and aid users and 12.50
to professionals and organisations, tel. 020 7619 7341.
www.scope.org.uk.
BenchmarkingNew benchmark statements for health care professions including speech
and language therapy will help in the design and review of education
and training programmes.
Covering both the academic and practice elements of health care pro-
grammes, the statements were drafted by groups including practitioners
and representatives of professional bodies. Benchmark statements repre-
sent general expectations of the attributes and capabilities that those
possessing a qualification should be able to demonstrate.
The Quality Assurance Agency for Higher Education reports that - as
work progressed on dietetics, health visiting, midwifery, nursing, occupa-
tional therapy, orthoptics, physiotherapy, podiatry, prosthetic and
orthotics, radiography and speech and language therapy - it became clear
that a common health professions framework was emerging.
http://www.qaa/ac/uk/crntwork/benchmark/nhsbenchmark/benchmarking.htm.
~
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news & comment
A potentcombination
How many of us describe spending time being creative - whether through art,
music or movement - as therapeutic? In a profession so dependent on words,
turning to other methods of self-expression and communication provides
welcome relief. The actual doing enables us to say things we had previously
found difficult to put into words while, at the same time, words inform and
help us improve our creative skills.
This potent combination of expressive arts and words can be harnessed in
speech and language therapy to great effect and enjoyment for all
concerned, as is shown in How I use music in therapy(p.25) In the Expression
project (p.11) the creative process of printmaking allied with facilitated
discussion, at a time when they were ready to reflect, enabled the
participants to explore their aphasia and its implications, and describe this
verbally and non-verbally. Margaret Glogowska and colleagues (p.8) also
amply demonstrate how giving people an opportunity to reflect on services in
a way that is meaningful to them produces a wealth of information so these
services can develop in a user-friendly way. Sometimes changes needed are so
small or subtle that they can be incorporated very easily into our everyday
practice. At other times, asAnthea Masarei et al (p.17) have discovered, a
full-scale research and development project is needed.
Sue Dobson (p.4) and her key worker colleague ran a group with adults with
learning disabilities, with Sue as the speech and language therapist working
in a supportive but gradually less direct way. The key worker used a reflective
diary which proved useful for gathering qualitative information on outcomes,
and provided motivation for her to persevere. The collaborative aspect of the
approach to the group was crucial, particularly the speech and language
therapist continuing to do as well as to be involved in the reflection.
We so often want to work collaboratively but need to address this both from
a top down, strategic and a bottom up, clinical governance perspective. The
newJoint Professional Development Framework(p.22) seeks to provide an
impetus and a context for individuals to work more collaboratively but leavesthe creative detail to the individuals concerned. Wendy Rinaldi(p.20) suggests
an overall approach to working more effectively with teachers and several
ways of creating these opportunities, and this issues My Top Resources provides
some very specific practical ideas for working on language and literacy.
As loyal readers you already know that Speech & Language Therapy in
Practice values that potent combination of doing and reflecting. I am
delighted to tell you that subscription rates are again being held at their
current low level, and I look forward to your continued custom in 2002.
With best wishes for the New Year,
...comment...Avril Nicoll
Editor
Kinnear Square
Laurencekirk
AB UL
tel/ansa/fax
email
avrilnicoll@speechmagcom
EarlybirdAn innovative centre for children with autism
spectrum disorder and their families has entered
its fifth year with a new director.
Jo Stevens, who has taken over the helm of the
National Autistic Societys EarlyBird Centre, is a
teacher and licensed user of the programme
which she has been running in Lincolnshire.
The EarlyBird Centre continues to offer three
day training courses for teams of at least two pro-
fessionals wishing to become licensed users of the
programme. The centre has found this skill shar-
ing amongst teams of different disciplines and
agencies is an appropriate and effective way to
help parents cope with the pervasive effects of
autism spectrum disorder.
NAS EarlyBird Centre, 3 Victoria Crescent West,
Barnsley, South Yorkshire, S75 2AE. Tel: 01226 779218.
Technology in the communityA multidisciplinary team specialising in the assess-
ment of electronic technology for severely disabled
people is taking its service into the community.
Speech and language therapy, occupational
therapy and rehabilitation engineering staff making
up the core Compass team are from the Royal
Hospital for Neuro-disability, a national medical
charity. Assessments for communication aids,
computers, environmental controls and powered
wheelchairs for clients who require simple switches
to operate the equipment can now be carried out in
the community, nursing homes and other hospitals.
The Compass team can also draw on other services
at the Royal Hospital if extra help is needed with
setting up equipment or with support and training.
Details: Compass Project Coordinator Gary
Derwent, tel. 020 8780 4500 ext. 5237.
Speaking out about strokeA new report shows how far health services have
to improve before they can be seen to provide a
reasonable stroke service.
Although treatment in stroke units reduces
death and disability by 25 per cent, the Stroke
Association survey found that only 22 per cent of
respondents were treated in a stroke unit. Further
difficulties arose over discharge and rehabilita-
tion arrangements.
The charity is now carrying out a survey of NHS
hospitals in England and Wales on their specialist
stroke services as the government does not collect
this information centrally. It plans to use evidenceof gaps to lobby for improvements.
Speaking Out About Stroke Services from the
Stroke Association, tel. 01604 623 933.
Implant improvementsChildren receiving a cochlear implant are set to
benefit from a technique which reduces scarring,
psychological trauma and infection rates.
The Queens Medical Centre in Nottingham is
pioneering the insertion of a cochlear implant
through a small, 3cm incision behind the ear. The
childs hair can be pinned back while the opera-
tion takes place and there are no stitches to
remove afterwards.
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evaluation
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 20014
if you want to do less handson
therapy monitor qualitative
change
share your enthusiasmfor communicationevaluation
Wheneffectiveness
is hard toproveChanges in the way speech and language therapy
is delivered means therapists are improving their
skills in facilitating, teaching and joint working.Although welcome, this shift away from one-to-
one direct intervention presents extra challenges
when we try to demonstrate effectiveness. Could
reflective diaries be a useful method?
Sue Dobson reports on a feelings project with
adults with learning disabilities.
here are considerably fewer speech
and language therapists employed to
work with adults with learning disabil-
ities since the closure of the larger
institutions and the advent of commu-
nity care (Dobson & Worral, 2001). This factor,together with changes in working practices to a
more advisory / consultative role (Money, 2000),
has led to a difficulty in measuring the effective-
ness of recommended interventions.
An episode of communication intervention is
now usually delivered and led by the day-care
workers or residential staff in the community
(Purcell et al, 2000). The role of the speech and
language therapist has become more of a facilita-
tor, supporter, trainer, and joint planner of inter-
ventions rather than to deliver hands-on therapy.
This means the therapists concerned often have
difficulty in evaluating the outcomes of their
action, as they cannot control many of the vari-
ables that influence the delivery of the therapeu-
tic process. Communication is viewed in the con-
text of the perspective and influence of the com-
munication partners - staff, peers and significant
others. Interventions therefore have to focus on
influencing:
1. the staff group
2. the activity
3. how it will be organised and delivered
4. using an appropriate tool to evaluate its effect.
The programmes, therefore, do not lend them-
selves to standard evaluation packages or meth-
ods. Some detailed quantitative evaluations may
take longer than the actual delivery of the inter-
vention itself; the danger then becomes that theprogrammes are rarely fully monitored or
reviewed. So, different styles of effective methods
of evaluation need to be explored.
This article concentrates on the intervention
offered to a lady with autism spectrum disorder.
The intervention, which spanned a twelvemonth
period, focused on her emotional distress and her
inability to express it in a socially acceptable way.
As a project, it included all her peers and aimed to
develop an evaluation method which would be
useful to all those participating - peers and staff.
Qualitative changesThe initial three month period of joint working
with the group of service users involved was a
matter of routine style of evaluation: joint plan-
ning of each session, end of session discussions,
and monitoring and recording of individual and
group outcomes against the stated aims and
objectives. The second stage, of monthly visits to
the group by the speech and language therapist
and generalisation of the service users skills, and
the final stage of monthly meetings and discussion
with the group leader, presented greater difficulties.
The main focus of the work - qualitative changes
in communication, social interactions and the
environment - was evaluated using a reflective
diary written after each session by the group leader.
This was supplemented by records of facilitated
Read this
T
see
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speech
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inside
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cover
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evaluation
reviews of progress during the joint monthly dis-
cussions. Reflective diaries have become a com-
mon feature in accredited courses at universities
for nurses, therapists and social workers. They can
also be used in the personal development log of
registered speech and language therapists, andare regarded as acceptable evidence within clinical
governance activities.
Our client, R, was 29 years old with severe learn-
ing disabilities and autism spectrum disorder. A
lot of her speech was echoing commonly used
staff phrases. She was very emotionally volatile
and often became distressed about disruptions in
her routine or her inability to obtain items about
which she was currently obsessed. When this
occurred she shouted using repetitive phrases.
When extremely distressed she abused herself by
throwing herself violently on the floor or against
walls. Her general demeanour was that of
extreme anxiety. She constantly prowled around
the day centre looking for things to collect and
making excessive amounts of noise. It was diffi-
cult to engage her in activities and she rarely
interacted with her peers. It was felt her lack of
adaptability and poor level of social
competence were major factors in her
continuing distress.
Rs key worker reflected on referring
her for speech and language therapy:
Id been poorly for quite sometime
and when I returned to work, I felt Id
lost touch with my group. One of my
students was bouncing off walls and
screaming, one was shouting and
interrupting over the top of everyone.Two of my students were always in
tears and one hid others belongings just to upset
them. Another student scratched herself and oth-
ers until they bled and the final one was very
withdrawn.
The agreed years plan was to establish a discus-
sion group which focused on emotions and creat-
ed a feelings communication book for each stu-
dent (sample pages in figure 1). The first months
led to the following comments by the group
leader:
For weeks we have cut out happy arms, happy
eyes, happy bodies! Weve made lists of things
which make us happy, temperature charts about
how happy we are and what we would say and
when wed say it...Its evident that its hard work for
them to see from our faces what we are feeling.
TransitionIn the fourth month the therapist stopped attend-
ing every group but remained in close weekly con-
tact with the group leader for discussion. She also
supported the making of charts, symbolic material,
or social stories about situations in the centre. The
group leader was recording at this time of transi-
tion in delivery of the planned intervention:
At the beginning I felt I was preaching. Now
some of the group are beginning to think this
work applies to them. If they miss a group theyre
saying Im sorry to let you down. I was worried
about some aspects of the emotions such as cross
and that it would cause me problems but its been
a realisation. Its allowed the group to wave feel-
ings that they have had to keep quiet about. They
feel what they say is important If one of themmisses a group the others are passing on the best
of what we did to let them know too.
Individual records also showed that R had spon-
taneously approached the group to apologise for
screaming. Other group members were interrupt-
ing less frequently or volunteering comments
without prompts. One of the more withdrawn
group members was getting materials out in
preparation for the group without being asked.
The group leader felt:
This work has given the group a lot of order
which we didnt have before ... they are staying
on the section and joining in more.
There were also records about how some emo-
tions seemed to cause more difficulty than others.
Sadness had posed particular problems. However,
when R was seen to be crying two days after the
session the group leader recorded:
She was so distressed she hardly
noticed when I sat next to her. I
said, Oh dear, you are sad. Whats
the matter, love? She answered
me very quietly saying, I want my
mum. After a bit she used a much
louder voice and said, Enough
now, much better now and gave
me a cuddle and got up and left.
Some feelings, such as tired,
seemed to affect the groups imme-diate physical behaviour. R
wrapped herself in a blanket and went to sleep
when tiredness was the topic. They found those
feelings which had clear physical symptoms easier
to describe; for example, tiredness was described
in terms of yawning, aching legs, and difficulty in
keeping your eyes open. Certain sessions were of
more relevance to some of the group. When this
happened they showed greater interest, made
more comments and participated to a higher
degree than usual. One of the group who is often
seen as lethargic described tiredness as:
If you are tired you can look ill. You may feel
cross for no reason, get in a muddle and find it
hard to talk.
Another woman, who was seen as energetic,
showed a complete lack of interest in this topic.
On the day tiredness was discussed she increased
her rate of interrupting and talked over the top
of others to a point where they objected.
Throughout this time R had always been pre-
sent, but never sat at the table with the group.
She had usually been seated in a corner of the
room. She came to the table when it was her turn
and participated but then returned to her space.
The group had started in a small but quiet room.
R had found this too confining so eventually the
group returned to the larger, key worker section
which was less private and noisier. After the
At the beginningI felt I waspreaching. Nowsome of the groupare beginning tothink this workapplies to them.
Figure 1 Sample pages from feelings communication boo
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evaluation
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 20016
moves, the level of discussion improved. The
leader recorded in her diary:
It was as if home ground made it easier to
discuss sensitive topics.
They send their loveDespite distancing herself from the group physi-cally, it became clear R was listening and process-
ing what was being discussed. The leader had
noted, when being loved had been the groups
topic, that love seemed to be equated by all par-
ticipants with presents, and that most of the
group had really failed to fully understand the
concept. However, two weeks later, R forgot to
bring her home-to-centre communication book.
When the group leader expressed her disappoint-
ment at this, R offered the alternative and con-
textually appropriate reply of, They send their
love. This script had been used within the group.
Later, during the groups discussion of mischief, R
approached the table when it was not her turn in
the discussion, took the group leaders plan for
the group, screwed it up and put it in the bin. She
then said, Only kidding. The group leader was
by this time making short notes at the end of
groups such as a very productive session.
A month before the group finished, the leader
was noting R was now joining in the group on
occasions when it was not her turn. Her comments
were recorded as calm, quiet and appropriate.
The group leaders reflections indicated that R no
longer seemed threatened by the situation and
that her general manner in the centre was qui-
eter, and she was less often seen to be upset. She
reflected:Its almost full circle now and we still need to do
anger. They have never discussed what it looks
like or how it feels and although Ive discussed
anger as a side effect of a lot of the situations
weve discussed, theyve always avoided it Some
clearly struggle to see the difference between
angry, jealous and sad I think they are scared of
showing it or talking about it They are expected
to be happy, angry isnt acceptable.
The record for the last group talked about the
need to build up trust and feel safe within the
group before being able to say anything about
anger or say what they could do to help each
other in angry situations. The last entry in the
reflective diary listed what had happened to the
service users over the year. The lady who hid other
peoples things touchingly discussed her feelings
of how she couldnt enjoy life as she wanted
because of her medical conditions.The lady who
hit and scratched herself was able to say she
wished to leave the centre and, once in control of
her anger, was able to attend another centre. The
lady who was withdrawn started to say what she
didnt like. The student who cried most of the
time told the group how lonely she was, how too
much was asked of her, and how much she liked
praise. The service user who interrupted all the
time now has an awareness of it, and she does it
less frequently and is seen as being prepared to
listen to other points of view. Finally R who, to
start with,
was bouncing off walls finds it easier to express
herself... she repeats less and has much better eye
contact. She shows her sense of humour.
SpontaneousR was recorded as using more spontaneous utter-
ances which were longer and had a higher level of
structure; for example, Louise, Look at me,
mince pie please, when a promise had been for-
gotten. She was also using a wider range of com-
municative functions. Prior to the group, most of
her utterances had been requests for objects or
immediate needs. Some of her utterances now
also reflected the work on scripts for communica-
tion of feelings and emotions, such as, Oh my
god, its David! on seeing someone she found
frightening.
The group leader felt
running the group had
been a great learning
experience but, best of all,
I feel I understand my stu-
dents better and the issues
that are important to them.
It was truly a communication
breakthrough for every-
one.
Her initial intention had
been to use the group
work to help her complete
individual communication
profiles for the group
members. She stated thatthis group had enabled
her to understand and
describe the quality of
their communication and
their needs in much greater depth. In the group
leaders evaluation of the therapy service and its
support she described that in the beginning shed
been sceptical and unsure of what the planned
group was likely to achieve. All she had initially
wanted was to create good communication pro-
files for each service user in the group. However,
the value of having someone to share both the
frustrations and the real breakthroughs with had
been important. The support of having someone
to prepare the necessary material, create the com-
munication books and record the work from an
outside perspective had been helpful. Her feeling
was that, without this kind of support, the group
would have stagnated and fizzled out. Part of the
pleasure of running it and completing the inter-
vention was the excitement of sharing what the ser-
vice users felt, their achievements and the books
they had created.
Reflective diaries are most often used as a medi-
um for staffs personal development. It seems, how-
ever, that they can also provide useful informa-
tion about the service users development. In the
case of this group, only measuring their perfor-
mance against the aims and objectives of the
intervention plan would have left a lot of the
qualitative changes unrecorded. How, for exam-
ple, do you define a sense of fun or an aware-
ness of hurting others feelings? The group
leaders regular record keeping in the form of a
reflective learning log for herself meant it waspossible to look back and compare her impres-
sions of how much the participants understood
and applied their new knowledge. Without the
reflective diary and contemporaneous records of
discussions, the speech and language therapist
and the group leader would have only had the
option of feeling, Havent we done well?
(which could have occurred just because the very
large project had finally finished).
This method of recording change also enabled
the inclusion of Rs peers progress in a lively and
interesting format. The log includes some heart
touching insights into the
frustrations experienced by
the participants in everyday
situations and the similarity
of the kind of everyday
annoyances which affect us
all. The group leader put it
in her final entry in the log:
/ have noticed a distinct
change in my relationship
with them, We have grown
closer and more trusting of
each other, student to stu-
dent and students to me. ...
Our sameness has modified
our behaviour. Although the
groups finished I can stillhear the work coming back
to me in the scripts we
planned together.
Sue Dobson is a specialist speech and language
therapist with the clinical liaison team at Horton
Park Health Centre, 99 Horton Park Avenue,
Bradford BD7 3EG, tel. 01274 228900, e-mail dob-
AcknowledgementThanks to Linda Thresher, Bradford Social Services,
for making this study possible.
ReferencesDobson, S. & Worrall, N. (2001) The way we were
... Bulletin of the Royal College of Speech and
Language Therapists. May 589, 7-9.
Money, D. (1997) A comparison of three
approaches to delivering a speech and language
therapy service to people with learning disabilities.
European Journal of disorders of Communication
32 (4) 446-449.
Purcell, M., McConkey, R. & Morris, I. (2000) Staff
communication with people with intellectual dis-
abilities: the impact of a work based training pro-
gramme. International Journal of Language and
Communication Disorders 35 (1) 147-158.
Do I actively seekuseful methods ofevaluating everydaypractice?
Do I make use of areflective diary for mypersonal andprofessionaldevelopment?
Do I recognise that mysupport can be as
crucial to a projectcontinuing as it is to itstarting?
Reflections
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further reading
APHASIAYasuda, K., Nakamura, T. & Beckman, B. (2000) Comprehension and storage of four seri-
ally presented radio news stories by mild aphasic subjects. Brain Lang75 (3) 399-415.
The present study investigated aphasic subjects ability to comprehend and store serially
presented discourse. Sixteen mild aphasic subjects, eight age-matched normals, and eight
younger normals listened to four serially presented radio news stories and a single radio
news story. Half of the aphasic subjects performed as well as age-matched normals in a sin-
gle-news-story comprehension task. However, they demonstrated a drastic deterioration
in performance when asked to listen to a series of four news stories. Age-matched nor-
mals, and aphasic subjects, to a lesser extent, showed an impairment in the comprehen-
sion and storage of the news story heard last in a series of four news stories. These results
were discussed in terms of the comprehension and storage resources of working memory.
FURTHERREADING
This regular feature
aims to provideinformation aboutarticles in otherjournals which maybe of interest toreaders The Editorhas selected thesesummaries from aSpeech & LanguageDatabase compiledby BiomedicalResearch IndexingEvery article inover thirty journalsis abstracted forthis databasesupplemented by amonthly scan ofMedline to pick outrelevant articlesfrom others
To subscribe to theIndex to RecentLiterature on
Speech &Language contactChristopher NorrisDowne BaldersbyThirsk NorthYorkshire YO PPtel fax
Annual rates areCDs (for Windows):
Institution Individual Printed version:Institution Individual Cheques arepayable toBiomedicalResearch Indexing
USER INVOLVEMENTDixon-Woods, M. (2001) Writing wrongs?
An analysis of published discourses
about the use of patient information
leaflets. Soc Sci Med52 (9) 1417-32.
Much has been written about how to com-
municate with patients, but there has been
little critical scrutiny of this literature. This
paper presents an analysis of publicationsabout the use of patient information
leaflets. It suggests that two discourses can
be distinguished in this literature. The first
of these is the larger of the two. It reflects
traditional biomedical concerns and it
invokes a mechanistic model of communica-
tion in which patients are characterised as pas-
sive and open to manipulation in the interests
of a biomedical agenda. The persistence of the
biomedical model in this discourse is contrast-
ed with the second discourse, which is smaller
and more recent in origin. This second dis-
course draws on a political agenda of patient
empowerment, and reflects this in its choice of
outcomes of interest, its concern with the useof leaflets as a means of democratisation, and
its orientation towards patients. It is suggested
that the two discourses, though distinct, are
not entirely discrete, and may begin to draw
closer as they begin to draw on a wider set of
resources, including sociological research and
theory, to develop a rigorous theoretically
grounded approach to patient information
leaflets. (141 References)
MUTISMGordon, N. (2001) Mutism: elective or selective, and acquired. Brain Dev23 (2) 83-7.
When a child does not speak, this may be because there is no wish to do so (elective
or selective mutism), or the result of lesions in the brain, particularly in the posterior
fossa. The characteristics of the former children are described, especially their shyness;
and it is emphasized that mild forms are quite common and a definitive diagnosis
should only be made if the condition is significantly affecting the child and family.
In the case of mutism due to organic causes, the commonest of these is trauma to
the cerebellum. Operations on the cerebellum to remove tumours can be followed
by mutism, often after an interval of a few days, and it may last for several months
or longer, to be followed by dysarthria. Other rarer causes are discussed, and also
the differential diagnosis. The so-called posterior fossa syndrome consists of mutismcombined with ataxia, cranial nerve palsies, bulbar palsies, hemiparesis, cognitive
impairment and emotional lability, but the post-operative symptoms are often dom-
inated by the lack of speech. The most accepted cause for the condition is vascular
spasm with involvement of the dentate nucleus and the dentatorubrothalamic tracts
to the brain-stem, and subsequently to the cortex. Diaschisis may be involved in
causing the loss of higher cerebral functions, and possibly, complicating hydro-
cephalus. The treatment of elective mutism is reviewed, either using a psychotherapeutic
approach or a variety of drugs, or both. These may well be ineffective, and it must
be remembered that the condition often resolves on its own. The former treatment
must concentrate on the training of social skills and activities of daily life and must
be targeted to both the child, the family, and the school. Also, all kinds of punishment
and insistence on speech must be discouraged. The drug, which seems to be most
effective, is fluoxetine. Discovering more about the causes of mutism due to organic
causes may well depend on studies using such techniques as magnetic resonance
imaging and single photon emission tomography. (42 References)
STROKESundin, K., Norberg, A. & Jansson, L. (2001)
The meaning of skilled care providers
relationships with stroke and aphasiapatients. Qual Health Res 11 (3) 308-21.
Little is known about the reciprocal influ-
ence of communication difficulties on the
care relationship. To illuminate care
providers lived experiences of relationships
with stroke and aphasia patients, narrative
interviews were conducted with providers
particularly successful at communicating
with patients. A phenomenological
hermeneutic analysis of the narratives
revealed three themes: Calling forth
responsibility through fragility, restoring
the patients dignity, and being in a state of
understanding. The analysis disclosed car-ing with regard to the patients desire,
which has its starting point in intersubjec-
tive relationship and interplay, in which
nonverbal communication is essentialthat
is, open participation while meeting the
patient as a presence. Thus, care providers
prepare for deep fellowship, or commu-
nion, by being available. They described an
equality with patients, interpreted as fra-
ternity and reciprocity, that is a necessary
element in presence as communion. The
works of Marcel, Hegel, Stern, and Ricoeur
provided the theoretical framework for the
interpretation.
STAMMERING / PARKINSONS DISEASEShahed, J. & Jankovic, J. (2001) Re-emergence of childhood stuttering in
Parkinsons disease: a hypothesis. Mov Disord16 (1) 114-8.
OBJECTIVE: To characterize speech patterns in patients with Parkinsons disease (PD) who
have a history of childhood stuttering. BACKGROUND: Childhood stuttering usually
resolves, but it re-emerges in some patients after stroke or other brain disorders. This phe-
nomenon of recurrent stuttering has not been characterized in childhood stutterers who
later develop PD. METHODS/PATIENTS: Twelve patients with a history of childhood stut-
tering that remitted and subsequently recurred were included in the study. A structuredinterview was administered to seven patients, and six were able to answer questions
about childhood stuttering. The Johnson Severity Scale (JSS) (range 0-7) and a Situation
Avoidance Scale (SAS) were used to rate stuttering severity (range 0-15) and avoidance
(range 0-15). RESULTS: The mean age at onset of childhoodstuttering was 6.2 years (range
5-10), the mean latency from the onset of childhood stuttering to adult stuttering was
46.1 years, and the stuttering recurred on average 5.9 years (range 0-21) after the onset
of PD. The stuttering characteristics in childhood and adulthood included repetitions of
sounds and syllables at the beginnings of words, blocks and interjections, physical tension,
and a worsening of symptoms with stress. The patients rated themselves as having mild-
to-moderate childhood stuttering by the JSS (mean 3.0, range 2-4) and mild-to-moderate
stuttering and avoidance by the SAS (mean stuttering score 5.3, range 3-7, mean avoid-
ance score 4.2, range 3-6). There was no apparent association between the severity of
childhood stuttering and the severity of PD, but those patients who had higher Unified
Parkinsons Disease Rating Scale scores tended to have more and worse symptoms of stut-
tering. CONCLUSION: Our patients provide evidence for the hypothesis that childhoodstuttering may re-emerge in adulthood with the onset of PD. (45 References)
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user involvement
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 20018
he need to involve clients in health
care decisions and the evaluation of
services is now widely acknowledged.
In recent years the participation of
parents in their childrens speech and
language therapy has increased. There has, how-
ever, been little attempt to investigate parents
opinions of the services they receive.
There have been some attempts to use clients
perceptions as a measure for audit (van der Gaag
et al, 1993; van der Gaag et al, 1998), but formal
measures of consumer satisfaction have rarely
been built into research designs evaluating treat-
ments for early speech and language delays.
When a randomised controlled trial to evaluate
the effectiveness of community-based speech and
language therapy for speech/language delayedpreschool children (described in Roulstone et al,
1999; Glogowska et al, 2000) was initiated, a
questionnaire was designed to investigate
parental views of the interventions. We hoped
that, by improving our understanding of why dif-
ferent people choose to accept or decline therapy,
we could gather ideas for planning services and
approaching parents in a way that would max-
imise uptake and cooperation.
The questionnaire was aimed at the parents of
159 pre-school speech/language delayed children
who participated in the randomised controlled
trial. The children were initially randomised to
receive either immediate treatment (Therapy
Now) or to watchful waiting for a period of 12
months before receiving therapy (Therapy Later).
The Therapy Now children received the same
intervention that would have been available to
them outside the trial. The parents of the Therapy
Later children were given general advice only but
could start receiving treatment for their children
at any point over the 12 month period if they
wished. All the children in the trial were re-
assessed at 6 months and 12 months post-ran-
domisation. The questionnaire was administered
at the 12 month re-assessment point, when the
childrens involvement in the trial ended.
Altogether, 147 parents participated in the survey
- a response rate of 92.5 per cent.
T
Evidencebased practice:
seeking the whole truthConvenientIn the questionnaire, parents were asked to
respond to closed questions about organisational
aspects of the service. Open questions were also
included where parents could raise their own
issues. With regard to the location of appoint-
ments, usually the local community clinic, 140 par-
ents (95 per cent) found it convenient. However,
attendance was difficult for some, especially
when parents relied on public transport.
Appointment times were acceptable, with 133
parents (90 per cent) rating them as convenient.
However, in the open sections of the question-
naire, parents mentioned difficulties in attending
when they worked full-time. The time allowed for
the appointments was considered satisfactory,
with 126 parents (86 per cent) rating the length ofappointments as about right. (Routine data
available from the speech and language therapy
services being evaluated in the trial showed that
the length of sessions ranged from thirty minutes
to one-and-a-half hours). However, some parents
(4 per cent) considered the length of the appoint-
ment too long, particularly where the childs con-
centration span was short.
Parents were asked about the number of
appointments they had received. While 96 par-
ents (65 per cent) said the number of appoint-
ments was about right, 32 parents (22 per cent)
said they had received too few. Likewise, when
questioned on the gap between appointments,
103 parents (70 per cent) said the gap was about
right but 27 parents (18 per cent) said it was too
long. The responses of Therapy Now and Therapy
Later parents were compared in these areas but
no difference was found between the groups.
Routine data collected from the speech and lan-
guage therapy services involved showed that, on
average, Therapy Now children attended 7.7
appointments (the range was 0 to 17) during their
involvement in the trial and, on average, were
seen monthly (the range was from once weekly to
once every two months). Post-randomisation,
Therapy Later children were seen for re-assess-
ment after six months and for final re-assessment
after a further six months. The number and fre-
quency of appointments were major differences
between them. However, this suggested that,
even where children received intervention, par-
ents still did not feel that the amount of speech
and language therapy provision was adequate.
In the questionnaire, 130 parents (88 per cent)
responded that the therapist had given them an
explanation of their childs difficulty which was
helpful and 128 parents (87 per cent) felt that the
therapists understanding of the childs difficulties
had been good. Also, 132 parents (90 per cent)
found the therapists advice helpful and 135 par-
ents (92 per cent) said they were able to make use
of the advice. The open question on the question-
naire, What has the speech and language thera-
pist done? prompted a wide range of positive
responses from parents of both Therapy Now andTherapy Later children, including helped the childs
talking, improved their confidence, given parents
guidance about helping, given parents reassurance
and increased parents understanding of the childs
difficulty. A few parents, again of both Therapy
Now and Therapy Later children, did not feel that
the therapist had done anything to help.
Feeling betterParents were asked whether speech and language
therapy had made them feel better about their
child, themselves and the difficulties experienced
by the child. While 100 parents reported that
speech and language therapy had made them
feel better about their childs difficulties (68 per
cent), 50 parents reported that speech and lan-
guage therapy had made them feel better about
the child (34 per cent) and 27 parents reported
that speech and language therapy had made
them feel better about themselves (18 per cent).
Parents could give negative responses to the
above statements too, although few did. Parents
were also asked about how the child and the fam-
ily had coped with the communication difficulty
over the period of their involvement in the trial.
Broadly, parents of children in both groups
answered that the child and the family had coped
well with any difficulties and that positive
changes in the childs relating to others had
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user involvement
Are you frustrated when people fail to attend
or seem ambivalent about their childs therapy?
As Margaret Glogowska and colleaguesdiscovered, better communication between
therapists and parents and more flexible services
could make a difference.
occurred.
Parents were questioned about their views on
changes in their childrens difficulties over the
course of the year. For 139 parents (95 per cent)
there had been improvement in their childs diffi-
culty, with five parents responding that the diffi-
culty had stayed the same or got worse. Of those
parents who felt that there had been positive
change in their child, 104 parents (71 per cent)
felt that speech and language therapy provision
had contributed to the change. All the parents
were also questioned about their perceptions of
the childs need for further therapy, with 103 par-
ents (70 per cent) feeling that their child contin-
ued to be in need of therapy.
The questionnaire showed that both interven-
tion strategies were acceptable to differing sets ofparents. Many of the Therapy Now parents (96
per cent) were happy with the help they had
received and attributed their childrens improve-
ment to the treatment: Made a great difference
with his speech as he can now use short sen-
tences; Improved my sons speech and put my
mind at rest. Some parents (56 per cent) of the
children who had waited for therapy had found
the monitoring condition satisfactory: I wasnt
terribly concerned so I wasnt too worried about
waiting; I didnt mind as I wanted to see how
my child developed on his own; It gave us
chance to use the advice given to help him. For
some parents, Therapy Later was the intervention
strategy they would have chosen for themselves.
This was particularly true where the family was
experiencing difficult circumstances. For example,
one mother found it increasingly difficult to bring
her child for regular therapy, as she was also car-
ing for a terminally ill relative at the time.
Another mother explained that postponing her
childs therapy would have made life easier for her
as she was heavily pregnant with a second child,
had no car and found using public transport to
attend clinic very inconvenient.
Therapy Later was not universally acceptable,
however, as these comments show: I thought he
was not talking as well as he should; We felt he
was falling behind because of his ability to com-
municate with other children; I was concerned
about him starting school. When asked what
immediate therapy could have done, 46 parents
(71 per cent) of Therapy Later children felt that it
would have helped the difficulty. When asked
how having therapy straightaway
would have made them feel, 33 par-
ents (51 per cent) reported that it
would have made them worry less
about their childs difficulty.
However, a further 20 parents (31
per cent) felt that therapy would
have made no difference to their
concerns and 3 parents (5 per cent)
felt that therapy would have caused
them to worry more about their
childs difficulty.
HelpfulWhen asked about the games and activities pro-
vided in therapy, 71 parents (87 per cent of those
who received intervention) rated them as good.
Likewise, rating the strategies given them during
the therapy sessions, 68 parents (83 per cent)
found them to be good. A number of parents
made comments in the questionnaire about these
aspects: I was provided with lots of pictures and
given advice of games to play; The games and
activities that we did with her were very helpful.
When questioned about what aspects of the ser-
vice they were particularly happy with, several
parents singled out treatment activities and being
able to carry these on outside the clinic: General
advice and worksheets given in order to work
with at home; The way I was able to encourage
him at home with our sheets we were given.
However, not all parents perceived the activities
as constructive and helpful - the most common
negative perception of parents was that they
wished something more specific could have been
worked on: I felt I was guided by the speech
therapist on what to or not to do with him. I
would have liked tasks to be more specific, ie.
work on this group of words and well see how he
has got on with them next time; No answers for
the problems. Never felt it was very positive or
reassuring. Thought it would be more construc-
tive than assessments. A number of parents
expressed dissatisfaction over the lack of informa-
tion given to them about what they could do with
their child at home: The guidance was long-
winded and applicable ideas were
few; Games/activities were very lim-
ited. I would have benefited from a
few more suggestions.
Overall, parents expressed positive
views about the organisation of the
services they received. Parents them-
selves often seemed to benefit from
the provision offered because they felt
something was being done and that
their concerns about their childs
development were being taken seri-ously. They had the opportunity to dis-
cuss the emotional aspects of having a
child with a communication difficulty and receive
support. Also, they felt they were being given the
means to help the child themselves.
The questionnaire, however, revealed areas of
difficulty for parents which might affect their sat-
isfaction with the service and even influence
whether they were prepared to attend therapy.
These included practical difficulties with getting
to clinic, the need for flexibility in arranging
appointment times, and the parents desire for
more frequent appointments. Greater awareness
of these on the part of speech and language ther-
apist and providing the opportunity for parents to
discuss these issues with the therapist might help
to increase parental adherence to therapy.
The acceptability of watchful waiting to cer-
tain parents is also of importance for speech and
language therapists. The acceptability of defer-
ring treatment to some parents will come as little
surprise to therapists. They may well have encoun-
tered families who do not cooperate with therapy
offered because they do not appreciate the sever-
ity of their childs difficulties, or because they find
it difficult to organise their lives. On the other
hand, therapists may feel disappointed and
threatened by parents who, aware of the degree
of their childs problems, are not persuaded that
They had the
opportunity to
discuss the
emotional aspects
of having a child
with a
communication
difficulty
if you want to take account of users
views encourage uptake of
your service
target limited resources
Read this
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user involvement
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 200110
therapy should be undertaken and prefer a
watchful waiting option.
Need for discussionThe questionnaire demonstrated that, even
where parents felt immediate therapy might help,
it was not always the intervention strategy of
their choice and would not have necessarily alle-
viated their concerns. However,
the choice to delay therapy
became more explicable in the
light of the explanations dis-
closed by parents on the ques-
tionnaire. This highlights the
need for discussion with parents
about what other events may be
currently happening or about to
happen in their lives which may
interfere with regular atten-
dance at the clinic and make
speech and language therapy
seem less of a priority in their eyes. Taking into
account family circumstances should help the par-
ent and therapists to determine the best course of
action, weighing up the needs of the child and therest of the family in a realistic and manageable
way. Even where a parent attends clinic regularly
and willingly, it should not be taken for granted
that the family is not under severe stress.
The comments of some of the parents revealed
a large perceptual gap between them and the
therapists they saw in the area of treatment activ-
ities. One parent perceived that the play activities
undertaken by the therapist with her child were
merely ongoing assessment and therefore did not
constitute treatment for her childs difficulties.
Clearly, what the therapist aimed to achieve was
not transparent to the parent. This highlights the
need for therapists to make explicit to parents the
therapy they give. Others complained of the lack
of specific, applicable ideas. They sometimes felt
that the ideas passed on to them by therapists
were common sense or what they were already
doing with their children, to no noticeable effect.
For this reason, a check from the therapist to find
out what parents were already doing to try to
help their child, what ideas they had gleaned
from books, magazines or other media, or what
advice they had already received from friends,
family and professionals might have avoided this.
The trend towards evidence-based practice calls
for evidence of the acceptability as well as the
effectiveness of health care services. The study
reported here investigated parents response to
speech and language therapy provision for their
children alongside a trial of the clinical effective-
ness of the intervention. While the randomised
controlled trial provided information about the
progress of the children in Therapy Now and
Therapy Later, the questionnaire was designed to
show the limitations and advantages of the two
intervention strategies and to investigate other
aspects of the service from the viewpoint
of the parents whose children participat-
ed.
As a means of evaluating the accept-
ability of speech and language therapy
services, the questionnaire should be
regarded in speech and language thera-
py as a valuable tool. As this report
demonstrates, use of this method has
the potential to explain why some ser-
vices are accepted while others are
declined, and by whom. In these days of
limited resources, it is hard to overesti-
mate the importance of maximising the uptake of
services provided and cooperation with therapy.
Margaret Glogowska and Sue Roulstone arespeech and language therapists at the Speech and
Language Therapy Research Unit, Frenchay
Hospital in Bristol. Rona Campbell and Tim J. Peters
are based in the Department of Social Medicine at
the University of Bristol. Pam Enderby is at the
School of Health and Related Research in Sheffield.
ReferencesGlogowska, M., Roulstone, S., Enderby, P., &
Peters, T.J. (2000) Randomised controlled trial of
community-based speech and language therapy
for pre-school children. BMJ321: 923-926.
Roulstone, S., Glogowska, M., Enderby, P. & Peters,
T. (1999) Issues to consider in the evaluation of
speech and language therapy for pre-school chil-
dren. Child: Care, Health and Development 25(1),
141-155.
van der Gaag, A., Glass, K. & Reid, D. (1993) Audit:
A manual for speech and language therapists.
London: College of Speech and Language
Therapists.
van der Gaag, A., McCartan, P., McDade, A. &
Reid, D. (1998) An audit tool for health visitors
and speech and language therapists working with
the pre-school population. Proceedings of the
Royal College of Speech and Language Therapists
Conference, International Journal of Language
and Communication Disorders, 33: 37-41.
1. Find out family circumstances and priorities.
2. Check what carers are already doing to help.
3. Discuss pros and cons of starting or delaying intervention.
4. Offer advice that is as specific as possible.5. Make sure people understand what you are doing and why at every stage.
Five steps to better practice
Taking into
account familycircumstancesshould help theparent andtherapists todetermine thebest course ofaction
Career initiativesA pioneering cadet scheme is opening up a career
in speech and language therapy to more people
from black and minority ethnic backgrounds.
The Birmingham programme offers a new way
into the profession for people who may not
have followed a traditional route through edu-cation, but understand the language and cul-
ture of the diverse communities living there.
The cadets, supported and mentored by quali-
fied speech and language therapists, start by
obtaining a Btec in speech and language thera-
py, an NVQ in therapy skill and higher level
study skills, before going on to the three year
speech and language therapy graduate course
at the University of Central England.
The cadet scheme is funded by the West Midlands
South Workforce Development Confederation
which is also targeting career break health profes-
sionals, including speech and language therapists,
with return to practice initiatives.
Following on from successes in Shropshire and
Staffordshire, the Confederation is now offering
a multidisciplinary six week, part-time test the
water course at Keele University, aimed at peo-
ple who used to work in the NHS. Course fees
and financial assistance are available, and flexi-
ble returns to work are emphasised.
Details of the Keele University course from June
Spencer or Tracey Allen, tel. 0121 415 2185.
Multimedia project- request from
CommunicationsForumAre you working with communication-impairedchildren within mainstream classrooms?The Communications Forum has gained fund-ing to develop multimedia training resourcesfor schools. These resources will be aimed
primarily at teachers working at key stage 2within mainstream schools.If you work in this area or provide training andwould like to comment on any of the follow-ing points please contact me on 0191 413 1818or e-mail me at [email protected] training medium would your school/
department find most useful eg. video;
CD ROM?2.What information would be of most
interest to teachers and therapists?3.Are you involved in collaborative working
with teachers / speech and languagetherapists in your area?Let me know where and how.
4.Are you involved with training in schools?I would like to hear from you.
5.Would you like to know more about theproject? Let me know.
Looking forward to hearing your views andcomments,
Karen DixonProject Manager
news extra...news extra...
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research
(Braun & Palmer, 1985) to the development of
devices such as pressure transducers and manome-
ters used to measure intra-oral pressures generated
during sucking, fiberoptic cameras placed withininfant bottles allowing direct visualisation of
intra-oral movements during sucking, ultrasonog-
raphy, videofluoroscopy, cervical auscultation,
and oximetry (Braun & Palmer, 1985; Wolff, 1968;
Eishima, 1991; Bosma et al 1990; Newman et al,
1991; Vice et al,1990; Rogers et al, 1993).
Unfortunately, many of these techniques are not
readily transferable to the speech and language
therapy clinical environment. They often rely on
specialist staff with technical expertise and bulky
equipment from other departments. This may
require that the assessment be carried out within
the schedule for these departments. Timing (in
terms of feeding routine), requirements of the
assessment (such as positioning of the infant and
the food / substance being given) and environment
(for example, large noisy equipment) may be less
than ideal in providing a valid assessment of the
infants usual feeding pattern. In some situations,
an infant may require several of these assessment
procedures to provide a complete picture. Few of
these procedures can be carried out simultaneous-
ly and, as a result, the whole series of investigations
may be time consuming, intrusive and expensive.
Well toleratedThere is clearly a need for a non invasive, easily
transportable system which will be both well tol-
erated by infants and allow objective and simul-
taneous assessment of several aspects of infant
feeding without relying on the support and facil-
ities of other departments during the assessment.
The Great Ormond Street HospitalMeasurement of Infant Feeding (GOSMIF) has
been developed to address this need. The system
allows the therapist to video-record the infant
bottle feeding, enabling the therapist to subse-
quently evaluate behavioural aspects of the feed
using scales such as the NOMAS (Meyer Palmer et
al, 1993). At the same time, the therapist is able to
identify swallows using auscultation, to measure
intra-oral pressures generated during sucking,
and to record patterns of respiration.
At this stage in its development the system only
allows assessment of bottle fed infants. Whilst
breastfeeding is the recommended means of
feeding infants, a significant number of infants
who experience feeding difficulties are bottle fed.
Where the mother has been keen to breastfeed,
but this has not been possible, she is encouraged
to give her baby expressed breastmilk via a cup or
bottle.
RoutineThe GOSMIF assessment can be carried out in the
infants home, on the ward or in the clinic as part
of their clinical assessment, ideally at the time of
a routine feed for the child. The infant is fed by
the mother or carer as per routine. For clinical
purposes, the child can be fed their usual milk.
However, for the purposes of research, we use 5
per cent glucose solution, allowing us to control
Intothe
mouthsof babes
Infant feeding is an emotive area at
the best of times so it vital that,
when difficulties arise, they are not
compounded or skewed by the
assessment process itself. With this
in mind, a research project has
developed a new assessment tool for
infants having difficulty feeding
.Anthea Masareiand colleagues detail
the progress of the Great Ormond
Street Measurement of Infant Feeding
(GOSMIF): An Objective Assessment
of Infant Feeding.
n recent years there has been an increasing
use of technology in the assessment and man-
agement of speech disorders - electrolaryn-
goscopy, fibreoptic nasendoscopy and elec-tropalatography, for example, are all well-
established systems. However there have been few
recent advances in the application of technology
to the clinical assessment of infant feeding.
Feeding is a complex process which may be
adversely affected by many intrinsic, environmental
and health factors. Even in healthy, term infants
the physiological feeding process can be influ-
enced by a number of factors including:
maternal and child factors - bonding, skin-to-
skin contact after birth, and the level of sedation
or pharmacological pain relief the mother
required during labour and birth;
child factors - the infants behavioural state and
level of arousal;
feed factors - the type of breastmilk or formula
milk, its taste, consistency and fat content; and
equipment factors - the flow rate achieved with
breastfeeding or different types of nipples/teat
(Kron et al, 1966; Wolff, 1968; Crook & Lipsitt,
1976; Nysenbaum & Smart, 1982; Wolf & Glass,
1992). These factors are compounded and added
to when a baby is born with a physical difference
which interferes with its ability to feed efficiently.
The complex nature of feeding has resulted in
the development of many different assessment
approaches in an effort to understand and
analyse the process. These vary from the use of
structured observation scales such as the NOMAS
I
if you want to take technology to your
clients minimise harmful
effects of assessment
include objective measuresin your evaluations
Read this
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14/32
research
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 200112
review screen (Figure 3(a)), it can be seen that ini-
tially during the feed the infant uses a continuous
sucking pattern (as one might expect with non-
nutritive sucking). He then settles into a pattern
of organised sucking bursts and pauses before
returning to a continuous sucking pattern, per-
haps related to fatigue. Also evident from the
summary screen is the high proportion of positive
pressure generation in contrast to the predomi-
nant negative pressure generation evident in the
healthy infant. The lower half of the screen
demonstrates a suck swallow ratio of 4;1 and 2;1.
The data analysis screen allows further analysis of the
strength of pressures generated. Figure 3(b) indicates
the point of greatest negative pressure generation
during the study, measuring at -9.96 mm H2O.
Figures 4(a) and 4(b) represent data collected from
the assessment of a three week old infant with Pierre
Robin Sequence with cleft of the soft palate, 2/3 of the
hard palate and micrognathia. This infants airway
difficulties are being managed with a nasopharyn-
geal airway at this point. The data review screen
(Figure 4(a)) shows an initial continuous sucking
burst, then a period of sucking bursts and pauses of
varying length. Over the feed the sucking burstsappear to become shorter and weaker, and towards
the end of the feed return to continuous sucking
(non-nutritive pattern). From the data analysis screen
(Figure 4(b)) it can be seen that the point of maxi-
mum negative pressure generation is -7.5mm H2O.
ObjectiveThe GOSMIF is an easily transportable, non-inva-
sive system which allows objective, simultaneous
assessment of three aspects of infant feeding in a
natural and routine environment. We do not sug-
gest that the GOSMIF should replace the clinical
observation assessment but rather that it is used
as an adjunct to the feeding evaluation, as it pro-
vides objective data about several aspects of
infant bottle feeding. Preliminary experience sug-
gests that it is well tolerated by infants and their
mothers / carers. It provides objective data about
suck: swallow: breathe ratios and coordination.
Measurements of aspects of sucking such as pres-
sures generated can be calculated. Simultaneous
video-recording of the feeding process permits
the use of behavioural rating scales and reduces
the possibility of inappropriate conclusions being
drawn where there are artefacts in the data.
Anthea Masarei is Research Fellow in the Speech
and Language Therapy Department, John Veness a
Clinical Scientist, Biomedical Engineering
Department, and Dr Debbie Sell is Head of Speech
and Language Therapy, at Great Ormond Street
Hospital, London. Dr Angie Wade is Senior Lecturer
in Medical Statistics in the Department of Paediatric
Epidemiology and Biostatistics at the Institute of
Child Health, London. Sheena Reilly is Professor of
Paediatric Speech Pathology at Latrobe University,Bundoora, Melbourne, Australia.
AcknowledgementThe GOSMIF was developed as part of a study
funded by ACTION Research and the Colin
Bramley Parker Memorial Fund. We would like to
thank them for their support. At this stage the
GOSMIF is being used for research purposes only,
but we are investigating the possibility of making
the GOSMIF available for sale.
ReferencesBosma, J.F., Hepburn, L.G., Josell, S.D. & Baker, K.(1990) Ultrasound demonstration of tongue
motions during suckle feeding. DevelopmentalMedicine & Child Neurology32:223-9.Braun, M. A. & Meyer Palmer, M. (1985) A pilotstudy of oral motor dysfunction in at-riskinfants. Physical and Occupational Therapy inPediatrics 5; 13-25.Crook, C.K., Lipsitt, L.P. (1976) Neonatal nutritivesucking: Effect of taste stimulation upon suckingrhythm and heart rate. Child Dev47:518-22.Eishima, K. (1991) The analysis of sucking behaviour innewborn infants. Early Human Development27:163-73.Kron, R.E., Stein, M. & Goddard, K.E. (1966)Newborn sucking behavior affected by obstetricsedation. Pediatrics 37;1012-6.Newman, L.A., Cleveland, R.H., Blickman, J.G.,Hillman, R.E. & Jaramillo, D. (1991) Videofluoroscopic
analysis of the infant swallow. InvestigativeRadiology26:870-3.Meyer Palmer, M., Crawley, K. & Blanco, I. A. (1993)Neonatal oral-motor assessment scale: A reliabilitystudy.Journal of Perinatology13:28-35.Nysenbaum, A.N. & Smart, J.L. (1982) Sucking behav-ior and milk intake of neonates in relation to milkfat content. Early Human Development6;205-13.Rogers, B., Arvedson, J. C., Msall, M. & Demerath, R. R.(1993) Hypoxemia during oral feeding of children withsevere cerebral palsy. Dev Med Child Neurol35; 3-10.Vice, F.L., Heinz, J.M., Giuriati, G., Hood, M. &Bosma, J.F. (1990) Cervical auscultation of sucklefeeding in newborn infants. DevelopmentalMedicine & Child Neurology32:760-8.
Wolff, P.H. (1968) The serial organization of suck-ing in the young infant.