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ISSN 1368-2105 (print) ISSN 2045-6174 (online)

Winter 2011

Choices, apps and possibilities

Impairment therapy Case reports Transcription Broad or narrow? Training A practical focus Journal Club Single subject designs Goal negotiation The right wording

PLUS...heres one...winning ways...ethics... in brief... top resources... reader offers www.speechmag.com

Reader offers

Grow Words Sequencing giveaway!


Grow Words publishes a range of practical resources containing photocopiable games, activities and worksheets that target a range of language and literacy skills.

Win a subscription to S&L World!


S&L World is a global bulletin for speech and language therapists and speech-language pathologists. Encouraged by contact with therapists around the world through blogging, facebook and twitter, editor Libby Hill launched the online subscription magazine in January 2011. It aims to offer an informal forum for sharing features, ideas, news, stories and interviews from around the world. Libbys company Small Talk Ltd coordinates S&L World in conjunction with creative agency Milton Bayer. A subscription to S&L World usually costs 24, but Small Talk Ltd is offering THREE readers of Speech & Language Therapy in Practice the chance to win one FREE. Just email your details with Speechmag S&L World offer in the subject line to editor@slworldbulletin.com by 25 January. The winners will be notified by 1 February 2012. The first issue of S&L World can be accessed free at www. slworldbulletin.com. For further information, tel. 0844 704 5888 or email editor@slworldbulletin.com.

Grow Words is offering THREE lucky readers of Speech & Language Therapy in Practice a CD containing Sequencing, a resource that not only includes a range of picture sequences, but also: the vocabulary cards that are required to describe each sequence of events a range of sentence building strips to develop simple, compound and complex sentences a range of graphic organisers to support the range of text types targeted. Each CD is worth approximately 20, but you can enter the draw to win one FREE by emailing info@growwords.com.au with Speechmag Winter Grow Words Offer in the subject line by 25 January. The winners will be notified by 1 February 2012. Everyone who enters will receive an order form that will allow them to purchase the sequencing resource at 50 per cent off! Grow Words is run by two Australian speech pathologists. Information about all Grow Words resources, including sample pages and how to order, is at www.growwords.com.au.

Congratulations to our Autumn 11 winners


The lucky winners of our fantastic Autumn 11 offers are: Christine Eales, Elizabeth Wainwright and Belinda Robbins (Grow Words Sea Words CD) and Susan Bannatyne (New Reynell Developmental Language Scales). We also had a number of textbooks which went to Janet Robinson, Tamsin Rycroft, Annette McLaren, Sara Knox, Marion Watts and Belinda Robertson. Congratulations to you all, and thanks to Grow Words, GL Assessment and Plural Publishing for their generous prizes.

Win Speaking & Listening Through Narrative and Story Starters!


Two popular Black Sheep Press resource packs have been fully revised. To celebrate, the company is offering TWO copies of each FREE to lucky readers of Speech & Language Therapy in Practice. The Key Stage 1 pack 'Speaking & Listening through Narrative' by Bec Shanks has been expanded to 220 pages (plus black and white duplicate picture pages) to incorporate revised instructions and additional activites with rationales. Session plans link to associated worksheets, and tabs alongside activities indicate any items needed. What Happened has been expanded to two sessions, and an additional week of consolidation activities included. A new section offers suggestions for incorporating the Narrative Approach throughout the curriculum. Story Starters has also been updated. This 33 page pack has fully coloured illustrations, revised text and improved icons. It is designed to complement all Black Sheep Press narrative packs from Key Stage 1 on by providing a visual framework for structured progression in oral and written storytelling. To enter this free prize draw, email gillian@blacksheeppress.co.uk with Speechmag narrative offer in the subject line by 25 January. (NB Please state whether you are entering for Speaking and Listening Through Narrative, Story Starters or both resources.) The winners will be notified by 1 February 2012. The new Speaking & Listening through Narrative pack costs 72. Purchasers of the previous colour edition can buy an upgrade for 15. Story Starters is 19. Details of these and other Black Sheep Press resources are at www.blacksheeppress.co.uk.

Winter 2011 (publication date 30 November 2011) ISSN 1368-2105 (Print) ISSN 2045-6174 (Online) Published by: Avril Nicoll 33 Kinnear Square Laurencekirk AB30 1UL Tel/fax 01561 377415 email: avrilnicoll@speechmag.com Printing: Many thanks to Ian Shearer, Mike Tutt and all at Manor Creative for their long service! 7 & 8, Edison Road Eastbourne East Sussex BN23 6PT Editor Avril Nicoll FRCSLT Speech and Language Therapist

Winter 11contents
INSIDE FRONT READER OFFERS Fantastic offers for you in the Winter 11 issue! A Grow Words resource set, Speaking & Listening Through Narrative, Story Starters, S&L World and, on p.33, Jessica Kingsley books. 6 REVIEWS Supervision, hearing impairment, communication skills, neurorehabilitation, cluttering, adult acquired, motor speech disorders, therapeutic relationship. 8 TRAINING Throughout the process it was the practical aspects...and the personspecific elements that appeared to motivate the assistants and make a direct difference to clients. Trish Morrison and Eugenie Smuts consider the lessons from a multidisciplinary eating, drinking and swallowing refresher course project for special needs assistants. 10 GOAL NEGOTIATION (4) ...we are continually inspired by therapists commitment to radically changing the philosophy of their services in order to increase clients involvement in their own rehabilitation process... Sam Simpson and Cathy Sparkes conclude their series on goal negotiation with advice about writing goals and listening to the feedback of clients. 4 COVER STORY: CHOICES, POSSIBILITIES AND APPS I became rather obsessively preoccupied with framing objectives for anyone who was keen to be involved in trying the app...The reality gradually dawned on me that testing out this intervention had to start with the truth that there was not one jot of evidence it would be of the slightest use to anyone. Dot Reeves shares her experience of working with an entrepreneur, a software developer, The Makaton Charity and a host of users to create MyChoicePad as a flexible, quick and high quality iPad application.
Cover photo at Derwen College by www.stephenfordphotography.co.uk

16 IN BRIEF Jon Hunt on differential diagnosis of the difficulties underlying apraxia of speech; Wendy Best and colleagues introduce the Centre for Speech and Language Intervention Research website; and Tim Grover and Sallie Bollans encounter Animal Assisted Therapy. 18 JOURNAL CLUB (6) SINGLE SUBJECT DESIGNS ...psychologists working in the field of adult acquired brain injury also continue to employ single subject designs, valuing them in particular for their flexibility and sensitivity to individual differences. Thanks to this, there is a practical and validated appraisal tool... Jennifer Reids series takes the mystery out of critically appraising different types of journal articles. 22 RESOURCE REVIEWS Joanne Curtis looks at the Newcastle University Aphasia Resources, while Louise Tweedie examines the New Reynell Developmental Language Scales. 23 HERES ONE I MADE EARLIER Having offered 70 low cost, fun and flexible therapy suggestions since 2003, Alison Roberts concludes with End of course recap cards and a Heres one with a difference. 24 WINNING WAYS Life coach Jo Middlemiss has written over 20 Winning Ways articles for the magazine since 2003. Here, she reflects on the series and on the meaning and opportunities of lifes transitions.

25 HOW I OFFER IMPAIRMENT THERAPY (1) REANIMATING INTERVENTION After the speech and language therapist has edited the animation movie, both child and clinician view it together. The child is then asked to tell the story. Ravit Cohen-Mimran on Animation Therapy, an approach to narrative intervention with older children. 28 EDITORS CHOICE 29 HOW I OFFER IMPAIRMENT THERAPY (2) STEP BY STEP Recent evidence challenges our traditionally held beliefs by showing that improvement in long-standing chronic aphasia is possible. With the help of Simon and his wife Lesley, Jane Mortley and Rebecca Palmer present the StepByStep program. 34 MY TOP RESOURCES Julie Phillips, Jen Read and Helen Bell reveal the results of a two month student ballot to find the top ten resources at the Manchester Metropolitan University on-site clinic resource centre. E1 CONFERENCE REPORT ONLINE Our developing understanding of normal development and the natural history of speech, language and communication difficulties is largely thanks to the greater availability of longitudinal studies. These dont, however, always tell us what we want to hear. In New dimensions, Avril Nicoll reports on the take home messages from the Child Language Seminar 2011 in Newcastle.

Subscriptions: Tel / fax 01561 377415 Avril Nicoll 2011 Contents of Speech & Language Therapy in Practice reflect the views of the individual authors and not necessarily the views of the publisher. Publication of advertisements is not an endorsement of the advertiser or product or service offered. Any contributions may also appear on the magazines internet site.

12 SOFTWARE SOLUTIONS Corinne Dobinson reviews the Scoring Software for the Comprehensive Aphasia Test. 13 BOUNDARY ISSUES (7) I have frequently asked myself where my ethical responsibility as a magazine publisher ends. Speech & Language Therapy in Practice editor Avril Nicoll reflects on ethical dilemmas of publishing and promotion. 14 TRANSCRIPTION Knowing that narrow transcription is often held up as the gold standard...it makes me feel rather uncomfortable to admit to my clinical reliance on broad transcription. Fay Windsor discusses the implications of a possible gap between theory and practice of phonetic transcription.

Speech & Language Therapy in Practice can be found on EBSCOhost research databases.

news

Speech & Language Therapy in Practice editor Avril Nicoll has been elected to the Fellowship of the Royal College of Speech & Language Therapists having carried out work of special value to the profession. She is pictured with her mother Olwyn Jack after receiving the award at the Honours and Giving Voice dinner in London. Avril said, It was a very happy evening celebrating the many and varied achievements of people in and connected with our profession. I was particularly pleased to spend it in the company of Emma Winn, a longtime reader of the magazine who was kind enough to nominate me. www.rcslt.org

Fellowship for editor

Redevelopment of popular site

As a result of changes in her web hosting arrangements, speechlanguage pathologist Caroline Bowen is in the process of redeveloping her renowned website. Regular users should note that, while the home address will remain the same, all the other URLs will change. Having built up the content of the site since 1998, Caroline describes the redevelopment as an enormous undertaking, particularly having to re-write or re-code or replace the informational pages and articles. As the free resources section will be replaced with mainly new content, many of the current worksheets and articles will disappear. Caroline is urging anyone who has favourites to download them by the end of the year before the new site goes live. www.speech-language-therapy.com

Institute recognised

The influential Aphasia Institute, incorporating the Pat Arato Aphasia Centre, has become the first international recipient of The Robin Tavistock Award. Under the leadership of Aura Kagan, the Canadian facility is known for its pioneering work on training conversation partners and encouraging a focus on the impact of aphasia. The award recognises the contribution of the staff and volunteers over the past 30 years. www.aphasiatavistocktrust.org; www.aphasia.ca

Aphasia aspirations

Connect has launched a short online research survey to find out what people with aphasia and health and social care professionals think of the organisation, and the aspirations they have for services. To encourage as many entries as possible, there is a free prize draw for an iPod. The results will help Connect develop and plan future ways of working. http://ashridge.orsl.co.uk/connect

Over 250 speech and language therapists and service users gathered at Westminster in October for a key event in the Royal College of Speech & Language Therapists Giving Voice campaign strategy. The Council of the College started planning the campaign two years ago when it recognised that speech and Speech and language therapy students from City language therapy services would be University and RCSLTs Dominique Lowenthal vulnerable to cuts if the voices of the (right) Give Voice on Westminster Bridge profession and people with speech, language and communication needs were not heard. They have employed key members of staff with expertise in public relations, and the Westminster event was an important stage in the process of raising awareness among MPs that speech and language therapy transforms lives. Speech and language therapist Moira Ryan from Cornwall had met her MP the day before, and was able to reassure everyone that they are just normal people, and you can have a chat. Her MP had voted for the reforms but wants to hear if they are not working, so has given Moira their card with phone number and email. Derek Munn, RCSLT Director of Policy and Public Affairs, stressed the importance of constructive dialogue. He said MPs were likely to ask What do you want from me?, How many people in my constituency does it affect? and How much does it cost? He also advised therapists to avoid jargon, be positive, and keep it clear, short and local. Over 100 meetings with MPs were held, and RCSLT hopes this will be the start of productive, ongoing relationships. www.rcslt.org/giving_voice

A political voice

A reflection on Speech & Language Therapy in Practice

As the magazine draws to a close, its first publisher and editor Elinor Harbridge looks back on its 26 year history. Speech Therapy in Practice, as it was called then, grew from an idea by two speech therapists Renata Whurr and Stephanie Martin. In 1985 they approached me when I was editor of Remedial Therapist, a fortnightly newspaper for the remedial professions, outlining a plan to produce a regular update of speech and language articles to be included in the newspaper. They had already commissioned articles for the first one when the axe fell on the group of magazines published by Thomsons for the hospital, medical, nursing and paramedical professions. A plan then evolved to publish the articles as a quarterly magzine. I undertook to finance the publication hoping that it would get sufficient advertising and subscriptions to sustain it which, after a worrying period, it did. The following years saw some significant growth and one of the initiatives we were able to make was a travelling scholarship funded by British Telecom who were at the time running Speak Week, an event to raise funds and awareness about the needs of people with speech and language problems. The scholarship allowed several therapists to travel to countries around the world and write up what they had learned for the magazine. However, by 1994, subscriptions to the magazine had begun to fall away and it was badly in need of a fresh approach. I was very glad when Avril responded to my ad for an editor and when I moved to Somerset in 1996 I started to think about a new publisher for the magazine. In 1997, Avril took over, changed the title to Speech & Language Therapy in Practice, and it began to flourish again under her ownership. But today the market is very difficult for small magazine publishers facing fierce competition from the internet. I fully understand Avrils decision to close the magazine and congratulate her on the competent way she has done it. What is the legacy of Speech Therapy in Practice and Speech & Language Therapy in Practice? It is a 26-year archive of articles reflecting the growing expertise of the profession, something we should all be proud of.

SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2011

RESOURCES & COMMENT

Resources

The Tavistock Trust for Aphasia has launched a free online resource to help people with aphasia, their carers and speech and language therapists find software that could help improve their communication. www.aphasiasoftwarefinder.org Video Profiling is a secure site that supports the sharing of therapy and assessment videos on a need to know basis within the team around the child or adolescent. Free trials are available. www.facebook.com/pages/wwwvideoprofilingcouk/34572300309?ref=ts Peter Limbricks TAC interconnections supporting shared information includes a free online TAC (Team Around the Child) Journal. www.teamaroundthechild.com People in Research is a database for members of the public to find out how they can get involved in clinical research. Researchers can also advertise opportunities. www.peopleinresearch.org Blue Tree Publishing produces software, printed media, models and crystal art for medical professionals. It focuses on ear, nose, speech and language, throat and neurology. www.bluetreepublishing.com A GP who is also a parent of a child with a chromosomal disorder has made a short video for Contact a family explaining how parents of disabled children can build a good relationship with their GP and why that is important. www.youtube.com/watch?v=IO_1PTQW8EU&feature=channel_video_title www.cafamily.org.uk I CANs Understanding Communication Development - Working with under 5s Toolkit is aimed at early years practitioners and childminders. http://shop.ican.org.uk/node/30 (75) All Black Sheep Press worksheets are now downloadable on purchase. www.blacksheeppress.co.uk The Health Professions Council is to treat the English and Welsh languages equally when providing services to the public in Wales. www.hpc-uk.org/aboutus/welshlanguagescheme/ Punky is a new animated cartoon featuring a lead character with Down Syndrome. View more information and a trailer at: http://blogs.dsegroup.org/blog/2011/10/05/punky-goes-global/?dm_ i=9MS,KK18,10ZHSX,1O4XH,1 Getting Better and Getting Better in Hospital are cartoon DVDs for people who have learning disabilities. The pack includes an easyread booklet. All voices on the soundtrack are of actors who have learning disabilities. www.leedsanimation.org.uk A website to support professionals working with children and families in the foundation years. http://foundationyears.org.uk The Council for Disabled Children has developed new tools as part of its Managing My Way project to increase the responsibility disabled children and young people are able to take for managing their own health conditions. www.councilfordisabledchildren.org.uk/resources/cdcs-resources/ managing-my-way Talk to Your Babys Community of Research and Practice is an online network bringing together researchers, academics and practitioners who share an interest in the development of young childrens speech, language and communication. Register free at www.literacytrust.org.uk/talk_to_your_baby/corp

Comment:
Room to grow
s I am reliably informed that New Zealand is having a national day of mourning to mark the demise of Speech & Language Therapy in Practice, it is perhaps just as well that Jo Middlemiss has returned with a Winning Ways (p.24) which focuses on managing and appreciating transitions! The many cards, letters and emails I have received following the news that the magazine is ending have been humbling. They have reinforced my experience over the past 14 years that we are very fortunate to have so many forwardthinking, creative, enthusiastic and generous people in our profession. So many have contributed in so many ways to making the magazine what it is, and I hope you all know how grateful I am. Pam Enderby emailed to say, Speech & Language Therapy in Practice seems to have been very much part of my life informative, educational, controversial, always interesting and sometimes irritating, adding, It filled a gap. Fay Windsor (p.14) includes a lovely quote about celebrating gaps within professions because, without them, there is little impetus for growth. When one thing comes to an end it opens up other possibilities and routes. Alison Roberts (p.23), for example, is now sharing her practical therapy ideas through an e-newsletter, which includes interactive elements and can be easily distributed. Leafing through the opening issue of Speech Therapy in Practice from June 1985, I noticed this introduction to an article: The rapid expansion of electronic communication aids can be bewildering to therapists expected to understand the technical jargon and keep up with all the developments (p.6). Fast forward to the closing issue, and we could be talking about apps (Dot Reeves, p.4), making an animated film (Ravit Cohen-Mimran, p.25) or software for aphasia (Jane Mortley & Rebecca Palmer, p.29). Technology will keep marching on, people will spot gaps in the market and they will always find new ways of doing things. When the magazine was first published, I read it as a student. Today I am publishing the results of a ballot of students to find their favourites from their on-site clinic resource centre (p.34). Such facilities are a great example of a creative way to bridge the gap between university and clinic. In 1985, we didnt have so many discussions about dysphagia (Trish Morrison & Eugenie Smuts, p.8), goal negotiation (Sam Simpson & Cathy Sparkes, p.10), ethics (p.13) or critical appraisal (Jen Reid, p.18), but the first issue has clear signs of the direction of travel. The editorial is headlined The challenge of a changing world and articles call for therapists to be more systematic and to think about outcomes. They also press the case for early intervention and more scientific research. So, as the first editor Elinor Harbridge says (p.2), lets celebrate the professions developing expertise, and the legacy the magazine leaves. Lets also look forward to seeing what will happen now there is even more room for growth. Thank you it has been a privilege,

SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2011

COVER STORY

Applying choices and possibilities

READ THIS IF YOU WANT TO DISCOVER YOUR ENTREPRENEURIAL SIDE MAKE INTERACTION MORE DYNAMIC INVOLVE USERS IN DEVELOPING INTERVENTIONS

The increasing prevalence of tablet computers and mobile phones has led to an explosion in applications to support people with a variety of communication needs in the clinic, at home, in school or out and about. There are apps for everything from counting stammering, modelling social skills and drilling speech sounds to practising prepositions. Here speech and language therapist Dot Reeves, an advocate for both the Makaton Language Programme and assistive technology, shares her experience of working with an entrepreneur, a software developer, The Makaton Charity and a host of users to create MyChoicePad as a flexible, quick and high quality application.
o you think it might be helpful for anyone to access, at an instant, the spoken words, signs and symbols which are used with Makaton, via an app on an Apple iPad? When Zoe Peden asked me this question, I immediately said yes! The Makaton Language Programme is well-known to those of us who support people with learning or communication difficulties as an established and highly respected multi-modal programme, which makes use of speech, signs and symbols to support communication. Since it was established in the late 1970s, it has evidenced itself as a truly flexible and adaptable method. Many individuals who use Makaton are also familiar with - and enjoy the benefits of assistive technology. I am a devotee of Makaton, having experienced for myself the profound impact its application can have on those who use it. I have become heavily involved in the various training programmes on offer via The Makaton Charity, and thus get to meet an extraordinary number of extraordinary people using Makaton in a huge variety of ways. I have also been fortunate over the years to gain plenty of hands on experience bringing various aspects of technology into my work with people with learning and communication difficulties. My response to Zoes question was therefore not only enthusiastic but realistic. Zoe, who had previously worked at The Makaton Charity, and Andrew Jackman, a software developer, took their creative thoughts around Makaton and the iPad to the organisation. The charity took a detailed look at the fledgling ideas and agreed this was a project worthy of support. The involvement of a wide range of experienced professionals was seen as an important element, and I felt very honoured to be invited to be part of the process.

Dot

We wanted to harness the possibilities that arose from the availability of a relatively affordable mass market device - the iPad - and produce something that would be a genuine support to the implementation of the Makaton Language Programme. The main challenges were: designing a simple interface designing a positive user experience with touch sensitivity incorporating signs, symbols and speech together designing an approach which supported and reflected the Makaton Language Programme. We never aimed to produce a communication aid. The long-term philosophy was more around a dynamic application (commonly known as an app) on a portable device, the iPad. We wanted it to bring the

full breadth of the Makaton Vocabulary to the fingertips whether in the park, on the beach, in the classroom, or pretty well wherever the iPad could be taken. The approach we used for evolving the software is called Feature Driven Development. This method was perfect for us as we wanted to start with a small, flexible piece of software that could be adapted and improved in quick iterations of development as we got feedback from users. The starting prototype contained the bare bones of the MyChoicePad app the way in being via the cool, simple and famously welldesigned Makaton Symbols. The display could be small, medium or large, so straightaway this offered a choice about how much to display on the iPad screen. The initial trial content was the entire Core Vocabulary of the Makaton Language Programme. Touch the symbol, and the concept depicted is clearly spoken by an English accented male or female voice. Long touch the symbol, and the line drawing and a video can be viewed, or the feature disabled. The starting point of the app was quick-as-aflash production of the vocabulary you might need to support communication. This was important because it could help the Makaton user and communication partner learn the vocabulary they need and would offer a direct reference point for a user wanting to join in the action. We built up the features by accepting or rejecting statements about functions which we could rank hierarchically in terms of priority. Through using this approach, we began to see the required development work ahead. Not only were we able to build an app full of features we knew people wanted, we could also prioritise the development of these and release a minimum viable product. With this bare bones app available to test out, the next phase was to gauge its usefulness

SPEECH & LANGUAGE THERAPY IN PRACTICE winter 2011

COVER STORY

Makaton users have provided invaluable feedback about MyChoicePad. Their responses have driven design and development priorities.

www.stephenfordphotography.co.uk

Thank you to our models and Derwen College

with some target users. Within our profession we are only too aware that an intervention has to have a purpose, be evidence based, and demonstrate good practice. Objectives need to be set, outcomes measured and statistics logged. In theory it is all gloriously logical and measurable and, in the first instance, I became rather obsessively preoccupied with framing objectives for anyone who was keen to be involved in trying the app. I wanted to get the plans down on paper and then review whether the objectives had been achieved. The reality gradually dawned on me that testing out this intervention had to start with the truth that there was not one jot of evidence it would be of the slightest use to anyone. The central philosophy when using Makaton is that it is personalised we dont have a rule book for application. My remit in the development process was to reflect on the ethos of the Makaton Language Programme and draw on my speech and language therapy wisdom regarding ways we could promote successful communication for and with people with learning or communication difficulties. As Makaton is all about meeting individual needs, I realised we needed to hand over the basic app and iPad to people who were keen to help us, then listen closely to their findings. In short, we spent four months trialling the app and experimenting with approaches to its use that supported the Makaton Language Programme. We filmed the trials with schools, speech and language therapists and families. This provided case studies for us to learn from, but also gave us a way of showing other people the wide variety of uses and benefits MyChoicePad could deliver. These short films are available in the stories section of the MyChoicePad website. If we had had any doubts about embarking on this project, the feedback from the trials put paid to them. Even within the first few weeks of having iPads out on loan with MyChoicePad installed it became clear the users were working

things out for themselves and providing us with some fabulous examples of innovative and entirely personalised use. This was good news, as having an iPad and downloading an app seems very much of the people.

Working resource

MyChoicePad was designed to be a working resource for users and their communication partners. While it can end up being an aid to communication, it is not designed to be a communication aid. Within the field of AAC there are awesomely experienced practitioners with a breadth of knowledge and wisdom about technological devices which can support communication, but I am fairly sure Id struggle to find any who can nail a solution in one easy move. A huge part of the process is building up a picture of what a person can already do, or might be able to do. MyChoicePad can help develop a picture of what could be possible. Charmaine (8) has a chromosome disorder. Her mum describes issues with: word recall conversational skills clarity of speech when she is tired the need to know what happens next. After being involved in the development of the app, her mum Eve said, My daughter struggles with the world understanding her; with this app she has a voice in society. She can order her dinner in a restaurant, ask a

friend for tea, go shopping and make her feelings known. She is unable to use a PC, DS or any other computer device, but the touchscreen of an iPad, together with the very visual, familiar special needs-friendly concept that is MyChoicePad, really has opened up a whole new world in terms of freedom, independence and choice. Staff at Severndale Specialist School for Communcation and Interaction in Shrewsbury have been using the app with their secondary aged students to : improve social skills help in making requests aid independence provide confidence to communicate. Assistant head teacher Judith Pilkington commented, We wanted an easy to use aid device that would help in lots of different settings that would not need specialist knowledge to be able to make grids... We found it very cost effective and versatile. Independent speech and language therapist Heather Grainger has been using the app as a therapy tool and for assessments with individuals, and for group sessions with young adults. She says, Dashing between different pupils and students in different locations with differing needs and abilities can be a challenge on the best of days. I use MyChoicePad with young people with a broad range of speech abilities at key and functional word level, and it is a lifesaver when it comes to remembering and helping others with their signs. As speech and language therapists, we like functionally effective intervention strategies. We know when something looks impressive and is probably fun to doodle around with but does absolutely nothing of note to enhance communication. We do however have an open mind when a tool or approach adds positively to motivation or confidence to communicate. (Perhaps thats why we all seemed to like The Kings Speech!) So, without harbouring delusions about its scope, I was

SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2011

COVER STORY / REVIEWS


genuinely inspired by what came out of the trials of the MyChoicePad app, and could see it would be madness not to proceed with development work. MyChoicePad has grown and evolved significantly since I was first asked for an opinion. One of the most recent developments is that people can download a free lite version as a taster, a try before you buy option from iTunes. We also hope the app can be developed for other tablets and devices, but this depends on success with marketing the product and attracting new investment. Marketing is probably the most alien of the activities I have had to think about recently. It is necessary not just so that people who might benefit from the app get the chance to hear about it, but so it can start paying its way and continue to be enhanced. Developing a product might feel very different to developing a service but, from my experience working with Zoe and Andrew, it doesnt have to mean your professional integrity is going to take a battering. Quite the contrary it has been great to offer a voice from a speech and SLTP language therapy perspective. Dot Reeves is a speech and language therapist employed by Shropshire Community Health NHS Trust. She also works freelance as a consultant and trainer and is a Senior Tutor with The Makaton Charity, email dotreeves@gmail.com. You can find out more about MyChoicePad from chief juggler Zoe Peden, email zoe@ mychoicepad.com, or see www.mychoicepad. com and www.makaton.org. Resources Feature Driven Development of software, http://en.wikipedia.org/wiki/Feature_ Driven_Development Minimum viable products, http:// en.wikipedia.org/wiki/Minimum_viable_ product The Kings Speech, www.kingsspeech.com/ Use of Makaton and assistive technology, www.makaton.org/research/research.htm

reviews
SUPERVISION
Inspiring Creative Supervision Caroline Schuck & Jane Wood Jessica Kingsley ISBN 978-1-84905-0790-1 16.99

Enthusiastic and practical

This book is relevant to anyone who wants to get the most out of supervision, as supervisor or supervisee. It contains enough detail and example to guide the relative novice, but a large enough range of strategies to extend a more experienced supervisors repertoire. The clear, informative style draws on a wealth of experience. It gives a reader-friendly overview of theory while offering an enthusiastic and lively resource bursting with practical frameworks, ideas, activities and strategies for group and one-to-one supervision. The layout is easy to navigate and allows for dipping in and out. I will definitely enjoy revisiting this book and look forward to trying out some of the ideas within my own work, reflection and training sessions. It is an excellent buy for those interested in extending their supervision experience. Tamsin Crothers is a speech and language therapist specialising in AAC, and part of the supervision working party in the speech and language therapy department of Ashton, Leigh & Wigan Division of The Bridgewater Trust. She is also co-founder of 1Voice - Communicating Together, supporting children, young people and families who use AAC.

with families. The appendices provide some interesting frameworks and checklists. Whilst the book refers to American terms and systems, the information is still useful. In places it is slightly repetitive (for example, the importance of good early hearing technology) and would benefit from more therapy suggestions, examples and sample sessions. However, I would recommend it as a detailed reference for students, a good resource for those new to the field and a refresher for more experienced clinicians, particularly with its discussion around recent research. I certainly enjoyed reading it and will dip into it again. Rachel Millward is a speech and language therapist working for the Durham Sensory Support Service with children who have a hearing loss.

COMMUNICATION SKILLS

Helping Children to Improve their Communication Skills: Therapeutic Activities for Teachers, Parents and Therapists Deborah M. Plummer Jessica Kingsley ISBN 978-1-84310-959-4 18.99

Best for groups

HEARING IMPAIRMENT

REFLECTIONS DO I KEEP ABREAST OF MASS MARKET TECHNOLOGICAL INNOVATION THAT COULD BENEFIT MY CLIENTS? DO I THINK THROUGH THE ETHICAL DIMENSIONS OF WORKING ON PRODUCT DEVELOPMENT? DO I SET OBJECTIVES IN A WAY THAT IS APPROPRIATE TO THE TASK IN HAND?
How has this article changed your views? Let us know via Speech & Language Therapy in Practices Critical Friends, see www.speechmag.com/About/Friends.

Children with Hearing Loss - Developing Listening and Talking, Birth to Six (2nd edn) Elizabeth B. Cole & Carol Flexer Plural ISBN 978-1-59756-379-6 41.00

Very readable

This detailed book looks at the skills and knowledge needed to promote the development of spoken language through listening in young children and babies with a hearing loss. Despite its length it is very readable. Each chapters key points give a clear and concise explanation of the information to come. The comprehensive contents page makes it quick and easy to look up specific information. Early chapters provide a good overview of hearing loss, with information on terminology, technology, the structure and function of the ear, and causes. It includes data on good language learning environments and early language development. Later chapters look at intervention and are more practical, exploring strategies and activities for working

This book links research to clinical practice through the use of play. Five of the twelve chapters describe the theoretical background of play as an integral aspect of communication. There is not a lot of new information in these chapters, however they act as a useful reminder of the importance of play and the need to consider all processes involved in play when communicating with children. Parents felt these theory chapters were quite excessive, with information overload, however teachers appeared more aware and informed on completing them. The remaining seven chapters provide a wide range of activities split into different skills and communication outcomes and goals, which is extremely beneficial. A range of useful adaptations are also presented. The range of activities is excellent, but I feel they are a lot more suited to a classroom or group setting where you can include a larger number of children. They could be used with individual children but would require altering. Parents felt there was a lot to read and may be of increased benefit if directed to specific activities for their child rather than accessing the whole book. I feel this book would be of good value as a departmental resource, particularly if you work in group settings and can integrate therapy into classroom settings. Lynsey McDowell is a community speech & language therapist in Newry, Northern Ireland. She reviewed this book with the help of parents and teachers.

SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2011

REVIEWS

NEUROREHABILITATION

The Strands of Speech and Language Therapy: Weaving a Therapy Plan for Neurorehabilitation Katy James, Jacqueline McIntosh, Nicole Charles, Brenda Lyons & Beverley Leach Speechmark ISBN978-0-86388-815-1 36.99

balanced some of the more academic detail presented in the book. Although the book is not easily accessible due to its academic style, it is of value to clinicians working in this field as a unique source of information. Grace Lawson-Baker is a speech and language therapist working in Portsmouth for Solent NHS Trust.

Sound and relevant

This book is written by a team of speech and language therapists from the Wolfson Neurorehabilitation Centre. They have the luxury of working intensively with selected patients with acquired communication disorders following stroke or brain injury. This is provided in individual sessions, groups, multidisciplinary joint sessions and working with families. They describe their approach to treatment as an interwoven scarf with the six strands of assessment, education, goal planning, involving family and friends, specific treatments and psychological adjustments. This resource is easy to read and based on sound methodology and evidence. It is relevant to everyday work in the clinic for experienced therapists and for students. The excellent printable sheets cover a range of subjects, from explaining aphasia to conversation rating scales. Ann Gosman is a senior specialist speech and language therapist with NHS Orkney.

ADULT ACQUIRED

Assessment of Communication Disorders in Adults M.N. Hegde & Don Freed Plural ISBN 978-1-59756-414-4 51.00

(International Classification of Functioning, Disability and Health). Conversation analysis, telehealth, imaging and neural modelling are also covered. Although some chapters are relevant to developmental motor speech disorders, the focus is primarily on acquired disorders. Some aspects of assessment are more applicable for research, however much is relevant for clinical assessment of this complex range of disorders. This text is accessible and would be of use to newly qualified and experienced clinicians alike. Claire Bagness is a speech and language therapist working with adults with acquired communication and swallowing disorders in Northumberland.

Easy to dip into

THERAPEUTIC RELATIONSHIP
Therapeutic Processes for Communication Disorders Robert J. Fourie (ed.) Psychology Press ISBN 978-1-84872-041-1 34.95

CLUTTERING

Cluttering - A Handbook of Research, Intervention and Education David Ward and Kathleen Scaler Scott (eds.) Plural ISBN 978-1-84872-029-9 44.95

Unique source

For those wishing to gain a greater understanding of this Cinderella disorder this provides the latest research findings including fascinating chapters on the nature and neurology of cluttering. For the practising clinician its strongest and most useful areas are in the section describing the assessment and treatment of cluttering. These present the reader with in-depth methodologies for assessment and include chapters that discuss disorders that may co-occur with cluttering, such as Downs Syndrome and stuttering. The chapters on treatment are well described and provide the clinician with evidence-based intervention paradigms suitable for children and adults. The chapter on self-help and support groups for people with cluttering was of particular interest. The personal stories it contains provided an insight into the disorder and its impact on people who clutter, that

This American text provides a comprehensive set of resources and protocols for the assessment of a range of acquired communication disorders: aphasia, dysarthria, dyspraxia, dementia, fluency and voice. There are also chapters describing right hemisphere syndrome and traumatic brain injury. Definitions and key characteristics of each of these disorders are provided, albeit quite superficially, with key questions for case history taking and a summary of standardised assessment tools where relevant. The focus is primarily upon the medical model of communication disorders, with minimal mention of the social impact of acquired communication disorders, now an integral part of care pathways in UK. The text is reasonably priced and includes a CD containing all the assessment and protocol resources, which can be modified by individual clinicians. This is very useful given the American nature of the text. I would recommend this resource to a student or newly qualified clinician. It is easy to dip into to select a relevant clinical tool for day to day practice. Lynn Dangerfield is principal speech and language therapist with a shared clinical lead for stroke care employed by Solent NHS Trust.

Considerable depth

MOTOR SPEECH DISORDERS


Assessment of Motor Speech Disorders Anja Lowit & Raymond D. Kent Plural ISBN 978-1-59756-367-6 51.00

Holistic and comprehensive

This is an up-to-date comprehensive overview of holistic assessment of motor speech disorders. Phonetic and physiological assessment are thoroughly detailed as well as evaluation of the impact of motor speech disorders on an individual through adoption of the ICF framework

Intelligent and thought-provoking, this book is a must read for therapists dedicated to the task of real change in the speech and language processes of clients. It aims to bring our attention to the human face of our work. It specifically focuses on the umbilical purpose of the emerging therapeutic relationship, and argues its inevitable impact on therapeutic outcome. The contributors (mainly from Ireland and the U.S.) present us with a myriad of perspectives, from the more familiar arena of supervision, to a perhaps more eyebrow-raising exploration of the effect of spirituality and the soul. What sets this book apart is the detail gone into by each author, as they describe the mechanisms and processes in their respective areas of expertise. More significantly, they also compel us towards a realisation that, if we are to enhance our understanding and efficacy, we have to undertake our work in concert with the emerging relationship and the processes therein. Such a determined advancement of the therapeutic relationship as touchstone is a stark contrast to the current practice of many, particularly those who work within the NHS. The emergence of the Consultative Model is - in my opinion - the negative heritage of the sole use of the scientific model as a methodology to provide us with professional credibility. This book is a well-timed and much needed reminder of why it is critical to reinstate the therapeutic relationship into our practice and recognise it as an integral part of our professional enquiry. In short, a book we all need to read, with a message we ignore at our peril. Geraldine Wotton is an independent speech and language therapist in East London and Essex.

SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2011

TRAINING

A practical focus
Trish Morrison and Eugenie Smuts want to ensure pupils with eating, drinking and swallowing difficulties receive the safest and most appropriate help at school lunchtimes. Here they consider what lessons they can learn from a project to develop and evaluate a multidisciplinary refresher course for special needs assistants.

READ THIS IF YOU WANT TO PROVIDE TRAINING THAT IS MULTIDISCIPLINARY TIME EFFICIENT MOTIVATING FOR PARTICIPANTS

e are involved in assessment and management of individuals with eating, drinking and swallowing difficulties at a centre which provides services to people with physical disabilities from birth throughout life. As we spend considerable time in our schools eating, drinking and swallowing service on training, we were interested in developing and evaluating a refresher package for special needs assistants. In highlighting the pitfalls and what we found worked best, we hope this article gives you food for thought when developing your own staff training. Given the number of communication training packages around (see for example Manolson, 1992), we were struck by the paucity of training packages for people supporting children with eating, drinking and swallowing difficulties. In an attempt to locate what might already be available we googled, as per the first port of call in the 21st century! This identified some online dysphagia training (at www.nursingtimes.net) and articles (such as Miller & Krawczyk, 2001) which focus on training for nurses working with adults with acquired dysphagia. Bailey et al. (2008) address dysphagia services in a school setting and examine speech-language pathologists perspectives. Among the concerns highlighted is the need for the therapist to be appropriately trained and supported by a team. Our training has the advantage of being delivered by members of the core multidisciplinary team involved in dysphagia management. Miller & Krawczyk (2001, p.38) cite Pediani & Walsh (2000) as providing useful guidelines for effective training, including: Keeping new ideas simple, understandable and communicating effectively. Ensuring that new ideas are obviously and immediately useful. Supporting the teaching with clear practical demonstration. Miller & Krawczyk also recommend engaging the learners from the outset by agreeing objectives and learning expectations. In terms of core content, an informal discussion with colleagues indicated the importance of including: a. The normal swallow b. The effects of physical disability on eating, drinking and swallowing

Trish

Eugenie

The need to be aware of eating, drinking and swallowing issues d. Aspiration e. Positioning f. Utensils g. How to make feeding safe h. Information on food consistencies i. Oesophageal reflux j. Effect of hyper- and hypo- sensitivity on eating, drinking and swallowing. From our reading and clinical experience, we believed that: i. carer knowledge would improve following refresher training ii. carers would prefer training that includes a one-to-one practical component iii. feeder compliance with management recommendations and strategies would increase following training.

c.

Our course

The course we developed and coordinated is run by a multidisciplinary team comprising an occupational therapist, physiotherapist, dietitian and speech and language therapist. It takes approximately 3.5 to 4 hours and can be comfortably fitted into a morning or afternoon. Topics covered are supported by practical activities, video clips and handouts. The session begins with a 7 point questionnaire we developed to assess participants knowledge prior to training. Questions are practical, and probe the participants awareness of signs of aspiration and ability to identify and describe why and how utensils might be used. Finally it asks them how to prepare food and drink of a specified consistency. The course includes a review of the normal swallow and revision of aspiration and reflux led by the speech and language therapist. The

physiotherapist and occupational therapist then jointly present positioning to maximise safe swallowing. This includes information on cerebral palsy, tone and patterns of flexion and extension. They particularly emphasise repositioning a child before feeding them to achieve a correct seating position. The presentation then moves on to look at the impact of the feeders position. At a later stage the speech and language therapist relates patterns of extension and flexion to what is observed in the childs oral motor structures and the implications for management. Sensory aspects of eating, drinking and swallowing are covered jointly by the speech and language therapist and occupational therapist. The occupational therapist then reviews use of utensils to enhance oral motor skills and independence. In an effort to make the training practical and relevant, yet feasible within our centre, we look at the influence of environmental factors and both the childs and the feeders communication. We practise strategies such as providing jaw support, and review when and why they might be useful. The morning concludes with a presentation from our dietitian, who looks at the importance of good nutrition and reviews the guidelines for nutritional intake in children and how these change with age. She covers the effects of poor weight gain, spillage, nutritional deficiencies, and the use of supplements. The participants are then shown how to use thickeners and have the chance to practise producing drinks of a specified consistency. The theory part of the course ends with readministration of the questionnaire.

Evaluation

This course was part of a week-long training package in July 2009 for Special Needs Assistants working in the Central Remedial Clinic School. It was offered to 27 people, of whom 26 attended on the day (1 was absent due to illness). We evaluated the impact in three ways. Firstly, we asked those attending to complete a general feedback form. Secondly, we looked at the pre- and post- training questionnaire responses. Finally, we allocated each assistant a number between 1 and 9,

SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2011

TRAINING
and used a random sampling table from the internet to select 10 people who would be offered additional one-to-one training. a) Written feedback We received written feedback on the training from 13 of the assistants, and in general it was positive. They liked the opportunity to have a refresher, particularly as it was presented by members of the multidisciplinary team. Three of the respondents rightly did not appreciate questions that went off topic, which was a lesson to us as presenters that we need to be more proactive in crowd control! Other comments reflected a broad range of themes and were mainly practical questions relating to clients the respondents were feeding. b) Questionnaire responses A number of people arrived late on the day so didnt complete the first questionnaire. Others left early before completing the second, so just 14 of the 26 completed and submitted both the pre- and post-training questionnaires. We had to exclude one of these where the person had answered same as before on a number of occasions, as it was unclear whether this referred to the previous question or to their previous questionnaire. Of the 13 remaining, we scored correct answers as 1, partially correct as and wrong as 0. All post-questionnaires showed improved total scores, but some were minimal; for example, 3 of the 13 only improved by to 1 point. Interpretation of the results is tricky, particularly as it could be argued the percentage of errors in most areas was already relatively low on the pre-questionnaire. Our conclusion was that our coverage of aspiration had an impact, and that there may have been small positive changes in terms of utensils. However, the assistants knowledge of food consistencies and how to prepare them did not change, and we have therefore decided we need to review and alter this aspect of the course. c) One-to-one The one-to-one sessions took place during lunchtime while the assistants were feeding their client. As 2 of the 10 selected were repeatedly absent for the scheduled observations, 8 people were included in this phase of the project. Special Needs Assistants usually feed the same client for a period of 6-12 months, and allocation of feeders to clients falls under management of the nursing department. The first one-to-one training session took place during October-November 2009 and the second in January-February 2010, approximately 8 weeks later. During each of these sessions the speech and language therapist completed a feeding observation checklist which we had devised for this project, and provided advice and on the spot training as needed. Every client attending the school eating, drinking and swallowing clinic receives a laminated placemat. This lists recommended food and liquid consistencies and supplements for the individual, along with guidelines on pacing, spoon placement and communication as well as seating and positioning. The placemats are updated as required. Copies are kept in the nursing department, and responsibility for distribution and collection falls under the remit of the nursing department. During the one-to-one sessions the speech and language therapist monitored compliance to the placemat guidelines, putting yes if recommendations were followed and no if they were not. The checklist included an area to note down any additional comments, and the speech and language therapist followed up any concerns or queries reported by the assistants with relevant professionals. Overall, the checklist used in the first oneto-one observation session showed there was already generally good compliance for use of recommended utensils, for solid and liquid consistencies and supplements, and for following feeder guidelines. Only 2 of the 8 assistants needed a practical demonstration or additional guidelines, and at the second session they maintained the strategies recommended. We were somewhat concerned that 3 of the 8 placemats were missing on the first occasion, and 2 on the second. Reasons ranged from accidental misplacing on another table to a client not having a placemat as they had been discharged from the eating, drinking and swallowing service and were awaiting review. Of the 8 assistants, 3 reported not receiving sufficient and appropriate guidelines from staff prior to feeding a client for the first time, and 7 said they had concerns about the high number of pupils they are supervising whilst feeding a client. They find this distracts their attention and eats into the time needed to feed their client. via an online module, which we would update regularly to keep pace with development of knowledge. We would then focus our time on supporting assistants on a practical level. We would welcome comments or contact from other services offering paediatric SLTP feeding training packages. Trish Morrison (email tmorrison@crc.ie) and Eugenie Smuts (email esmuts@crc.ie) are speech and language therapists at the Central Remedial Clinic in Dublin.
References Bailey, R.L., Staner, J.B., Angell, M.E. & Fetzner, A. (2008) School-based Speech Language Pathologist Perspectives on Dysphagia Management in the Schools, Language Speech and Hearing Services in Schools 39(4), pp.441-450. Manolson, A. (1992) It Takes Two To Talk: A Parents Guide to Helping Children Communicate. Toronto: The Hanen Centre. Miller, R. & Krawczyk, K. (2001) Dysphagia Training Programmes: Fixes That Fail or Effective InterDisciplinary Working, International Journal of Communication Disorders 20(S1), pp.374-384. Bibliography American Speech-Language-Hearing Association (2007) Guidelines for speech-language pathologists providing swallowing and feeding services in schools. Available at: http://www.asha.org/docs/html/ GL2007-00276.html (Accessed 26 September 2011.) Colodny, N. (2001) Construction and Validation of the Mealtime and Dysphagia Questionnaire: An Instrument Designed to Assess Nursing Staff Reasons for Noncompliance with SLP Dysphagia and Feeding Recommendations, Dysphagia 16(4), pp.263-271. Crawford, H., Leslie, P. & Drinnan, M.J. (2007) Compliance with Dysphagia Recommendations by Carers of Adults with Intellectual Impairment, Dysphagia 22(4), pp.326-334. Homer, E.M. (2008) Establishing a Public School Dysphagia Program: a Model for administration and Service Provision, Language Speech and Hearing Services in Schools 39(2), pp.177-191. Huffman, N.P. & Owre, D.W. (2008) Ethical Issues in Providing Services in Schools to Children with Swallowing and Feeding Disorders, Language Speech and Hearing Services in Schools, 39(2), pp.167-176.

The implications

Overall our three beliefs about training at the start of this project were reinforced, but the process raised a number of issues we need to reflect on. Even when a course is mandatory, and is run by core members of the on-site multidisciplinary team, levels of engagement by participants differ. Some are already knowledgeable and comply with recommendations, but we do not know about those who didnt complete both questionnaires, or who were unavailable for the observations. Furthermore, while the majority of those giving feedback on the 13 point questionnaire wanted both theoretical and practical components, 2 wanted only practical training. Throughout the process it was the practical aspects, including the activities and videos used during the initial days training, and the person-specific elements that appeared to motivate the assistants and make a direct difference to clients. Given this, and the current financial pressures on the health service, we are considering providing the theoretical training

REFLECTIONS DO I ACCEPT THAT PEOPLE NEED DIFFERENT BALANCES OF THEORETICAL AND PRACTICAL TRAINING? DO I CAPITALISE ON AN INDIVIDUALS INTEREST IN THEIR OWN CLIENT AND SITUATION? DO I ADDRESS ANY WIDER SYSTEM PROBLEMS REVEALED THROUGH TRAINING AND ITS EVALUATION?
What feedback can you offer? Let us know via Speech & Language Therapy in Practices Critical Friends, www. speechmag.com/About/Friends.

SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2011

GOAL NEGOTIATION (4)

Whose goal is it anyway?


Part 4: Getting the wording right
Sam Simpson and Cathy Sparkes conclude their series by considering the final stage of the process and reflecting on how people with whom they have worked have been supported by goal negotiation.
n this final article we will consider the skills involved in writing goals, and reflect on clinicians service developments that we have supported in recent years. We will conclude with the views of some of our clients regarding the role goal negotiation has played in their rehabilitation. READ THIS IF YOU WANT THERAPY TO BE MORE CLIENT-CENTRED MEANINGFUL FOCUSED

Goal writing skills

Our decision to hold off discussing the actual process of writing goals until our final article has been a conscious one. It reflects our view that this comprises the final stage of the goal negotiation process. When we facilitate training days this is often the area that many clinicians are keen to cover. However we strongly believe that, if time has been taken to engage clients in the previous stages detailed in the first three articles, then the actual writing of clientcentred goals becomes a more natural process and more meaningful to each individual client. Thus, it can be seen that we place considerable emphasis on the goal negotiation process in addition to the actual writing of goals. In terms of the knowledge and skills involved in writing and documenting goals, we believe the following are important: 1. an openness and willingness to listen to what has meaning for the client and to suspend your own agenda 2. the capacity to support clients aspirations with respect to time frames and negotiate what is possible and meaningful within the boundaries of the service you work in 3. knowledge of useful frameworks for writing and wording goals in addition to experience and practice of these 4. flexibility in style according to the target audience and their accessibility needs 5. a clear differentiation between goal areas, long-term goals, short-term goals and plans of action 6. a commitment to transparency of documentation for clients, families and professionals 7. effective communication within the team and a shared ownership of the goals negotiated

Cathy and Sam

8. an understanding of the need to review opportunities across the team to regularly evaluate the quality of the goals that are being written involving feedback from different sources (including clients and families).

Frameworks for writing goals

The most well-known framework used to structure the writing of goals is the S.M.A.R.T. acronym. Having originated from the world of business, this framework was quickly applied to many other contexts, including speech and language therapy. Indeed, we are first exposed to this model of goal writing at university in relation to writing our own personal learning objectives as students as well as in relation to the goals negotiated with clients. Whilst S.M.A.R.T. remains a well-used term by many healthcare professionals, it is apparent that what is meant by the term varies greatly. Wade (2009, p.294) summarised the words associated with the S.M.A.R.T. acronym that appear in the literature, some of which are:

S: specific, significant, stretching, simple, stimulating, succinct, straightforward, self-owned, self-managed, self-controlled, strategic, sensible M: measurable, meaningful, motivational, manageable, magical, magnetic, maintainable A: agreed upon, attainable, achievable, acceptable, action-oriented, ambitious, appropriate, aspirational, accepted / acceptable, accountable R: realistic, relevant, reasonable, rewarding, results-oriented, resourced, recorded, reviewable, robust T: time-based, timely, tangible, trackable, tactical, traceable, toward what you want. This lack of consensus highlights the intrinsic difficulty in using this framework as a clinical standard across a multidisciplinary team. Our clinical experience has also led us to question a number of the parameters espoused by this framework. We wholeheartedly agree on the importance of specific, meaningful goals that are relevant to the client and clearly framed

10

SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2011

GOAL NEGOTIATION (4)


Question Whose goal is it? Consideration Is the goal really your clients? To be sure, check with your client as only they can judge what truly has meaning for them. Be open to changing tack according to their wants and priorities. When writing the goal always use their name or I to make ownership clear. How specific can you be regarding your clients goal(s) at the start of intervention? Are you respecting the process or rushing to an outcome? Try working with a provisional goal area until a more specific long-term goal can be negotiated. Check whether it is possible to collapse some goals into one / make the goals more multidisciplinary / develop a more overarching goal. Remember that meaningful goals are likely to embrace a broader life perspective. On average a client might have 2 or 3 longer-term or discharge goals. More than 4 becomes unwieldy to review regularly. Consider yourself in the position of reviewing the goal after the allotted time frame and review the writing in that light. How confident do you feel in being able to assess whether the goal has been achieved or not? Consider the balance of professional language and your clients language. Where appropriate, can you have different formats for different audiences? For example, can you develop a communication-friendly goal sheet for the client and their family and have an additional document for the multidisciplinary team / commissioners? Sometimes there is a tendency for clinicians to prefer one level of goal writing. To ensure variety and that you are working at a level that has meaning for your client, check with them. Peer review of goals can also be helpful. Context will be influential here, eg. acute stage, rehabilitation, at home. Goals can be written at all levels in all contexts but some contexts lend themselves more readily to goals at certain levels. Are the goals agreed with a client and their family / friends readily available and clear to all? Are they written in an accessible format for the whole team? Are they used to form the basis of reports and / or the transfer of important information to further services / stakeholders? Consider using a future verb, eg. John WILL, to express a future intent and commitment to the goal. Avoid professional speak such as mobilise for walk and upper limb for arm. It is often helpful to include a description of the rehabilitation plan within the goal (see figure 1). 1. 2. 3. 4. 5. 6. Knowledge, eg. describe, identify, list, present Comprehension, eg. explain, give examples, decide how realistic it is to Application, eg. demonstrate, show Analysis, eg. discriminate, distinguish Synthesis, eg. organise, plan Evaluation, eg. compare, contrast

Is a goal area more useful?

How many goals does your client have?

How easy will it be to determine whether the goal has been achieved at the agreed time in the future? To what extent are you using your clients language? How accessible is the goal summary sheet to the client and their family? Are you negotiating goals at impairment, activity and participation levels?

How visible are the goals that you negotiate?

What type of language are you using?

Consider the types of goals

Longer-term vs. shorter-term goals?

For longer-term goals / discharge goals we are looking at a sustainable change. Shorter-term goals may reflect that your client has managed to carry something out once and that this was a stepping stone to the next task. Ensure this difference is clearly reflected in the goals you write. Some clients are not keen for their families to be involved in their goals / care and this needs to be respected. For those who are, however, it is helpful to include them either in a goal or even negotiate goals for them independent of the client. Independent has many connotations and we need to be especially clear as to what our clients understand by the term. The same applies to appropriate and to be able to. It is often more helpful to describe the conditions under which someone will be doing something more specifically.

Are you including your clients family and friends as much as you can? Are there any words / phrases to be wary of?

Figure 2 Grid for reflection on goal writing processes

in time. However, we question the need for goals to always be achievable and would certainly be willing to negotiate an ambitious goal in order to preserve motivation and promote self-awareness. What is key here is a willingness to listen to what has meaning for a client whilst also holding onto your own professional integrity and not colluding. We have over time developed an alternative framework to S.M.A.R.T., which was outlined in our first article (figure 1). We believe this framework can guide and support professionals and clients in creating goals which have meaning to the client,

but which can also be measured at the appropriate time in the future.
Figure 1 Alternative framework WHO Will be doing WHAT Under what CONDITIONS To what DEGREE of succcess Within what period of TIME

Common pitfalls

We hope that the grid in figure 2 will enable readers to reflect on their own goal writing processes both at a macro and micro level. We have tried to make it as user-friendly as possible by targeting questions we frequently encourage clinicians to consider on training courses or in supervision.

eg John will go to the cinema with a friend (James or Susan) at least once a month for the next three months.

Service developments

It is evident from this series of articles that client-centred goal negotiation encompasses elements that operate at a service level as well
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2011

11

GOAL NEGOTIATION (4) / SOFTWARE SOLUTIONS

SOFTWARE SOLUTIONS
Scoring Software for the Comprehensive Aphasia Test Robin Keith & Elise Croot Psychology Press ISBN 978-1-84872064-0 100

I looked forward to reviewing this software as I am all in favour of using technology where it can save time or enhance the working day. Sadly, though, I found it disappointing. The CAT scoring software (v2.24) presents as a prototype rather than a ready-for-market product and therefore lacks appeal. It is essentially an Excel document with formulae incorporated to make calculations. The programme components (Scoring software, User-Manual, Demos, Help) are filed separately in a Windows explorer folder and it was irritating to have to return to the start menu to open each one; links would be better. I found the scoring interface busy and confusing and had to enable macros for it to work properly. While this is apparently normal, it might be off-putting for some people and a basic knowledge of Excel would be helpful. Despite this, I think CAT users will find some of the features useful. Scores from the CAT subtests are entered into the appropriate cells on the worksheet and T-score values are automatically calculated, which saves time. Providing the scores of 6/8 modules of the language battery have been entered, it will provide the Overall Severity of Aphasic Impairment Estimate automatically. It also allows for three assessments per client and will display the results in a graph for comparison over time. These can be copied into a report, but the graphs are rather unattractive and require colour printing, which may pose problems for some clinicians. It is not clear if one can add more assessments per client; this would be a helpful feature for those doing research. The demos are static examples of scores sheets which I did not find particularly helpful. For online support one has to post questions and wait for a reply; it does not give immediate assistance or provide FAQs. There were also a few other glitches that need attention. While a patients document can be transferred for other people to read, the single-user licence requires each staff member to have their own copy if they wish to use the software. Retailing at around 100 I think the hard-strapped purchaser deserves a more polished, user-friendly and professionally designed software product, particularly as the CAT retails at approximately 150. Maybe the next version? Dr Corinne Dobinson is a speech and language therapy clinician and researcher. She works with people at Bristol General Hospital who have acquired neurological communication problems.

as at the clinical interface between client and therapist. Whilst we have primarily wanted these articles to be practical in order to bolster confidence and skills in relation to the negotiation and writing of goals, we believe it is important for therapists to appreciate the extent to which the process of goal negotiation is influenced by the values and structures of the service within which they work. Having co-facilitated training days on client-centred goal negotiation for over a decade, we are continually inspired by therapists commitment to radically changing the philosophy of their services in order to increase clients involvement in their own rehabilitation process as well as contributing to developments in more flexible service delivery. Achievements that are particularly worthy of note are: a. The use of focus groups to critique goal negotiation practice, and develop clearer pathways and written materials b. Revision and creation of clientcentred materials to support clients understanding of the goal negotiation process in rehabilitation and the role they play within it c. Pictorial representations of the rehabilitation pathway including goal planning steps d. Different multidisciplinary note formats to ensure the client is regularly consulted throughout the process e. Specific client information, such as pictographic goal sheets at bedside, in client folders and in care plans / Kardex f. General information regarding the goal planning process on ward / centre / unit pin boards, in information leaflets and in client handbooks g. Service-specific goal planning training for all staff including devising a method of cascading information to new / subsequent staff h. Inclusion of information on goal negotiation in the induction pack for new staff and for clients (such as a client handbook) i. The development of specific roles / responsibilities for goal planning, for example a key worker j. Allocation of a goal negotiation co-ordinator to oversee service developments with the support of a multidisciplinary working party.

in a split second. This leaves you in terrible confusion as to whether it can be put back together; you know deep down that it can as it is in arrangeable pieces but you have an overriding fear that the picture has changed and some pieces are lost; so how and where do you get the drive and guidance to start rebuilding? By breaking long-term goals down into shortterm goals that could be dealt with in stages I was shown how a problem that I had feared (and disliked myself for fearing) was changed from an all-enveloping cloud into a much less daunting series of problems. I felt that I was at college and the subject being studied was myself, and this was a major part of my starting to accept what had happened to me, that I had a future, that all was not lost and new experiences could be had. I could think about how I want to be, what I want to do and where I could find these things then I could pick what bit I wanted to look at and change Everything became a reality once Id written it down something to aim for getting them written down made a valid point of me doing it. As each goal was achieved I felt I gained courage and insight, enabling me to realise and face more problems, though this was not without difficulty. Keeping a diary of goals, achievements and problems is still an important part of my life, a personal reference book helping me to see progress or understand the reason if I am feeling despondent. These help me deal with challenges because I now have positive experiences to draw on. We hope that this series of articles has provided you with a useful revision of goal negotiation principles and processes, a fresh look at your existing practice(s) and an opportunity to consider creative ways to approach your service in the future. We appreciate that the extent to which a fully person-centred approach to goal negotiation can be applied needs to be considered within the context of available resources and structures and values of your service. However, we encourage you to identify a small change you can make to your clinical practice over the next few weeks in the first instance as well as to make links with a possible ally with whom you can work towards change at a service level. We welcome any comments you have in relation to this series of articles (info@ SLTP intandem.co.uk). Sam Simpson (email sam@intandem.co.uk) is a specialist speech and language therapist and trainee counsellor. Cathy Sparkes is a specialist speech and language therapist and counsellor. Together they are intandem (www.intandem.co.uk).
References Wade, D. (2009) Editorial - Goal setting in rehabilitation: an overview of what, why and how, Clinical Rehabilitation 23(4), pp.291-295.

The client voice

The following are a small selection of client quotations illustrating the important role they attribute goal negotiation to have played in their rehabilitation process: Picture your life as a jigsaw that is coming together nicely and has taken 31 years to get this far. Then imagine the feelings of dismay, anger and ruined effort when someone knocks your jigsaw off the table. All that concentration, effort and patience in building your picture is lost. Shattered into pieces

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BOUNDARY ISSUES (7)

Drawing the line


As Speech & Language Therapy in Practice draws to a close, editor Avril Nicoll reflects on some of the ethical dimensions of publishing and promotion.
n page 6 Dot Reeves discusses how being involved in marketing a new product felt alien to her. At the same time she realised that the people who might benefit needed to hear about the product, and it could only be improved if it paid its way. In the event she was reassured to find that this kind of activity doesnt have to mean your professional integrity is going to take a battering. The Health Professions Council Standards of conduct, performance and ethics have been constructed to apply to all registrants whatever their professional role. The way the NHS is shifting suggests we may increasingly seek creative ways to put our speech and language therapy skills to good use and attract funding. The detail of the expectations under standard 14 is therefore worth a closer look (HPC, 2008, p.14): If you are involved in advertising or promoting any product or service, you must make sure that you use your knowledge, skills and experience in an accurate and responsible way. You must not make or support unjustifiable statements relating to particular products. Any potential financial reward should not play a part in the advice or recommendations of products and services you give. Although we are discussing products and promotion, Body & McAllister (2009, p.1) observe that Ethics is basically about people and how they relate to each other. In a social world we depend on connection and reciprocity. The ethical boundaries can be messy or confusing, and often we may not even realise they are needed. Publishing and editing Speech & Language Therapy in Practice has raised my awareness of such dimensions, and some of this might strike a chord with clinicians and managers who are having to negotiate an increasingly commercial space. I am not against advertising, marketing and public relations. Indeed, the magazine could not have survived so long if I hadnt used all these methods to promote and sustain it. The challenge, as always, comes in recognising there is a line and deciding where to draw it. In the same way as conference organisers seek sponsorship to mitigate their costs, any additional income from advertising potentially helps keeps down the price of a subscription magazine to the customer. Disclaimers and clear physical separation attempt to distance organisers and publishers from sponsorship and advertising, but I have frequently asked myself where my ethical responsibility as a magazine publisher ends. Is it possible to avoid the consequence of the reader forming an association between the magazine and the product? Should we even care?

BOUNDARY ISSUES EXPLAINED The Health Professions Council Standards of conduct, performance and ethics (2008) require us to behave with honesty and integrity at all times (p.14). We are reminded that poor conduct outside of your professional life may still affect someones confidence in you and your profession (p.9). Arguably, our clinical conversations and research literature do not focus sufficiently on moral principles, but they at least touch on the ethics around issues such as prioritisation and evidence-based practice. In this series we think through everyday events which receive much less attention but also need to be on our ethical radar. To do the best for their clients in line with the bioethical principle of beneficence (Beauchamp & Childress, 2001), therapists need access to tools for continuing professional development. I have happily accepted adverts for communication aids, advanced courses, assessments and therapy programmes. After some soul searching I decided to include adverts from recruitment agencies, on the grounds that individual therapists have the autonomy to decide who they will work for. I declined to deal with a company that I boycott in my personal life as this would produce conflict in what is known in virtue ethics as narrative unity (Hodkinson, 2008). But was I right to use my position as a gatekeeper in this way, especially if the products might benefit clients? In any publication there is huge reliance on trust that articles are original and fair representations, that due acknowledgement is given to contributing parties, that claims and references are accurate and that any service user referred to has been properly consulted and involved for their opinion and informed consent. You dont have to be familiar with philosophical theories and ethical principles to recognise this ultimately comes down to common sense and respect for yourself and others. However, when an author writes about a product in which they have a vested interest, or even one they believe in and wish to promote, it is important to be extra vigilant in balancing the ethical risks and benefits (Long & Johnson, 2007). I ensure the author gives away information that is potentially useful to readers whether or not they buy the product. I also make explicit any links between the author and the product, or the product stakeholders and the references. But are such measures enough?

It is standard practice for publishers to send complimentary books and products for review in publications, as the authoritative recommendation of a peer has more impact on sales than a marketers blurb. There is always a risk that the review will be negative, but on balance it is worth taking the chance. It is important that reviewers are independent of the publisher and author and, if in doubt, that they declare any connection. I usually decide which conferences I want to go to and pay my own fee but occasionally I am offered a press pass with the expectation that I will subsequently write about it. Writing and disseminating a conference article can take 20-30 hours, so is this a fair exchange or a potential conflict of interest? To be on the safe side, I have started adding information about the source of funding so readers can interpret what they are reading with that in mind. On one occasion I didnt write up a conference, in spite of its topicality and impressive list of speakers. Perhaps I just spend too much time reading Private Eye or am too prejudiced against the medical model, but the event was very heavily subsidised by a drug company and involved high profile exposure of its product. I felt this muddied the waters to the extent that I would have been endorsing the product by reporting on the event. This decision wasnt easy, but how much harder would it have been if I had not paid my own fee? Ultimately, conference speakers, reviewers, recognised experts and journalists should all be aware of their position of power (Carne, 2010) and the responsibility to use it wisely and avoid being used. Body & McAllister (2009, p.10) believe the profession currently needs as much in the way of ethics debate as it can get. I hope the boundary issues series has played a part in helping you discuss and reflect on where you SLTP will draw the line. Avril Nicoll is editor of Speech & Language Therapy in Practice, email avrilnicoll@speechmag.com.
References Beauchamp, T.L. & Childress, J.F. (2001) Principles of Biomedical Ethics. 5th edn. Oxford: Oxford University Press. Body, R. & McAllister, L. (2009) Ethics in Speech and Language Therapy. Chichester: Wiley-Blackwell. Carne, V. (2010) Just a harmless perk of the job...?, MIDIRS Essence. Available at: http://www.midirs. org/development/MIDIRSEssence.nsf/articles/70F4 55A280AB4A8D802576D4004B4A2F (Accessed: 23 November 2011). Hodkinson, K. (2008) How should a nurse approach truth telling? A virtue ethics perspective, Nursing Philosophy 9, pp.248-256. HPC (2008) Standards of conduct, performance and ethics. London: Health Professions Council. Long, T. & Johnson, M. (2007) Research Ethics in the Real World. London: Churchill Livingstone Elsevier.

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TRANSCRIPTION

The broad or narrow way?


Can you remember the symbol for a voiced palatal fricative, or the diacritic for no audible release? Does it even matter? Having carried out a survey of phonetic transcription practice among student speech and language therapists to probe their use of broad and narrow techniques on clinical placement, Fay Windsor discusses the implications of a possible gap between theory and practice.
READ THIS IF YOU WANT TO EXPLORE THE THEORYPRACTICE GAP REDISCOVER LOST SKILLS CAPTURE GRADUAL CHANGE

s a speech and language therapist involved in teaching phonetics to speech and language therapy students, I have often reflected on my own clinical experience and related transcription practice. My clinical experience has been gained mainly from working with children in community clinics and mainstream schools, and my related transcription practice has been almost entirely broad or impressionistic in nature. Knowing that narrow transcription is often held up as the gold standard (Howard & Heselwood, 2002; Louko & Edwards, 2001), it makes me feel rather uncomfortable to admit to my clinical reliance on broad transcription. Unsurprisingly, I have often found myself asking the question: if broad, impressionistic transcription is the norm in clinical practice, why do we persevere in the learning and teaching of narrow phonetic transcription skills? After all, phonetic transcription, whether broad or narrow, is a skill which quickly deteriorates if not used. These issues encouraged me to undertake a fact-finding study investigating the type of phonetic transcription used on clinical placement by students from Manchester Metropolitan University where I am a lecturer. I first explored what the literature has to say on the subject. Speech and language therapists use phonetic transcription to describe their clients speech production as part of assessment, to inform intervention and to document change. It is considered a basic clinical skill (Powell, 2001) and, in the UK, it is recommended that pre-registration training in phonetics should include production and transcription of all the sounds represented by the International Phonetic Alphabet (IPA, 2005a) and the extIPA Symbols for Disordered Speech (IPA, 2005b), together with analysis of prosody and voice quality (RCSLT, 2010). Post-registration, depending on the client group we work with, phonetic transcription may be more or less relevant, or possibly not relevant at all. In terms of everyday practice, it is unclear to what extent speech and language therapists actually make use of narrow transcription. Presumably our transcription practice will be influenced by the purpose

Fay

2009b) stress the importance of narrow transcription, not only for highly unintelligible speech, but also in relation to the growing linguistic diversity of our clients whose spoken output may reflect the influence of languages other than English. In addition, and notwithstanding the problems of reliability and validity connected with the different types of transcription, Hewlett & Waters (2004) provide evidence, including data from The Edinburgh Articulation Test (Anthony et al., 1971), to show how childrens mastery of the articulatory targets required to signal phonological contrasts proceeds in a gradual as opposed to an all-or-nothing fashion. Whereas narrow transcription can capture these gradient changes in pronunciation over time, broad transcription encourages the erroneous idea that children make a sudden jump from one phoneme category to another (Hewlett & Waters, 2004).

Day-to-day

of our assessment, the types of assessment we use, and the nature and severity of our clients communication difficulties. While to a certain extent it will also be influenced by the type of training we have received, my own experience demonstrates that being trained in narrow transcription does not guarantee it will actually be used. The literature suggests that, in some cases, broad transcription is acceptable: if there are just a few sound errors it may not be necessary to use diacritics (Louko & Edwards, 2001, p.3). Dodd et al. (2002) go further, recommending that In most cases a broad transcription system (i.e. without phonetic detail) will be sufficient (p.14). There is also evidence to suggest that broad phonetic transcriptions may actually feature more frequently than narrow transcription in some aspects of the research literature, for example, on phonological development (Hewlett & Waters, 2004).

Value highlighted

More recently, however, a small number of articles have highlighted the value of narrow transcription. For example, Ball et al. (2009a;

Although there is some support for the utility of narrow phonetic transcription, I have a hunch that, on a day-to-day basis, the transcription style of speech and language therapists is probably more broad than narrow. If so, and if training in narrow transcription has been received, the disparity between what is taught and what is practised would represent what is known as a theory-practice gap. Such gaps have been identified within other vocational subject areas such as nursing, and attributed in a practice setting to pressure on time, staff shortages and the influence of poor role models (Maben et al., 2006). In addition, a mismatch between the situations in which knowledge is acquired and applied has been highlighted (Swain et al., 2003). The aim of my study was to explore a possible gap between theory and practice in speech and language therapy. I wanted to find out what type of phonetic transcription is used on clinical placement by students, with a view to investigating the issue more widely in the future. Having first obtained the necessary ethical approval, I designed and piloted a short online survey comprising seven questions covering clinical placement experience, opportunities

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TRANSCRIPTION
for using phonetic transcription and, more specifically, opportunities for using narrow and / or broad transcription. An optional question allowed participants to express an interest in being interviewed about their experiences of using phonetic transcription on clinical placement. Where appropriate, a Likert scale ranging from 1 = always to 6 = never was incorporated. Speech and language therapy students at Manchester Metropolitan University in Years 3 and 4 (n = 89) were then invited to complete the survey. Fifty students participated. The first four students to express an interest in being interviewed subsequently took part in a semistructured interview in two pairs. Figure 1 shows the majority of respondents had sometimes (46 per cent) or fairly often (32 per cent) had some sort of opportunity to use phonetic transcription on clinical placement. A small percentage (12 per cent) indicated that they had almost never had any opportunities but no students indicated that they never had. Regarding type of transcription, most students indicated that they had sometimes (44 per cent) or fairly often (22 per cent) had opportunities to use broad transcription, whereas most had never (36 per cent) or almost never (32 per cent) had opportunities to use narrow transcription. Just over a quarter of participants (26 per cent) indicated they had sometimes had the opportunity to use narrow transcription. I analysed transcripts of the interviews for themes relating to the students experiences of using phonetic transcription on clinical placement. Those that emerged included: type of placement role models level of skill utility of narrow transcription. The students were clear that, overall, their paediatric placements had offered more opportunities for using phonetic transcription. Within paediatrics, they gave examples of particular client groups (cleft lip and palate and hearing impairment) where narrow transcription had sometimes been used.

50 40 30 20 10 0
Always Very often Any Broad Percent Narrow

Fairly often

Sometimes Almost never

Never

Figure 1 Percentage of students surveyed who had the opportunity to carry out phonetic transcription on clinical placement

In terms of role models, the students rarely observed their clinical educators using narrow transcription, and the educators were sometimes perceived as delegating transcription tasks to students on the basis that the students skills were likely to be better than their own: I just havent seen narrow being used at all; Therapist told me she wasnt confident. Tied to this, and in relation to their own competence, students were acutely aware that any sort of transcription requires repeated practice: I see it as a skill and unless you use it frequently . Regarding the overall utility of narrow transcription, the discussion suggested that students felt better able to attend to speech and that narrow transcription had allowed

Role models

them to make more sense of broad transcription: I think its made me listen a bit more to the finer detail, tuned me in a little bit more. However, pressure of time was an issue around using narrow transcription in day-to-day practice and there was a sense that broad transcription did the job, allowing you to record essential information and plan intervention without the problems of transcription reliability: Bit of a rush in community clinic; Narrow lot less consistent. Related to this was a feeling that narrow transcription was more of an academic activity: General opinion is youve used that [narrow transcription] in uni but you never use it [outside]. Finally, the students were not sure if using narrow transcription in practice would make a difference, especially in terms of type of intervention. They suggested that more evidence was needed: If youd done a broad transcription [only] this is what youd have missed. Despite small numbers of participants, my study provides tentative support for a theorypractice gap in speech and language therapy between phonetic transcription as taught and practised. The implications of this potential gap include issues around training opportunities and the availability, within a service, of specialist speech and language therapists to support colleagues working with children and adults. The fragile evidence base surrounding the utility of narrow transcription in day-today clinical practice is also highlighted and, at the same time, questions are raised about the way in which simply learning to do narrow transcription impacts on the way we interpret our clients speech. Interestingly, two clinical assessments which encouraged in-depth assessment of childrens phonetic and phonological capabilities are now out of print (see Anthony

the good news is that ....gaps within professions should be celebrated since, without them, there is little impetus for growth

et al., 1971; Grunwell, 1985). This leads me to wonder whether there is a parallel here with what Nunes (2011) described as the current overemphasis by speech and language therapy as a profession on confidence and communication at the expense of diagnosis and therapy (p.11). Either way, the good news is that gaps between theory and practice are not a bad thing. On the contrary, Haigh (2009) argues that gaps within professions should be celebrated since, without them, there is SLTP little impetus for growth. Fay Windsor is a senior lecturer in speech pathology and therapy at Manchester Metropolitan University. She hopes readers will continue the transcription debate and get in touch with their comments, email f.windsor@ mmu.ac.uk.

Anthony, A., Bogle, D., Ingram, T.T.S. & McIsaac, M.W. (1971) The Edinburgh Articulation Test. Edinburgh: Churchill Livingstone. Ball, M., Muller, N., Klopfenstein, M. & Rutter, B. (2009a) The importance of narrow phonetic transcription for highly unintelligible speech: some examples, Logopedics Phoniatrics Vocology 34(2), pp.84-90. Ball, M.J., Muller, N., Rutter, B. & Klopfenstein, M. (2009b) My client is using non-English sounds! A tutorial in advanced phonetic transcription part 1: consonants, Contemporary Issues in Communication Science & Disorders 36, pp.133-41. Dodd, B., Hua, Z., Crosbie, S., Holm, A. & Ozanne, A. (2002) Manual of Diagnostic Evaluation of Articulation and Phonology. London: Harcourt Assessment.

References

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TRANSCRIPTION / IN BRIEF
Grunwell, P. (1985) Phonological Assessment of Child Speech (PACS). Windsor: NFER-Nelson. Haigh, C. (2009) Editorial: Embracing the theory/practice gap, Journal of Clinical Nursing 18(1), pp.1-2. Hewlett, N. & Waters, D. (2004) Gradient change in the acquisition of phonology, Clinical Linguistics & Phonetics 18, pp.523-533. Howard, S.J. & Heselwood, B.C. (2002) Learning and teaching phonetic transcription for clinical purposes, Clinical Linguistics & Phonetics 16(5), pp.371-401. International Phonetic Association (2005a) The International Phonetic Alphabet (Revised to 2005). Available at: http://www.langsci.ucl. ac.uk/ipa/ (Accessed: 11 August 2011). International Phonetic Association (2005b) extIPA Symbols for Disordered Speech (Revised to 2002). Available at: http://www.langsci.ucl. ac.uk/ipa/ (Accessed: 11 August 2011). Louko, L.J. & Edwards, M.L. (2001) Issues in collecting and transcribing speech samples, Topics in Language Disorders 21(4), pp.1-11. Maben, J., Latter, S. & Clark, J.M. (2006) The theory-practice gap: impact of professionalbureaucratic work conflict on newly-qualified nurses, Journal of Advanced Nursing 55(4), pp.465-477. Nunes, A. (2011) A question of scale, Bulletin of the Royal College of Speech & Language Therapists September, p.11. Powell, T.W. (2001) Phonetic transcription of disordered speech, Topics in Language Disorders 21(4), pp.52-72. RCSLT (2010) Guidelines for Pre-Registration Speech and Language Therapy Courses in the UK (Incorporating Curriculum Guidelines). Available at: http://www.rcslt.org/about/work_with_ educators/curriculum_guidelines (Accessed 11 August 2011). Swain, J., Pufahl, E. & Williamson, G.R. (2003) Do they practise what we teach? A survey of manual handling practice amongst student nurses, Journal of Clinical Nursing 12(2), pp.297-306.

In Brief...
Apraxia of speech diagnosis: opening the can of worms
Jon Hunt argues that we need to be clearer in differential diagnosis of phonological and articulatory difficulties underlying what we refer to as apraxia of speech.

supported by

this suggests a discrepancy. If they cant, this could again point to a phonological problem. Similarly with syllable number judgement. Does it matter if we get it wrong? Is articulatory therapy necessarily invalid if a problem is more phonological? Well, thats another debate, but at least its good to be as clear as we can be about what were dealing with. Jon Hunt is a speech and language therapist with North Bristol NHS Trust.
References Darley, F.L., Aronson, A.E. & Brown, J.R. (1975) Motor Speech Disorders. Philadelphia: Saunders. McNeil, M.R., Robin, D.A. & Schmidt, R.A. (1997) Apraxia of speech: Definition, differentiation, and treatment, in M.R. McNeil (Ed.) Clinical management of sensorimotor speech disorders. New York: Thieme (pp.311-344).

REFLECTIONS DO I PROVIDE A GOOD ROLE MODEL FOR STUDENTS ON CLINICAL PLACEMENT? DO I DRAW ON THE SPECIALIST KNOWLEDGE OF COLLEAGUES WHEN APPROPRIATE? DO I USE ANY TEACHING MOMENTS TO THINK ABOUT MY OWN PRACTICE?
How has this article changed your thinking? Let us know - see information about Speech & Language Therapy in Practices Critical Friends at www.speechmag.com/About/Friends.

hen we describe someone as having apraxia of speech, what are we effectively saying? Most speech and language therapists would agree that in issuing this diagnosis we are claiming that the person in question has a difficulty with motor programming, that is the ability to place the articulators in such a way as to represent the intended sound sequences. In other words we are claiming that the person is demonstrating a discrepancy between the sound of the word in their head, and what comes out of their mouth. In psycholinguistic terms, we are claiming that there is a discrepancy between phonological output and articulatory output. Making this claim implies that we have evidence that the person has the sound of the word(s) correctly represented in their head or at least more correctly than the spoken output would suggest. At present in speech and language therapy we tend not to make any effort to substantiate such claims. We base our apraxia of speech diagnoses on overt speech behaviours such as sound mis-selection and groping, and on awareness of errors. These criteria were initially proposed in the 1970s by Frederic Darley and his colleagues, who arrived at their symptoms of apraxia of speech by taking patients whom they believed to have it and then describing their symptoms, an approach which McNeil et al. (1997) call experimental tautology. McNeil et al. argue that the vast majority of Darleys proposed (and still widely used) diagnostic criteria are invalid, since they are at least as likely to reflect phonological difficulties as articulatory ones. Darley and his colleagues stated that most if not all their subjects had aphasia as well as (allegedly) apraxia of speech. So how did they know which symptoms were due to which disorder? How can we tell if the underlying phonology really is intact? One way is to look at the effects of cueing. If the person is helped by cues which give no articulatory information, such as semantic, phonemic (unseen), closure or orthographic cues, then this points to a phonological instability. And if the person is an adult with good cognitive skills, try showing them pairs of pictures of objects which have names that either rhyme or dont rhyme. If they can judge which pairs rhyme but cant realise those distinctions in spoken output,

Research centre on the web


Wendy Best, Suzanne Beeke, Caroline Newton & Rachel Rees invite you to make use of the Centre for Speech and Language Intervention Research website for event information, making new contacts and accessing evidence based resources. ave you heard of the Centre for Speech and Language Intervention Research? We would like to give you an overview so you can see why it and its website may be of interest to speech and language therapists and their colleagues. The Centre is based in University College Londons Division of Psychology and Language Sciences. It focuses on research in speech and language disorders, with an emphasis on intervention and practical implementation. Members come from the UK and abroad, work in health and education settings, and their interests span developmental and acquired communication difficulties. The aims of the Centre are to: foster collaborative health service related research in the field of speech and language pathology and intervention disseminate current research information and encourage implementation in clinical practice foster partnerships in order to build research capacity across speech and language therapy centres be a resource for practitioners by providing access to web-based materials for use in assessment and therapy. We achieve these aims through holding regular events, disseminating research and resources via our website and through joint Higher Education Institution / National Health Service research projects. Our Doctoral students also have their projects linked to the Centre. Perhaps you or a colleague could come to a Centre event?

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IN BRIEF

One lucky contributor in each issue receives 50 in vouchers from Speechmark, which publishes a wide range of practical resources for health and education professionals (www.speechmark.net).

Might a local initiative benefit from contact with someone carrying out current research in your clinical field? You can find the contact details of researchers conducting relevant projects on our website. Could your work benefit from a web-based resource? We have useful links to related websites and resources ranging from lists of minimal pairs to the Arizona Academy of Neurologic Communication Disorders & Sciences Aphasia Treatment website and SpeechBITE, the Australian searchable intervention database. If you are working with either adults with aphasia or children with specific language needs who have word finding difficulties, you might wish to access the cueing aid KeyPhone. Dr Carolyn Bruce devised the aid back in the 1980s when working with a man with aphasia who benefited from phonological cues and who could sometimes chose the correct initial letter for words he was unable to retrieve. Keyphone (a version of the aid by Dr Mike Coleman) provides the missing link turning letters into sound cues. It is possible to select the number of letters a client sees. There is evidence that it can be used effectively in therapy to improve word finding with adults (Bruce & Howard, 1987) and with children (Best, 2005). KeyPhone is free via the Centre website and has already had over 10,000 hits. Might it be useful for someone you are working with? We hope that you might access something of use to you via the Centre website, at an event, or by signing up to our newsletter (via the website). We also welcome applications for our part-time Professional Doctorate (www.ucl.ac.uk/slt/ research) for experienced therapists wishing to carry out research in their clinical setting. Wendy Best is a Reader, Suzanne Beeke the Research Department Head, and Caroline Newton and Rachel Rees lecturers at University College London.
Resource Centre for Speech and Language Intervention Research website, www.ucl.ac.uk/cslir/ References for cueing aid Best, W., Howard, D., Bruce, C & Gatehouse, C. (1997) A treatment for anomia combining semantics, phonology and orthography, in Chiat, S., Law, J. & Marshall, J. (eds.) Language Disorders in Children and Adults: Psycholinguistic approaches to therapy. Chichester: Wiley-Blackwell. Best, W. (2005) Evaluation of a new intervention for word-finding difficulties in children, International Journal of Language and Communication Disorders 40(3), pp.279-318. Bruce, C. & Howard, D. (1987) Computer-generated phonemic cues and effective aid for naming in aphasia, International Journal of Language and Communication Disorders 22(3), pp.191-201.

An encounter with Animal Assisted Therapy


As converts to Animal Assisted Therapy, Tim Grover and Sallie Bollans believe George Eliot got it right when she said, Animals are such agreeable friends - they ask no questions, they pass no criticisms...

hen approached by Occupational Therapy Technical Instructor Sallie Bollans, and asked whether I had any speech clients that would be appropriate for Animal Assisted Therapy, I didnt know quite what to make of it. Weve all heard of Dr Dolittle of course, but how Animal Assisted Therapy could benefit people with communication difficulties did not come to mind immediately! I asked Sallie to tell me more about it. She explained it is defined as a goal directed intervention where there is a specific therapeutic end in mind, where the animal plays a key role in meeting specific criteria (Gammonley et al.,1997). Sallie explained that Animal Assisted Therapy had been utilised as a treatment intervention within neurological rehabilitation at Chase Farm hospital since 2004, with the dedicated support of Pets As Therapy volunteer Paula Rowe and her English Setter / Collie cross dog Izzy. Sallie had also completed a training course (Companion Animal Interventions in Therapeutic Practice), delivered by The Society for Companion Animal Studies. Unlike in the community, functional goal setting can be more challenging in the inpatient environment as everyday interactions on the ward can be limited. As such, I felt that Animal Assisted Therapy might offer a new setting in which to work with patients away from the ward. What I didnt anticipate, however, was an activity in which patients felt comfortable to initiate and use their residual communication in a nonconfrontational environment. This stood in stark contrast to impairment based therapy which inherently confronts a persons deficits. Research has suggested that a dog may act as a unique catalyst to motivate the client to talk and provide an atmosphere of unconditional acceptance for the disordered speech that is produced (Macauley, 2006, p.8), and I observed this in a session when a patient with severely impaired comprehension and largely fluent empty speech proclaimed there, there, what a beautiful dog and later spontaneously produced language such as well done Izzy when rewarding with a biscuit. Research has also suggested that introducing a living animal into the therapy

session can result in patients feeling more at ease, more communicative and motivated to engage in therapy (Levinson,1962). Also simply stroking a dog has been shown to reduce high blood pressure (Odendaal, 2000) and increase levels of oxytocin (Odendaal & Meintjes, 2003). I recall one patient in particular, a great dog lover, who presented with relatively intact comprehension alongside telegraphic speech and articulation difficulties. In Animal Assisted Therapy, each activity with the dog elicited some appropriate spontaneous verbal output. For example, whilst grooming the dog, she would spontaneously produce soothing language: ahh, Izzy, beautiful! Furthermore, with direction, she could produce functional language to accompany an activity such as up and down, incorporating giving orders to Izzy, like wait, come here or sit. From a speech and language therapy perspective Animal Assisted Therapy offers a unique opportunity to work as part of a multidisciplinary team within a patient-led activity. The presence of the dog provides motivation for the client to work towards targets based around communication, physical, psychological and psychosocial goals in a fun and relaxed atmosphere. Since my involvement with Animal Assisted Therapy I have worked with other client groups including people with progressive neurological diseases. I believe that it is just as relevant for them and offers huge scope for providing stimulating, effective and enjoyable therapy. Tim Grover is a speech and language therapist, now at the National Hospital for Neurology and Neurosurgery. Sallie Bollans (email sallie. bollans@nhs.net) is an occuptational therapy technical instructor at Chase Farm Hospital.
Resources Society for Companion Animal Studies, www.scas.org.uk Pets as Therapy, www.petsastherapy.org References Gammonley, J., Howie, A.R., Kirwin, S., Zapf, S.A., Frye, J., Freeman, G. & Stuart-Russell, R. (1997) Animalassisted therapy: Therapeutic interventions. Renton, WA: Delta Society. Levinson, B.M. (1962) The dog as co-therapist, Mental Hygiene 46, pp.59-65. Macauley, B.L. (2006) Animal-assisted therapy for persons with aphasia: A pilot study, Journal of Rehabilitation Research & Development 43(3), pp.357-366. Odendaal, J.S.J. (2000) Animal-assisted therapy magic or medicine?, Journal of Psychosomatic Research 49, pp.275-280. Odendaal, J.S.J. & Meintjes, R.A. (2003) Neurophysiological correlates of affiliative behavior between humans and dogs, The Veterinary Journal 165, pp.296-301.

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journal club (6)

Journal club 6: single subject designs


Jennifer Reids series aims to help you access the speech and language therapy literature, assess its credibility and decide how to act on your findings. Each instalment takes the mystery out of critically appraising a different type of journal article. Here, she looks at single subject designs.
ave you ever felt uneasy about speech and language therapy clients being lumped together for group intervention studies? Arent our client groups simply too heterogeneous to expect that one intervention will be effective for them all? How do you know if a complex intervention will be right for your clients if it has been tested with participants and clinicians whose characteristics are described only in very broad terms? After all, speech and language therapy interventions need to be moulded to meet a clients individual needs and circumstances to be successful, dont they? It feels against the grain to allocate clients randomly to different intervention groups so that all their individual differences are washed out! Perhaps such misgivings about group intervention methods are one of the reasons that single case designs remain popular in speech and language therapy research, despite their low ranking in the evidence hierarchy. We are not alone in this for example, psychologists working in the field of acquired brain injury also continue to employ single subject designs, valuing them in particular for their flexibility and sensitivity to individual differences. Thanks to this, there is a practical and validated appraisal tool we can use for these sorts of studies the Single Subject Experimental Design Scale (SCED) (Tate et al., 2008). Note the word experimental in the name. We are not talking here about case studies in which clinicians simply describe clients and their care pathway. In order to contribute to the evidence base, single subject studies need to be of good quality and that means robust methods, pre-planned interventions and accurate, reliable measurement. Not unlike group studies then Do not be misled by the name, though, as single subject design does NOT mean that the studies necessarily involve only one participant. You still need to work out which method has been used group or single subject design to choose the right appraisal framework for an intervention study. READ THIS SERIES IF YOU WANT TO yy BE MORE EVIDENCE-BASED IN YOUR PRACTICE yy FEEL MOTIVATED TO READ JOURNAL ARTICLES yy INFLUENCE DEVELOPMENT OF YOUR SERVICE

So when a study presents results from a number of participants, how do I know if this is a group study or a single subject one? If participants are allocated to groups receiving different intervention regimes, and group results, rather than individual, are reported, then you are most likely to be dealing with a group intervention study. Your appraisal tool of choice will be one

...to contribute to the evidence base , single case subject studies need to be of good quality - and that means robust methods, pre-planned interventions and accurate, reliable measurement
for randomised controlled trials (RCTs) and other group intervention studies such as the one I presented in Journal club 4 (Speech & Language Therapy in Practice, Summer 2011). Single case design, single subject design, n-of-1 trial if any of these terms are used in the title or abstract, then you are probably dealing with a single subject design with several participants. Single subject experimental studies involve repeated measures from

individual participant(s). The wording you will often find is that participants served as their own control, which means that the study used repeated measures over time of the individuals performance in an area not being treated as the comparison for measures in the treated area. The quality essentials of single subject experimental designs are: Performance is measured repeatedly to ensure that any intervention effects are sustained over time. Repeated measures designs show how performance varies over time in a way that is usually not possible with group designs reporting group averages. Sometimes it is hard to tell from the title or abstract whether a single subject or group design has been used; indeed, sometimes researchers report both group results and repeated measures. In any case, the SCED Scale will allow you to appraise how well a study using repeated measures was conducted. Even if you are reading a simple (anecdotal) case report, such as those often seen in Speech & Language Therapy in Practice or the Bulletin of the Royal College of Speech & Language Therapists, the domains will help you think about the reasons why the author may be barking up the wrong tree in their conclusions, especially if causal relationships are being implied.

Appraisal

The SCED Scale is available as a single sheet pdf file to download from the PsycBITE website (http://www.psycbite.com/docs/The_SCED_ Scale.pdf). It has 11 domains for appraisal, which I have converted into questions and explained. You may, however, wish to start your appraisal with the general questions we usually ask about a study, including whether the question being asked is one that is important for your practice or for your service, and whether a single subject design was a sensible choice of method to answer that question. You should also consider whether the intervention is described in enough detail for you to implement it yourself.

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Question 1: Was the participants clinical history adequately described? out which aspect of the clients functioning is being addressed in the intervention. Then check whether the intervention goals have been defined for the purposes of the intervention (an operational definition) in such a way that allows change to be observed. It might help here to apply your knowledge of so-called SMART targets (specific, measurable, attainable, relevant, time-framed). Are the measures likely to be reliable across different raters or contexts? The intervention programme in the Fry et al. (2009) study included fluency management and cognitive behaviour therapy techniques to target both overt and covert stammering symptoms. Appropriate measures were selected to measure change in both these targeted areas, and therefore to assess intervention success. Measures of overt stammering included relatively objective, quantitative measures, which are precisely described and replicable (percentage stammered syllables and mean of the three longest stammered syllables from the first 500 syllables of 5-minute video recordings made by the participant at home while talking to a family member or friend). Covert symptoms are assessed via three externally validated self-report measures. So the study gets a tick for this question too. Question 3: Is the design good enough to provide evidence of an intervention effect? The SCED Scale specifies as the minimum for acceptability a 3-phase design, which should be either: A reversal or withdrawal design (A-B-A) in which baseline performance is established before treatment is given, performance measured during treatment and then again after treatment has been withdrawn (or switched to another goal), or A multiple baselines method across different behaviours where only one behaviour is being treated at a time. These designs introduce essential controls which allow you to see whether or not any changes in performance appear to be associated with the intervention. The association should show that change is specific to the intervention goals, and also linked in time with the phases of the study. Here is the description of the 4-phase design adopted by Millard et al. (2009 p.63) to enable any evidence of a treatment effect to be provided. The authors also display the phases and timeline in a helpful figure. This was a single subject design replicated across participants. There were four phases, each lasting 6 weeks. The length of the phases and the data collection points were arranged to coincide with the current delivery of the [therapy for children who stammer] program. The duration of the study (from the first week of phase A1 to the last week of phase A2) was matched to the time that families were on the waiting list for an assessment appointment, so that taking part in the study did not disadvantage those who did not receive therapy. This allowed us to establish a no treatment group. During each phase parents video recorded parentchild play sessions at home, once a week. Children who were allocated to the therapy condition completed all phases, while those who were allocated to the waiting list condition completed only the assessment phases (A1 and A2).

One of the main advantages of a single subject design study is its flexibility; it can provide a lot of scope for individualisation of the intervention. Consequently, you may see a more direct application to your own context if there is enough information on the participant(s) to make a reasoned judgement on how similar they are to one or more of your own clients. The SCED Scale suggests age, sex, aetiology and severity must be reported but you may want to know about other issues, for example, response to any previous speech and language therapy intervention. Here is an extract from a helpful description of a participant in a study of an intensive group intervention for young adults with a stammer: TM was a male, mono-lingual English speaker of African ethnic background, aged 18;0 at the beginning of the study. He had no history of identified speech, language, communication or other difficulties. There was a family history of persistent stuttering, with both TMs father and one brother stuttering into adulthood. TM was reported to have started stuttering at 11 years of age Limited referral information identified that TM had been known to his local speech and language therapy service for several years and had periodically received both individual and group therapy since the age of 13. He had not attended therapy in the 12 months prior to the start of the study (Fry et al., 2009, p.13). Question 2: Does the study identify measures that can be used to evaluate intervention success? The intervention goals need to be precise and properly defined so that they can be measured accurately and reliably. The first thing to do is to work

Question 4: Was an adequate baseline established before intervention commenced?

We are in the realms of causality here, and, as discussed in Journal Club 5 on observational designs (Speech & Language Therapy in Practice, Autumn 11), water-tight evidence of cause-and-effect can be elusive even when we are using reasonably robust research methods. A single subject design study never provides definitive evidence of intervention efficacy but if participants show large amounts of specific changes, the results from such a study can be pretty compelling, providing useful preliminary evidence of an intervention effect and therefore of approaches that look promising.
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Baseline assessment provides information on a participants performance in the period before intervention begins. It is good practice to establish performance trends during the baseline period, such as whether performance is stable, fluctuating, deteriorating or improving. If this trend reverses or changes dramatically during the intervention, this is evidence to support an intervention effect. Trends can only be established if the baseline phase is long enough to allow sampling of performance over time. Here is Christina Samuelssons (2011, pp.59-60) description of her baseline assessment from a multiple baseline study of prosodic intervention: The participating child was a boy of 4;6 years. Before the intervention was introduced, the childs prosody was assessed repeatedly (3 times over a period of 9 weeks) using the previously described assessment tool [which] covers production of prosody at word, phrase and discourse level. The baseline assessment was carried out every third week over the 9-week period. In addition, assessment was also made of other linguistic skills the boy had problems with prosodic production [which] were shown to be stable across baseline observations [presented with a bar chart display of these data]. Question 5: Can a treatment response be distinguished from fluctuations resulting from other factors? change in frequency of stammering cannot be attributed to chance alone. Graphs of the results from individual participants provide compelling visual evidence of a treatment effect in some. However, at least one of the no treatment participants showed significant improvement during the second assessment phase so, as the authors point out, other factors must therefore have been operating for this child. Question 6: Is data displayed to show variability? are difficult to measure objectively, such as perceptual measures of voice quality. With regard to inter-rater reliability, Fry et al. (2009, p. 643) report that, the transcriptions from one point in each phase of the study were randomly selected for blind analysis by a second rater. Percentage interrater agreement was based on point-by-point agreement for the presence of stuttering in each syllable (Hubbard & Yairi, 1988). Interrater agreement was calculated using the percentage agreement index (Suen & Ary, 1989): the number of agreements divided by the sum of the number of agreements and the number of disagreements, multiplied by 100. Interrater agreement was 96.9%. Okay, no argument there then not only careful consideration of the issue of interrater reliability, but also measurement using approaches supported by previous research. Tick! Question 8: Were independent assessors used? Remember that one of the strengths of single subject designs is preservation of individual variation, so studies should employ good visual displays of variability data. Graphs or tables of raw, rather than converted, scores or data from pre-, during and post-intervention phases are usually recommended. So, in the data displays from the study being appraised, can you see at a glance how things vary over time? Millard et al.s (2009) charts are a good example of appropriate visual displays of individual variation, both of within-phase fluctuations in individuals and in differences in trends across individuals. Question 7: Are measures used reliable?

The design should control for undue influence on assessment from over-familiarity with the participants and the phase of the study (more observer bias). It is good practice for assessment data to be analysed blind to the participant and / or their study phase. Here is an example from a study of constraint-induced therapy for aphasia (Faroqi-Shah & Virion, 2009): All tests were independently scored for accuracy by both authors and a third research assistant who was blind to the treatment conditions. All discourse samples were transcribed by one of the authors, and 20% of randomly selected samples were transcribed by an independent research assistant who was blind to the treatment condition and time of testing for reliability purposes. Morphosyntactic codes were independently assigned by both authors. Of these samples, 20% were also coded by a research assistant for reliability purposes. Coding reliability exceeded 90%.

There are two issues at stake here. First, an adequate baseline will have captured information on the range of fluctuation present prior to intervention. Second, there needs to be sufficient sampling of performance during intervention to be able to differentiate changes that appear to go beyond the range of normal fluctuations seen in the baseline. In the Millard et al. (2009) study, percentage words stuttered for each participant is calculated from a weekly video-recording throughout the 6-week baseline phase. This allowed calculation of a mean percentage words stuttered for the baseline phase and then of a range for percentage words stuttered beyond which a

Remember that reliability is about getting consistency of results. You will want to be reassured that there is good agreement between different assessors in how they measure or rate the performance in question, otherwise systematic differences between assessors could skew the results (observer bias). If assessment was done by a single individual, is there evidence of intra-rater reliability? Interor intra-rater reliability will be particularly important for any aspects of functioning that

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Question 9: Have the data been analysed statistically? provide only anecdotal information on carryover to other settings of the particpants increased responsiveness and use of AAC.

To evaluate a study on this SCED Scale domain, you simply have to find out whether any statistical analysis was used to demonstrate an intervention effect by comparing the results over the phases of the study. You dont have to know whether it was an appropriate statistical technique that was used. Phew! It appears that authors get Brownie points simply for trying to use inferential stats. Millard et al. (2009) show changes in stammering over the phases of their study using a statistical technique called cusum analysis which they report has been applied to naturally fluctuating data. That sounds appropriate, doesnt it? Moreover, the cusum charts of repeated measures from each participant have the added advantage of displaying the raw data on percentage words stuttered, the upper and lower limits supporting the statistical (cusum) analysis and the changes over the timescales of the phases of the study. Neat! Question 10: Is there evidence that any intervention effect can be replicated?

Critical appraisal for speech and language therapists (CASLT) Download the SCED Scale from www.psycbite.com/ docs/The_SCED_Scale. pdf, or get Jennifers version with cartoons from www.speechmag. com/Members/CASLT. Use it yourself or with colleagues in a journal club and let us know how you get on.
Question 11: Is there evidence for generalisation and carryover?

Unwanted bias

In conclusion, when considering the merits of single-subject design studies, please remember that, however methodologically good they are, lack of randomisation does allow unwanted bias to creep in. It may be a lot easier to judge

from the results of a single subject study how the intervention might impact on one of your own clients, but the bottom line is that the study cannot provide the answer to questions about the overall efficacy of this intervention SLTP for all potential recipients. Jennifer Reid is a consultant speech and language therapist with NHS Fife, email jenniferreid@nhs.net. Cartoons are by Fran, www.francartoons.co.uk. References Beck, A.R., Stoner, J.B. & Dennis, M.L. (2009) An investigation of aided language stimulation: Does it increase AAC use with adults with developmental disabilities and complex communication needs?, Augmentative and Alternative Communication 25(1), pp.42-54. Ebert, K.D. & Kohnert, K. (2009) Non-linguistic cognitive treatment for primary language impairment, Clinical Linguistics & Phonetics 23(9), pp.647664. Faroqi-Shah, Y. & Virion, C. (2009) Constraintinduced language therapy for agrammatism: role of grammaticality constraints, Aphasiology 23(7-8), pp.977-988. Fry, J., Botterill, W., & Pring, T. (2009) The effect of an intensive group therapy program for young adults who stutter: a single subject study, International Journal of Speech-Language Pathology 11(1), pp.12-19. Millard, S.A., Edwards, S. & Cook, F.M. (2009) Parent-child interaction therapy: Adding to the evidence, International Journal of SpeechLanguage Pathology 11(1), pp.6176. Samuelsson, C. (2011) Prosody intervention: A single subject study of a Swedish boy with prosodic problems, Child Language Teaching and Therapy 27(1), pp.5667. Tate, R.L., McDonald, S., Perdices, M., Togher, L., Schultz, R. & Savage, S. (2008) Rating the methodological quality of single-subject designs and n-of-1 trials: Introducing the Single-Case Experimental Design (SCED) Scale, Neuropsychological Rehabilitation 18(4), pp.385401.

To make use of this intervention in your own context, you need to be confident that the apparent response to intervention is not a one-off. Its not much use to know that something worked if it is limited to that particular individual in that particular context. Has the effect been demonstrated with other clients, different therapists or in other settings?

For much of what speech and language therapists do, the emphasis in the long term is on the clients self-management. It is therefore important to know whether the changes kick-started by the intervention are shown to impact on functioning in other areas. For example, if the intervention was impairment-based, has there been any carryover to functional communication? Ebert & Kohnert (2009) suggest that treatment of non-linguistic cognitive processing skills may facilitate change in some areas of language processing for children with primary language impairment, but they go no further than demonstrating changes in performance on standardised language tests we are given no information on impact, if any, on everyday functioning. If the intervention targeted expressive communication using AAC, has there been any impact on the persons social participation? Beck et al. (2009) used group language stimulation to teach use of AAC techniques to seven participants with complex communication needs but they

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RESOURCE REVIEWS

Resource reviews
APHASIA
Newcastle University Aphasia Therapy Resources: Sentence Processing, Auditory Processing, Written Comprehension Julie Morris, Janet Webster, Anne Whitworth & David Howard Newcastle University in association with the Tavistock Trust for Aphasia ISBN 978-0-7017-0229-8; 978-0-7017-0230-4; 978-0-7017-0231-1 200 literate generation of clients. Perhaps with some reorganisation and reclassification of content this could become a more streamlined version of the old faithfuls and a useful e-resource? Joanne Curtis is a specialist speech and language therapist working in the Community Assessment and Rehabilitation Service in NHS Lanarkshire.
Reference Kay, J., Lesser, R. & Coltheart, M. (1992) Psycholinguistic Assessments of Language Processing in Aphasia. London: Lawrence Earlbaum Associates Ltd.

This aphasia resource is presented across three booklets, each with accompanying CDROMS of material to target the specific areas of sentence processing, auditory processing and written comprehension. In contrast to other products on the market, this resource is not interactive. Rather, the CDs contain a collection of printable worksheets and instructions as to their intended delivery and use. The supporting booklets contain further explanation of tasks and theoretical background related to the language processing involved. The feel of the booklets is in keeping with the PALPA model (Kay et al., 1992). For newly qualified therapists beginning to work in the field of aphasia the theory and explanation are likely to be useful. It fills a reasonable proportion of the booklets which, for more experienced therapists or PALPA devotees, is possibly excessive. The actual worksheets are clear and comprehensive, with multiple levels and options per task and target area; for example, there is an extensive variety of auditory discrimination minimal pair work. Picture stimulae are easy to recognise and avoid the failings of some other resources which can be somewhat childish or difficult to identify. The main negative is that it feels cumbersome. The layout means it takes considerable time to find the ideal task and level. The organisation of some tasks is also potentially misleading, for example what is classed as a written comprehension task may actually be better classified as a semantic task (or at least cross referenced as dual purpose). The supporting booklets contain great detail regarding the nature and delivery of tasks, but much of this is self-explanatory to any practising clinician. This only serves to make it feel overly wordy at times. Overall this could be a useful resource. However, the time required to become truly familiar with its contents, to the extent where appropriate tasks could be accessed straight away, could lead to therapists defaulting back to more familiar materials. This would be unfortunate, as the resource has positives to offer. The potential to send therapy resources via e-mail (copyright permitting) would be a move forward in an age of increased call for efficient service delivery and a more computer

Has potential

CHILD LANGUAGE

The New Reynell Developmental Language Scales (4th edn) Susan Edwards, Carolyn Letts and Indra Sinka GL Assessment (2011) ISBN 9780708720578 499.00

Evidence-base is strength

In my work with preschool children in childrens centres and busy community clinics, I need assessment tools which are robust, effective and based on sound evidence, and so I awaited the New Reynell Developmental Language Scales (NRDLS) with anticipation. It is 14 years since the last major revision (RDLS III, Edwards et al., 1997), and the authors have achieved a comprehensive update in response to developments in both research and clinical practice. There is a dedicated website introducing the assessment: http://reynell.glassessment.co.uk/. This includes introductory videos hosted by Professor Susan Edwards. On first inspection, I was pleased to see that the briefcase from the previous version has been replaced with a smart grey material bag, which is certainly more transportable between settings.The toy and picture materials have been updated. These are modern and appealing, and the number of toy items has reduced making assessment more manageable. The NRDLS has been standardised on a sample of over 1200 typically developing children, aged 2;07;5, with English as their first (or one of their first) language(s). The 1;61;11 age group was removed as the data was unreliable. In the standardisation sample, the authors addressed previous criticisms
Figure 1 Toms NRDLS scores Raw Score Comprehension Scale Production Scale 57/72 34/64

(such as Law, 1999), and provided data about the childrens socio-economic status, as well as age, gender and maternal education, although some groups, such as the most deprived, were under-represented. They also assessed 35 language impaired children aged 4;07;6, showing good validity. The manual provides a detailed description of the development of the assessment, as well as a very useful section describing the theoretical rationale and relevant research behind the items tested. Having read this eagerly, testing childrens understanding of non-reflexive (him/her) and reflexive object pronouns (himself/herself ) makes sense, as they can be persistently difficult for children with specific language impairment. The comprehensive reference list is a bonus for me as both a clinician striving for evidence-based practice and an MSc student. The evidencebased approach appears to be the strength of this assessment; the authors strived to include areas of vocabulary and grammar known to be particularly difficult for children with language disorders, thereby providing a diagnostic tool. As before, the assessment is arranged in two sections, Comprehension and Production Scales, with a progression from the simple (eg. selecting / naming objects and verbs) to the complex (eg. understanding and use of passives and relative clauses). The two sections are now closely aligned to allow easier comparison of skills. I particularly liked that the number of single objects (which children I assessed found easy) was reduced, and the number of verbs increased. Concepts such as colour and size are no longer assessed. There is more of an emphasis on verb morphology (eg. 3rd person singular present tense versus past tense), which have been proposed and debated as possible indicators of specific language impairment (Rice & Wexler, 1996). I found that younger children, and those with poorer attention skills, found this section of the assessment difficult and began to lose concentration, and so testing may have been discontinued before the full extent of their skills was established. The manual points out that the child needs to understand this task for the results to be meaningful, and that children may mark tense in their spontaneous language, but struggle to do the assessment task. Clinicians need to be familiar with the wording, and children may need to practise the procedure for this task. As is good clinical

Standard Score (confidence band) 91 (77.3-104.7) 74 (63.6-84.5)

Percentile Rank 28 4

Age Equivalent (confidence band) 4;3 (3;9-5;3) 3;4 (3;1-3;7)

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practice, a spontaneous language sample is recommended to supplement standardised assessment. I found the scoring fairly straightforward. The standard scores format has changed since the RDLS III, and are now Wechsler-style scores with a mean of 100, and a standard deviation of 15. This makes an easier comparison to other assessments, particularly in reports.

Sometime you naughty

I used the NRDLS with Tom, aged 4;9, who has a diagnosis of specific language impairment and some dysfluency. The purpose of the assessment (figure 1) was to evaluate progress following therapy, and plan the next steps. Toms comprehension scale score, although still within normal limits for his age, was lower than when previously assessed with the RDLS III (at C.A. 4;0, he obtained a percentile rank of 56, age equivalent 4;1-4;2), which I feel reflects the greater emphasis on morphology of the NRDLS; he found the verb morphology and pronoun sections difficult, mirroring the difficulties seen in his spontaneous language. His production scale score was as expected, and was specific in identifying Toms needs. We will now target his understanding and use of -ed past tenses and pronouns in therapy. Tom appeared to enjoy the assessment, particularly telling the monkey what to do, even commenting sometime you naughty when he saw a picture of the monkey kicking a box. He began to lose concentration towards the end. The authors note this can be a common experience with children with language impairments, and we should consider completing the test over two sessions as appropriate. The Multilingual Toolkit is a useful addition, and the experience and knowledge of the authors shines through. They describe a range of research literature and use examples from different languages to illustrate how each section of the NRDLS could be adapted culturally and linguistically for children who speak languages other than English. Although they cannot provide an assessment for a different language, they present issues to consider whether you are contemplating adapting the assessment for a research project or for just one child. Louise Tweedie is a specialist speech and language therapist (Early Years) with East Cheshire NHS Trust.
References Edwards, S., Fletcher, P., Garman, M., Hughes, A., Letts, C. & Sinka, I. (1997) Reynell Developmental Language Scales (3rd edn). Windsor: Nfer Nelson. Law, J. (1999) Its not just the pigsa comment on the RDLS III, International Journal of Language and Communication Disorders 34(2), pp.181-184. Rice, M. & Wexler, K. (1996) Towards tense as a clinical marker of specific language impairment in Englishspeaking children, Journal of Speech, Language and Hearing Research 39(6), pp.1239-1257.

Alison Roberts came up with Heres one I made earlier in 2003. She has generously inspired us with an incredible 70 low cost, flexible and fun therapy suggestions - and still the ideas keep flowing... End of course recap cards
MATERIALS A4 size blank card (coloured if you like) A5 envelope Pen and felt-tips

Heres one I made earlier...


These are good for reminders of course content, without being so formal as homework. They also add to parents information of what their child has been learning about.

IN PRACTICE 1. Fold the piece of card to make it A5 sized. 2. For the front, choose a simple and appropriate outline that is relevant to the school term or the clients interest. Draw, for example, a Christmas tree, a sun with rays, an oval shape, a heraldic shield, or the outline of a Dalek. 3. Decorate the shape by writing inside and around it the topics covered during that phase of work. For example, you could write Body language inside the Christmas tree, and add the words eye contact, smiling, waving, high fives and handshake as baubles on the branches. 4. Your client could add colours before they take it home.

Here are many Avril made earlier


MATERIALS Supreme energy Lateral thinking Determination Encouragement Good sense of humour Magnificent networking skills Wise editorship Fantastic comment and editorial work Gift of inspiring others Knowledge of the profession and what we like and need PREPARATION Set aside plenty of late nights Find brilliant staff to help Let writers know what sort of articles are needed Encourage contributors (this can change a contributors life!)

Over 14 years Speech & Language Therapy in Practice editor Avril Nicoll has created an absolutely brilliant magazine for us to read, study, and enjoy. How did she do it? This is a guess but, at the risk of embarrassing her, I think it goes something like this... Judge which articles are most relevant to the readership Proofread and tweak with a light touch Coax reviewers Write fluently and informatively Cope with financial matters Find advertisers IN PRACTICE Keep it all purring along by setting the print date and establishing deadlines Lay out the magazine so the readers are drawn in Approve the final version, take a deep breath, and send it off to the printer Arrange distribution, and promotional copies to expand the readership Relax for a tiny moment, then go off again, with the same steps. Then again. And again.. !

And finally

So huge thanks Avril, you have informed and entertained me for years with the magazine, and on top of that youve set me off in a new direction. Im now happily awaiting the arrival of the prints of my first book Heres one I made earlier (www.speechmark.net/heres-one-i-madeearlier-15016), a compilation of the articles Ive written for Speech & Language Therapy in Practice.
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WINNING WAYS

Transition time
From 2003 to 2010, Life Coach Jo Middlemiss generously wrote over 20 articles for the popular Winning Ways in Speech & Language Therapy in Practice. As the magazine comes to a close, Jo reflects on the series and on the meaning and opportunities of lifes transitions.
ne of the things I used to hate was saying goodbye. I can still be deeply touched when witnessing farewells on screen, in airports or at railways stations. In equal proportion, I love greetings, welcomings and new beginnings. Change means embracing beginnings and endings. With this in mind, I embarked on my final article for Speech and language Therapy in Practice, this wonderful periodical, so full of heart, wisdom, compassion, challenge and learning. In doing so, I have been looking back on the topics Winning Ways has tackled, and remembering the therapists I have worked with. I started off with the basic idea of Life Coaching at a time when it was a fairly new phenomenon, talking about work / life balance. This was soon to morph into life balance, which makes far more sense, as it is crazy to think about work and life as if they are separate entities. Whatever is happening at the moment is our life. There isnt another one parked alongside waiting for us to live it, just as there isnt another planet parked alongside to hop onto when this one is spoiled. Over the years I have come to realise that, if we dont use our own life, other people will - and then we feel used and unappreciated. Stepping up to the plate is part of the courage and challenge of living. Then there was the series themed with the Keys for Effective Living. I still use these often: Awareness Attitude Authenticity Action. These keys encompass so much of what we need to tackle lifes daily challenges. Without Awareness there can be no growth. So much of how we interact with and deal with others is down to our conditioning. Awareness calls us to notice our conditioning - and we are then in a position to accept or reject it. What rules from our childhood are we still living by? What upset that occurred years ago are we still allowing to impact on our adult lives? What prejudices and resentments still get to block our joy? The Attitude we take to any aspect of our lives is reflected in our interactions with others and life in general. Billy Connelly is thought

Life Coach Jo Middlemiss on

to have said, There is no such thing as bad weather, only bad clothing choices. I thought of this the other day when I got totally soaked by cold rain and hailstones when out on a summer walk! We play so many roles in life: woman / man, sister / brother, worker, colleague, driver, friend. Choosing to be friendly, loving, compassionate in any given situation makes such a difference. Not many people get out of bed in the morning planning to be a wretch but many do retire having been a bit of a moody misery. That mismatch comes from being reactive to the day. PowerMorning Questions (Spring 08 issue) help you to be proactive and decide in advance that, no matter what happens, how you are going to be through it all is 100 per cent up to you. The Authenticy key is really an essential part of lifes journey. Be yourself, and get beyond behaving as if the only thing that matters is what other people are thinking about you. Abraham Maslow asks us to Be independent of the good opinion of others. It sounds impossible, but is an aspiration worth pursuing. It is a great relief to know someone is as they seem, and that they can be trusted no matter what. It is also freeing, as it encompasses honesty and integrity. If you never lie, you never need to remember what you said - a brilliant thing as the years roll on! The Action key in the end is vital. We can think and think all day long but - until we make that phone call, start that project, get into that wardrobe - nothing will change. And if nothing changes, nothing changes. It is generally accepted that transitions cause stress. Transitions can be any event or non-event that results in changed relationships, routines, assumptions or roles. Awareness that one is either moving into, moving out of, or moving through a transition can be helpful in reducing the stress of it. Everyone has coping strategies for these journeys, some helpful and effective and some not. We need a twin-pronged approach: action and emotional acceptance. Sometimes the pull yourself together and move on approach is what is required and sometimes tea and comfort is the right one.

It is rarely either /or, but a sensible, sensitive and compassionate combination of the two. During the last eight years, I have lost a sister and gained two daughters-in-law and three grandchildren. My mother has changed from a vibrant, funny octogenarian to a sleepy confused and cared for 96 year old. I have moved house, seen my husband through a double hip replacement, spent a life-changing month in Ethiopia, and had a book published. I have got to grips with social networking and my iPad, employed a personal trainer and bought a big fat hula hoop (for the fun of it and the waist benefits!) So many changes and transitions. Many I was not even thinking about whilst they were happening. Living in the present moment is probably the best coping strategy there is, with little mantras like This too will pass or Whatever happens I can handle it. We can simply appreciate each day for what it is, a unique moment in time which we will never have again. Churchill said History is just one damned thing after another. Although this is true I always think he sounds a bit irritated by it. If we view events as one extraordinary thing after the other we move through lifes transitions with awe and wonder. That is probably what changes caterpillars into butterflies - and what a fun transition or even transformation that would be. So this article comes with love to all of you, and with confidence that you will all deal expertly with your transitions. For my part, I have loved the writing and the contact that Winning Ways has generated. I am also immensely grateful to Avril who gave me this opportunity and has painstakingly edited the articles with tact and skill. I know she will miss her baby, but I also know that she will make a fabulous success of her next incarnation.
With love, Jo

Jo Middlemiss is a qualified Life Coach, who offers readers a complimentary half hour coaching session (for the cost only of your call). You can contact Jo on 07803 589959 or see her website www.dreamzwork.co.uk.

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How I offer impairment therapy(1):

Re-animating intervention
Over the past two years Ravit Cohen-Mimran has developed and piloted a novel approach to intervention with older children with language impairment. Animation Therapy is a hybrid of skill based and naturalistic activities aimed at improving narrative. Here, she describes the stages of the intervention and the impact it had on 11 year old Ben.
READ THIS IF YOU WANT TO INVOLVE FAMILIES USE NEW TECHNOLOGY WORK ON NARRATIVE

developed Animation Therapy to enhance the narrative skills of children with language impairments. The important role of narrative abilities in the academic and social success of children has been affirmed by many researchers (see Boudreau, 2008 for a review). Narratives are stories about real or imagined events, constructed by putting together at least two utterances produced in a temporal order about situational contexts, characters, actions, motivations, emotions and effects (Gillam & Pearson, 2004). Effective oral narratives are essential for common activities, both in and out of the classroom, such as story telling or retelling, describing events, and sharing personal experiences with friends or teachers. Successful use of oral narratives is also connected to effective written expression and reading comprehension (Nathanson et al., 2007). Many studies have shown that school-aged children with language impairment have persistent story telling difficulties. Compared to children with no language impairment, they tend to compose stories that are poorer linguistically (eg. shorter utterances) as well as structurally (eg. fewer story grammar components) (Fey et al., 2004). Johnston stated, "literature has convinced me that narrative abilities should be included among the intervention goals for all school-aged children with language learning problems" (2008, p.93). She also wrote that, by focusing on narrative intervention, opportunities are created to decontextualise language, facilitate social relationships, provide practice in constructive listening, and identify language strengths and weaknesses. Some researchers have argued that schoolaged children with language impairment may need intervention focusing directly on their narrative abilities (Fey et al., 2004). Indeed, in the past few years, several studies have recommended use of narrative intervention programmes focusing on explicit teaching of story grammar structures (Stein & Glenn, 1979). Studies have demonstrated that such intervention has led to improved narrative skills not only in children with language impairment (Swanson et al., 2005), but also in children who have cochlear implants (Justice et al., 2008), learning disabilities (Nathanson

The setting for Bens animation movie

et al., 2007) and children coming from lowincome families (Zevenbergen et al., 2003). The intervention programmes used by investigators are diverse. However, all include the presentation of a story, either by means of a picture book or movie, followed by asking the children to tell the story they have just heard or seen (Nathanson et al., 2007). Animation Therapy is an activity-based intervention founded on the naturalistic approach. During the past 20 years, clinicians have tended to use more naturalistic intervention programmes to optimise social and verbal interaction, thus helping people with disabilities improve their communication and language skills. The aim of the naturalistic approach is to facilitate generalisation and maintenance, since it tends to rely more on language use and meaningful practice than on repetitious tasks (Vilaseca & Del Rio, 2004). It enables us to help children

improve their skills by setting up situations providing opportunities to learn through age-appropriate interactive processes in natural settings (Vilaseca & Del Rio, 2004). In this child-centered approach, the clinician uses activities in which they can incorporate modelling and reinforcement of therapy targets within contexts that are meaningful to the child. However, this leaves the therapist with less control over the focus of the session. Thus, to allow the clinician more control over specific pre-selected therapy targets, Animation Therapy also includes structured parts, which make it a hybrid language intervention combining skill-based and naturalistic activities. The Animation Therapy intervention programme consists of four one hour individual sessions over a four week period. The programme is also suitable for group interventions, where it would most

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HOW I
likely include additional opportunities for increasing functional communication skills and pragmatics.
Figure 1 Bens animated traffic jam story (translated from Hebrew) The story that Ben told Ravit in the beginning: There is a big traffic jam. There was a big traffic jam. There was this kid, a student. He decided to try and direct the traffic to get it going again. So he began to direct the cars. And in the end he makes a big mess. The story that was written with Ravit's help: Once upon a time, at an intersection in a regular neighbourhood, the traffic lights stopped working. Soon, all the cars stopped. No one could drive and all drivers were nervous. People heard loud sirens everywhere. Gal was on his way home from school. Gal, who had been chosen to be the classroom helper that day, heard the loud sirens. When he reached the intersection, he saw a huge traffic jam. Gal felt a responsibility to help. He raised the megaphone that the classroom teacher had given him that day, and started yelling "Stop the sirens! I'm coming to help!" He immediately walked into the middle of the intersection and starting directing traffic. Gal was turning around in all directions, and before he knew it, he had created a huge pile up of cars. Gal stood on the pavement, very satisfied with himself. "Way to go! I can direct traffic!"

Week 1: Brainstorming

This session includes two goals. First, the child is encouraged to invent and talk about a story plot. According to the seven story grammar elements (Stein & Glenn, 1979), child and clinician try to answer the following questions: who the story is about (characters); where the story takes place (setting); what the goal or plan of the main character is; what the obstacle to achieving the main character's goal is; how the main character tries to resolve the problem (attempts); and finally, what the outcomes are (resolution and conclusion). After the plot has been generated, dialogues are considered as a means of discussing the main characters thoughts and feelings. Second, the child is encouraged to think and talk about the story setting. Child and clinician plan the set for the shoot. Should the characters be created from playdough or should real toys be used? How should the set be built, and what materials are needed? Together, a list of toys, objects and materials is composed, and by the end of this session it is decided who is responsible for bringing what.

problem-solving are provided within the context of very natural situations.

Week 4: The writing

Week 2: The set

After the child recalls the story plot, the setting needs to be created. Dcor is cut, glued and built as needed. After the set is ready, the child recalls what was done during this session in temporal order. To foster recall, the clinician might provide the child with a sequence of photos depicting what had been done, or encourage the child to answer the question: And what did we do next?

After the speech and language therapist has edited the animation movie, both child and clinician view it together. The child is then asked to tell the story. Based on what the child recounts, the clinician encourages them to expand upon the story by providing more details concerning the setting, the main character's looks, and thoughts and feelings. In addition, both work together to reshape and lengthen the sentences, adding or changing words to use more sophisticated vocabulary. At the end of this session, the child is given a copy of the story and is encouraged to read it to their relatives a couple of times.

Principles

Week 3: The shoot

After recalling the story and organising the set that was built in week 2, picture shooting begins using the "stop motion" technique to create an animation movie. In this process, objects change step by step, within 120-150 individually photographed frames. This technique helps to create the illusion of movement when the series of frames is played in a continuous sequence. During this session, the child and the clinician move the characters as well as the other objects in the set according to the story plot. After each move they take a picture. To create smooth movements of the characters in a realistic environment, two principles must be adhered to. First, the characters must move in very tiny steps; second, the set must stand still. This procedure demands patience from the child. However, from my experience, the clinician can encourage the child by switching between the two roles of moving characters and taking pictures and by helping solve problems that can occur during the shooting (such as when part of the setting suddenly collapses or the dough-character's hand disconnects from its body). Thus, opportunities to discuss

In all sessions the following principles apply: 1. Language treatment goals are integrated into all activities, so the child has opportunities to learn via the interactive process. 2. The intervention structure includes planning, experiencing and reconstructing. 3. All participants (child, parent and clinician) are initiators who take part in all activities. 4. The family plays an important role in the therapy as they are involved in all stages of the programme; in particular, in generating the story and decorating the set. 5. The animation story must be based on: narrative knowledge (story grammar structure, temporal order of events) textual knowledge (coherence and cohesion) and linguistic knowledge (semantics and syntax).

Bens therapy

Ben, aged 11;1 years, was a fifth grader in a regular class. Two years previously, in third grade, he had been given remedial reading lessons, but his assessment visit to me was his first experience of speech and language therapy. Ben met all the exclusionary criteria for specific language impairment as he had no hearing impairment, showed no evidence of neurological impairment and was of average IQ for his age. At the same time, he showed low performance in language and reading skills.

I conducted all sessions in a quiet work room in a university clinic, and over the four weeks of intervention we created a short animation movie. In the beginning, Ben was excited and eager to start, as he had watched a few animation movies I had done with other children and was motivated to make one of his own. In the first session, he created the plot, choosing a child as the main character. He decided that the story would take place at an intersection. The main events were: the child returned from school, he saw a traffic jam (the problem), and tried to fix it by taking charge and giving orders as to where the drivers were to go (attempts). In the end, the character caused the cars to pile up instead of fixing the problem (result). After the plot was determined, we discussed the set and its materials. Ben decided that the people would be made from LEGO and Playmobil that he had at home. In addition, he offered to bring many little cars, little trees and a few traffic lights. His mother volunteered to find a picture of a street that could be set up in the background. I offered to bring coloured paper. We described the set in detail and recorded a list of the materials. During the second session, after Ben had retold the story, we built the set together with his mother. In the third session, Ben retold the story again and we took photos of the set. While doing this, we talked about the music and sounds to be added to the movie (such as the beep of a car's horn, a child shouting, and samples from the music of "Mission Impossible", originally composed by Lalo Schifrin). Between the third and fourth sessions, I mailed the final movie to Ben, with photos, music and sounds already edited. Thus, during the fourth session Ben was able to view the movie. In this session, we wrote the story. First, Ben told the story, and I refrained from making any corrections. Then we retold the story together, writing it down on the computer and printing it out, thus making it easily accessible for reading at home. During this stage, I asked leading questions and rephrased Ben's sentences. After the story was complete, Ben read it and promised to read it at home as well. These two stories (figure 1) have been translated from Hebrew. To ensure the language level stayed the same including mistakes a Hebrew speaker who is also a

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native English speaker translated the texts. It is important to note that the written story Ben received at the end of this session, intended for repeat reading at home, was a good story in terms of rich vocabulary, accurate grammar and an appropriate plot comprised of the seven story grammar elements. To test the outcomes of the intervention, I collected two spoken narratives from Ben before it, then again after it. I collected the pre-test stories as part of a large diagnostic battery which includes language, memory and reading tests. Immediately following the language evaluation I asked the family to participate in this study. This meant that Bens treatment would begin with Animation Therapy and focus only on this method for a few weeks. The family gave their consent and, four weeks after the pre-test, Ben received the four therapy sessions. A week later, the posttest took place. Thus, 2.5 months had passed between the pre- and the post-tests. To elicit the narratives, I used two sets of six sequence pictures, the campfire story and the painting story, from story cards published by Schubi. I didnt give any prompts. For both stories, I asked Ben to study the pictures and to think about the story that accompanied them. I then asked Ben to generate a story while still looking at the pictures. I wrote up and analysed the stories from digital audio recordings. Another speech and language therapist analysed them separately, with good agreement. We analysed the oral narrative performances at two levels: a. macrostructure - assessing the overall quality by addressing story grammar elements and overall coherence b. microstructure - testing linguistic structures. To examine the macrostructure level of oral narratives, we used the Index of Narrative Complexity. This index is differentially weighted in favour of episodic complexity and narrative cohesion (Petersen et al., 2008). The scoring system includes categories such as characters, setting, initiating events, internal responses, plans, action/attempts, complications, consequences, narrator evaluations, formulaic markers, temporal markers and causal adverbial clauses. The scores in each category range from 0 to 3 points. Based on the Index of Narrative Microstructure (Justice et al., 2006), we also included six indices reflecting both productivity and complexity. Productivity was measured by total number of words, total number of different words and total number of T-units. In linguistics, a T-unit consists of a single main clause and any dependent constituents, including clauses and phrases. Complexity was measured using mean length of T-units in words, total number of coordinating conjunctions and total number of subordinating conjunctions. These two indexes were designed for use as clinical tools in setting targets for therapy as well as evaluating the outcomes of the intervention. Figure 2 shows the macrostructure level analysis. Comparison between pre-test and post-test demonstrates a dramatic increase in
Figure 2 Intervention outcomes evaluation: macrostructure analysis (Petersen et al., 2008) Campfire story Pre Character Setting Initiating event Internal response Plan Action / attempt Complication Consequence Narrator evaluation Formulaic markers Temporal markers Causal adverbial clauses Knowledge of dialogue Total Score 1 0 0 2 1 1 1 0 0 0 1 0 0 7 Post 1 1 2 2 1 2 1 0 0 1 1 0 0 12 Painting story Pre 1 0 3 2 0 2 0 0 0 0 1 0 0 9 Post 1 2 3 2 0 2 0 2 1 2 1 0 0 16

Figure 3 Intervention outcomes evaluation: microstructure analysis (Justice et al., 2006) Campfire story Pre Total number of words Total number of different words Total number of T-units Mean length of T-units in words Total number of T-units of two or more clauses Total number of coordinating conjunctions Total number of subordinating conjunctions 30 25 8 4.38 1 0 1 Post 64 45 9 7.11 4 3 2 Painting story Pre 29 20 6 4.14 1 1 0 Post 50 38 6 8.33 6 3 5

Figure 4 Resources needed for Animation Therapy A software tool for making animated films - I use "stop motion pro-action" (www. stopmotionpro.com), which is perfect for children and educators looking for an inexpensive and easy-to-use tool A digital camera that has a USB connection Tripod Playdough Small toys - small plastic people and objects Office supplies such as coloured papers, glue and scissors

Bens post-narrative score. Both stories show improvement in setting and formulaic markers. Improvement in initiating event and actions is seen in one story, and in consequence and narrator evaluation in the other. The four narratives - in Hebrew, parsed into T-units and translated into English are available in the members area of www.speechmag.com. They illustrate use of structures characteristic of mature narratives in post-narratives compared to pre-narratives. For instance, past tense verbs appear in the post-narratives, compared to present tense verbs more common in the pre-test stories ("are angry", "sees", "doesn't like"). In addition, the temporal marker in the post-narratives is "when", compared to "then" in the pre-narratives. The deictic maker "here", characteristic of narratives of younger children (Shen & Berman, 1997), was used in one of the pre-narratives.

Figure 3 demonstrates the microstructure level analysis. Pre- and post-test comparisons reveal a dramatic score increase in both parameters: productivity and grammatical complexity. Ben used more words and more words per T-unit in the post-narratives. The increase in grammatical complexity in the postnarratives was expressed through the presence of more subordinating and coordinating conjunctions, revealing more complex T-units. Results indicated a reliable change in Ben's narratives following one block of intervention. In particular, his narratives were longer, containing a greater number of different words and more complex structures. The plot was extended by adding setting, consequences, formulaic markers and even evolution remarks. Furthermore, it is important to mention that this was achieved within the time allotted.

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how i / EDITOR'S CHOICE

Editors choice

Editor Avril Nicoll gives a brief flavour of articles that have got her thinking.
Nouns are generally easier to learn and teach than verbs. Japan has a standardised system of Pictogram Symbols for use by people with communication difficulties and the general public, which Fujisawa, Inoue, Yamana & Hayashi used to investigate The Effect of Animation on Learning Action Symbols by Individuals with Intellectual Disabilities. Results were positive, particularly for the participants at a lower level of linguistic development. As an alternative to arrows, the researchers offer a number of ideas to indicate motion in static pictures. These include blurring, vibration marks, and a visual wake (p.59), as well as capturing a state of disequilibrium which cannot be maintained. Augmentative and Alternative Communication (2011) 27(1), pp.53-60 Work and study can make it difficult for people to attend regular clinic appointments. In The use of email as a component of adult stammering therapy: a preliminary report, Carolyn Allen draws on a range of literature and experience with 16 clients. Email can offer easier access at a convenient time and place. It gives client and therapist opportunities for immediate expression or detailed reflection, and may support maintenance and transfer. Although I would quibble with the use of clients...are not permitted to receive therapy exclusively via email (rather than we have chosen not to offer therapy exclusively via email), Carolyn successfully sets the scene for efficacy studies with a comprehensive overview of benefits and risks. Journal of Telemedicine and Telecare (2011) 17, pp.163-167 Carole Pound is one of the great thinkers of our profession. Her influence on practice and research with people with aphasia, particularly through work at Connect, has been profound. With Reciprocity, resources and relationships: New discourses in healthcare, personal and social relationships she raises the bar yet again, pulling together findings from a wide range of disciplines and two successful projects. We are challenged to address the power and inequality rooted in healthcare practice, and to be more creative in co-creating opportunities for friendship, participation, contribution and personal development which make a difference to health, identity, resilience and happiness. International Journal of Speech-Language Pathology (2011) 13(3), pp.197-206

The innovation inherent in Animation Therapy is that it was developed to suit older children (8-16 years old). As speech and language therapists, we are constantly seeking new intervention tools to enable children to learn and communicate effectively; in particular, therapies which address older children with language impairment. These children generally receive treatment from an early age and sometimes are quite familiar with various intervention tools. Reactions such as: "Not this again", "Can we do something else?" or "It's boring" are often heard. Thus, I have tried to arouse students curiosity by choosing a method that is more playful than usual. Moreover, today's children are growing up in a high technology world and it is incumbent upon us to offer them something more suitable to their areas of interest. This particular treatment requires the clinician to devote out-of-therapy time, especially for editing the movie. However, I use very friendly software (figure 4, p.27) and the entire editing process takes me approximately half an hour. My experience with Ben, as well as with other children who have participated in Animation Therapy, reveals that they seem to enjoy the materials and activities, and also cooperate readily in all tasks. Children learn they have "good ideas", and that their ideas are valued. As a result, there is an increase in self-confidence regarding narrative production skills. It is important to note that, although most of the children improve their narrative skills after Animation Therapy, the level of the change varies. Usually I use Animation Therapy together with other traditional tools, such as re-telling stories and looking at picture books, so it is hard to define the effect of the Animation Therapy itself. The case study I have described in this article was the only time I have asked a family to participate in it immediately following the language evaluation, thus the treatment began with the Animation Therapy and focused for several weeks on this method only. In future, this approach must be tested in a larger study with more participants. Another important issue is the role of the child's family in Animation Therapy, being involved in all stages of the programme. In actuality, the clinician, rather than being the "instructor", shares her role with the parent. The parent becomes a full partner, with responsibilities in the process. The atmosphere is such that all work as a team to achieve a mutual goal the creation of the movie. These relationships motivate the child to take responsibility for the success of the movie, as well as the success of the SLTP treatment. Dr Ravit Cohen-Mimran is a speech and language therapist and Head of the Clinical Education Unit at the Department of Communication Sciences and Disorders, University of Haifa, email rmimran@univ.haifa.ac.il. See two videos at www.speechmag.typepad.com and the four narratives at www.speechmag.com/members.

References Boudreau, D. (2008) Narrative abilities: Advances in research and implications for clinical practice, Topics in language disorders 28(2), pp.99-114. Fey, M.E., Catts, H.W., Proctor-Williams, K., Tomblin, J.B. & Zhang, X. (2004) Oral and written story composition skills of children with language impairment, Journal of Speech, Language and Hearing Research 47, pp.1301-1318. Gillam, R. B., & Pearson, N.A. (2004) Test of Narrative Language. Austin, TX: PRO-ED. Johnston, J.R. (2008) Narratives: twenty-five years later, Topics in Language Disorders 28(2), pp.93-98. Justice, L.M., Bowles, R.P., Kaderavek, J.N., Ukrainetz, T.A., Eisenberg, S.L., & Gillam, R.B. (2006) The Index of Narrative Microstructure: A Clinical Tool for Analyzing School-Age Childrens Narrative Performances, American Journal of Speech-Language Pathology 15 pp.177191. Justice, E.C., Swanson, L.A., Buehler, V. (2008) Use of narrative-based language intervention with children who have cochlear implants, Topics in Language Disorders 28(2), pp.149-161. Nathanson, R., Crank, J.N., Saywitz, K.J. & Ruegg, E. (2007) Enhancing the Oral Narratives of Children with Learning Disabilities, Reading & Writing Quarterly 23(4), pp.315-331. Petersen, D.B., Gillam, S.L. & Gillam, R.B. (2008) Emerging procedures in narrative assessment: The Index of Narrative Complexity, Topics in Language Disorders 28(2), pp.115-130. Shen, Y. & Berman, R.A. (1997) From single event to action-structure: stages in narrative development, in J. Shimron (Ed.) Psychological Studies of the Language in Israel. Hebrew University, Jerusalem, Israel: Magnes. (In Hebrew.) Stein, N. & Glenn, C. (1979) An analysis of story comprehension in elementary school children, in R.D. Freedle (Ed.) Advances in discourse processes: Vol. 2. New directions in discourse processing (pp. 53-119). Norwood, NJ: Albex. Swanson, L.A., Fey, M.E., Mills, C.E. & Hood, L.S. (2005) Use of narrative-based language intervention with children who have specific language impairment, American Journal of Speech-Language Pathology 14, pp.131-143. Vilaseca, R.M & Del Rio, M-J. (2004) Language acquisition by children with Down syndrome: A naturalistic approach to assisting language acquisition, Child Language Teaching and Therapy 20(2), pp.163-180. Zevenbergen, A.A., Whitehurst, G.J., & Zevenbergen, J.A. (2003) Effects of a shared-reading intervention on the inclusion of evaluative devices in narratives of children from low-income families, Journal of Applied Developmental Psychology 24, pp.1-15.

REFLECTIONS DO I OFFER THERAPY THAT IS CONSISTENT WITH RESEARCH FINDINGS ABOUT THE SKILLS THAT MATTER? DO I USE PRE AND POST INTERVENTION MEASURES THAT ARE SUFFICIENTLY SENSITIVE TO CHANGE? DO I LOOK FOR RESOURCES WHICH CAN REPRESENT THE DYNAMIC NATURE OF COMMUNICATION?
What ideas has this article given you? Let us know via Speech & Language Therapy in Practices Critical Friends, www.speechmag. com/About/Friends.

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From idealism to realism, step by step


Evidence shows that impairment based treatment for people with chronic aphasia can make a difference but is it a realistic proposition for everyday clinical practice? With the help of Simon, his wife Lesley and information and communication technology, Jane Mortley and Rebecca Palmer chart the effectiveness and time efficiency of the StepByStep program.
t is our impression that people with chronic aphasia rarely receive impairment based therapy from speech and language therapists, and that long-term input often focuses on compensatory techniques to assist the individual to communicate. However, many people with aphasia still report the motivation to improve several years post stroke, their goal being to use more language (Mortley et al., 2004). It is generally accepted that approximately 250,000 people are living with aphasia at any one time in the UK alone (RCSLT, 2009) and national guidelines support the provision of speech and language therapy for as long as these people are benefiting from and able to tolerate it (NICE, 2010). Recent evidence challenges our traditionally held beliefs by showing that improvement in long-standing chronic aphasia is possible (Meinzer et al., 2005; Raymer et al., 2008; Kurland et al., 2010). Neuroscience research has identified that the brain has the capacity for structural and functional plasticity throughout the human lifespan, with imaging studies showing a significant relationship between neuro-plastic changes and language recovery (Raymer et al., 2008). A key principle of neuro-plasticity is that intensity matters, and systematic reviews support the idea that the greater the intensity of language treatment, the greater its effectiveness (Robey, 1998; Bhogal et al., 2003). A further important principle is use it or lose it. Compensatory communication techniques of gesture, writing and picture charts are essential for most people with aphasia. However, it is important that this is complemented by effective impairment based therapy, as the active avoidance of words or phrases that are difficult may lead to learned non use of these words and grammatical structures. Language action therapies in aphasia encourage the use of residual language skills, even when the vocabulary and grammatical structures are difficult to produce, to promote the READ THIS IF YOU BELIEVE IN USING THE EVIDENCE BASE LISTENING TO CLIENTS WISHES ONGOING CAPACITY FOR CHANGE

How I offer impairment therapy (2):

reactivation and strengthening of language circuits that have survived the brain lesion (Pulvermuller & Berthier, 2008). Constraint Induced Aphasia Therapy (CIAT) is a form of language action therapy in which constraint refers to the principle of focusing clients on their remaining language abilities, especially those they avoid using. Constraint induced aphasia therapy involves pairs games, encouraging use of language by constructing barriers between players to prevent pointing or gesturing. This therapy is carried out intensively for 30 hours over 2 weeks using the principle of massed practice. The target words, phrases or sentences are shaped to increase the level of difficulty as the client improves (Pulvermuller et al., 2001; Meinzer et al., 2005; Pulvermuller & Berthier, 2008). Pulvermuller et al. first demonstrated evidence for the effectiveness of this technique in aphasia treatment in 2001, and a preliminary systematic review of 10 studies conducted over the decade concluded that the evidence for intensive and constraint induced therapies for aphasia is favourable (Cherney et al., 2008). Learning theory suggests that the personal relevance or salience of language material being practised is also of importance (Raymer et al., 2008). Meinzer et al. (2005) recognised the need to promote lost language functions repeatedly in real life situations for people with chronic aphasia, so introduced CIAT plus. This combined written materials and photographs of everyday scenarios with a training module including a clients relative in daily communication exercises, which provided an additional valuable element to the therapy. The behavioural relevance principle, based on experiments which show cortical links between actions and words, also states that it is advantageous to practise language in relevant action contexts (Pulvermuller & Berthier, 2008). Structured therapy tailored to the individuals difficulties is another important aspect. Barthel et al. (2008) found effects of

Lesley and Simon

Model Oriented Aphasia Therapy - which tailors treatment according to individual symptoms - were comparable to CIAT when delivered at similar intensity. High intensity of treatment is common to many effective therapies. Unfortunately the resources required to achieve this through face-to-face speech and language therapy sessions are often prohibitive, particularly in the long term. The use of volunteers has been recognised as a potential way to enable intensive practice. Meinzer et al. (2005), suggested volunteer assistance in carrying out CIAT, and Fink et al. (2005) proposed trained volunteers to support computer practice. There is a growing body of evidence that computer software can be used effectively to enable clients to practise language based exercises independently from their therapist, consequently increasing the intensity of practice that can be achieved with face-toface contact only (Katz & Wertz, 1997; Lee et al., 2009). Case series studies have shown the use of computers to support varying levels of independent practice. Fink et al. (2002) demonstrated the effectiveness of computers to increase intensity of word finding treatment by using them to offer treatment between face-to-face sessions with a therapist, whereas Ramsberger & Marie (2007) report improvements in word finding

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No. correct Cognition screen Line bisection Semantic memory Word fluency Recognition memory Gesture object use Arithmetic Part 1: Language comprehension Comprehension of spoken language Comp. of spoken words Comp. of spoken sentences Comp. of spoken paragraphs Section TOTAL Comprehension of written language Comp. of written words Comp. of written sentences Section TOTAL 14/15 8/16 28/30 18/32 46/62 55 51 53 15/15 6/16 30/30 12/32 4/4 46/66 65 44 60 49 0.5 10/10 10 10/10 12/12 2/6 59 60 54 59 98 44

Score

T-score

T-scores explained: T-scores put scores from different subtests onto a common scale of difficulty showing relative strengths and weaknesses across different tasks. The CAT (Comprehensive Aphasia Test) T-scores are based on the results from 266 people with aphasia. A T-score of 50 represents the mean score within the sample of people with aphasia; 96 per cent of scores from people with aphasia will fall between 30 and 70.

Figure 1a Comprehensive Aphasia Test - Cognition and Language comprehension sections No. correct Part 2: Expressive Language Repetition Repetition of words Repetition of complex words Repetition on non words Repetition of digit strings Repetition of sentences Repetition TOTAL Spoken Language Production Naming objects Naming actions Word fluency Naming TOTAL Reading Aloud Reading words Reading complex words Reading function words Reading non words Reading TOTAL Writing Writing copying Writing picture names Writing to dictation Writing TOTAL 11/24 0/3 3/3 0/5 16/33 12/24 2/5 16/16 3/3 4/5 3/14 3/12 29/50 Pre-therapy 32/32 6/6 9/10 6/14 6/12 59/74 Pre-therapy 22/48 4/10 3 29 Pre-therapy 22/24 0/6 6/6 0/10 33/70 Pre-therapy 27/27 6/21 5/28 38/76 61 46 46 48 44 40 62 40 47 16/24 1/3 3/3 0/5 20/33 50 50 47 49 20/24 2/5 65 62 62 46 48 55 16/16 3/3 5/5 3/14 3/12 30/50 Post-therapy 32/32 6/6 10/10 6/14 6/12 60/74 Post-therapy 42/48 4/10 10 56 Post-therapy 34/48 2/6 6/6 0/10 42/70 Post-therapy 27/27 16/21 7/28 50/76 61 55 47 51 47 40 62 40 51 61 50 54 57 65 62 67 46 48 56 Score T-score No. correct Score T-score

when the speech and language therapists role was only to set up and monitor the use of computer exercises. Advances in information and communication technology have made it feasible to monitor therapy from a different location through the use of the internet (Mortley et al., 2004), in keeping with the growing recognition of the crucial role of telehealth in delivering health services efficiently. The Department of Health (2006) prioritises self management of long term conditions using such technical innovations. The StepByStep treatment approach incorporates these key elements of successful impairment focused aphasia therapies in the resource efficient manner required to achieve the necessary levels of intensity. It uses a computer program through which the therapist can tailor therapy exercises to each clients language needs and select personally relevant vocabulary. It is designed to be easy for an individual to use independently for self managed intensive (daily) practice, with the support of a relative or volunteer where possible. It also follows the principle of errorless learning (Fillingham, 2006), starting with tasks that the individual can achieve with ease. This limits the struggle to produce words and increases confidence by promoting faster, easier retrieval.

Simons therapy

Figure 1b - Comprehensive Aphasia Test - Expressive language sections pre and post therapy % words named correctly pre-therapy 42 16 % words named correctly post-therapy 70 18

Word type Objects Actions

Figure 2 Object and Action Naming Battery pre- and post- therapy

Jane, an independent specialist speech and language therapist, developed the StepByStep program. She used it with Simon, a 52 year old man who suffered a stroke 9 years ago. Simon and his wife Lesley have agreed to their story being shared. Simon is right handed and English is his first language. Prior to his stroke he ran his own haulage business. In 2002, at the age of 43, Simon had an infarct located in the inferior frontal gyrus area of the left hemisphere, resulting in severe aphasia. After 6 years he still wished to improve his ability to use language, and his wife Lesley assisted him in finding options for impairment based speech and language therapy. At this stage Simon was frustrated and withdrawn, showing little initiation of speech. According to Lesley he would use about 10 words a day, a few recurrent phrases such as too true or yes I know, and no sentences. He communicated through gesture, drawing and sky writing the first letter, and had a Say-it! SAM communication aid. Simons pre-intervention Comprehensive Aphasia Test (Swinburn et al., 2004) scores are in figures 1a and b. They show that comprehension of both spoken and written single words was good, but impaired at the sentence level. Simons aphasia affected all areas of expression including repetition, spoken language production, reading aloud and writing. Jane also administered the Object and Action Naming Battery (Druks & Masterson, 2000) to assess Simons naming ability further (figure 2). He scored 42 per cent correct on objects and 18 per cent correct on actions. His errors were mixed in terms of

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semantic paraphasias, phonological errors and no response. His word retrieval was helped by phonemic cueing. Intervention was offered in four steps over a 6 month period: Step 1: Computer therapy at single word level a) Spoken naming The target word was shown with a succession of cues to facilitate word retrieval as shown in figure 3. Simon would attempt to say the word but if he was not able to he could choose from a number of different cues to facilitate the word. Simon was encouraged firstly to say the word without help. If he was unable to do this he would try to type the initial letter for selfphonemic cueing. If this did not trigger the word then he would listen to the first phoneme. If this did not cue him then he would click to hear the whole word spoken which he was able to repeat. It was important that he was able to say the word with or without cues for each picture to ensure the connections were being made in the brain. b) Written confrontation naming The target words were also put into a range of spelling exercises from initial letter spelling, copying the whole word, anagram solving, and flash where the word is shown and then disappears when he started to type the target word (figure 4). Only correct responses were accepted and help was given in the form of the on-screen keyboard which reduced the number of letters displayed to ensure that he could progress through each question. The exercises were presented in levels of difficulty and the next exercise in the sequence was presented when he achieved 85 per cent on two occasions, shaping the therapy tasks in response to improvement. Step 2: Computer therapy at sentence level Sentence based tasks (figure 5) incorporated the target word within the context of a meaningful functional sentence based on I would like a [target word] please. In a level 1 task the sentence was shown. When Simon clicked on the blue button he would hear the whole sentence spoken. He was also able to click on each word within the sentence to hear it spoken and try to repeat the whole sentence. When he felt confident in producing the sentence, he would move up to level 2 which showed him the target picture and the question only. He was required to try to say the sentence without the written prompt. If he found it difficult he could again click on the blue button to see the written sentence and hear it spoken. Step 3: Language action therapy game Simon and his wife were shown how to do the language action therapy tasks, incorporating the concept of use it or lose it. Two copies of the word sets were printed out, and a wooden partition was positioned on the table between them, low enough to see their faces, but high enough to avoid use of gesture or pointing instead of language. Jane, who was

Click to see video giving first sound of word Click to type initial letter Click on dictionary to see written word Click to see video showing mouth movements

Figure 3 Cues to facilitate word retrieval

Figure 4 Screenshots of an anagram and flash

Figure 5 Sentence level tasks

monitoring the therapy remotely, asked them to play a pairs game. This involved them each having four cards, with Simon required to say I would like the [target picture] please in order to win pairs. The winner was the person with the most pairs. When Lesley asked Simon for a card, his response was either here it is or no, I havent got it. The constraint aspect to this task was that Simon had to produce a sentence containing the correct target word, otherwise Lesley would not give him the card. Imposing such constraint can be difficult and risk exposing the language weaknesses of the person with aphasia. The StepByStep approach reduces such discomfort by ensuring that the person with aphasia can retrieve the target words in sentences in step 2 with the computer before moving on to the barrier games. In addition, the language action therapy is introduced very much as a game to be enjoyed by the person with aphasia and communication partner. Step 4: Using scenarios in every day speech This step follows the behavioural relevance principle and the notion of using language functionally with relatives and communication

partners. Lesley encouraged Simon to use the new language in everyday contexts to promote generalisation. So instead of saying would you like a coffee? to which he would respond yes or no, she would say what would you like to drink? or she would give him his breakfast or cup of tea without sugar so he would practise I would like some sugar please. A key element of StepByStep is remote support. Jane reviewed progress every 6 weeks by teleconferencing with Simon and Lesley through Skype, using webcams so they could see each others faces. A commercially available program called TeamViewer enabled Jane to connect to Simons computer remotely in order to control the StepByStep software. Jane adjusted the computer exercises if needed and offered instruction to Simon and Lesley when he was ready to start practising the new vocabulary in phrases using the pairs game (Step 3). Jane shaped the use of the words in the game during the sessions to encourage more complete phrases and sentences. Once sentences were being used easily in the pairs game, she guided the practice of the new vocabulary and sentences into everyday situations.

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Over the 6 months, Simon completed 49 hours of computer therapy independently at home and received 6 hours of therapy from Jane. This consisted of 2 face to face sessions (3 hours) and 3 videoconferencing sessions (3 hours). We do not have a record of how much time Simon and Lesley spent doing the language action therapy tasks. Intensive, massed practice is a key component but, although StepByStep is 20 minutes per day, this approach is less intensive than CIAT (30 hours over 2 weeks) and is delivered over a longer period of time. This may be more manageable for some people with aphasia, particularly those still experiencing the effects of fatigue post stroke. Simons Comprehensive Aphasia Test results in figure 1b (p.30) indicate an improvement in naming objects with a change in T-score from 50-61 and writing picture names with a change in T-score of 46 to 55. The Object and Action Naming battery (figure 2, p.30) shows an improvement in naming objects but similar scores for action naming. Lesley also reported functional use of sentences in everyday conversation. The StepByStep approach to aphasia treatment was effective for Simon, as naming of nouns improved and generalised to non treated words, and was maintained up to 3 months post treatment. The change in Simons use of language lends further support to findings that people with chronic aphasia can improve with treatment. For Simon as the client, Lesley as his wife and Jane as the speech and language therapist, the StepbyStep package made evidence based, intensive treatment for aphasia a manageable, realistic and acceptable option. Simon and Lesley reported that practising individual words and sentences with the computer built confidence to use the language in the CIAT activities. It empowered Simon to practise independently and have control over his progress in therapy. The approach also included his wife as the main communication partner, involving her in a supportive role and enabling joint responsibility for use of the new language in contexts that were functionally relevant to them.
behavioural relevance real life massed practice Lee, J,B., Kaye, R.C. & Cherney L.R. (2009) Conversational script performance in adults with non-fluent aphasia: Treatment intensity and aphasia severity, Aphasiology 23(7-8), pp.885-897. Meinzer, M., Djundja, D., Barthel, G., Elbert, T. & Rockstroh, B. (2005) Long term stability of improved language functions in chronic aphasia after constraint-induced aphasia therapy, Stroke 36, pp.1462-1466. Mortley, J., Wade, J. & Enderby, P. (2004) Superhighway to promoting a client-therapist partnership: Using the Internet to deliver wordretrieval computer therapy monitored remotely with minimal speech and language therapy input, Aphasiology 18(3), pp.193-211. NICE (2010) Stroke quality standard: Ongoing rehabilitation. Available at: http://www.nice. org.uk/guidance/qualit ystandards/stroke/ ongoingrehabilitation.jsp (Accessed: 27 October 2011). Pulvermuller, F. & Berthier, M.L. (2008) Aphasia therapy on a neuroscience basis, Aphasiology 22(6), pp.563-599. Pulvermuller, F., Neininger, B., Elbert, T., Mohr, B., Rockstroh, B., Koebbel, P. & Taub, E. (2001) Constraint induced therapy of chronic aphasia after stroke, Stroke 32, pp.1621-1626. Ramsberger, G. & Marie, B. (2007) Self-administered cued naming therapy: a single-participant investigation of a computer-based therapy program replicated in four cases, American Journal of SpeechLanguage Pathology 16, pp.343-358. Raymer, A., Beeson, P., Holland, A., Kendall, D., Maher, L.M., Martin, N., Murray, L., Rose, M., Thompson, C.K., Turkstra, L., Altmann, L., Boyle, M., Conway, T., Hula, W., Kearns, K., Rapp, B., Simmons-Mackie, N. & Gonzalez-Rothi, L.J. (2008) Translational Research in Aphasia: From Neuroscience to Neurorehabilitation, Journal of Speech, Language and Hearing Research 51(1), pp.259-275. Robey, R.R. (1998) A meta-analysis of clinical outcomes in the treatment of aphasia, Journal of Speech, Language and Hearing Research 41, pp.172-187. RCSLT (2009) RCSLT Resource Manual for Commissioning and Planning Services for SLCN: Aphasia. Available at: http://www.rcslt.org/speech_ and_language_therapy/commissioning/aphasia (Accessed: 27 October 2011). Swinburn, K., Porter, G. & Howard, D. (2004) Comprehensive Aphasia Test. London: Psychology Press. Resources Say-it! SAM, www.words-plus.com Skype, www.skype.com StepByStep, www.aphasia-software.com TeamViewer, www.teamviewer.com

neuroplasticity

remote a

confidence

constraint induced

ccess high intensity


software
tailored

salience
telehealth ce volunteer

independen

errorless learning

Figure 6 Key vocabulary

Research for Benefit Programme is underway to evaluate the effectiveness and cost effectiveness of using this approach more widely as a method of service delivery for aphasia in the long term. Kirmess & Maher (2010) used Language Action Therapy principles in the earlier stages, one to two months post onset of aphasia, with positive results. In a similar way it would be useful to investigate the effect of using the StepByStep approach to investigate whether an earlier start helps to avoid learned non use of language experienced by those SLTP with chronic aphasia. Dr Jane Mortley is an independent speech and language therapist, and clinical director of Steps Consulting, www.aphasia-software.com/. Dr Rebecca Palmer is a speech and language therapist in Health Services Research at the University of Sheffield, email r.l.palmer@sheffield.ac.uk.
References Barthel , G., Meinzer, M., Djundja, D. & Rockstroh, B. (2008) Intensive language therapy in chronic aphasia: Which aspects contribute most?, Aphasiology 22(4), pp.408-421. Bhogal, S.K., Teasell, R. & Speechley, M. (2003) Intensity of aphasia therapy, impact on recovery, Stroke 34(4), pp.987-993. Cherney, L.R., Patterson, J.P., Raymer, A., Frymark, T. & Schooling, T. (2008) Evidence-based systematic review: Effects of intensity of treatment and constraint-induced language therapy for individuals with stroke-induced aphasia, Journal of Speech, Language and Hearing Research 51, pp.1282-1299. Department of Health (2006) Our health, our care, our say: a new direction for community services. Crown copyright. Available at: http://www.officialdocuments.gov.uk/document/cm67/6737/6737.pdf (Accessed 20 September 2011). Druks, J. & Masterson, J. (2000) An Object and Action Naming Battery. London: Psychology Press. Fillingham, J.K., Sage, K. & Lambon Ralph, M.A. (2006) The treatment of anomia using errorless learning, Neuropsychological Rehabilitation 16(2), pp.129-154. Fink, R., Breecher, A., Schwarz, M. & Robey, R. (2002) A computer-implemented protocol for treatment of naming disorders: evaluation of clinician-guided and partially self guided instruction Aphasiology 16(10/11), pp.1061-1086. Fink, R., Brecher, A., Sobel, P. & Schwartz, M. (2005) Computer assisted treatment of word retrieval deficits in aphasia, Aphasiology 19(10-11), pp.943-954. Katz, R.C. & Wertz, R.T. (1997) The efficacy of computer-provided reading treatment for chronic aphasic adults, Journal of Speech, Language and Hearing Research 40(3), pp.493-507. Kirmess, M. & Maher, L.M. (2010) Constraint induced language therapy in early aphasia rehabilitation, Aphasiology 24(6-8), pp.725-736. Kurland, J., Baldwin, K. & Tauer, C. (2010) Treatmentinduced neuroplasticity following intensive naming therapy in a case of chronic Wernickes aphasia, Aphasiology 24(6-8), pp.737-751.

Ready and motivated

At the age of 52 years, Simon is now a more confident communicator who wishes to continue to use more language. This approach lends itself well to continuing treatment in the long term as relevant vocabulary can be included and changed as the persons daily needs change over time. As improvement can be made with treatment several years after onset of aphasia, the approach can be used whenever an individual is ready and motivated to work at the required intensity. Although Simons experience suggests the StepByStep approach is practical and offers people with chronic aphasia renewed opportunity for improvement, we cannot assume this will be the same for everyone. A pilot randomised controlled trial funded by the National Institute for Health Researchs

REFLECTIONS DO I REALISE WHEN MY BELIEFS ABOUT WHAT IS POSSIBLE LIMIT WHAT I OFFER? DO I UNDERSTAND THE VOCABULARY AND CONCEPTS OF IMPAIRMENT FOCUSED THERAPIES (FIGURE 6)? DO I EXPLOIT TECHNOLOGY TO INCREASE THE INTENSITY OF PRACTICE?
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My Top Resources
Julie Phillips, Jen Read and Helen Bell are all part of the Speech Pathology degree team at Manchester Metropolitan University. We provide an on-site clinic resource centre which is invaluable to students who need to borrow and create materials for clinical placement. It allows the students to have their own identified space, where they can engage fully with the course and read and view materials in a quiet environment. The items presented here are the results from a ballot across the whole student group. it was set up for two months to find out which items were viewed by the students as the most indispensable resources.

1. Mr Potato Head You can never have too many of this iconic toy, according to the students, and it has been borrowed by almost everyone who passes through the clinic doors. Used in a variety of paediatric settings, Mr Potato Head is a simple but flexible resource. Mr Potato Head has been used to work on prepositions, body parts and emotions. It is also useful as a simple reward system that children love and are motivated by. www.mrpotatohead.com 2. Colour cards These brightly-coloured lively picture cards are used by students with a huge range of clients - adults with aphasia, children with autism spectrum disorder and people with head injury; the list goes on. Students use them in a range of situations, whether that is working on specific grammatical constructs such as verb tense, or to aid a discussion about hobbies with a person who has aphasia. They are adaptable, often humorous, and a really popular resource. ColorCards, see www.speechmark.net 3. Photocopier, laminator and scanner Simple yet invaluable, the photocopier, laminator and scanner allow our students to adapt other resources to suit individual clients and to get creative making their own resources for clinical placements. The laminator is brilliant, you can use your resources over and over again and create a bank for use in the future. Students find the access to these resources saves time as all are based within the clinic. Theres always a queue! 4. Each other One of our students greatest resources is each other. Our clinic provides a space for students to work together in small groups and share experiences of their clinical placements. Learning from each other is key whether thats having theoretical discussions, or learning about new resources used out on placements. Academic and technical staff are always on hand to listen, help and advise learning is a two-way thing in our clinic! 5. Working withseries One of the most requested resources, the Working with... series of books is clearly written

boards and overlays for VOCAs (voice output communication aids) and lots of other resources. Easy to get to grips with, colourful and, once printed out and laminated, look as good as anything that can be bought. www.mayer-johnson.co.uk/category/ boardmaker-family/
The top resources ballot box!

Students in the on-site clinic resource centre

8. Renfrew Action Picture Test (RAPT) A screening test for language development that is quick and easy to use. Feedback from students is that it doesnt need lots of practice, which is important as time is always the issue. The Renfrew Action Picture Test is suitable to use from three year olds and upwards and is A great first tool to gauge a childs skills in grammar and information carrying words. Weve noticed that it is extremely popular when students are faced with second year placement. www.speechmark.net 9. Elklan This companys series of Language Builders plays a popular role in student learning, and There are never enough to go around. Ranging from Early Years to Post-16, they offer advice and activities to encourage childrens communication skills. Students find a starting point is quite often what they need to spark an idea when working with a client, and they describe these as brilliant and easy to understand and use. The checklists placed at the back of the publications are good to refer to, and another factor that appeals to the students is that you can copy pages and use them to support clients out on placement rather than taking the whole book. www.elklan.co.uk 10. Puppets Having to perform to an adult in a one to one or group session can be an overwhelming experience for many children. Puppets are a popular choice for students working with children with special needs, or who are withdrawn or hyperactive, and so the increase in demand on this resource has grown. Whether finger, hand or large animal, puppets have made a considerable difference to therapy sessions. Students say, The children were engaged and tried harder to complete the activity. The puppets kept them motivated for much longer. www.puppetcompany.com

and highly practical, covering diverse topics such as dysphagia, pragmatics and phonology. These books clearly link theory to practice - a major selling-point for our students and a vital skill to take forward into the workplace when they are on placement. Available from www.speechmark.net 6. Black Sheep PRESS What could be simpler than a set of photocopiable resources which provide a first base of sorting out phonology or brain storming for words? This is what Black Sheep Press offers, and all our students constantly refer to these resources when working in paediatric settings. Black Sheep Press resources assist in the development of childrens speech and language. They are low cost, reduce preparation time, and the students say they are straightforward to use and easy to follow for the children they are working with. www.blacksheeppress.co.uk 7. Boardmaker Studio An effective and invaluable software resource which suits adults and children, Boardmaker is the next step on from using ready made materials. It provides templates for interactive computer based sessions and ones for printing. The bank of Picture Communication Symbols (PCS) gives the flexibility to create tailor made resources, from sound cards and visual timetables to topic based