speech & language therapy in practice, autumn 1999

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READER 0Win over 400Winslow resourc

the lderl A lucky Speech & Language The rap inPractice subscriber is in line for a bumpercollection of therapy materials. Thesecome courtesy of Winslow, the providerof practical and accessible resources forlanguage, education, health, rehabilitation, ercJerly care, therapy and all aspectsof social care .

Just look at what you willreceive:FCTP (Functional CommunicationTherapy Planner), VASES (VisualAnalogue Self-Esteem Scale),Counselling Carers, The Carer'sCompanion, BASOLL (Behavi oura lAssessment Scale of Later Life),Working With Dement ia, PersonCentred Dementia Care, Validation -The Feil Method, Wandering,Aggressi on, Screaming & Shouting,Incontinence, Problem Behavi ou r,Reality Orientation, Reminiscence:Social Care, Treasured Memories,Memory Games for Groups,Groupwo rk for Elderly People .

There are also ten runner-up prizes of a5 Winslow voucher, to be used againstany product in their catalogue.

To enter, all you have to do is name yourfavourite item from the Winslow 1999catalogue, with a brief sentence explaining why you like it. The winner will bedrawn randomly from all valid entries.Mark your entry 'Speech & LanguageTherapy in Practice / Winslow draw'and send it to Jane Lindsay,Winslow, Telford Road, Bicester,

Oxon OX6 OTS, e-m ail janel@winslow-press .co.ukby 30th September, 1999.

Competition rules:1. En trants must subscribe pe rsonally or as one of a department toSpeech &Language Therapy in Practice. and only one entry is allowed persubscriber number.2. Entrants must work at least some of the time with elderly peo ple.3. Entries must be received by Winslow on or before 30th September, 1999.4. The winner will be randomly selected from all valid entries.5. The winner will be notified by 6th October, 19996. The winner will provide a review of one of the reso urces received toSpeech &Language Therapy in Practice by a date agreed with the editor.

For a FREE copy of the Winslow catalogue,tel. 01869 244644 or see http://www.winslow-press.co.uk

99 READER winner of the Earo bics Pro PLUS Sep 1 and Step 2 software is

s, Selkirk, wh o will review it in a la ter issue. The two CDstraining program were provided by Don Johnston

Needs and Super Duper Publications . The seven real wordsetters of the words ear could have included: ear, a, er, re,rare, rarer, rear, rearer, area, err, era, ere and arrear.nica Larki n is going to be busy read ing the 100 of books from

r Publishing.the five winners of their new publication,

: a social skills approach for children and ado lescents byre en Aarons and Tessa Gittens . They are M. Swindells,ingham, M iss C. Ward, Exeter, Anna Bovoli , Greece, Mrs Sevens,ash ire an d Julie Hunt, Eal ing.

Commu nications had so ma ny entries th ey decided to offerof t heir photocopiab le resource Rhyme Time instead of one.

are Katharine Howard in Exteter and Chris Brebner in

tula tions to all winners and good luck to everyone entering t hemn 99 reader offer.

lEW FROM WINTER 98

- Interactive Speech and Language Therapy CD-ROMClose

EH10 7EE

uire lots of repetitive prac tice? Limited t ime to produce varherapy tasks? Fed up with dog-ea red worksheets? Want rea lly easy

software that 's gentle on yo u and patients but also interesting,en ging and fun? Yes? Then REACT is for you with the ad ded benof sound and video used in innovative ways .t f rom 146 exercises wi thin auditory process ing; visual matching;

comprehension; semantics; sentence processing; spe lli ng; time. The bu lk of the ma ter ial Is for severe to moderate aphasia

of re levance to other types of communicat ion disorder) and willinterest psychology an d occu pational therapy in th e areas oftion, speed , problem solving an d memory. Choose an inputod to su it the patient 's ab ility and preference (for example touchn, mouse or tracker ball). Independently or w ith minimal guid, your patient can com plete exercises, rec eiving clear feedback an dan ce after th ree failures . When f inished, patients can check the ir

satisfying!) Details of score and speed are ma in tained autolly fo r therapy records.down side the occasional graphic is difficult to interp re t or you

t quibble with t he grading of a task (fairly ins ignificant wi th 1700You can no t al ter t he configuration of an exercise (but I did

t a simple to use pack age). Expensive, yes, as is oth er aphasia soft. l ower cos t ve rsi ons wi th fewer opt ions are available.

nst quality, quant ity and frequency of use, t his ish pushing the boat out for.ag Hunter is speech and language therapis t at the Centre for Brain

Reha bilitation for Tayside Primary Care Trust.


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1999

31st August)1368-2105shed by:

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01561 [email protected]

ReidReid DesignFarm

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of Speech & Languagein Practice reflect the viewsindividual authors and notof the publish

of advertisements isan endorsement of the adverr service offered.may also appearsite.

picture: Intensivesee page.

Contents 2 News / Comment4 Outcomemeasures" It is vital that this process is not carried outin an atmosphere of ustification for clinicaldecisions, but in the spirit of comparingpractice, exploring different approaches andlearning from variance factors. "Jenny Huntand AlysonSlater ontheir team'sprogress inusing outcomemeasures.

Autumn 1999 *116 COVER STORY Intensive group therapy"We see two major benefits of group therapy: Structured therapy for language and social skills isdelivered in the context of familiar social activities - teamgames, play, construction activities. This increases each child'sability and opportunity to generalise the skills learnt. Course design can enable children to recognise theirprogress and to gain confidence and motivation fromsucceeding at activities with other children. This oftencontrasts with their experience at school. "Liz Spooner and Sally Hewison report on their successfulgroup for children with autism.

20 In My Experience"My personal and professional experience is that7 Assessments assessed strongly held views of specialists who spend theirPublished assessments and programmes are given lives pursuing rather narrow fields of impairmenta rigorous evaluation by practising therapists. Find focused study and practice place serious constraintsout what they really think of The Apraxia Profile, on listening to stories about the breadth of a lifethe Tinnitus Questionnaire, Hear-Say and the lived with that same impairment. "Cooper Assessment for Stuttering Syndromes Do we really listen to our clients) Carole PoundChildren 's version. finds we have much to learn.22 Further Reading10 Working Floating-harbor syndrome, stammering, virtualtraining, conversation, voice, learning disability.ith carers

"The idea of introducing arange of approaches is 23 How I manage oraLcancerased on my experience

" ... it is crucial for speCialists and non-specialistsfeel obliged to correct theirthat many carers naturally

alike to have an appreciation of what is requiredrelative irrespective of at the pre-operative, post-operative and - in somewhether it is in their relative's cases - terminal stages, and to work together tobest interests. " provide the best possible service. "

Standards, team working and palliative care .extent do carers ofindividuals with dementia benefit from 30 My Top Resourcescommunication advice and training? "I was given an aged laptop PC ...1realise how much I

have come to rely on it and am eagerly awaiting its all14 Reviews singing and dancing replacement. "

Colin Barnes asks, to what

ALD, stammering, dysphagia, voice, brain injury, Susan Hamrouge works with children and adultsneurology, Parkinson's, phonology, counselling. with a hearing impairment.

WINTER 99 will be published on 29th November, 1999IN FUTURE ISSUES ethics' stammering adolescents' more assessments' bilingualism. learning disability. aphasia voice

Speech &. Language Therapy in Pradice has moved.All co rrespondence should now be sent to : Avril Nicoll , 5peech & Language Therapy in Practice, 33 Kinnear Square, laurencekirk AB30 1Ul tellfax 01561 377415. For subscribers in the UK, the FREEPOST address is nowAvril NicolL 5peed1 & Language Therapy in Practice, FREEP05T 5C02255, LAURENCEKIRK, Aberdeenshire, AB30 1ZL. The magazine's complementary internet site. speechmag, has also moved to http://www.speechmag .come-mail [email protected] (Mail is being re -directed from the old addre55 and callers to the old telephone number wi ll hear a recorded mess.age WI th the new number.) ApologIes for any inconvenience caused by these changes_

SPEECH & LANGUAGE THERAPY IN PRACTICE AU TUMN 1999
http:///reader/full/www.speechmag.commailto:[email protected]:///reader/full/http://www.speechmag.comhttp:///reader/full/http://www.speechmag.comhttp:///reader/full/http://www.speechmag.comhttp:///reader/full/http://www.speechmag.comhttp:///reader/full/http://www.speechmag.comhttp:///reader/full/http://www.speechmag.commailto:[email protected]:///reader/full/www.speechmag.commailto:[email protected]:///reader/full/http://www.speechmag.commailto:[email protected]


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I

news

Dental healthSpeech and language therapists, dental staff and the MakatonVocabulary Development Project have produced a book to help peoplewith learning disabilities visit the dentist.Homefirst Community Trust staff in Northern Ireland were alerted to theneed for such a resource by learning disabled people and carers. Dentalhealth among children and adults with a learning disability is worse thanthat found in the general population and, if they cannot cope with dentalcare, they have to receive treatment under general anaesthetic or sedation.The book uses a combination of simple sentences, colour photographs,symbols and signs to help carers explain what happens during a visit to thedentist, including simple procedures such as fillings and extractions. Theauthors hope the book will help improve attendance, confidence, understanding and dental health among people with learning disabilities.

u

]: .... y"O 1\ @ ~You nct'd your I("elh d ' - ' 4 l n ~ d .

HealthdiscriminationThe Down's Syndrome Associationhas launched a campaign to enddiscrimination demonstrated bysome health professionals againstpeople with Down's syndrome.This follows a survey whichestablished that 28 per cent ofrespondents had experienceddiscrimination - overt orunconscious - by healthprofessionals. Examples included

'Go i ng to th e Den t i s t ' is 20 p lus 2 .50 p&p , t e l . 01266635213 . glasses and hearing aids notbeing prescribed and, in one case,pain relief not beingBAS administered after an operation

The national interest group formed in I brain injured people has opened in because "They don't feel pain, do~ ~ d ! ~ ~ f ~ ~ i ~ i ~ o r young1987 to increase the understanding Cheltenham. they?"of aphasia has produced a publicity The Centre for Acquired Brain Injury Rehabilitation is the only facility in the While the main thrust of theleaflet to encourage new members. UK to offer residential care and further education to newly brain injured 'Health Alert' campaign is toMembership of the British people exclusively in the 16-25 year age group. In addition to speech and lan improve screening for heartAphasiology Society is open to all guage and other therapies, students will have access to an on-site sports cen defects in babies with Down'sprofessionals interested in the study tre, swimming pool, theatre and information technology. syndrome, there are plans fo r aof aphasia. Benefits include confer In the UK, 135,000 people suffer from the long-term effects of severe brain nationwide training programmeences, study days, reduced journal damage caused by head injury. The 15-29 age group are at highest risk of sus fo r all health professionals andsubscriptions and a research data taining a brain injury, along with the over 75s. Males in the younger group guidelines for staff breaking thebase. are four to five times more at risk than females. Each year, 10000 people will news to new parents.Copies from Jo Robson, suffer moderate brain damage and will still have physical or psychological Down's Syndrome Association,tel. 0171 477 8000 ext 4668, problems after five years. A further 11 600 will receive severe brain injuries of tel. 0181 [email protected] which only about 15 per cent will return to work within five years.

Stroke latestThe Stroke Association has condemned variationin access to and use of stroke services as unacceptable and requiring urgent action.Its national survey of stroke services Stroke Care- A Matter of Chance sought information fromconsultants and commissioners and confirmedpiece-meal services and a lack of integration.Although interdisciplinary teams includingspeech and language therapists seem to beavailable, consultants expressed concern at theamount of time they have for patients.The report concludes that up to 50 per cent ofstroke patients are not getting the best treatment available, that is, via admission to a strokeunit. Better collection of statistics and strongermedical leadership are also required.Following publication of the report, a profileraising postcard has been produced by theStroke Association. The five silhouettes represent the five people who die every day becausethey do not have access to organised stroke care.For copies of the postcard, tel. 0845 3033100.

Scholarships awardedTwo speech and languagetherapists have beenassisted with furtherstudy by awards from theHSA HealthcareCharitable Trust.The photo includes awardpresenters LawrenceDallaglio and TessaSanderson and recipientsTessa Ackerman fromLeeds and YvetteCrompton from London.The scholarship is to assistthem with study for further degrees.

Evidence-based rehabilitationA m u l t i ~ d i s c i p l i n a r y team including a speech and language therapist is aiming to encourage evidencebased stroke rehabilitation in a three year project.The Stroke Therapy Evaluation Programme (STEP), funded by Chest Heart and Stroke Scotland, plans toproduce systematic reviews of rehabilitation treatments, disseminate research results and identify priority areas fo r future research.Readers who wish further information on STEp, who would like to become involved in a systematicreview within the area of stroke rehabilitation, or who would like to receive a quarterly newslettershould contact STEP, Academic Section of Geriatric Medicine, 3rd Floor Centre Block, Glasgow RoyalInfirmary, Glasgow G4 OSF.

SPEECH & LANGU AGE THERAPY IN PRACTICE AUTUMN 1999
mailto:[email protected]:[email protected]:[email protected]


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at ADAfor Dysphasic Adults has appointed its first Chief

to develop the organisation and raise publicof the needs of people with dysphasia.

CancerShe is also a non-executive director of a

h authority. Horrified to learn that 200 000 peothe UK have dysphasia, her priority is to use her

to develop awareness andfurther up the healthcare agenda.

Coles is stepping aside as Director, as manageissues have taken up an ever-increasing amount

to work for ADA totel. 0171 261 9572

for childrenNominations for the Millenium

of AchievemenFMhild

their

awards are invited for individuals or groups of children.Children who help others by

everyday tasks, copewell with illness or disability,excel with fund-raising initiatives or show outstandingdevotion to friends and families in times of need are alleligible. The nominees mustbe under 16 years old at theclosing date of 12November 1999.The photo shows Johnwho was born with cerebral palsy. He received aLiberator AphaTalker following a Child ofAchievement Grant.Details:

www.childofachievement.co.uk. orforms from C&A stores.nium status

with reading andhas received an award for inno

Design Council's Millenium Product status hasgiven to textHELP! a Windows based tooloffers speech feedback, an advanced spelling

Systems Ltd, tel. 01849428105.

for children with epilepsy and' needs has been highly graded in an

by the Further Education Funding Council.St Piers Centre in Surrey received high praise for

in practical, vocational areas with studentsvery severe or profound learning difficulties

the aim is to help them make sense of theof

to further improvements, forresidential and daytime services.

tel. 01342 832243.

news & comment

...comment. .. Avril Nicoll,

Editor

33 Kinnear SquareLaurencekirk

AB30 1 UL

tel/ansa/fax 01561377415

e-mailavriln [email protected] om

Morelhaste, dess speeAs speech and language therapists in a technological age, we are faced dailywith high expectations of instant solut ions from clients, carers, colleaguesand, indeed, ourselves. Time and again in this issue it is clear we must holdout against this force. Fiona Robinson's sentence in How I manage oral cancerabout "the processes by which patients travel through this stage in theirlives" applies to any of our clients and emphasises the idea of a journeyrather than a quick fix. Jane Machin's experience suggests this will besmoother if supported by professionals all working together. To reinforce this,we are delighted to have Dr Susan Salt giving us the benefit of herexperience of palliative care work.Sue Hamrouge's top resources include an assessment which takes time andideally involves further training but provides very detailed and importantinformation to make therapy more effective. Our new series on assessingassessments and programmes aims to assist readers in deciding whichresources are worth investing time and money in.A gradual, long-term approach has ensured Jenny Hunt and Alyson Slater'steam are finding outcome measures invaluable in their drive to improveclinical effectiveness, rather than having wasted their time with a rushed,half-baked plan which looks good in a glossy annual report but ends upgathering dust on the shelf and making no difference to everyday practice.Ensuring staff have 'ownership' of a process such as outcome measures is noteasy for managers because it presents real problems and anomalies that haveto be addressed. Carole Pound's powerful arguments in favour of improvinglistening skills apply to our clinical work with clients and carers, tomultidisciplinary teams and to managers. The 'golden evidence' she believeswe will find by listening to unique narratives will be worth the wait becauseour work will be more relevant and effective.Making advice for carers relevant and effective has been exercising ColinBarnes as he develops his ideas for best practice in working with people withdementia. The idea that we may actually be increasing carers' 'burden' is anexacting one - it is tempting, as a speech and language therapist aware of allthe changes that" would improve communication, to throw all this knowledgeat parents I carers at once. But, perhaps particularly where carers are lookingfor more and more from us, we often need to draw back and encourage alonger-term view.Careful planning of an intensive group for autism, including working closelywith parents, paid dividends for Liz Spooner and Sally Hewison. Although thegroup itself only lasted a week, observable progress was made by the chi ldrenand the parents were won over by the advantages of group work comparedwith their previous view that individual therapy is always best.Outcome measures, standards, best practice, clinical effectiveness - all ordswhich can turn of f the most dedicated speech and language therapist ' hendelivered in a stuffy, non-specific, irrelevant, sound bite fash ion. But all ordsthat come to life when applied over time with real people.

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 1999 3
http:///reader/full/www.childofachievement.co.ukhttp:///reader/full/www.childofachievement.co.ukhttp:///reader/full/www.childofachievement.co.ukmailto:[email protected]:[email protected]:[email protected]:[email protected]:///reader/full/www.childofachievement.co.ukmailto:[email protected]


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outcomes

rom start to outcome e on

Jenny Hunt and Alyson Slater's team have been working with and refining outcomemeasures since 1995. They tell us why they are positively excited by the potentialbenefits they offer._11111_ he need for outcome measures with

in the speech and language therapyprofession has been recognised fo rmany years now, with the workdone by Professor Pam Enderby inparticular of paramount impor

tance. For the first time, there was a way of measuring our work which went beyond basic numbercrunching and moved away from the restrictivemedical model of diagnosis -> treatment -> cure. We all knew ourinvolvement could have real effects;now we could measure them.The introduction of outcome measures to our speech and languagetherapy team was a gradual process,and fo r twelve months the measureswere carried out in retrospect on current cases . This enabled therapists todevelop confidence in implementingoutcome measures and standardisation across the District. In addition, inservice training was carried out onsetting aims of intervention to ensure

We all knewourinvolvementcould havereal effects;now wecouldmeasurethem.

S.M .A.R.T. objectives (that is, ones that areSpedfic, Measurable, Achievable, Realistic andTimely).Our outcome measures were initiated 'live' on 1 tSeptember, 1996. For each client, therapists couldhave numerous short-term aims running concurrently, sequentially or overlapping.

Safe environmentsIt was essential that therapists 'owned' the outcome measures, so regular peer reviews were setup to evaluate their use and to maintain District-

wide agreement on scoring. Since therapistsunhappy or unsure about the outcome measureswould not produce reliable measures, it wasimperative that peer reviews were 'safe' environments. Any difficulties, queries or concerns couldbe shared w ith the team and treated seriously bycolleagues. Solutions could then be agreed andimplemented by the whole team . Difficulties thusaddressed include:

a) Problems in scoring short-term aims, particularly for client groups where therapeuticinvolvement could be long term, for exam-ple language group work. In response tothis, the short term aims scoring wasreplaced by achieved / not achieved.b) Learning and / or physical disabilitiesand autism were also considered problematic where the focus of input was onthe carers and the environment of theclient, such as through ENABLE.Therapists felt better able to set objectives and measure success of interventionwhen health benefits were identified (forexample Informing, Supporting,

Modifying, Maintenance) and included in thepatient information on case notes.c) For people with Motor Neurone Disease, therapists felt it was virtually impossible to set targetdates fo r short-term aims. Th is s one difficulty weare still trying to resolve.d) Transse xuals are another client group presenting problems fo r ratings . As the communicationof a transsexual is not in itself disordered, theimpairment rating was not appropriate. Theteam decision was therefore that we should nothave an impairment rating, but should rate the

appropriacy of voice on the disability and handicap dysphonia scales.e) A recurring problem has been the pressure therapists put on themselves to be perfect, and a lo t oftime has been spent stressing that it is alright notto achieve an aim or predicted outcome.f) It became apparent that a range of diagnosticterms was used within the team, often influencedby the year of qualification of the therapist. Theservice therefore used peer review to agree ondiagnostic terminology (figures 1 and 2). This dispensed with such permutations as "mild phonological delay" and "immature speech".External influencesAlong with the evolution of the outcome mea sures within the team, other external influencesbegan to make themselves felt. We becameincreasingly aware of the need fo r evidencebased practice and clinical effectiveness, which isculminating in the setting up of the NationalInstitute for Clinical Excellence (NICE). At thesame time, the nursing process of care pathwayswas being introduced to community health care .The Macmillan nurse in the Trust responsible forthis initiative agreed to do in-service training oncare pathways to the team.It was apparent that care pathways were moreappropriate for multi-disciplinary teams andneeded to be developed by all involved, not ledby one discipline. Although we felt care pathways were not a priority for us, the whole teamwelcomed the idea of variance factors (figure 3)as a useful tool to add to outcome measureswhere aims were not achieved. Variance factorshelped to ease the perceived problem of 'perfect

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 1999


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outcomes

1. Diagnoses for Adults with Acquired Disorderfluency Dysarthria I Anarthria

Disorder Dysphasia I Aphasiaerkinetic Dysphonia Dyspraxia I Apraxia

Cognitive Communication DisorderI Functional Dysphonia Dysphagia

ntial Diagnosis Unconfirmed N.A.D. (Nothing Abnormal Detected)Figure 2. Diagnoses for Under-16's and Adults with Congenital DisabilitiesLanguage - expression (delay I disorder) - comprehension (delay I disorder) - functional use (delay I disorder) - social communication disorder "Speech" - phonology (delay I disorder)- articulation (delay I disorder)- verbal dyspraxia- resonance (hyper I hyponasality, nasal escape, etc.)- lateral 151- interdental ls i- dysarthriaDysfluency - developmental- non-developmentalVoice - dysphonia- aphoniaAge appropriate speech and I or language.

also enabled us to look at whyinterventions might not have worked.

most recent change in the format of our outfrom the realisation that

the information was a time-consumingtime busy therapists could ill-afford. Thecodes (figure

this system, a clerk could, for example,all outcome measures relating to children

'PSB3' (forspeech, disorder, impairment rating 3)

knowing any professional terminology.outcome measures themselves provide mea

that therapy has affectedof whether or not objec

reasons for objec. They also give us infor

have been achieved,, frequency of therapy, group versustherapy and number of appointments.

by identifying particular case notesset via the Master Patient Index (MPI)

ber, di fferent therapeutic approaches can betrends in service delivery mapped.

vital that this process is not carried out in anof justification for clinical decisions,

in the spirit of comparing practice, exploringFor example, why do PSB3 children have

group therapy than individual in one clinicto another? And how does this affectof appointments needed to

the same outcome? The (for now) finalof our outcomes form is in Figure 5.

Fgu re 3.ABCDiDiiEFG

Figure 4.PNtIx:

Variance FactorsEnvironmental, Emotio nal, SocialMedicalAttendanceCarer ComplianceClient ComplianceService AvailabilityAdd itional Impairments (Cognition I Memory)Inappropriate Aim

Coding for Diagnoses - Outcome MeasuresA =Adult P = Paediatric L =earning I PhysicalDisabilityF = Fluency L =Language5C =Social Communicat ion FU = Functional Usesw .. Dysphagia 5 =SpeechVoIce

Followed by either A = delay or B = disorder51d11x: Impairment number rating

Figure 5 Sample formSPEECH AND LANGUAGE THERAPY SERVICECLINICAL EVALUATION US1NG WHO NAME: DIAGNOSIS: CODE: LONG TERM AIM(S):

START DATE: DISCHARGE DATE: NO. SESSIONS OFFERED: NO. ATTENDED:

- ENDERBYMPI:

START PREDICTED OUTCOMEIMPAIRMENTDISABILITYHANDICAPDISTRESS

AIM(S) ACHIEVED:VARIANCE FACTOR YESI NO

AGREEMENT

SHORT TERM AIM 1:START DATE:VARIANCE FACTOR(S):NO. SESSIONS OFFERED:

TARGET DATE:NO. ATTENDED:

ACHIEVED: Y INADVICE [ ) INDIV. [ I GROUP [ )

SHORT TERM AIM 2:

START DATE:VARIANCE FACTOR(S):NO. SESSIONS OFFERED:

TARGET DATE:NO. ATTENDED:

ACHIEVED : YINADVICE [ ) INDIV. [ ) GROUP [ )

(Continues up to short term aim 7)VARIANCE FACTORS:A B C Di Dii E F G

ENVIRONMENTAL, EMOTIONAL, SOCIALMEDICALATTENDANCECARER COMPLIANCECLIENT COMPLIANCESERVICE AVAILABILITYADDITIONAL IMPAIRMENTS (COGNITION I MEMORY)INAPPROPRIATE AIM



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Figure 6

outcomes

10987654321O ~ ~ ~ ~ ~ - - ~ ~ - - ~ J2 3

PSA2 PSA3 PSA4

speech and languagetherapy team.

Figure 6 shows a sam-ple graph demonstrat ing that the averagenumber of appoint-ments needed for children with phonologicaldelay correlates withthe severity of thedelay. Fgure 7 is oneexample of the out-comes form in use for afairly straightforward

Different options forcollating andcompannginformation seemendless, and theability to prove oureffectiveness willbe useful

Figure 7 Sample completed formSPEECH AND LANGUAGE THERAPY SERVICECLINICAL EVALUATION USING WHO - ENDERBYNAME: R.A. MPI:DIAGNOSIS: Phonological DelayCODE: P5A4LONG TERM AIM(S):

Phonology in line with general al1i1ities.

START DATE: 9.10.96 IMPAIRMENTDISCHARGE DATE: 3/11/97 DISABILITYNO. SESSIONS OFFERED 11 HANDICAPNO. ATTENDED: 9 DISTRESSAIM(S) ACHIEVED: @NO AGREEMENTVARIANCE FACTORSHORT TERM AIM 1:

To Estal1lish K In all positions in the word

START PREDICTED OUTCOME4 5 5

4.5 5 53.5 5 5 5 5 5

:3

phonology case . Suitable points for discussion in This happens in some instances but is not yet genpeer review might include the need for direct clin eral pract ice . ical work versus advice. The development and evolution of outcome meaAlthough our data is not yet statistically signifi- sures has been a long and occasionally painfu l

START DATE: 9.10.96 TARGET DATE: Jan '97 ACHIEVED: 0NVARIANCE FACTOR(S):NO. SESSIONS OffERED: 2 NO. ATTENDED: 2 ADVICE.{.II INDIV. [ I GROUP [SHORT TERM AIM 2:

To estal1l1sh 5 In word initial position in the wordSTART DATE: 22.01.97 TARGET DATE : April '97 ACHIEVED: VARIANCE FACTOR(S):NO. SESSIONS OFFERED: 6NO. ATTENDED: 4 ADVICE [ I INDIV. [ . I ] GROUP [

VARIANCE FACTORS .A ENVIRONMENTAL, EMOTIONAL, SOCIALB MEDICALC ATTENDANCEDi CARER COMPLIANCEDii CLIENT COMPLIANCEE SERVICE AVAILABILITYF ADDITIONAL IMPAIRMENTS (COGNITION 1 MEMORY)G INAPPROPRIATE AIM

cant, we are tremendously excited by thepossibilities for the outcome measures.Different options for collating and comparing information seem endless, andthe ability to prove our effectiveness willbe useful in presenting our service toPrimary Care Groups. Resources can alsobe targeted on interventions provingmost successful. A further developmentcould be the involvement of carers /clients in setting objectives and evaluating whether or not they are achieved.

process, but there is a real sense of pride in whatwe have achieved.Alyson Slater and Jenny Hunt are speech and lan-guage therapy managers for the newly mergedBedfordshire and Luton Community NHS Trust.This article is written on behalf of all the speechand language therapists in the former SouthBedfordshire Trust, past and present.References ENABLE (1990), Lucy Hurst-Brown and Alison Keens. Enderby, P. and John, A. (1997) Therapy Outcome Measures - Speech and Language Therapy. Singular.

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resources

sessmen sassesseresponse to requests from readers, Speech & Language Therapy in Practice introduces aw series to find out if, when it comes to published assessments and programmes, the

speak matches the practical reality.

Struc ure forThe Apraxia ProfileLori HickmanCommun ication Skill Builders(from The PsychologicalCorpora tion)47 .00Hardwick's clients were,the whole, responsive to theof this profile.

Apraxia Profile was devised fo r the Americanas a descript ive assessment tool fo r chil

. It identifies and describes the apraxic comof children's speech and consists of a slim

two types of record form to assess.

Profi Ie brings to gether many of the necessaryagement tools in a portable

age . It can be used as a screening assessmentmore time available, as a probing tool. It

a lso be used for monitoring as speech. Intervention strategies are formed onbases of intelligibility, mean length of utter

listener response and communicative impact.divided into three parts - the oral assessment,

st:oral assessment is similar to that which a

would usually administer if there wereinformal indication of dy spraxia. Tasks range

imitation of single movements or phonemesof multiple movement or phoneme

for highlightingical record calls fo r transcription

imitated and spontaneous words and sen-, w ith recitation of well-known nursery. It highlights distortion of phonemes,

assessment techniquein errors and - a major feature of developmentalverbal dyspraxia - reduced intelligibility as theutterance demands increase. The record of connected speech allows fo r scoring of mean lengthof utterance and helps to create a picture of overall intelligibility and therefore functional communication. It also documents syntact ical and morpho logical errors.o The third section is the checklist of dyspraxic features which results in a score of the percentage ofthe ten characteristics most commonly associatedwith verbal dyspraxia. The f inal Summary Page willthen indicate the intelligi bility level and how muchof that is influenced by the dyspraxic component.I was helped to evaluate this assess ment by severalchildren from both age groups and, on the whole,found them responsive to its demands. The test oforal movements and phoneme sequences appearedto be tedious for the younger children who oftenhave no idea of what they are trying to achieve, butthey appeared to enjoy the nursery rhyme recitation and to be unpressurised by the word imitation.The assessment was generally UK friendly but therewas the occasional lurking transatlant ic confusion .'Bozo' I thought to be better omitted completelybut it did cause some hilarity in the explain ing.AdjustmentIt too k some adjustment to evaluate the phonological errors in the suggested way but I foundthat taking some time at the end to use a colourcoding system made it very easy to see types oferrors at a glance.

It is debatable whether this particular toolimproves the therapist 's diagnost ic capability butit would give structure to the assessment technique of a recently qual ified therapist or thosewho work only occasionally w ith this client group.It would be useful fo r school screening or as a protocol in a busy NHS clinic where therapy ma y haveto be prioritised according to severity of disorder.One of my initial mistakes was to apply the schoolage assessment automatically to the over 5s when,in fact, some of the speech imitation tasks werebeyond the capability of young language disordered children. It was often more helpful to usethe pre-school assessment for those up to 8 years .I liked the assessment and found that it addressed,in one package, all the features that I would normally have assessed using several different means.I found the dyspraxia features checklist particularly useful in making a differential diagnosis. T isspectrum disorder has recently had considerablemedia attention but general lay understanding isstill often confused and inaccurate. To th is end heche cklist can be completed together with the parent and is helpful for opening a discussion anddirecting explanation. It also focused my attentionon the relevant points and helped e ta eclear decisions abou t onward eferral.A final point; as a so le independent erapa personal beady eye on he equ ipment bu get, Ifelt it to be reas onably priced.Compact, comprehensive and good value -0 ( money_Maggie Hardwick is a i depe dent speech a dlanguage the rapist in Hertfordshire. ~

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 199 9 7


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resources

Pinpointing concerns Tinnitus QuestionnaireThe PsychologicalCorporation Ltd69.50+VATR.S. Hallam

Is tinnitus relevant to your practice?If so, Liz Stott believes you willfind this questionnaire useful.The Tinnitus questionnaire was developed duringa programme of psychological research intomethods of alleviating the aggravation, annoyance and emotional distress that tinnitus maycause. It is used primarily by psychologists working in the field of tinnitus and / or deafness withthe aim of providing a quick assessment of thechief psychological effects of this condition. Itreportedly enjoys international status.The users' manual is well written, non-intimidatingand simple to follow. It provides a comprehensivebackground as to the origins of the questionnaireand its aims and outlines how to administer andscore the results with details of the standardisation. Chapter 2 of the manual provides a review ofresearch relating to dimensions of tinnitus distressand their validity which makes interesting reading.The questionnaire comprises 52 questions which

HEAR-SAYKathryn Gander andGill CloseSTASS Publications,70.00

Sam Dales is impressed by theflexibility of this new programmefor yrDung deaf and languagedelayed children.Hear-Say is a useful and practical resource for anytherapist working with young deaf children or,indeed, children with restricted language skills.The pack consists of six coloured story books and aresource book containing a language programmeand listening profile. The story books are nicely illustrated and enjoyable to the child. They can be usedwith prelingual children but can easily be adaptedto meet the linguistic level of the older child.

at agIan e are standardised on a clinical population of medical outpatients. It is quick and easy to administerwith the subject responding to a statement asTrue, Partly True or Not True. Likewise, it is simpleto score and interpret. The responses are scored 2,1,0 with the higher score indicating a complaint.There are five dimensions of tinnitus complaint measured which are listed as the following subscales:1. Emotional Distress2. Auditory Perceptual Difficulties3. Intrusiveness4. Sleep Disturbance5. Somatic Complaints.A score is obtained for every subscale in order toestablish the level of complaint, if any, in eacharea. It enables a clinician to pinpoint at a glancea particular area of concern for the subject.Working in the field of cochlear implants with profoundly deafened adults I did not find this questionnaire useful, as many of the questions were notapplicable and a little insensitive for a profoundlydeaf individual. However, for clinicians working

Practical, well-presented,value for moneyThe photocopiable language material provides a

practical language programme and activities whichare used in conjunction with the books. The activities themselves are well-known and original ideasfor developing language up to a three word level.By photocopying the pictures, you can access ideasand activities quickly but still produce somethingthat is user-friendly and looks professional. Thereare also photocopiable record sheets to map thechild's progress, a useful and simple measure ofclinical effectiveness or for preparing an IndividualEducation Plan (IEP). The listening profile providesan informal assessment which is easy to follow.Although the authors describe this approach as "by

with mild to moderate hearing losses it helps quantify the degree of distress tinnitus may be causing aclient. It is one of the few instruments availablewhich can measure specifically the effects tinnitus ishaving on an individual. It may well be a useful toolfor pre-post outcome measures for those workingwith tinnitus and is already widely used as aresearch instrument as it has psychometric properties. For those not working specifically with tinnitusit could be used as a screening tool - it may be thattherapy in a different area indirectly influences thelevel of tinnitus distress a client experiences.On a practical level, the questionnaire is expensiveto purchase and difficult to photocopy if resultsrequired duplication. If a clinician is working withthe intervention of tinnitus then this is a usefulquestionnaire to have - if tinnitus is not relevantto an individual's practice then I do not recommend purchasing it.Liz Stott is a Specialist Speech &Language Therapiston the UCL Cochlear Implant Programme at the RoyalNational Throat Nose and Ear Hospital, London.

no means new or original", I have found it to be avaluable clinical tool enabling me to approach listening work with my young deaf children in a moreorganised and systematic way. As the materials usedfor both the language programme and listening profile are similar, it allows language activities to be carried out simultaneously with sound recognition work.Overall, the children enjoyed the story books and theactivities provided a good stimulus for a range ofteaching objectives. This is a valuable clinical toolwhich is practical, well-presented and value for money.Sam Dales is a speech and language therapistworking with pre-school and school-aged hearingimpaired children for Bro Morgannwg NHS Trust.



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resources

-estrictinCASS-C (Cooper Assessmentfor Stuttering Syndromes Children's version)Cooper and Cooper 1995The Psychological Corporation12700+VATGourlay had high hopes ofprogramme but ended up

is a computer programme designed to allowand language therapists to complete a flu

assessment of a child's speech, aged 3 - 13whilst simultaneously preparing an assess

is important to noteyour computer must be IBM compatible and1MB of hard disk space. A printer is neces

if you wish hard copies for your records or foras part of a report.

as I set out to use this proA means of recording information and

same t ime - a busyl The first thing to note is that this

American protocol that has not been adaptEnglish use. However, this is not too much

ded you are careful to edit obvivocabulary differences such as mom for mumdon't mind the mild irritation of not having

space fo r a full telephone number if youfitting complicated countryinto boxes entitled "city" (American)

clearly don't mean "city" (English translation).next issue is whether you can place your com

in such a way that you can comfortablyuse the protocol without causing

The child I used this with was veryto see what was on the screen and - as this is

always appropriate - it proved a challenge.idea of being able to produce a report without

to me.it does presuppose that everything you

to include in your report is included in the pro-

an notmuch fun tocol. Sadly, this is not the case. The report CASS-Cdrew up was a comment on fluency only and didnot give me a rounded picture of the client. Forexample, there is no mention of case history de tailsother than those relating to fluency history andhearing and speech and language development arenot mentioned. Further, there is no reference tocurrent speech and language skills, other than thosethat relate directly to the stammer, such as theeffect of dysfluency on prosody. Assessment advicefrom other sources such as the Michael Palin Centrein London are certainly more comprehensive.The protocol gives a comprehensive picture of thechild's dysfluency in terms of chronicity prediction,parental and teacher observations and an assessment of the child's fluency based on various outputtasks using a mUltiple choice approach. It took meabout an hour to administer, although that doesnot allow for the extra time taken to persuade thefour year old I was working with that "i t won't takemuch longer" - somehow he didn't seem convinced.I can't imagine a three year old lasting beyond thefirst minute. I missed the flexibility of adding comments after each section where the choices may nothave adequately described observations made. Iliketo tape a session that can be structured to meet theneeds of the individual child. I found the fixed for

document. However all the issues raised are vital forconsideration and, if nothing else, serve as areminder of the required breadth of fluency assessment. The tabulated report allowed easy comparisonof parents' and teachers' views of the dysfluency withthat of my own and the child's. It also encouraged meto look more carefully at any discrepancies in perception of the dysfluency and to take these intoaccount when planning my management.The report can be presented in its entirety or as asummary. It is a tabulation of the collected data. I didnot find this of much use for the sort of report I tendto write. It did not include enough informationabout the whole child, and was something I mightconsider for an appendix, although I'm not sure Iwould want the parents 0" a child that has severefluency problems to see such a negative document.I am grateful to CASS-C for reminding me of thefactors I need to take into account when assessingfluency disorders but will not be using it regularly, as my caseload tends to be three to five yearolds for whom this assessment is too cumbersome,inflexible and for whom a lot of the affective andcognitive line of questioning is inappropriate andcould be tapped in other ways.Sara Gourlay is a speech and language therapist atUniversity College London. 0

mat too restricting and not much fun.ReminderAs is often the case with assessments, I came awayfeeling that it had not served the bottom end of itsage range particularly well. I could imagine childrenof 7-13 years understanding the line of questioningmore readily as well as having more insight into theissues, therefore providing a more useful assessment

Orders for The Psychological Corporation ontel. 0181 3085750 and for STASS Publicationson 01661 822316.Under scrutiny in the Winter 99 issue are theDysphagia Evaluation Protocol, Assessing andTeaching Phonological Knowledge and theBurns Brief Inventory of Communication andCognition.

...RSOURCS ...RSOURCS... R S O U R C S . ~ . R S O U R C S ...RSOURCS...Voice leafletshe Voice Care

Environmentalcontrol SigningSIGNALONG's latest publications include Signs of strokeThe Stroke AssociationNetwork (UK) is pro The manufacturers of the DynaVox 'This is Me', three sets of loose leaf pages, dupli has produce d a ne'ducing new leaflets, and DynaMyte dynamic display cated with and without symbols, to help the devel leaflet 'Kno" he "m'More Care fo r Your speech aids have launched environ opment of early reading skills ing signs' or d istr"

oice' and 'Keeping a mental control systems, which can and tion ia GP 5 fge -es aYoung Voice', fo r older be operated by these products. a manual of signs to match the word recogni hea lt h cemres.people. Details: David Morgan or Paul tion lists issued by the DfEE for primary pu pils. Availab le singly orDetails from Roz Comins, Asher, Sunrise Medical Ltd, tel. Details tel. 07634879975. For development ana packs o 50, eL Q1604tel. 07926864000. 07384446789. training enquiries, tel. 07634832469. 623934_



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dementia

care: Speech and languagetherapists are increasingly

involved in the managementpeople with dementia, often

working with carers ratherthan directly with the affectedindividual. But what do these

carers think about what wehave to say? Does it make any

difference to the person withdementia? And what

constitutes 'best practice'?Colin Barnes investigates.

See our FREEcompetition for 400worth of Winslow

resources for workingwith the elderly!

(inside front cover)

insights,practicalitiesand change

n common with the growing number ofspeech and language therapists involved inthe care of people with dementia, my role isbased around the assessment of communication and memory or feeding and swallowing difficulties. It also entails running group

or individual therapy programmes fo r peoplewith dementia and / or their carers to maintainexperience and skills of communication andmemory.At the first national meeting of speech and language therapists working in old age psychiatry inOctober 1997, 14 of the 17 people there reportedoffering some communication advice and trainingto carers. A review of the literature identifies asmall number of studies in which carers havereported that communication advice and trainingis useful, though none of these studies have givenspecific reasons why.To find out more - and to explore implications forour practice - I carried out a local study designedto consider the question" To what extent do car-ers of individuals with dementia benefit fromcommunication advice and training'"Initially, six individuals with mild to moderatedementia determined using the ABeD Assessment(Bayles and Tomoeda, 1993) were seen fo r a communication and memory assessment. I then contacted their carers and visited them at home with-in four weeks. For this study, the term 'carer'referred to immediate family members directlyinvolved in caring on a day to day basis andincluded one husband, three wives and tw o

daughters. During this visit carers were providedwith:1. the opportunity to talk about communicationdifficulties being experienced2. an explanation of the communication andmemory assessment results3. a standard presentation on approaches to communication and confusion in dementia(Barnes, 1998)4. demonstration of a range of approaches tocommunication5. the opportunity to have carer: patient interaction observed and discussed6. a written record of no more than three keyrecommendations7. an agreed number of follow-up appointmentsor telephone contacts.My approach to working with carers is based on anumber of beliefs, though particularly I attemptto:I. Discuss the possible range of approaches tomanaging confusion and memory difficultiesrather than prescribing carers one approach tocover all situations.II. Use visual material in the form of a colour presentation called Chatter Matters to help explainthe difficult abstract concept of 'communication'and provide some structure to giving advice.III. Limit the number of recommendations madeand subsequent pressure on the carer by setting alimit of no more than three key recommendations. Examples of these specific recommenda tions are in figure 1.



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dementia

When a carer asks "Whatshould I do when he sayssomething that isn'tcorrect?", I answer bydiscussing the range ofoptions open to them

Figure 2 - Options exampleQuestion from relative:What should I say when my husband tellsme he's off to work? His job was his life,bu t he's been retired fo r 10 years now!

CoI;n Barnes M.A., B,Se., regM.R,(S.L. T;s a full time specialistspeech and language therapist

HealthCare NHS Trust.

1 Specific recommendationsfo r two

day over lunch box with photographs andto act as subjects of conversaKeep the box by his chair, placing it oncoffee table when friends visit.

the family come for dinner, ask herthe vegetables. Talk abouthard work during the meal.from food cartons. Put these into a picture book to help her

which food she would like.

of optionswith the carer is primarily about

of approaches to communication andto equip them with an understanding of theand cons of a range of approaches that theyuse across most situations. When a carer asks

I do when he says something thatcorrec!? " , I answer by discussing the range of

to them (figure 2), from correctingto ignoring their

r and encouraging them to tell you moreIn some situations, it may even be

to talk with the relative about positivelyuraging some confused ideas, an approachh is used selectively by the Specal group in

.

Answer:You have a choice:1. You can correct him ('Reality Orientation'- see Zanetti et ai, 1995) bu t you should askwhether he is likely to remember what youhave said - this will depend on his memoryskills and ho w often the error occurs - andhow i t will make him and you feel.2. You can listen to what he says neutrallywithout comment, ignore him or even distract him. But you should consider i f he islikely to notice that you haveignored hisfirst comment. You may want to introduce awell established subject of conversation orask an alternative question ('Reminiscence' see Bourgeois , 1991), for example "Do youremember the good old days when we usedto ... ..3. You can le t him tell you more about whathe has said, fo r example about work. Askhim more using 'where', 'when', 'what','how' questions Ifke a reporter (,ValidationTherapy' - see Feil, 1995).He is more likelyto enjoy being listened to, but you shouldask yourself whether he is likely to realisethat he has madean error and that youhave gone along with it.4. You can positively reinforce the reality ofwhat he has said using props. For example,if he says he is off to work, you can givehim a briefcase and diary and wish him agood day at the office. This may seemdeceptive, bu t you should ask yourself howit will make him feel or whether you arereinforcing something that is likely to leadto further complications. This may dependon the value he attributed to work and theprevious nature of his job. ('Specal'approach - see Garner and Godel, 1996)

The idea of introducing a range of approaches isbased on my experience that many carers naturalIy feel obliged to correct their relative irrespectiveof whether it is in their relative's best interests . Atendency to orientate may be associated withcommon perceptions of caring as a job of 'makingbetter' or 'rehabilitating' , Another tendencyamongst carers may be the idea of respecting anindividual's rights, Unfortunately, though, this canmean carers asking patients to answer questionswhich are beyond their understanding, leading todecisions which are not in their best interests,The presentation Chatter Matters is also used toillustrate the equal importance of content andquality in conversation, I explain that too great afocus on the content of conversation may lead toa reduct ion in quality and ultimately cause theperson w ith dementia to lose interest and w i t ~ -draw, Other popular topics of discussion include: How to involve the ir relative in conversation Which things to correct and ignore What to say when they return from the day centre Asking questions How to make major dec isions between them What kind of activities they could be doing Coping with repetition,Real attitudesResearch suggests tha y en asked, GfEBinvariab ly comment po . Iy a posi .a service they ha e r ei ed, esp.::oabeing asked by the seMce provider1993). To identify e ca er;' rea l a-,itudes to my ~

SPEECH & LANGUAGE THERAPY IN PRAalCE AUTUMN 1999 11
http:///reader/full/1995).Hehttp:///reader/full/1995).He


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dementia

...when asked, carers willinvariably commentpo litely and positivelyabout a service they havereceived, especially if theyare being asked by theservice provider

visil, I employed an independent interviewer(another mental health professional) to visit eachcarer four weeks later. Other researchers argueth at interview responses alone are not sufficientto measure carer benefit and, therefore, following Knight et ai's (1993) recommendation, the carers in this study were also asked to complete aSubjective Measure of Carer Burden Scale(Montgomery et ai, 1985). This scale was completed twice, at the beginning of both the speech andlanguage therapy and i ntervi ewer visits. It consistsof thirteen statements designed to reflect theextent of burden the carer may be feeling, forexample 'I feel that my relative doesn't appreciatewhat I do for him/her'. The carer is as ked to ratetheir agreement with the statement from rarelyor never to most of the time.Along with a second independent researcher, Ianalysed the anonymous results from the interviews, typed ve rbatim onto transcripts, and theCarer Burden Scale. The results from the study canbe broken down into three areas:1. The Subjective Measure of Carer BurdenScaleThe resu lts from this measure were disappointing .On average, all carers reported an increase in burden between visits and following contact with thespeech and langu age therapi st. However,decreased burden was indicated in two questionswhich suggested that the majority felt le ss nerovous and depressed and interpreted their relativeas being less demanding.Th e scale was introduced to give an additionalquantitative element to the study though theresults did not illustrate the trend expected. Theanswers to the quantitative questions clea rlyshowed that the carers found the visit very helpful. It therefore seems unlikely that the carersshould have experienced an increase in burden .Closer examination of the results also suggeststh at some difficulties may have been experiencedin interpreting the questions in the measure andt hat additional differences were created by having tw o testers. Whilst I would tend to concl udethat no real significant increase in burden wasexperienced, we should never dismiss the real possibil it y that our intervention can add to a ca rer'sburden.2. Quantitativ e (Yes/No) responses from th einterviewUnfortunately, one carer was unable to completeth e interview fully as the patient had insisted onremaining in the room and objected to beingtalked about, therefore only the results fo r theother fi ve carers are given.

Interview QuestionsAverage ScorelResponse

1. Was the visit helpful? 2.8 *2. Was an explanation of the assessment results helpful? 3 3. Was it helpful to Simply talk about your communication difficulties? 3 4. Was it helpful to be given information on communication? 2.8 * S. Did the visit influence your thinking? All said Yes 6. Have there been any changes in your attitude and approach? All said Yes 7. Were you able to carry ou t the recommendations made? Al l said Yes

3. Qualitative (reasons why to whatextent) responses from the interviewThe comments made by each of the carers (fivepeople) were sorted into ten categories agreedby the two researchers, then key themes wereidentif ied using a method of content analysis.Although the quantitative responses in thestudy clearly indicate that this sample of carersfound their contact with a speech and languagetherapist useful, the qualitative data from thestudy is able to provide some possible reasons.The five most significant themes are describedwith resulting suggested learning points givingdirection for best practice:i. Comments and insights into the caringroleSurprisingly, over thirty comments about being acarer were volunteered though none of the interview questions had asked for these. Of these comments, twentyone were negative including beingtired, not sleeping, being alone with noone totalk to, only conversing when the patient wants toand having to compromise.

Learning Point: Be careful not toover-empathise. Although we mayspend much of our working life withpeople with dementia our experienceis emotionally very different from thefamily carer.

ii . Practicaliti es of th e v isit and speech and language th erap is t ap proach The majority of carers preferred having the meet ings in their own homes. They reported appreciat ing having time to talk, having realistic recom mendations and simply being encouraged . Difficulties arose when carers failed to understand the purpose of the visit that is, that it was for them as much as their relative.

Learning Point: Be clear about the purpose of our visits and offer the carer a range of options to ensure their interest and attention.

Carers were asked to give responses using a threepoint scale wherel=not helpful, 2= helpful and 3= very helpful.*One person gave a score of 2 instead of 3. Thisappears linked to their comments that some ofwhat was said was common sense .

Carers also varied in their ability to understandthe idea of 'communication'. Two appeared tomisunderstand what is meant by this term.It was also clear that carers were more able toapply and remember recommendations thatinvolved specific activities than more generalchanges in approach suc h as "Try talking in lesscomplex sentences".

Learning Point: Allow for varied understanding of 'communication' and consider using very specific, preferably activity based, recom mendations.

il l . Changes in Belief. Att i tude andUnderstand ingIn keeping with the aims of the visit, three out of sixcarers reported a change in belief that it was nowmore acceptable to go along with confused ideas orerrors. All six reported an increase in knowledge andtwo reported more tolerance in attitude.

Learning Point: The speech andlanguage therapist has a val id role inhelping some carers to broaden theirbeliefs and knowledge about ethicallyacceptable approaches tocommunication in dementia.

2 SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 1999


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dementia

Photographs courtesy ofAlzheimer Scotland

in approachcarers, twenty mainly activity based

. These included relaxationtalking to their relative and others about

tasks they can be given to do, such asThe car

lso reported difficulties in introducing anothFor example, one carer found

books didn't help and another was unablethe suggestion of returning from trips

a memento such as a menu because theygo out much.

who reported the greatestin introducing changes also reported look

four weeks.appeared to be looking for more variety,

was unlikely to appreciate

Point: We may need tocarers to cope withIt is likely that some ofmost successful changes madebe those that happen at leastaday.and patient well-being

in this section were related to comication activities and none to changes in comcation style. The main benefit reported by

carers was the value of being listened to andbeing encouraged. However, two carers found itdifficult to see how the carer contact could helpthe patient.

Learning Point: Carers by definitionprovide the majority of care for theirrelatives. If they find gratification inwhat they do, it would seem likelythat they will be able to careforlonger. The carers appeared toappreciate encouragement aboutthe job of caring they are doing andmay benefit from contact with a.'knowledgeable professional'.WorthwhileConsideration of the results of the study suggeststhat communication advice and training for carersof people with dementia is worthwhile because itprovides for more understanding of the patient'sdifficulties and needs, more success in communication and interaction, less difficulty being realistic about the future, encouragement about thejob of caring they are doing, confidence toemploy a broader range of approaches and anopportunity to talk about the difficulties they areexperiencing.This study considered the value of working withdementia carers on communication in more detailthan any other known published study. Even so anumber of limitations, including the relativelysmall sample size, call for future research. Thiscould address at least three further questions; Which and what proportion of carers benefit?

How long do the benefits last' What is the potential for and interest in furthercontact with a speech and language therapist'

ReferencesBarnes, C. (1998). Chatter Matters. A presentationfor carers of people with communication andmemory difficulties. To be submitted for publication in 1999.Bayles, K. & Tomoeda, C. (1993). The ArizonaBattery for Communication Disorders ofDementia. Canyonlands Publishing - distributedby Winslow Press in the UK .Bourgeois, M.S. (1991). Communication treatmentfor adults with dementia. Journal of Speech &Hearing Research 34, 831-844.Feil, N. (1995) The Validation Breakthrough.Simple techniques for communicating with people with Alzheimer's-type dementia. HPP.Garner, P. & Godel. M. (1996). Specialized EarlyCare for Alzheimer's: Making a present of thepast. A report available from the authors atBurford Community Hospital, Oxfordshire, OX184lS.Knight, B.G., lutzky, S,M. & Macofsky-Urban, F.(1993) A meta-analytic review of interventions forcaregiver distress: Recommendations for futureresearch, TheGerontologist 33 (2) 240248. Re ections:Montgomery, R,J.V.,Gonyea, J.G. & Hooyman, 1. Do' try toN.R. (1985). Caregivingand the experience of sub encouragejective and objective bur change withoutden. Family Relations 34, increasing19-26. Zanetti, 0, Frisoni, G.B., feelings of Deleo, D., Buono, M.D., burden?Bianchetti, A. & Traucchi, M, (1995). Reality 2. Do' Orientation Therapy in genuinely Alzhe imer' s Disease: attempt to alterUseful or Not? A controlled Study. Alz. Disease my practiceand Associated Disorders 9 based on what(3) 132- 138 . the users of myservice think?Resources 3. Do' enableThe 24 hour Dementia people to seeHelpline (Scotland) onfreephone 0808 808 3000 they alwaysand the have more thanlzheimer'sHelpline (England, Wales, one option?Northern Ireland) on 0845300 0336 (local rate) provide information or emotional support about issues to do with dementia.To contact Alzheimer Scotland - Action onDementia tel. 0131 2431453. For the Alzheimer'sDisease Society (England, Wales, NorthernIreland) tel. 0171 3060606.


0


16/32

reviews

EvidencePARKINSON'S basedParkinson's and th e Speech &language TherapistInformation Pack (Revised)Parlcinson's Disease Society 8.50Perhaps this is the best evidencebased information pack so far produced by the Parkinson's DiseaseSociety. It is mainly an overview andnot meant to be an in-depth resource.The seven sections are printed on different coloured A4 paper for ease ofreference. They include commun ication problems; eating, drinking andswallowing; handouts for carers andpeople with Parkinson's; a checklistfor the therapist to use as a summary of detailed assessment; and usefuladdresses . Each section has an up-todate list of references. Best of all isthe section on background papers ,highlighting recent clinical findings.Last but not least is the section onefficacy. It provides a useful list ofreferences on the ever increasingneed to promote "the level and standards of services which the providersof health care should deliver".Being so reasonably priced, nonewly qualified therapist should bewithout it.

C o m ~ r e h e n s i v e ':J;MIWII Il;i- and user-fnendlyRight Hemisphere Damage - Disorders of Communication and CognitionPenelope S. Myers Singular ISBN 1 56593 224 2 36.00 Right hemisphere (RH) communication disorders have always been difficult to define and therefore difficult to treat. Although further research into the RH is needed, this book takes you easily through every identified aspect of RHO, offering clear examples of deficits to aid the experienced and inexperienced clinician recogn ise and treat the often subtle intricacies of RH language impairments and the wider cognit ive implications. There are comprehensive sections on assessment and treatment techniques including a good overview of standardised

.._________- . tests and many user-friendly treatment ideas that can be easily adapted and built uponby clinicians working within this field .To aid the student or clinic ian new to the area of RHO, there are useful chapter out-Expensive lines and summaries to enable information to be located rapidly.but exc,'t,'ng A resourceful book for anyone working within the area of neurological impairment. ___________Neuroscience of Communication (2nd ed)

Douglas B. WebsterSingularISBN 1-56593-985-9 30.00It is tempting to assume that this book is the essential neurologyresource book for the student speech and language therapist but it isn't. What would be the impli


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reviews

eVlewsInspirational .aaaptations F u n d . ~Soft Options fo r adults who have difficulty chewingRita GreerSouvenir Press Ltd.ISBN 02856344X7X 9.99This recipe book is suitable for people with a wide range of cooking experience. Some of the detail(nutrition & healthy eating; cooking equipment & utensils; rationa le and techniques) is at a very basiclevel, but ideal for a spouse who is new to it all.I was impressed with the thought that has gone into the adaptation of meals, so that a near-normalvariety can be offered, including foods which are traditionally left out of a dysphagic diet, such asbread, cakes and pizzas. However, like all recipe books, it would have benefited from some colourphotos to whet the appetite!This is a valuable resource fo r inspiring and gu iding families and one I have alreadyrecommended several times. Catering departments should also find it

The Dysfluency Resource Book

helpful.Heather de la Croix is a speech & language therapist whodivides her time between the NHS in Wiltshire and her

STAMMERINGExcellent value

Independent Practice in the Bristol area.Jackie Turnbull and Trudy Stewart

WinslowISBN 0 86388 206 4 33.95Positive

IUeasGroupwork with LearningDisabilities- Creative DramaAnna ChesnerWinslowISBN 0-86388-190-4 27.50This is a very practical book, written by adramatherapist with experience of groupwork with people with learning

difficulties. It begins with a discussionof the value and benefits ofusing creative drama and

how to structure thegroup and the

sessions, andpresents a fiveA resource book offering practical t herapy ideas for working with adult phase sessionstammerers, covering individual and group therapy, and with over thirty

clear, concise and very useful (photocopiable) handouts thrown in - sounds design whichapproachof Adult Neurogenic too good to be true? Well, fo r once, it isn't. links up with theThere are thirteen chapters ranging from the general (for example, succeedingand Cathy A. Pelletier Communication Skills) to the specific (Desensitisation; Avoidance Reduction; chapters. TheseRate Control to name three), and the layout is user-friendly and flexible. The- 1-56593-871-2 40.00authors include well-trodden techniques by the usual suspects (Dalton, Kelly, chapters thenAmerican book, written in an easy-to-read Sheehan, Van Riper et al) while adding plenty of slants and suggestions describe activities

looks primarily at the long-termof patients with neurogenic

that can be used with thisbut its main strength is the

it gives to the role ofspeech and language therapist inhagia rehabilitation.

an excellent balancean overview of the

of dysphagia managementtherapists new to this area, and

to provide thewith newhow to

effectively to documentin our increasingly 'legally

Swain is a specialist speech &East YorkshireHealthcare NHS Trust.

gleaned from their own clinical experience. which can be usedAt 34, it represents excellent value for all the use you should get outof it. fo r each of the

John Swan is a speech and language therapist working with stages includingVOICE adults for Worcestershire Community Healthcare. When arrivals and greeting,I other caseload commitments allow, he runs an body and voice work,Wealth evening dysf/uency group in Worcester.information

Vocal Health and PedagogyRobert Thayer SataloffSingularISBN 1-56593-963-8 33.95This book is designed to be a clinical companion to the muchlonger and more expensive Professional Voice, 2nd Edition,and as such is focused on the professional performers' voice.However, it is able to stand alone with information relevant toother professional voice users and amateur performers' voicesmore commonly seen in clinic.The 31 chapters range from the standard Anatomy &Physiology and Vocal Tract Resonance to the not-so-standardChoral Pedagogy and the Singing Voice Specialist. Particularlyinteresting for clinical use are chapters about the vocal effectsof allergy, endocrine dysfunction, nutrition and medications.Overall, at under 35, it is very good value for money fo rthe wealth of information conveyed.Hilary Armstrong is a speech & language therapist withinthe adult team for Mid-Essex Community & Mental HealthNHS Trust, based in Chelmsford.

sensory activities, dramaactivities and closures. The activities

are clearly explained together with theirpurpose and how they can be furtherdeveloped.I found this a very easy book to read,with a fund of ideas fo r anyone workingwith a group, or providing advice onhow to run such a group. I wouldrecommend it as a useful resource fo rany special school, day centre, orcommunity learning disability team.Jenni Kay is a senior specialist speechand language therapist with CheshireCommunity HeaIthcare Trust working ina community team for adults withlearning disabilities.



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How do we deliver an effectivespeech and language therapyservice to mainstream school

children on the autistic spectrum?Following their highly successful

one week intensive group,Liz Spooner and Sally Hewison

provide us with a wealth ofsuggestions for therapy activities

and organisation,

I

-peech and language therapists in community clinics are receiving increasingreferrals of children on the autisticspectrum, These children have difficulties in understanding and using lan guage, and also with understanding

social rules, interacting appropriately with otherchildren and adults and developing insight into your behaviour can affect other people, usingtheir own and other people's feelings , Therapists knowledge about other people to make anoften feel unable to address such complex needs informed prediction ,effectively within the clinic setting so, last year,some children were removed from community Addressing all areasclinic caseloads and seen on a one week group All children were referred by community thera intensive course during school holidays, Therapists pists, Seven children attended ranging in agewho normally work in language units ran the from six years five months to eight years, workingcourse as they have a depth of experience work with two therapists and a therapy student.ing with school-aged children who Parents were asked to attend anhave pragmatic diffi culti es, One appointment before the course to ratetherapist who is term time only was Therapists their child using the Surreyfunded for one extra week to pilot Communication Profile (SCP) (Cave andoften feelthe course which was structured to McG regor, 1996) and to identifyunable toaddress: strengths, weaknesses and aims for the developing understanding of lan address such week, The SCP was chosen because itguage - semantics, impl ied meaning, rates children's expressive and receptivecomplexunders tanding and remember ing language along with behaviour, interacneedsnstructions, listening skills, tion and social skills, and the course using language - organisation of effectively aimed to address difficulties in all theseideas, giving instructions, giving areas , Therapists evaluated each childwithin theappropriate amounts of informa independently on the first day, Childrention , clinic setting were re-assessed by therapists using the understanding the rules of play SCP at the end of the week and againand conversation - turn- taking , win- with parents six weeks after the coursening and losing, sharing, teamwork, understand to determine whether any progress had beening other people's points of view, achieved and whether it had been maintained, self-control/insight into behaviour - developing Parents were also asked to complete a questionawareness of other people's feelings and how naire at the end of the course on course content,

16 SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 1999


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Task progressionet - Insight Into ownIother people's feeUngs

y 1 The Present Game real objects - asking children to Identify

present they woutd lHce, an d an appropriate member

y 2 How Do You Feel? Imaginary but extreme situations. ego

u have an InJection, It's Christmas

y 3 How Do Yo u Feel? Imaginary but a mbiguous situations. oyour teacher asks to hear you read. It Is for te a tonight.

y 4 How do they feel? Information about two imaginar y predict how they would feel In ent situations. eg osomeone Is of water - how wou ld they feel an Invitation to go sw imming

y 5 Guess Who?homework task was to write about whot

akes you hap py and cross. Children haveuse their knowledge Of other groupbers to match the homework to theld .

noted and preferences for types ofy was allocated the week before the course

and identifying a rangerities for ea ch chi ld, and the first day was

ned with these objectives in mind. The coursey morning from 9.30 - 12 .00 fo r one week,

le group activities combining with rotatedll groups. Each day contained about eight

es and eva luation and planning for thedone every afternoon. In the future

time should be required for planning as aof thera py resources and ideas has nowcre ated. A homework task was set at the

of each morning, which was incorporatedthe following day 's therapy. These tasks

us to build a guessing/pred icti on task andinto each day's activit ies (figure 1) .

of the rapy tasks fo r different tar getsn figure 2 and information for parents aboutession plan for day thr ee in figure 3.

Figure 2 Examples of therapy tasks1. Insight/PredictionSets of these happy/sad/cross/surprlsed cards were used dur- .Ing the week to help the ch. ldren Identify their own and otherpeople's feelings during octlvltles working on predictIon andinSight. They were particularly effective Ln activities designed toshow that people could have different responses to the samesituation and In providing a structure when asking children topredict how another group member might feeL2. Organising language/giving Instructions to other group members

, ' \ \ ( { (///1'"" \ {I r //" -:~,\(( (1 //-wW\ ( r/ ",.-" -w''" We used the barrier game as an activity during the week bu tgave It greater structure by giving the speaker in the group apicture prompt to help him tell the other group members what to do. This gave on added tochallenge, as he had to sequence his own Instructions accurately to achieve the correct goalfo r other group members. The speaker was able to look at what the listener was doing and,

during the week, the children became more effective at using this Information to mOdify thespeed, complexity an d number of their instructions.3. Team Gomes/Listening to instructionsA running race team game using semantic categories was Incorporated into each day's activity where each team member hod to carry out a sequence of 4 actions. a(:h da y we alteredthe Instructlons so that the sequence and/or one of the instructions changed. Initially the children relied on their memory of the previous day's game (and did not listen to the change ofinstruction) and consequently did not carry out the game correctly . By the end.of the weekthey had learned how important it was to listen to aU the instructions and not rely on theirknowledge of the previous day's routine.

Figure 3 Programme for day three1. The Family Photographs Guessing Game 30 minutesThe children have to Identify . Who is In the photo?

How they feel? How can you tell? Why they might feel that way? 2. Making happy , sad, cross or surprised masks 30 minutes

3. Take One Step 15 minutes A game where you have to listen to instructions and decide whether they apply to you - we didn't have time to play this yesterday!

4, . Chinese races 10 minutes Developing ey e-contact. recognising other people 's feelings and using non-verbal skills to convey Information.

5. Rotating Groups 15 minutes/group 0) Lotto by Description b) How might you feel? today the children take prediction of your own turns to describe the feelings and those pictures (developing of other group members self-organisation, listening. in a variety of settings and expressive language)

6. The Toybox Team game 10 minutes We are changing the structure Of our team game to check the children are listening to instructions, rather than following routine .

7. Who does thi s toy belong to? 15 minutes Guessing Game - the children need to identify other chi ld ren's likes an d di slikes rather than their own , to guess successfully .

8. Th e Present Game 15 minutes Develop ing o n ab ility to "read" other people's feeling s and predictin g possible causes for how peopl e feeL

HomeworkCan your chi ld b ring ina photo Of themse lves as a baby (With thefr nome on t e bac k please !)



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Figure 4 Post-course questionnaireSPEECH AND LANGUAGE THERAPY OUESTIONNAIRE

We would be very grateful If you would take ttme to fill In the following Ouestlonnalre about this week's Course . Your answershelp us In planning effective therapy in the future .Child's Name ............... .. .... .. .. ...... .. ...... .. 1. Do you think the Course helped your child in the following areas? (please tick)

No Change Slight Improvement Some Improvement Big ImprovementUnderstanding LanguageConfidenceConcentration an d ListeningTalking2. The Course also aimed to develop your child's understanding of other people an d insight into his/her behaviour. Do youthink the course helped your child in the following areas?

No Change Slight Improvement Some Improvement Big ImprovementSelf ControlUnderstanding of other people 'spoint of viewUnderstanding the rules of playan d conversation3. What did you think about the Information given about the Course? (please circle)

is likely that Too much Not Enough Useful Very UsefuLthe parents' 4. What di d your child enjoy about the Course?

view more closely

5. What kind of Speech and Language Therapy would you choose for your child in the future? (please circle)reflects anyIndividual Appointments Another Group Course

6. Do you have any other comments about the Course?of progress that resulted

from the Thank you for taking the time to comp.lete this Ouestlonnalre.course.results of a post-course questionna ire to par the course. another group and only two wanted some level of

an immedia te positive response (figures It is interesting that the questionnaire completed individual therapy alongside another group . We5). We found the changes made in self con by parents immediately aher the course showed see two major benefits of group therapy :

of other people's points of only three of the children's parents felt they had 1. Structured therapy for language and socialof play and conver made any improvement in understanding of lan skills is delivered in the context of fam iliar social

as these kinds of guage. However six weeks later, when completing activities - team games, play, construction activihad not been targeted in the previous the SCP, all parents ident if ied some progress . All ties. This increases each child's ability and oppor

of individual therapy. the children made some progress in interaction to tunity to generalise the skills learnt.s identified more progress on re-assess varying extents as measured by both parents and 2. Course design can enable children to recognise

with the SCP than the parents did (figure 6) . therapists . This is particularly pleasing because it thei r progress and to gain confidence and motiva, it is important to consider exactly what had not been targeted in the individual therapy tion from succeeding at activities with other chil

. The therapists judged the progress of the children had received prior to the course. dren. This ohen contrasts with their experience atto the routines school.

of the group while the parents rated Group benefits If we were repeating the same type of group, weown child according to their experience of Parents were asked on the questionnaire which would complete the SCP with each child's Special

/her in a range of settings over a period of six kind of therapy they would prefer for their child Educational Needs Coordinator (SEN-Co) and. The parents' ratings may also be affected in the future - ano the r group, or individual identify with them their priorities for that child

the interpretation of their child's difficulties appointments. Given our previous experience prior to the course. The SCP provides a usefulwithin the group). It is when asking this kind of question, we felt the framework for discussing a child's needs withthat the parents' view more closely reflects answer was likely to be 'both'. It was, therefore, teachers and we feel more information about

of progress that resulted from pleasing to see that five parents would prefer how each child is managing in school would pro



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Post-course questionnaire resultsNo Change Slight SomeImprovement Improvement

4

2ing

of

resu lts (6 weeks post-cou rse)of Children making progress In at teast half of the Items In each

(total number of children = 1)Expressive InteractionLanguage

rating 5' rating 3

vide an extra perspective to make therapy more often made us realiseeffective. We would also re-assess with the SEN-Co the extent of a chill'J'spost-course to establish whether any progress had difficulties.generalised to school. 3. Homework:We learned a lot generally from the course which Pred iction / guesswe will take into account when planning further work - bringing babygroups. In particular, we would recommend:1. Take nothing fo r granted: All children on thecourse are functioning in a mainstream schoolenvironment but we still had to teach very bas icskills -., for example, recognising basic facialexpressions - at the beginning of the course .2. Incorporate a craft ' practical activity: Weplanned a practical activity for each day to support our themes for the week, for example mak ing masks of different emotions and a bedroomdoor sign to show how you feel. This also gave usthe opportunity to see how the children appliedtheir listening and organisational skills in a structured activity outside speech and language therapy. The results were always enlightening and

pictures, family photos and favourite toys from home enabled us toincorporate a guessing game into an activitywhere children had to use their knowledge aboutother group members to inform their predictions.4. Planning and evaluation with parents:Working w ith parents to plan priorities for thecourse enabled us to establish very spec if ic targetsfor each child and to use the parents' knowledgeof their child's strengths and interests to ensureactivities were motivating for each child.Involving parents in evaluation enabled us toident ify progress made on the course, and to seehow progress had been generalised in the children's everyday lives.

5. Location: The course was held in a -;:, porary classroom of a local ,

speech & language therapy in practice, autumn 1999

Documents