Speech & Language Therapy in Practice, Summer 1999

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R ~ D E R O F F E R
Win a FREE copy of Earobics!
Step 1 .. Developmental Ages 4 .. 7
Step 2 .. Developmental Ages 7 ..10
Speech & Language Therapy in Practice has a copy
of Earobics Pro PLUS Step 1, courtesy of Don
Johnston Special Needs and Step 2, courtesy of
Super Duper Publications. These auditory develop
ment and phonics software programs on CD nor
mally retail at 199 each. To enter, all you have to
do is find at least seven real words using only the
letters of the word 'ear'; you can use all or some of
the letters and repeat the letters within the word
as often as you like. The winner will be picked ran
domly from all correct entries. Send your list with
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Please note the winner will also be required to
review Earobics or provide a case study based
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* For readers outside the UK, the address is Lynwood Cottage,
High Street, Drumlithie, Stonehaven AB39 3YZ.
Competition rules:
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to run the CD-ROMs.
3. Entries must be received by the editor on or before 30th June 1999.
4.A person nominated by the editor will randomly select the winner from
all correct entries, but will not know who the entrants are.
5. The winner will be notified by 6th July 1999.
6. The winner will provide either a review of Earobia or a case study based
around it to Speech & Language Therapy in Practice by an agreed date.
Earobics Pro PLUS consists of six interactive games in Step 1 and five in
Step 2 to develop phonological awareness, auditory processing, phon
ics and language comprehension skills.
There are two other CDs in the Earobics collection, home practice CDs
for Step 1 and Step 2. A Super Duper Publications catalogue is available
from http://www.superduperinc.com. e-mail custserv@superduperinc.com
The UK supplier is Don Johnston Special Needs, tel. 01925241642.
ToPP
The winner of the Test of Pretend Play (Spring 99 reader offer)
is Alison Webb. She will review the assessment in a later issue.
Thanks to all entrants. The seven three letter words from play
are pay, lay, pal, lap, yap, ply and alp .
The photograph shows Laorag Hunter,
winner of the Winter 98 competition for
React software, receiving her prize from
Propeller Multimedia's Gordon Russell. A review will appear in
the Autumn 99 issue. The new address for React is 28 Queen
Margaret Close, Edinburgh, EH10 7EE, tel/fax 01314452515.
ISSN (online) 2045-6174 www.speechmag.com
I
Child language, phonological awareness.
22 Further Reading
Brain injury, language development, dementia,
www.sol.co.uk/s/speechmag
SUMMER 1999
(publication date 31st May)
ISSN 1368-2105
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Contents of Speech & Language
Therapy in Practice reflect the views
of the individual authors and not
necessarily the views of the publish
er. Publication of advertisements is
not an endorsement of the adver
tiser or product or service offered.
Any contributions may also appear
on the magazine's Internet site.
Cover picture courtesy of
Action for Dysphasic
Adults. See page 18.
Contents
Summer 1999
2 News I Comment
4 Objects of reference
"For learners who do not communicate with
intent, a communication strategy needs to be
idiosyncratic, context-dependent and individually
directed. In other words,
before there are objects of 18 COVER STORY
reference, there are objects." t---------------------------t
Keith Park asks, whose
needs come first?
Training the carers
"Communicate's emphasis throughout is
on fostering good practice in
7 Rhyme communication. .. such skills are essential to
enable carers to tackle the disabling
barriers associated with communication
time
"It is vitally important
impairment. "
when teaching rhyme skills
Lesley Jordan, Linda Bell, Karen Bryan,
to a speech disordered
Jane Maxim and Catherine Newman,
child that the teacher and reflect on 'Communicate' to date.
speech and language
therapist get
together to discuss
and decide upon
joint strategies to aid
this development. "
Jill Popple and
Wendy Wellington
share their rhyming
ideas.
11 Reviews
12 Adolescents
"For language disordered pupils, making friends is
a long process... even the short, positive experience
of the group has been enough to give one pupil
the confidence to join a basketball club, initially
with support and now on his own. "
Barbara Paulger on the success of an I CAN social
communication group.
15 Speechmag
Top Tips on therapy for children with a voice
problem.
16 In My Experience
"No matter how brilliant you are technically, if o ~
don't have the capacity to stick it out with the
client then you may never see the end results."
Geraldine Wotton introduces our new series with
a defence of the therapy process.
AUTUMN 99 will be published on 30th August, 1999
IN FUTURE ISSUES
stammering new assessments autism dementia head and neck cancer
bilingualism Fragile X hearing impairment aphasia outcomes
SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 1999
dysphagia, referral.
23 How I use
computers
in therapy
"Programs need to be inter
esting, motivating, easy to
use and relevant to therapy. "
Computer software for
voice, paediatric and adult
neuro work and a report on BEn 99.
30 My Top Resources
"a student on placement with me drew a
simplified mid-sagittal view of the head and
neck... 1use copies galore in training and
information for new staff. A laminated version is
pinned to a cupboard in my room with blu-tac,
easily accessible for explanations at any time."
Pippa Wilson on her brain injury rehabilitation
work.
news
Training advance
Access to a new training method for speech and language therapy stu
dents is to be widened.
PATSy - Patient Assessment Training System -is web-based and uses video
clips to enable students to rehearse and practise their selection of assess
ments and diagnostic skills before meeting 'live' clients. In addition,
PATSy will be used as a research resource and will help standardise stu
dents' experience with different cl ient groups.
A student at Queen Margaret University College where PATSy is being
developed commented it is "a bit like a simulator - the patient doesn't
suffer" .
It is envisaged this non-profit community resource will 'go live' in June.
http://patsy.cogsci.ed.ac. uk
I am what I am
A new f ilm giving an insight into the lives of people with cerebral palsy will
be used to improve disability awareness.
Featuring nine young people, I am what I am includes Alan Martin who, at
age thirty, after years of limited communication through sign language,
received a communication aid which is now enabling him to write poetry
and his autobiography. A fieldworker for the charity Scope suggested mak
ing the film to improve awareness and answer difficult questions about dis
ability that people may want to ask but feel they cannot.
Scope, tel. 0171 619 7200, www.scope.org.uk
Therapy shortfall
Speech and language therapy is not provided for over a quarter of young pri
mary school aged children with Down's Syndrome in mainstream education,
although at least half have a specific language problem.
This disparity in provision is identified in a report from the Down's Syndrome
Association which explores the inclusion of children with Down's Syndrome
into mainstream education. By late secondary school stage, the number of
young people with Down's Syndrome in the survey not receiving speech and
language therapy rises to 71 per cent.
Although their survey suggests some progress is being made on inclusion, the
Down's Syndrome Association is calling on all Local Education Authorities to
allow parents to make a real and informed choice of mainstream or special
schools for their children by ensuring that adequate resources are allocated
and that proper provision is made according to the individual child's needs.
Particular problems in accessing mainstream education are identified at sec
ondary level, with staff training and wifh variations in quantity and quality of
provision also causing concern .
One in every thousand children born in the UK has Down's Syndrome.
'Experiences of inclusion' from the Down's Syndrome Association, tel. 0181
682 4001.
TULIP campaign
Only 20 per cent of people with Parkinson's are referred to a speech and lan
guage therapist, according to a survey by the Parkinson's Disease Society.
The Society'S TULIP (Towards Understanding, Learning and Improving
Parkinson's) campaign includes a drive to increase referrals to rehabilitation
services. It has produced a checklist for people with Parkinson's to take to
their GP when they are being reviewed to try to encourage partnership in
management decision making.
Launching the checklist, Mary Baker of the PDS said "A 4 per cent increase in
20 years of people with Parkinson'S using occupational therapy, a 13 per cent
increase in speech and language therapy and a 7 per cent increase in physio
therapy is just not good enough . Partnership between GPs and other profes
sionals is vital in supporting people with Parkinson's. This checklist highlights
all avenues of help."
The PDS has collaborated with the its group for younger people (YAPP&Rs) to
produce a video The Uninvited Guest
to illustrate younger
people's difficulties with
Parkinson's.
(From Sharward Services,
tel. 01473 212113,
price 22 inc p&p.)
PDS, tel. 0171 931 8080.
Towards l inderslaoding. Learning & Improving Parkinson 's
Poor care highlighted
A det ailed survey of stroke clients
and their carers makes uncomfort
able reading for health care work
ers ircludlng speech and language
therapists.
The findings of the report Stroke
Rehabilitation - Patient and carer
views will be incorporated in the
national evidence-based guidelines
for stroke care due out later this
year. The organisations Involved*
also plan to use the information in
future when producing guideli nes
and evaluating st roke services, and
have assured participants that #we
will do our best to make sure your
views make a difference.
Among recommendations are bet
ter training, shared decision mak
ing. more i nformation once the
cli ent Is home, improved patient
and carer i nf ormati on and the
development of li nks with pati ent I
carer organisations. Specifically,
they advocate advance warning of
changes in service provision. named
contacts and more wri tten informa
tion, and demonstrate t he value of
using ' patient quotes' to highlight
inadequacies in services.
The particular problems with therapy
were that "help was only available
in the short term, with no follOW-Up,
no ongoing assessment of progress,
no t ime to digest how far people
have got in their recovery and no
long-term help with recovery. When
help stopped, it often stopped sud
denly with li ttle if any warning or
explanation." More flexibility and
understanding was called for, such as
a realisation that people may initial-
Iy refuse therapy for various reasons
but want to re-access the service at a
later date. The quotes also make it
clear how often people si mply don't
take in who is visiting them and
what they are t old, particularly In
the early stages or after the return
home, and the human impact of
staff shortages and absences.
(* Intercollegiate Working Party for
Stroke, Research Unit of the Royal
College of Physicians, The College
of Health, The Stroke Association,
Different Strokes)
Stroke Rehabilitation - Patient and carer views is 8.50 inc. p&p (0 if collected in person) from the Royal College of Physicians Publications Department tel. 0171 935 1174 ext 358.
SPEECH & LANGUAGE THERAPY IN PRACTICE SUM M ER 1999 2
news [, comment
Carers appreciated
An essay competition is encouraging people with
disabilities to write about the crucial empowering
role carers play.
The Limbless Association has received funding for
the project from The Prudential Carers Awareness
Fund including a 1000 prize.
Details: The Limbless Association, tel. 0181 788 1777,
e-maillimbassc@aol.com
I CAN move
I CAN, the national educational charity for children
with speech and language difficulties, has moved to:
4 Dyer's Buildings
Holborn
London
EC1N2QP
tel. 08700104066
fax 0870 0104067
The charity is inviting adventurous cyclists to ride the
Rift Valley in Kenya in the Autumn to raise money
for its work. Call Hannah Bence on 0870 0104066 as
soon as possible for a full information pack.
Teachers' special needs
AFASIC has called for improvements in training of
teachers to help children with speech and language
difficulties.
Responding to a government consultation paper
Teachers: meeting the challenge of change, the char
ity called for:
* opportunities for teachers and speech and lan
guage therapists to train together
* all teachers to be fully trained, prepared and sup
ported to provide effective special needs education
* all head teachers to be more aware of special
needs issues
* teachers to be rewarded for promoting pupils'
emotional, social and communication development
* formal qualifications and special needs experience
for learning support assistants.
Two or three children in every classroom are likely to
have a speech and language difficulty.
AFASI(, tel. 01712366487, e-mail info@afasic.org.uk
AFASIC now has a web site including lists of publica
tions and training courses - http://www.afasic.org.uk
Voice aids
A recent survey of available voice amplification aids
suggests users need to be more specific and forceful
with their requests so companies can adapt their
existing products.
Improvements in provision could also be seen with
the injection of more money into research and
development, although limited demand makes this
unlikely. The survey identified potentially helpful
businesses including a microphone manufacturer
who would make adaptations if approached and a
designer who would be able to improve the aesthet
ics, technical specifi cations and ergonomics of exist
ing products for a consultancy fee.
Details of suppliers and companies willing to consid
er developments for a fee from Dennis Netcott,
Regional Disability Service, South West Region
(Client Assessment Team), tel. 01454848550.
Avril Nicoll ,
Editor
Lynwood
Cottage,
High Street,
Drumlithie,
Stonehaven
AB393YZ
tel/ansa/ fax:
01569 740348
e-mail:
avrilni coll@sol.co.uk
... comment. ..
Makes 't et?
uoesn I.
Who, where, when, how, what, why? All questions we ask - or should be
asking - about what we offer every client. The question of where we provide
therapy is as crucial as the tasks we employ. Who we involve is as important
as how we get our message across. When we are best to intervene continues
to exercise the profession. And the fundamental why question is possibly the
most interesting.
The addition of 'Reflections' to articles and our new series In my experience
seek to explore this in particular. It may be uncomfortable at times, but it is
only by thinking critically about why we do what we do that we can move on
as individuals and as a profession. As a crucial partner to research evidence
we must hear and value the voice of experience. In our first example,
Geraldine Wotton gives what she sees as a discarding of traditional skills a
fascinating perspective by relating it to the wider context of changes in
society. A reminder perhaps that, while we have to move with the times, we
also have a role in shaping them.
But are we, as individuals and team members, flexible enough to do this?
I CAN's social communication group at a youth club is surely a step in the
right direction. Children with language disorders have a real life too, outwith
school and home. We have a lot to learn about what they want from this life
and how we can help them achieve it. Barbara Paulger cautions: "It is very
easy for us to project potential problems onto pupils and to have objectives
for them that we think are right, but perhaps they do not."
The importance of functional communication is emphasised by Pippa Wilson's
My Top Resources but, sadly, Keith Park's experience suggests real life is not
always a top priority. He can find little evidence of objects of reference being
used in client's homes and is frustrated by the tendency to standardise rather
than individualise systems, even for people with very complex needs. He
emphasises the importance of solving such issues by acting on Lenin's
assertion that "theory without practice is barren and practice without theory
is blind". Jill Popple and Wendy Wellington's article on rhyme is one example
of how motivating therapy games come from a robust theoretical
understanding.
And the very honest assessment of the progress to date of the Communicate
package reminds us that training others needs the same rigorous evaluation
as our work with individual clients: who, where, when, how, what, why?
SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 1999 3
The val.iia
of objects of reference with children and adults with severe and profound
dis;abUities raises many questions. Advisory teacher Keith Park challenges us to
learning dlsablUt\l
ose nee s
come irst?
ues of inclividualisation, theory and practice, multidisciplinary collaboration and
working iVith p a ~ n t s .
This article is a resume of the
author's presentation in January
1999 co the Royal College of
Speech & Language Therapists'
Special /nterest Group in
Augmentative and Alternative
Communication (S/G MO at
the ACE Centre in Oxford
...._ he term 'objects of reference' refers
to the use of objects as a means of
communication. Although this may
have much to offer people with pro
found and multiple learning disabili
ties, there remain important issues of
both theory and practice that have not yet been
addressed. The apparently ad hoc method of using
objects of reference, and the apparent lack of eval
uation studies, mean that the quality of practice is
extremely variable, and there seems to be little
consideration of the importance of the social con
text within which objects of reference are intended
to be used (McClarty, 1995; 1997). poses user
How do we know
Objects of reference were first described stands the distance between
by Jan van Dijk in the mid-1960s as a means what an object vehicle (the object itself) and
of communication for people with congen referent (the concept to which
mayor may not
ital deafblindness. Since then, although it refers). For example, why
the literature is scarce, there have been
represent for
should a purse represent or
some examples of work in the United
someone else?
'stand for' shopping? How do
States, Australia, Denmark, and the United
Kingdom. A full review of this literature is in an
article entitled ' How Do Objects Become Objects Of
Reference' (Park, 1997a). As the title suggests, the
article is also concerned with the development of a
theoretical model of object use that might shed
some light on some murky subject matter' Most of
the literature reviewed deals with the use of
objects of reference with children and adults who
are already communicating intentionally. There is
very little, if any, literature on its potential use
with individuals with profound and multiple learn
ing disabilities who are not communicating with
intent.
Representational objects
The literature review (Park, 1997a) identified one
particular issue in the use of objects of reference
with people with profound and multiple learning
difficulties in that the objects of reference - cho
sen by teachers or therapists to represent signifi
cant activities, objects, or people - may be repre
sentational. In other words, the objects may
stand for, or represent, something other than
themselves: a purse or wallet for shopping, a
piece of material to indicate the sensory room and
so on. Using objects of reference may appeal to
us because we think they have a 'common sense'
value: they are permanent, manipulable, and
concrete. Most of the literature reviewed, how
ever, suggests using them in a way that pre-sup
that the under
we know what an object may
or may not represent for someone else? How can
we validate the assumptions of our practice? On
a theoretical level, we might ask how objects
become objects of reference: how does meaning
develop?
Provisional model
The literature review (Park, 1997a) proposed that
a provisional model of object use might be
designed by using three terms from semiotic the
ory: index, icon and symbol. These are described
by Elizabeth Bates in her pioneering work on
early communication and language as follows:
1. Index
"Signs that relate to the things they stand for
because they participate in or are actually part of
the event or object for which they stand"*
If we wish to
complain about
academics
2. Icon
being divorced
"Signs that are related to the things they
stand for by virtue of some physical resem from reality, we
blance"*
cannot divorce
3. Symbol
ourselves from
"Signs that are related to the things they
stand for by an arbitrary bond agreed upon theory.
by those who use the
symbol" (* Bates,
1976, p2).
Communication
needs
These terms ca n be
illustrated by two
teenagers, Alex and
Anna, and their com
munication needs.
Pre-intentional com
munication may be
described as being
idiosyncratic, context
dependent and indi
vidually directed. Alex, who is 16 and has multi
ple disabilities, has been observed by his carer, at
dinner times, to 'flutter' the fingers of his right
hand, a behaviour that the staff who know him
best have interpreted as meaning "This is nice / I
like this / I am comfortable with this." This behav
iour is, in one sense, unique to Alex, and so it is
idiosyncratic; it only ever occurs at dinner times
and so it is context-dependent. It is pre-inten
tional communication in that Alex is not inten
t ionally transmitting a message, although the
staff are able to interpret it as having a meaning.
This is a result of their efforts to communicate to
Alex certain essential items: he has been encour
aged to feel the plate and spoon, smell the food,
l isten to the carer talk to him and allowed time to
respond in his own individual way. In this way the
communication is individually-directed in that it
aims to help him make sense of his environment.
The final stage of intentional communication
when people begin to use words, signs, symbols,
objects or any other communication media - can
be described as conventional, context-indepen
dent and socially directed. For example, Anna,
also 16, is in a school leavers' group. All of the
teenagers in her group have a severe visual
impairment and severe learning difficulties. The
group shares an objects of reference board that
indicates school activities, school personnel, and
school rooms. The system of objects of reference
has been d e ~ e l o p e d to be the same for all the
group (conventional), it is used across home and
school environments (context-independent) and
one of its aims is communication between the
members of the group (socially directed) .
It seems reasonable to conclude that Alex's and
Anna's objects would not be appropriate for each
other. Alex's objects include a spoon for cooking
(t he same one he is helped to use in stirring the
various mixtures) and an armband for swimming
(t he same one he wears in the hydrotherapy
peers, include an
audio tape case
stuck on a piece
of card for
'leisure time'
(after dinner
when the stu
dents stay in
their classroom
"My granddaughter
and play thei r
own choice of is two and doesn't
music); a crushed
have an established
can on a piece of
toileting care
card for the cur
rent project routine, but she
(crushing cans
would rather talk
for an ecology
project); a guide
about the
cane for 'walking
Teletubbies! "
/ mobility train
ing'; a purse for shopping (this is also stuck on a
card and is not used in the activity); a bus ticket
on a piece of card for 'going on the bus.'
Standardisation
What would happen if Alex and Anna attended a
school where a standardised use of objects was
being implemented? As has been remarked so
memorably, "Is there life after toilet and biscuit?"
I am not suggesting that standardisation is a pri
ori a wrong decision, but it is important to
encourage discussion in this very complex area.
For learners who do not communicate with
intent, a communication strategy needs to be
idiosyncratic, context-dependent and individual
ly-directed. In other words, before there are
objects of reference, there are objects. In many
cases, people are being given 'objects of refer
ence' before they have been able to develop any
learning disability
understanding of signification
(that is, that one thing can stand
for another) . Would Anna's
objects of reference be appropri
ate for Alex?
Theory and practice
So how do objects become
objects of reference? Objects
may become objects of reference
because of their 'canonicality':
this refers to the 'canonical, or
socially standard, funct ion of the
object' (Sinha, 1988, 105-106).
The development of canonical
object use describes the process
of how objects become objects
of reference, and this is an area
of practice and theory that needs
much attention. Would this investigation
be appropriate for academics or practi
tioners?
Many of us may feel uncomfortable
when discussing issues from a theoretical
perspective, but I would argue that it is
essential - especially if we do feel uncom
fortable about it. Many teachers, and
perhaps therapists, may feel that some
academics within their field of work are
too removed from practice. This may be
so, but an academic might justifiably
reply by sayi ng that practitioners are anti
theoret ical. Two years ago when I was
invited to give a presentation on the use of
objects of reference the organ iser told me quite
emphatically: "this is a practical workshop that
provides practical answers to practical questions.
We don't want any theory or funny business like
that." I ignored the comment - and, of course,
people were quite happy to discuss theory when
it was made clear how it related to our issues of
practice. If we wish to complain about academics
being divorced from reality, we cannot divorce
ourselves from theory. A famous radical politician
once said that theory without practice is barren
and practice without theory is blind. Cynics might
reply this was one thing that Lenin got right I
Individualisation
When conSidering the use of objects of reference
with someone, it may be helpful to consider the
'MMF' prinCiple (Park, 1997b): choosing objects
that are Meaningful, Motivating and Frequent.
These real examples illustrate that objects of ref
erence - and the concepts to which they refer
need to be relevant to the individual user and not
to the therapist or teacher. In a recent arti cl e
(Park, 1997b) I asked, jokingly, if anyone knew of
someone of school age with severe and profound
learning di sabilities who was using an object or
modern foreign languages. This was evidently
not a joke. I have subsequently found anecdotal
evidence that suggests that many people in this
situation are given a separate object for each ~
..... National Curriculum subject with the justifi would like to hear from therapists who have
cation of "this is what we teach at schooL" experience of or an opinion on:
1. Meaningful 1. individualisation / standardisation of
Angela does not like to sit down and this
made school life very difficult for the class staff.
One day, when they had managed to persuade
Angela to sit down, her teacher gave her a string
of beads, and Angela sat at the table with the
others for nearly 15 minutes. This was quite a
breakthrough, and so, building on this success,
Angela was given the string of beads every time
she was expected to sit down with a group. After
a while, Angela was persuaded to leave the beads
on the back of the chair and to participate more
in the group activity. This strategy has been very
effective, and the string of beads - for Angela
means something like "sitting down with the oth
ers and doing things". Angela's teacher can then
differentiate the activities in her teaching file
according to the National Curriculum subjects.
When the activity is finished, Angela is encour
aged to drop the beads into a small cardboard
box that is presented to her. She then knows that
she is free to wander around the room for a while.
The 'meaning' of the beads from Angela's per
spective has been socially constructed, and not
arbitrarily imposed.
2. Motivating
One of the highlights of Jill's week is when she has
her hair washed. The bottle of shampoo is her
object of reference for 'hair washing.' One unfor
gettable day, only six weeks after the weekly hair
washing routine had started, Jill picked up the
bottle of shampoo and gave it to a member of
staff. According to the school staff, this was the
first time ever in school that Jill, then 18 years old,
had made an intentional communication. Her
teacher once said to me "Why does everyone have
objects of reference for toilet? My granddaugh
ter is two and doesn't have an established toilet
ing care routine, but she would rather talk about
the Teletubbies!"
3. Frequent
Abdul loves going to watch
rugby matches but can only go
oRe
twice a year. His special hat is
kept out of sight until a day or so
display as a frequent and realis
tic item of choice.
More work needed
This article is based on the issues discussed during
my presentation to the RCSLT SIG in AAC. It was
sad to see that among the fifty or so people, there
was just one example of successful home use of
objects of reference. As one therapist ruefully
pointed out, it seems that service users exist to
make professionals feel they are providing a
professional service. Clearly, much more work
needs to be done here.
Recently I met a parent of a four year old child
with disabilities who is successfully using objects
of reference at home (without any therapist or
teacher being involved!) The school where she
starts later this year has a standardised approach
to the use of objects of reference. When I asked
the mother what she thought about this, she
replied that she was going to meet with the
speech and language therapist and the class
teacher, discuss the needs of her child, and they
would then draw up a list of communication aims
and methods that would be shared between
school and home. She added that this agreement
would then be one of the items discussed at each
annual review. I asked what she thought of stan
dardised systems. She said "my daughter's needs
come first." Parent power may sound like a
cliche, but it is one we should hear more often.
Uneven quality
Several of the people at the SIG meeting had pos
itive examples of co-operation between therapists
and teachers, and this was encouraging.
However, there was a general agreement that
communication is far too important to be left to
anyone profession or person, and perhaps the
uneven quality of practice concerning objects of
reference may point out the need for a much clos
er collaboration between therapists and teachers,
and most importantly parents.
Collaboration
Objects of reference is just one subject among
many that are important for multidisciplinary col
laboration: eating and drinking difficulties, aug
mentative communication in general, and of
objects of reference
2. successful home use of objects of reference
3. working with children with multi-sensory
impairments.
Keith Park is an advisory teacher for Sense (The
National Deafblind and Rubella Association),
based at the Family Centre in Ealing, West
London. He is also a teacher for children with
visual impairment and learning disabilities for
Greenwich Visual Impairment Service.
Address for correspondence
Keith Park, Sense Family Centre, 86 Cleveland
Road, Ealing, London W13 OHE, tel. 0181-991
0513, email kpark@busheyhillrd.demon.co.uk
Acknowledgement
Coming to the SIG AAC meeting as a teacher to
talk mainly to speech and language therapists, I
learned that therapists have a positive attitude
towards multidisciplinary collaboration, a readi
ness to discuss theoretical issues and, perhaps
most importantly, an enthusiasm for their work. I
would like to thank Gillian Nelms and her col
leagues for inviting me.
References
Bates, E. (1976) Language and Context: The
Acquisition of Pragmatics. London: Academic Press.
McLarty, M. (1995) Objects of Reference. In
Etheridge, E. (ed) The Education Of Dual Sensory
Impaired Children: Recognising and Developing
Ability. London: David Fulton Publishers.
McLarty, M. (1997) Putting Objects of Reference
in Context. European Journal of Special Needs
Education 12 (1) 12-20.
Park, K. (1997a) How Do Objects Become Objects
Of Reference': A review of the literature on
ections: Whose needs come irst?
before he goes to a match.
Do I give sufficient weight to the needs Of individuals.
However, he also enjoys going to
the video shop to hire a video,
and this object of reference - the
Do I impose meaning on clients. or allow it to develop
plastic ticket given out by the
shop - is kept out on permanent
Do I ensure communication systems work in real life?
course involving parents in using communication
systems at home. The Sense Family Centre at
Ealing welcomes the opportunity to continue to
develop multidisciplinary collaboration between
speech and language therapists and teachers in
the very complex area of augmentative and alter
native communication with people who have
severe and profound learning disabilities and
multi-sensory impairments. In particular, we
objects of reference and a proposed model for
the use of objects in communication. British
Journal of Special Education 24 (3) 108-114.
Park, K. (1997b) Choosing and Using Objects of
Reference. The SLD Experience 19,16-17.
Sinha, C. (1988) Language and Representation:
A Socio-naturalistic Approach to Human
Development. Hemel Hempstead: Harvester
~ ~ . 0

hyme is one of the earlier phonologi
cal skills that a child shows any overt
signs of learning. But what is "rhyme"
exactly? At an auditory level, words
can be broken up into smaller compo
nents, namely syllables and individual
sounds. If we divide a syllable further, we have an
'onset' or the first part of the syllable which
extends up to the vowel sound and then the sec
ond part of the syllable consisting of the vowel
sound and subsequent consonant elements of
that syllable. This final part is called the 'rime'.
Words that have the same rimes are therefore
said to ' rhyme' . The spellings of the 'rime' may be
different, but the sound of the 'rime' is the same
(eg. bite I fight) .
Phonological awareness
Chaney (1992) refers to work by Adams (1990)
and Tunmer and Herriman (1984), and says the lit
erature suggests the following order for the
development of phonological awareness:
1. Tasks involving monitoring and correcting
speech errors
2. Knowing nursery rhymes I sound play
3. Comparing the sounds of words for rhyme or
alliterat ion
4. Sound blending I syllable splitting (recognition
of initial sound)
S. Phoneme segmentation
6. Phoneme manipulation (adding, deleting or
moving phonemes).
Research has been done into the importance of
listening to and knowing nursery rhymes at an
early age (Maclean et ai, 1987; Bryant et ai, 1989)
with the conclusion that "nursery
II
Underlying phonological skills are vital for the
development of spoken and written language, so
children who are struggling need a collaborative
approach from therapists and teachers.
Jill Popple and Wendy Wellington recommend a
levels and that, rather than metalinguistic skills
emerging suddenly after si x to eight years old, the
process begins much earlier with a more gradual
development. She feels there are strong indica
tors that, from two to four years old, there is a
very active period of metalinguistic learning and
that "self corrections and sound play can be con
sidered at the border of awareness". Maclean et
al (1987) established that " many three year old
children had a reasonable knowledge of nursery
rhymes" and that there is "a degree of phonolog
ical awareness in children as young as three. Many
of them did well in the rhyme and alliteration
tasks, and in rhyme and allitera
rhymes enhance phonological sensi- from two to four
tion production tasks as well".
tivity (rhyme and phoneme detection) They also found an "extraordi
in general, which in turn enhances years old, there is a narily robust relat ionship
reading" (Bryant et ai , 1989). A child between the knowledge that
who is able to recall or partially recall very active period children had about nursery
nursery rhymes is already showing a rhymes when they were three
sensitivity to the sounds and sound of metalinguistic years old and their subsequent
patterns within words and to the fact .
that some words have a segment in learntng
common . This sensitivity in these early
stages is at a very subconscious level and the child
is unlikely to be able to say why these words go
together. Chaney concludes that children as
young as three years old have already started to
develop metalinguistic awareness - "the ability to
think explicitly about language" - but at varying
phonological development".
This ability to rhyme and
detect rhyme and its subsequent
link with developing an improved phonological
sensitivity has been shown in many studies to
have a significant influence and impact on the
ch ild's ability to develop their reading and
spelling skills. Goswami and Bryant (1990) suggest
that "to recognise that words rhyme is to put
psycholinguistic approach
to assessment and share
therapy ideas for one of
these skills, rhyme.
them into categories" and, as these categories
share a common sound, the child is enabled to
start making the links between words with com
mon sound patterns and common or potentially
common spellings.
Joint strategies
So, rhyme is an important measure of a child's
speech processing skills and develops at a very
young age. To appreciate rhyme a chil d must
recognise the similarities and differences betwee'l
words - what is the same about tv'JO words and
what is different. For example, dog and log are
similar in that both end in logl but they are dif
ferent in that one starts with Idl and the other
with II!. Rhyme skills show an understanding of
onset and rime which are the major con-
_______
.... of a syllable. This ability to segment words
a child to read and spell words by analogy
elps to develop a motor programme for saying
2nd writi ng new words. Without this knowledge a
m:!d would have to learn each part of a new word
as 3 separate item rather than using existing knowl
edge of these rhyme families. It is vitally important
en teaching rhyme skills to a speech disordered
-'d that the teacher and speech and language
erapist get together to discuss and decide upon
joint strategies to aid this development.
evels of difficulty
aclean et al (1987) suggest that adults can playa
significant role in the development of phonological
skills with the help of "informal linguistic rou
tines". Nursery rhymes are one example of infor
al ways parents draw the attention of their chil
dren to the sounds and sound patterns in words
and thus build on their phonological awareness
skills. Knafle (1973; 1974) looked at the comparison
of f our categories of difficulty of rhyming words:
category 1 where the final part of the rime is a
single consonant comparison (eg. kill; pill; kiss)
category 2 where the final part of the rime is a
comparison of two different consonants (melt;
felt; mend)
category 3 where the rime ends in two conso
nants the last one of which is the same (silk; milk;
sink)
category 4 where the rime ends in two conso
nants and the final consonant is different (tend;
send; tent).
The children were given a target word and asked
w hich of two other words rhymed with it, ego
w hich word rhymes with lift - list or gift? Knafle
found that there were significantly more respons
es correctly identifying rhymes in categories 1 and
2 - which provided the maximum contrasts - than
in categories 3 and 4. She subsequently found
that there were more correct responses in catego
ry 3 than in 4. The rhyming words we choose to
work with should therefore start with the easiest
category of discrimination, namely categories 1
and 2, where there are the maximum contrasts of
the final sounds.
Tasks can be structured to be easier or harder
by a) including or excluding the production of
rhymes and b) minimising or maximising short
term memory involvement in performing the task
(Marion et ai, 1993).
At our school we use a psycholinguistic frame
work developed by Joy Stackhouse and Bill Wells
(1997) to assess phonological skills. This is an
approach to investigating the child's processing /
input skills, storage system and programming and
expressive / output skills. This approach contains a
range of rhyming tasks which "tap different levels
of phonological processing skills in children".
These incl ude
a) Rhyme judgement - making a decision about
whether two words rhyme
b) Rhyme detection - deciding which of a
sequence of items rhyme and which do not
at

( )

cat

hat
Figure 1 - Posting game
In

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

Figure 2 - 0
The aim is to
,to identify th
Three Pictur1
family and 01
this level the
ported by thE

The child has two sets of pictures with the words also printed on
them. These are placed face downwards. The post-boxes have the
written rimes, one on each. As the child turns over the picture the
adult says the name of the picture and the child posts it in the cor
rect box. This can be played at all the levels a) - e) mentioned, but
it can also be played at just this written word matching level. The
teacher then takes the cards from each set and shows how they
rhyme, ego cat, mat, fat, sat all end in 'at'.
or counter or
family the we
[L
)
/
adults can playa
significant role in
the development of
phonological skills
with the help of
"informal linguistic
routines"
c) Rhyme production - spoken production of a
word or number of words that rhyme with a given
target.
With the responses to these tests, and looking
at how they integrate with other test responses
from the approach, we can hypothesise what pro
cessing skills the child can use or what difficulties
they are having and devise a programme accord
Figure 5 - Rhyme strings
Child generates rhyme strings. This
can be done at the level of "I spy"
or making words using the rime and
drawing down letters from an
alphabet arc to make new words. In
this way, a child learns to synthesise
the two elements of the word to
form a new word. This level can
also be worked at by having a com
plex picture with rhyming words
around the side - the child has to
find a rhyming picture from the
complex picture that corresponds to
named picture from the edge.
ingly, using their strengths to help their weak
nesses. This also leads us to devise our therapy
programmes at an appropriate level of processing
skills and therefore difficulty.
Introducing rhyme
We have found it very useful to start this proce
dure by developing a general awareness of rhyme
and then making the concept of rhyme and
rhyming explicit. We introduce the word "rhyme"
as meaning the "last chunk" of a word. We also
develop rhyme corners in the classroom, sing nurs
ery rhymes and carry out cloze procedures with
the adult missing out a rhyme word for the child
to supply. Rhyming story books such as Pat the Cat
( Hawkins & Hawkins, 1985) can be very useful for
this. When the child becomes familiar with the
idea of rhyme it can gradually be brought into
more specific exercises.
At first the child may need to be supported visu
ally when working with rhyme and may need the
adult's verbal model to aid their detection of
rhyme. The aim would be eventually for the child
to be able to understand the process of rhyme
and be able to detect and use rhyme for the
development of both spoken and written lan
guage. For the child to do this, a series of steps in
the teaching of rhyme needs to be devised:
a) The rhymes are presented auditorily with the
teacher supplying the model. The words are rep
resented with pictures and written words (figure 1).
SPEECH &LANGUAGE THERAPY IN PRAalCE SUMMER 1999 8
therapy ideas
d One Out
uild up an awareness of rhyme within a set of words and
word that does not belong to a rhyme family.
are presented to the child. Two belong to the same rhyme
is different The child is to identify the" odd one out". At
dult gives the child the auditory model and the child is sup
picture but there is no written word. This can be done with
out" being very dissimilar ego man, pan, elephant, or with
g quite similar, ego man, pin, pan. The child can put a cross
the odd one out picture. The child can also say which rime
ds belong to, so making the rhyming element explicit
"
Figure 3 - Rhyming dice
The ch ild generates the word for comparison, supported by the
picture and written word. A game for this could be a rhyming
dice. The words and pictures from two rhyming families are decided
upon and drawn on to a baseboard. The rimes are written on to a
dice. The dice is thrown and to move forward on the track the child
has to move to the next picture I word from that rime family.

hat

/pin

0
P
cat
G

tin
\:>

fin

at t

b) The rhymes are presented with the teacher sup
plying the auditory model; the words are repre
sented by pictures alone (figure 2).
c) The child generates the words for comparison
the wards are represented by pictures and words
(figure 3).
d) The child generates the words for comparison
the words are represented by pictures a lone (fig
ure 4).
e) The child generates rhyme strings with or with
out the use of the visual support of letters
arranged alphabetically in an arc (figure 5).
It is useful to start to develop a child's specific
awareness of rhyme by choosing rhyming words
whose rime is already in their sight vocabulary,
Figure 4 - Rhyme collection
The child generates the word from a picture card for comparison.
A game for this level could be rhyme collection. Rhyming pictures
from two rhyming sets are dealt out between two players face
downwards Player 1 turns over their card and names it, player 2
turns over their card and names it S/he looks to see if the card
belongs to the same rime family as player 1; if it does, both cards
are taken. The game continues until all the cards have been used.
ego at and in. Other useful rhymes can then be
developed by using a structured approach to
teaching letter order and therefore rime order
such as described by Broomfield and Combley
(1997).
The activities in Figures 1 - 5 can be done at any
level, but the more unsure the child is the more
visual support s/he will need. We have also found
it is very helpful if these verbal rhyming activities
can be backed up by the child saying and writing
the words so that the child not only forms a ver
bal motor programme for rhyming words but also
carries this forward into his written language. The
case study (page 10) shows how we worked with
one child, Donald, to improve his rhyming skills.
Jill Popple and Wendy Wellington are speed! a
language therapists at a special school for
munication disordered children in Sheffield.
References
Bradley, P.E., Bryant, L., McLean, M. and
J.(1989) Nursery rhymes, phonological s .
reading. Journal of Child Language 16.407 - !J:
Broomfield, H., and Combley, M _ :+=
Overcoming dyslexia. Whurr.
Chaney, C. (1992) Language develop ..
alinguistic skills and print awareness in 3 .:.e :: :
children. Applied Psycholinguis '(513, - - :;''':
Dowker, A. (1989) Rhyme and alii E'raNr '
SPEECH & LANGUAGE THERAPY IN PRACTICE SU .1 ER 1% 9
Ideas
... poems elicited from young children. Journal of Knafle J. (1974) Children's discrimination of
Child Language 16, 181 - 202. rhyme. Journal of Speech and Hearing Research
Goswami, U. and Bryant, P. (1990) Phonological 17, 367 - 372.
r--------------,
Free
photocopiable
rhyme sheets!
For readers interested in pursuing
rhyme work with children,
Langlearn Communications is
offering a copy of Rhyme Time, a
photocopiable activity book, as
the prize in a free draw. Carefully
graded by 'Metaphon' authors Liz
Dean and Janet Howell, the book
(retail price 30.00) can be used to
introduce the concept of rhyme to
children from 3'1> years.
To enter the draw, send your name
and address marked 'Speech &
Language Therapy in Practice
rhyme prize draw' to Janet Howell,
Langlearn Communications, 8
skills and learning to read. Lawrence Erlbaum
Associates Ltd.
Hawkins, C. and Hawkins, J. (1985) Pat the Cat:
Picture Puffin books. Penguin Group.
Kamhi, A. (1987) Metalinguistic abilities in lan
guage impaired children. Topics in Language
Disorders 7, 1 - 31.
Kamhi, A. and Koenig, L. (1985) Meta awareness
in normal and language disordered children.
Language, Speech and Hearing Services in Schools
16,199 - 210.
Knafle J. (1973) Auditory perception of rhyming in
Kindergarten children. Journal of Speech and
Hearing Research 16, 482 - 487.
Marion, M.J., Sussman, H.M. and Marquardt, lP.
(1993) The perception and production of rhyme
in normal and developmentally apraxic children.
Journal of Communication Disorders 26, 129 - 160.
McLean, M., Bryant, P. and Bradley, L. (1987)
Rhymes, nursery rhymes and reading in early
childhood. Merrill-Palmer quarterly 33,255 - 281.
Stackhouse, J. and Wells, B. (1997) Children's
Speech and Literacy Difficulties; A psycholinguistic
approach. Whurr.
Van Oosterom, J. and Devereux, K. Rebus
Symbols. The Symbol Collection (Software for PC
and Acorn) Widgit Software, 102 Radford Road,
Leamington Spa, CV31 lLF.
Re lections: Rh me time
1. Do I use an approach to assessment that helps me work
collaboratively?
2. Do I have adequate knowledge of task hierarchies to be
flexible when faced with an individual's difficulties?
3. Do I provide sufficient visual support when auditory skills
are impaired?
Traquair Park East. Edinburgh,
I
EH12 7AW, tel. 01313345232. The
I
dosing date is 30th June.
I
I
I

OFFER
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In celebration of Autism Awareness
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To enter the draw, send your name and
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Theragy in Practice autism prize draw'
FAO Jane Lindsay, Winslow, Telford
Road, Bi cester, a xon OX6 OTS, e-mail
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.date is 30th June.
More information about the publication
is in the 1999 Winslow catalogue and at
http://vvww.winslow-press. co. uk
L______________ .J
Case study - Donald
Donald's attention and listening skills have improved but remain fluctuati ng. His copying of rhythmic
patterns is now OK but he still occasionally finds it difficult to hear an unstressed syllable in a word.
He has made a si gnificant amount of progress with rhyming skills, particul arly when given choices of
words that rhyme or when he has pictures to help him. He st ill fi nds i difficult to internali se or work out
rhyme for himself, so has a strategy which he can use to help himself when reminded.
1. Look at the first word and see what "family" it belongs to
2. Look at the "family" of the second word
3. See if both words are in the same family: if they are, then they rhyme
For example:
,is
A
0
at an
Look at the first word and see what "family" it belongs to
Look at the" family" of the second word
If both words are in the same family I then they rhyme!
Although thi s strategy has increased his awareness, rhyme is not a firmly establ ished, spontaneous skill .
Overall, the input side of Donald's profile as compared with the output side suggests he continues to
have difficulties at a representat ional or storage level as well as some difficulties at an articulatory level.
Consequently, it is more difficult for him to Judge word components and patterns automatically.
10 SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 1999
organises
and C arifies
Children's Speech and Literacy
Difficulties - A Psychological
Framework
Joy Stackhouse and Bill Wells
Whurr
ISBN 186 1560303 17.50
Many of us are already familiar with
the work of Stackhouse and Wells
through their many articles and train
ing courses. This book, based on those
courses, has become essential reading
for therapists and other professionals
working with children with speech and
literacy difficulties.
ing a fascinating, longitudinal study of
Zoe chronicling her changing profile
from the age of 3;9 to 9;8 years.
One of the strengths of this psycholin
guistic approach is that it highlights how
children presenting with the same diag-
Nothing
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Kate Padfield is speech and language therapist
for European Services for People with Autism,
South Hills College, 9 The Cedars, Ashbrooke.
Sunderland.
reviews
particularly new
Their aim is to produce a practical, sys
tematic, hypothesis-testing approach to
the investigation of speech processing
skills. Through carefully structured chap
ters, using thought-provoking activities
and neat summaries, we are enabled to
profile a child's speech processing
deficits and meaningful, individualised
targets for teaching and therapy.
The first half presents the psycholin
guistic model of speech processing in
terms of input skills, lexical representa
tions and output skills and emphasis is
given to the development of literacy
skills and how this relates to speech .
An assessment framework is discussed
based on their speech processing
model. Questions are posed which
attempt to identify the level at which
breakdown occurs. Practitioners are
encouraged to think critically about the
nature of tests used to assess speech
processing and phonological awareness
as the book clearly states that it does
not purport to be an assessment battery.
The authors offer a developmental per
spective in the second half, and hypoth
esise that various speech disorders can
be explained by failure to progress
from one phase to another. Detailed
clinical case studies are offered includ
Sourcebook of Phonological Awareness
Activities: Children'S Classic Literature
Candace L. Goldsworthy
Singular
ISBN 1-56593-797-X
Written by a speech and language pathologist
and based on discussions in a previous text, this
offers a variety of phonological awareness
activities based around eight well-known
children's stories, for example, 'Snow White and
the Seven Dwarves'.
It looks at the importance of phonological
awareness in learning to read and describes the
stages of development for phonological
awareness skills. It then describes various
assessments of phonological awareness and
explains how to use the programme.
Phonological awareness activities are given for
each children's book the author has chosen and
record sheets are included to chart progress.
This book may be useful for a teacher who
wants to work around a specific project or set of
books and needs something she can pick up and
use. Pictures, however, are not provided and, if
a different children's book from those
recommended is used, the activities have to be
altered to accommodate the different
vocabulary. The activities used in each chapter
nosis may have very different sets of
underlying deficits which will affect
their prognosis and efficacy of their
treatment plan. The careful and rigorous
nature of assessing and profiling a child's
strengths and weaknesses enables the
practitioner to identify more subtle, hid
den skill deficits and examine the close
relationship between speech processing
skills and literacy development.
This is not a book for bedtime; though
written in a clear, careful manner and as
jargon-free as possible considering the
subject matter, it is a taxing, thoughtful
read. Stackhouse and Wells do admit
that, initially, profiling a child's speech
processing skills may take some time but
that, with practice, filling in profiling
sheets can be done quite quickly. My
own experience suggests it focuses,
are exactly the same - only the book used and
the vocabulary around it change. They are not
particularly different from phonological
awareness activities presented in other
published books and programmes, although the
idea of using familiar books may make the
activities more interesting for the child.
The author suggests that a child should master
one level before progressing to the next and
that activities should be repeated using different
children's books until the child can cope with
that level. As children tend to develop
phonological awareness skills in different ways,
this may lead to a child being "stuck" on one set
of activities when they may be able to cope
with higher or lower level tasks. It may have
been more useful to suggest a variety of tasks
at different levels to prevent the child from
becoming frustrated.
While this book may be useful for people who
want something they can pick up and use, for
anyone who has experience of working with
children with phonological awareness
difficulties, it does not offer any particularly
new ideas.
Lynne A. Kemp is a senior speech and
language therapist with Tayside Primary Care
(NHS) Trust.
--,
lan
lucky
in
at
Helps Children Communicate
For pupils with language
disorders, making friends
. or even coping in social
situations - can be a long,
challenging process.
Barbara Pau/ger reports
on a pi lot project where a
group of 11 to 13 year
olds with poor social
communication skills
"were given strategies
and opportunities for
integration at a youth club.
CAN, the national educational charity for
children with speech and language impair
ments, opened its first of four secondary
school language Resources in 1995 with the
aim of offering a unique combination of
specialist support and opportunities for
inclusion within the main school. However, even
these cannot address the pupils' difficulties with
communicating in other situations. We therefore
decided to run a Social Communication
Community Group as a pilot project over nine ses
sions from January to April 1998 to focus on the
application of social communication skills outside
of school and home. The success of the pilot has
led to a family support worker being appointed.
She is continuing support to Resource pupils who
are participating in local community groups.
Eight pupils from I CAN secondary school lan
guage Resources in Surrey took part in the group;
five from I CAN at The Park (a resource for pupils
with speech and language impairment in addition
to moderate learning difficulties) and three from
I CAN at Broadwater (a mainstream secondary
school language resource). The pupils were either
in Year 7 or Year 8 (ages 11 - 13 years).
Difficulty making friends
The pupils who attended the group had difficul
ties making friends due to social communication
problems including:
1. poor eye contact
2. poor listening and turn taking
3. a lack of awareness of the needs of others
4. poor understanding of what constitutes a
friend
5. difficulties expressing feelings or intentions
6. lack of confidence in talking to others
7. inappropriate touching
8. poor awareness of when to stop / say no / com
promise
9. inability to talk through a problem with others.
The pupils themselves were asked during their
first session at the youth club to suggest reasons
for the group's existence and their attendance.
Having picked up on clues such as who was run
ning the group, the pupils who were attending it
and where it was being held, they cited:
1. so can tell friends at school about new friends
2. play games
3. have fun
4. to know each others' names
5. to make new friends
6. to hang out with your school mates
7. to be friendly with others
8. to calm your nerves
9. help with speech
10. play sport
11. learn language skills
12. to talk to people with same problem as us
13. to make new friends from different schools
14. to learn how to listen.
The group was in two parts, structured activities
followed by less structured activities, each lasting
one hour. The group was run by two speech and
g r o ~ p s
In addition to I CAN's Mainstream Support Programme, the charity's services include:
a, An Earl y Years Programme: a national network of specialist speech and language nurseries,
b,Three Special Schools: Dawn House in Nottinghamshire, John Horniman School in Sussex and Meath in
Surrey,
c. A Training & Information Programme: sharing I CAN skills and expertise with professionals, parents and
the general publi c.
For further information please contact I CAN's Central Office on 08700104066,
Below: Barbara Paulger with social communication group members from I CAN at The Park.
language therapists from the Resources, Youth
workers were responsible for organising activities
in the second part of the evening and these were
discussed with the therapists,
Strategies and support
The structured activities aimed to develop friend
ship strategies and to identify, discuss and solve
problems encountered in social situations and to
provide support in experiencing new and chal
lenging situations, We found the Social Use of
Language Manual (Part 2) and Games for Social
and Life Skills by Tim Bond useful for ideas,
However, a flip chart, paper and pens were the
ost essential items as we used mainly brain
storms, discussion and role play resulting from
events which had happened the previous week in
th e unstructured session, The subjects discussed
were:
a) How to introduce yourself to someone,
b) What to do if someone is rude to you,
c) Saying no, '
d) Persuading,
e) Problem solving; some people always play on
t he pool table, is this fair, what could we do'
f) We have not made many friends at the youth
club, Why?
g) Evaluation,
The aim of the second part of the evening was for
pupils to use the skills and strategies they had
earned and practised in the first part in their
'nteraction with the youth club members, The less
structured activities included football, basketball,
pool, table tennis, trampolining, team games,
quizzes, cooking pancakes, computer photo scan
ning, use of a camera for developing stories and
an outing to Laser Quest in Guildford,
Initially all the pupils found it hard to settle in
the group, their eagerness to sample the facilities
of the club obvious, However, they all responded
positively to discussions and to targets set, and
the group gelled well ,
Recognising problems
The nature of the pupils' communication difficul
ties often made it hard for them to recognise
when a problem situation had arisen or to put
their difficulties into words, They tended to walk
away and then miss out on activities, so they
became unhappy and had negative experiences.
However, when a problem was presented to them
that had been observed by one of the speech and
language therapists they were excellent at talking
about the situation and then problem solving, It is
therefore crucial that therapy is not just confined
to made-up situations in a clinic / therapy room /
classroom, It must involve real life situations and,
while discussion and problem-solving is invalu
able, it needs to be put into practice over and
over again, Videoing is also a powerful tool for
feeding back and, the more the pupils are able to
see what led up to the problem and discuss it, the
better they should become at recognising it at the
time it happens, ~
a flip chart,
paper and pens
were the most
essential items as
we used mainly
brainstorms,
discussion and
role play
The nature
of the pupils'
communication
difficulties often
made it hard for
them to recognise
when a problem
situation had
arisen or to
put their
difficulties into
words.
Re ections: Thera
.... For the first few sessions there were very few
pupils from the youth club available to integrate
with the Resource pupils, so they were able to
concentrate on becoming familiar with the club
and its facilities. They were very keen on the
sports activities but did not get involved with the
more verbal activities - video, chat, story boards
and quiz sessions. The Resource pupils were ini
tially reluctant to try some of the new experiences
offered at the club, but with support they even
tually joined all of these exciting activities.
Integration
The Resource pupils had an initial target of find
ing out the name of a pupil from the youth club,
which they achieved, but they were unable to
really sustain a friendship. However, towards the
end of the sessions there was a core group of
pupils who knew the names of all the Resource
pupils and vice versa. They interacted well and
the youth club pupils often encouraged the
Resource pupils to join in activities with them.
The youth club pupils also approached the speech
and language therapists and asked questions
about the Resource pupils in an interested and
positive way. If we were running another similar
group, we would talk to the youth club pupils
before it started to explain what it was all about.
We would also consider inviting some of the
youth club pupils to the structured part of the
evening to facilitate better integration.
We asked the Resource pupils to think about:
"Why didn't we make more friends?" They
responded:
"Keep forgetting, other things on mind."
"Talking to friends is wasting time, having fun
doing other things."
"We were making friends with people from the
group."
"Not enough time, only one hour."
"Because we are not in the same group as them,
so don't get to meet them."
"Not many people here."
or real li e
exciting than making friends! In addition, few of
the Resource pupils had previously had the oppor
tunity to socialise with their classmates outside
school, so it is not surprising that cementing exist
ing friendships was more of a priority than mak
ing new ones. For language disordered pupils,
making friends is a long process. This is especially
true for some of the project pupils who had had
negative experiences in the past. They appeared
to be happy just to be accepted in the club with
out any negative reactions such as teasing. I am
confident that some of them would have made
real friendships had the project been longer but
even the short, positive experience of the group
has been enough to give one pupil the confidence
to join a basketball club, initially with support and
now on his own.
The Social Communication Community Group
was a success for those pupils who attended. They
were able both to explore strategies for coping in
social situations and to participate in community
youth activities. Staff were however aware of the
less than ideal circumstances, with school staff
used to run after-school activities and children
taken outside their own localities to integrate
into community activities.
Local support
I CAN has now recruited a family support worker
whose role includes the support of Resource
pupils participating in appropriate local groups.
She is using the findings of the Social
Communication Community Group to guide her
practice. She gets to know the pupils, finds out
their main interests and liaises with school staff in
the first instance, then meets with the staff and
young people at the out of school activity the
Resource pupil is going into before they start. The
most valuable advice we have been able to pass
on to her from our group is that the pupils have a
range of needs, but all need support, even if it is
just an initial presence.
Barbara Paulger is a specialist speech
and language therapist, I CAN at The
Park, The Park School, Onslow
Crescent, Woking, Surrey GUl2 7AT,
tel: 01483 726913.
I attempt to address a client's communication needs in real life situations?
I see beyond my own aims for a client to what they want from therapy?
I exploit the problem-solving and motivating potential of groups?
Solutions that they offered were:
Make the unstructured part longer.
Invite some of the youth club pupils to join in
the group.
It is very easy for us to project potential problems
onto pupils and to have objectives for them that
we think are right, but perhaps they do not. We
must bear in mind that some of the pupils in the
project were experiencing a youth club environ
ment for the first time which was exciting - more
Acknowledgement
Funding for the social communication
community group was generously pro
vided by the Joint Commissioning
Panel of Surrey Education and Social Services.
Resources
Social Use of Language Programme by Wendy
Rinaldi, 77.25 + VAT from NFER Nelson, tel.
01753858961
Games for Social and Life Skills by Tim Bond,
13, Stanley Thornes, tel. 01242 228888. 0
Internet
http://www.sol.co.uk/s/speechmag
The Winter 1998 speech mag asked for top tips for therapy for
children with a voice problem. We are indebted to Collette
McCallum and Claire Hood of Lanarkshire Healthcare NHS Trust
for this collection of ideas and resources:
1. Ideally, a dysphonic child should not be placed on a waiting
list. They should be viewed as a priority and treated as soon as
possible.
2. Therapy can be individual and / or in a group.
3. Individual therapy can focus on rela xation, posture, move
ment, breathing, phonation, resonance. The area(s) focused
on depends on assessment results.
4. Therapy will involve working through a series of steps.
5. Paren ts and teachers are extremely important in helping
the child deal with therapy. Therapy may involve major
lifestyle changes and dealing with feelings.
6. Intensive therapy with a contract is best.
7. Treatment of dysphonic children is difficult and challenging
- but rewarding.
8. Relaxation: tin soldiers v raggy dolls; puppets on a string;
flowers opening; giraffes and monkeys; imagery.
9. Posture: explain and show the benefits of good posture.
10. Movement: we base this on "Move and Rela x with Music".
11. Breathing: Mr Big Breath; blowing out birthday candles;
silly putty; blow football/ fish.
12. Phonation: puppets - hard and soft; describe their voice in
general terms, eg loud / quiet, soft / hard, dancing / marching.
13. Pitch: ladder; high and low sentences.
14. Give clear and concise aims. A chart is excellent as a visual aid.
15. It's a good idea to use a tape recorder and / or video cam
era for feedback. Keep the child informed of what is expected
of them.
16. Dysphonia groups can be varied according to need. We
have run a pre-school, older children and an adolescents'
group. The younger group incorporated Mr Men characters,
Mr Noisy and Mr Quiet.
17. Group aims were: to improve awareness of voice; to pro
mote voice care and therefore eliminate vocally abusive
behaviours; to develop self-monitoring.
18. Each session included: topic and associated vocabulary;
individual and group activit ies; relaxat ion; homework .
19. Weekly plan:
Week 1 - general awareness of sounds (environmental); con
cept of noisy and quiet; introduce relaxation.
Week 2 - recogni sing voice as a special sound; developing
understanding of relationship between sounds and feelings;
unique characteristics of voice - loud/ quieti rough/ smoot h/
nice/unpleasant.
Week 3 - learning about voice production and voice care;
introduce rela xation through imagery.
Week 4 - good vocal habits - introduce alternative means of
communication (non-verbal, facial expression, body la n
guage); discuss pitch/hard/soft attack.
20. ENT consultants are extremely reluctant to operate on chil
dren. Full pre-operative counselling is essential. The decision
will take into account the length of t he dysphonia and the
degree of handicap caused (eg. children studying music). The
optimum age is 9 - 11 years. The outcome is still dependent on
the child's abilities to change behaviours with speech and lan
guage therapy help. Therapy should always be tried before
surgery.
21. Voice advice sheet for parents:
Your child is experiencing some voice difficulties and needs
your help to improve their voice. Here are some ideas to try:
Encourage your child to speak quietly and try to reduce back
ground noise, ego TV, washing machine
Encourage your child not to throat clear or cough and instead
offer them a glass of water or ask them to swallovil hard
Encourage your child not to sing
Encourage your child to drink lots of water or suck blackcur
rant pastilles to keep their throat moist
Encourage your child to have quiet times
Encourage your child to have good vocal habits by trying to
have these good vocal habits yourself
If you are worried in any way about your child's voice please
contact your speech and language therapist.
22. (With picture of frog) Mr Croaky says:
Don't croak like me,
Try the tips below and make
your voice croak free.
1. Do not shout.
2. Do not clear your throat.
3. Do not sing.
4. Drink lots of water.
23. Useful resources
Andrews, M. (1986) Voice Therapy for Children. Longman.
Fawcus, M.F. (ed) (1986) Voice Disorders and their
Management. Chapman & Hall.
Greene, M. and Mathieson, L. (1989) The Voice an its
Disorders. Whurr.
Martin, S. (1987) Working with Dysphonics. Winslo .
Prater, R.J. and Swift, R.W. (1984) Manual of Voice Therapy.
Little, Brown and co.
O' Neill, C. (1993) Relax. Child's Play.
Wilson, D.K. (1972) Voice Problems in Children. Wil liams and
Wilkins.
In my experience '
II
sp.0sab e or
dsp sa
In the first of a new series giving therapists
the opportunity to reflect on what they have
learned from experience, Geraldine Wotton
urges us to recognise and value the
emotional and technical skills involved in the
therapeutic process and considers the
r - - - ~ implications if we do not.
comment so well; I would rather he had been
impressed by my in-depth knowledge of psy
cholinguistics. I now realise that 'old fashioned'
qualities such as patience are absolutely crucial if
we are to have a chance of effecting change. No
matter how brilliant you are technically, if you
don't have the capacity to stick it out with the
client then you may never see the end results. It is
often the client knowing that you can indeed stick
it out with them in spite of the grave problems
they encounter that provides and maintains their
motivation to continue and move forward .
I love my job as a speech and language thera
pist. It challenges me at all levels intellectually and
emotionally as it is not about teaching language /
speech / communication skills as if the client is
some passive container into which I pour my end
less wisdom. The 'work' of a therapist is a 'process'.
This process involves the therapist using intellec
tual and emotional skills to understand the client's
current impairments and strengths, from which
follows an interaction between this understand
...7

ollowing a particularly stressful session
with a very disabled dysphasic gentle
man recently, his son said "I can' t get
over the extent of your patience with
my father", Early on in my career I
would perhaps not have taken this
16 SPEECH & LANGUAGE THERAPY IN PRAOICE SUMMER 1999
~ ills
he bottom line. Not doing so cuts us
Re ections: The thera rocess
off from the very essence of our rai
<5on d'etre and, if it continues, I feel
Do I truly appreCiate what I do?
.ery negatively about our long-term
prospects as an autonomous thera
Do I value my relationships with clients?
peutic profession.
The lack of recognition of those Do I have the emotional capaCity to see my work through?
reflects a wider shift seen
ithin society as a whole. This includes a devalu- Geraldine Wotton is an Independent Speech &
g of traditional skills of wisdom, experience and Language Practitioner in Walthamstow, London El7.
ing, the client's current appreciation of their own
needs and the therapist's insights. Ultimate inte
gration of these will depend upon the level of the
client's cognitive ability and emotional state and
crucially - the therapist's emotional capacity to
w ithstand the inevitable 'uncertainty' that is so
much a part of the work. The relationship
between therapist and client is therefore the cor
nerstone of the process.
Appreciating depth
My true recognition for the work we do devel
oped when I became interested in the disciplines
of counselling and psychotherapy.
Previously only my gut instincts had
hi nted at it, but this involvement
enabled me to appreciate the
depth of the work we undertake.
Because of this I feel ardently that
' the process' encountered through
out the relationship between client
and therapist is something to be
cherished, respected and valued. It
i s not something that should be so
easily passed over or - perhaps even
more controversially - handed over
t o an untrained person. This is a
process which takes skill, experi
.ence and courage and cannot be
art ificially manufactured or produced after one,
two, three, four, five or however many years.
Indifference
While my appreciation grows, I am concerned at
what appears to be an increasing lack of appreci
ation for these skills by others. Like so much else
in our consumer disposable society, they appear
t o be treated as if they are easily acquired and
equally easily disposed of. This indifference is also
unfortunately apparent within our profession,
although recent debates have highlighted con
cerns about the consultative models adopted by
many therapists and other moves which involve
t herapists working seemingly at a distance and
leaving the therapy to others who do not have
our skills or training.
Raison d'etre
Finance is the reason used to explain such a state
of affairs but this is a false economy. Maturation of
the profession can only come through an under
standing and recognition of the skill of experi
enced clinicians and, with this,
rewarding them financially. This is
I love my job as
aspeech and
language therapist.
It challenges me
at all levels
intellectually and
emotionally
nurturing. Women have largely been viewed as
guardians of these skills and values. However - to
borrow a phrase from one of my colleagues - 'in
pursuit of professional careers' we women have
also colluded with this devaluation. I was sharply
reminded of this recently by a mother who, when
I asked if she went out to work, retorted "I work
at home raising my kids".
Pursuit of machismo
This apartheid is also seen within the work place.
The discrepancy in pay scales in jobs for those
who opt to work in areas of hands-on child care,
Sadly, the current NHS philosophy has forced
many of us to adopt ways and methods of work
ing which we feel instinctively are not offering us
or our client group the way forward. In our bid to
compete and prove ourselves we are throwing
out the ba by with the bath water.
Timing and level of input, environmental I insti
tutional I organisational support for the thera
peutic process and financial and political support
for the therapeutic relationship are vital and, if
not present, must be fought for. The longer I work
the more I realise that the process we engage in is
indeed complex and rarely straightforward. It
does not easily sit or fit with the constraints and
demands most of us professionally face. Yes,
these constraints are a reality that inevitably
invades the therapeutic process and are therefore
not easily ignored. It is down to us to make those
who insist on them aware of the impact of their
demands on our work. We really cannot make a
silk purse when only offered a sow's ear - and
they, not just us, have responsibility for that.
Particularly when it comes to assessing outcomes.
for instance, is considerable when
compared with the less hands-on pro
fessionals involved in the same field.
There seems to be increasing respect
for the machismo, the intellectual, the
package, the short term objective and
the quick-fix, easy answer. Good old
fashioned values such as patience are
- in spite of what is said - becoming
less respected and valued . They are
just not fast-track or sexy enough. It is
the pursuit of the machismo that real
ly underlies the current cultural trends
and is also influencing how we as a
profession are viewing the way for
ward.
the current NHS
philosophy has
forced many of us to
adopt ways and
methods of worki ng
which we feel
instinctively are not
offering us or our
client group the way
forward.
tralnlnQ
_earnln
I
ommunicate'
There is an expectancy in
speech and language
therapy that priority should
shift from working on
impairments with individuals
to improving communication
environments by training
carers, but how often has
such training been
systematically marketed and
evaluated? Lesley Jordan,
Linda Bell, Karen Bryan, Jane
Maxim and catherine
l)Iewman reflect on the first
three years of Communicate
training and ask what we can
all learn from the experience.
n Autumn 1995, Action for Dysphasic Adults
(ADA) launched its training programme for
carers of older people with communication
impairments. Communicate's emphasis
throughout is on fostering good practice in
communication: listening skills; carers' ways
of expressing themselves; and use of different
modes of communication including facial expres
sion, body language and gesture as well as lan
guage. These are general skills which are rele
vant whatever the cause of the communication
impairment, in relation to clients without any
specific communication impairment and for inter
action with cl ients' relatives and, indeed, in other
working relationships. Above all, such skills are
essential to enable carers to tackle the disabling
barriers associated with communication impair
ment (Kagan, 1995; Jordan and Kaiser, 1996).
The programme has been described in some
detail elsewhere (Bryan et aI., 1996), so, after
briefly explaining its background and aims, the
focus here will be on administrative issues, take
up and effectiveness, the purpose being to reflect
on experience to date of ADA's first venture into
the health and welfare training market. The
authors are engaged in a Middlesex University /
University College London research project to con
duct an evaluation of Communicate, funded by
the NHS Executive North Thames Health of Older
People Research & Development Programme.
Need identified
The impetus to develop the Communicate train
ing came from two sources. ADA's Director, Ruth
Coles, became increasingly aware of the number
of requests for advice being received from care
workers in residential homes, and from relatives
concerned about these care workers' inability to
communicate with a dysphasic person. At the
same time two of us, Karen Bryan and Jane Maxim
of the Department of Human Communication
Science, University College London (UCL), identi
fied the need for a short, inexpensive training
course for care workers. This stemmed from work
over many years with older people in residential
care. Several approaches to charities for funding
to develop such training proved fruitless. Once
ADA and the UCL therapists discovered that they
were thinking along similar lines they worked
together, with colleagues, to obtain a year's fund
ing from the Department of Health (DoH) to
develop and pilot what became the Communicate
training package.
It was decided to focus on carers working in res
idential accommodation for older people because
this is where communication impairment is most
concentrated. There are an estimated 165,000
communication-impaired people aged 60 and
over living in institutions (hospitals, nursing
homes, residential care) in Great Britain. Studies
of older people in residential settings in two areas
found that over 50 per cent had communication
limitations (Bryan and Drew, 1989; Lester, Soord
and Trewhitt, 1994).
Paucity of services
Evidence also suggests considerable unmet need
in relation to communication impairment. In par
ticular, work on ADA's National Directory of
Language Opportunities (1995) revealed the
paucity, in many parts of the UK, of speech and
language therapy services for people needing the
service to be brought to them in residential care
or in their own homes (see also Bryan and Maxim,
1996). Current resourcing for statutory speech and
language therapy services would be most unlikely
to extend to the provision of staff training in
more than a small percentage of residential
homes.
Communicate is designed as a workshop for 8
16 participants, aiming:
to increase communication awareness;
to provide knowledge about communication
impairment;
training..
to facilitate development of practical communi
cation skills for use with communication-impaired
people.
The first of Communicate's two half-day ses
sions draws on the NHS Trust Community Health
Sheffield's communicat ion disability awareness
pack (Lester, Boddy et ai , 1994). Whilst the main
f ocus of Communicate is on dysphasia, the second
session includes 'options' on Parkinson's and
Alzheimer's diseases and the accompanying book
let, distributed to all participants, gives informa
ti on about these conditions.
A key innovative feature of Communicate is
that all tutors are qualified and experienced
speech and language therapists inducted by ADA
on the delivery of Communicate .
For Communicate's first year ADA received a
fu rther DoH grant to employ a marketing and
development officer, but since September 1996
he training has been funded primarily by receipts,
supplemented as necessary by ADA. The price has
been kept as low as possible and is calculated to
(Over costs rather than to make a profit.
ADA now employs a part-time project manag
er who is a registered speech and language ther
apist. She is responsible for:
recruiting, training and maintaining a network
of speech and language therapists as accredited
Communicate tutors;
marketing: liaising with potential purchasers of
Communicate in the statutory, voluntary and com
mercial sectors;
organising the provision of the training package
t o purchasers;
monitoring purchaser satisfaction.
Local liaison
tutors are employed by ADA on a
sessional basis. The 30 tutors cover most parts of
the country. They are expected to liaise with the
HS speech and language therapy service nearest
,0 where training is to take place, to enable accu-
Table 1: Characteristics of Communicate purchasers to Sept. 1998
Type of Agency Number of Agencies Number of Workshops
Independent Care Sector Agencies
local Authority Social Services Departments
National Health Service (NHS) Trusts
Other
TOTAL
rate and appropriate information to be provided
about local services.
By the end of September 1998, 98 Communicate
workshops had been provided for 49 health and
social care organisations. Table 1 shows the types
of organisation that have purchased
Communicate. Three things are clear:
1. Communicate has been purchased by a
wide range of agencies
It has been taken up by agencies in statutory, vol
untary and private health and social care. The
independent care sector agencies comprise main
ly providers of residential and nursing homes pur
24 37
12 36
9 19
4 6
49 98
chasing either individually or as consortia. They
also include a small number of domiciliary and
day care providers and a Housing Trust that has
taken on home care responsibilities. The NHS
Trusts are mostly community Trusts but include
also two hospital Trusts and a mental healt h Trust .
'Other' purchasers are mainly voluntary organisa
tions concerned with disabled people.
2. Take-up in the residential care sector has
been disappointing
The training was initially designed for the resi
dential care sector but only a very small percent
age of approximately 15,000 residential and
~ nursing homes for elderly people in England have
sent any staff to a Communicate workshop.
Some, but by no means all, participants in the
workshops purchased by Local Authority Social
Services Departments (SSDs) have been residential
care staff.
3. Communicate has been purchased for a far
wider range of participants than anticipated
The majority of participants' occupations are
available from evaluation forms completed at the
end of each workshop. These include over sev
enty different job titles. Care assistants are the
largest group, comprising over 20 per cent of all
participants. SSD employees have included staff
from day care and domiciliary settings and, in one
instance, informal carers. A number of managers
and professionally qualified staff have attended,
the latter including nurses, social workers, and
occupational therapists.
Take-up patterns
Table 2 gives the geographical distribution of
take-up by NHS region. It shows a wide but
uneven spread.
There has been no take up yet in Wales and
Northern Ireland, and only minimal take up in
Scotland . Communicate has not yet 'taken off' .
The largest number of workshops so far for any
one organisation is six, purchased by a social ser
vices department in the Northern and Yorkshire
region.
Figure 1 shows the distribution of bookings
among purchasers. Nearly half the purchasers
have booked at least two workshops. Take-up
patterns vary, with some purchasers making an
initial booking for more than one workshop.
Fourteen agencies have re-booked after experi
encing a workshop, two of these having rebooked
twice and one three times. This suggests that a
small number of agencies have become regular
customers. Most bookings are made three to six
months in advance. ADA clearly has much 'spare
capacity' since, during the first three years, only
18 of the 30 accredited Communicate tutors deliv
ered any workshops.
A complementary service!
ADA sees Communicate as complementary to
statutory services. How do speech and language
therapists view it?
One factor affecting demand might be assump
tions about Communicate among NHS speech and
language therapists and care providers. Do the
former see Communicate as a potentially useful
resource? Could one reason for low take-up be
that Communicate is identified too strongly with
dysphasia, and wrongly perceived as less relevant
to other commun ication disorders?
Systematic evidence is lacking, but it is clear that
some speech and language therapists have wel
comed Communicate. Nearly all Communicate
tutors work either full time or part time for the
NHS. About a third of tutors have asked that
ADA should pay the NHS Trust for their time, so
Table 2: Geographical distribution of
Communicate workshops to Sept. 1998
NHS Region Number of Number of
agencies Workshops
Anglia and Oxford S 1S
North Thames 8 16
North West 8 21
Northern and Yorkshire S 12
South Thames 7 9
South and West 3 4
Trent S 9
West Midlands 11 7
Scotland 1
TOTAL 49 98
Figure 1: Distribution among purchasers
30,-------------------,
CJl 25
!La:
om 20
a:
~ is 15
:::;;a:
~ ir 10
5
o
Communicate
has not yet
'taken off',
these therapists, at least, have their managers'
approval for this work. The others work free
lance for ADA in addition to their NHS contracts.
Recently, two NHS speech and language therapy
services in different parts of the country have
expressed interest in getting a member of their
own staff accredited by ADA to deliver
Communicate workshops as part of their NHS
employment contract. NHS speech and language
therapy services are known to have been instru
mental in several purchases, in two cases them
selves being the purchasers. Communicate is thus
beginning to be incorporated into NHS services in
a few areas.
There has also been a little localised friction . In
a few instances concerns were raised about how
Communicate training would relate to local provi
sion. There have also been several cases of an NHS
manager asking speech and language therapists
why they could not develop such training them
selves and market it to generate income for the
NHS Trust. However, the extensive development
resources (in terms of time and, therefore, money)
required to prepare and pilot such a programme
would strongly suggest that income generat ion is
not viable. The strategy mentioned above of
sponsoring a local therapist to become a accred
ited Communicate tutor would be Ii ely to prove
more cost effective where a traini ng initiative in
care settings is being planned.
Liaison with local services is built into the job
specification for ADA Communicate tutors.
Occasionally such contact has proved difficult,
raising questions about the adequacy of commu
n ication systems in the Trusts concerned and
increasing tutors' workloads. Where attempts to
Figure 2'- Practical points: Learning from 'Communicate'
Communicate was designed as a flexible package,
adaptable to particular needs and capable of use
in different ways. The range of agencies purchas
ing Communicate perhaps provides indirect evi
dence of success in this respect. Re-bookings also
suggest consumer satisfaction.
Answers to the following questions are not
known:
1. Does Communicate makes a difference to com
munication-impaired people?
2. How important is it to have a high proportion
of staff trained? Is there a 'critical level' of train
ing required in a particular setting for effective
ness?
3. Are any positive effects maintained over time?
4. How frequently is training needed to cater for
staff turnover?
5. To what extent is carers' job satisfaction
improved?
Our evaluation aims to address questions about
outcomes of Communicate training and processes
involved in its purchase and provision (Jordan et
ai, 1998). A fur
1. A considerable investment of time and other resources is required to develop even a
short training programme like Communicate.
2. There is a continuing need for 'marketing' in order to create/maintain enough demand
to justify development and ongoing costs. What is required here will vary; for example,
we would expect a training programme intended for purely local use to require different
marketing strategies from a centrally produced package available across the country.
3. Access to training may be particularly difficult for unqualified staff in the independent
care sector.
4. An important factor limiting take-up, especially in the independent care sector, is the
necessity to organise cover for released staff. This factor can be seen as a 'cost' to agencies
that is separate from charges for the training itself.
5. It is essential to establish pre-<ourse guidelines on local liaison and to check on the
needs and prior experience of the audience.
6. However well prepared, tutors have to be flexible.
7. You can't please an of the people all of the time.
The difficulties in marketing
Communicate have led ADA to
attempt to influence government policy
towards training of care workers.
make contact have not succeeded, AD/JIs standing
with the local service may be put at risk.
Communicate aims to provide only a basic level of
training. ADA hoped that, once the basics had
been transmitted and interest raised, local speech
and language therapists might be offered (and
take) the opportunity to provide more advanced
training. It is not known whether this has hap
pened, but resource constraints are likely to have
been a limiting factor.
Questions remain
Regarding effectiveness of Communicate training,
there is some encouraging evidence, though
many questions remain to be answered.
The Communicate pilot provided evidence that
the training is believed by participants and man
agers to be effective (Bryan et aI., 1996).
leagues and other agencies.
ther question is
whether there
are links
between train
ing in commu
nication skills
geared to those
working with
communica
tion-impaired
people, and
training to
improve com
munication in
general with
clients, col-
A separate research
project is being funded by Middlesex University to
investigate this issue.
Communicate training has not, so far, achieved
significant dissemination in terms of percentage
of potential target area, despite considerable
marketing efforts. Furthermore, independent
sector residential and nursing homes, identified
by ADA as having the 'prime need' for
Communicate training, account for under 40 per
cent of workshops purchased. Following the
1990 NHS & Community Care Act, the trend is for
both health and social care agencies to refer older
people requiring long term care to independent
sector provision, making this an increasingly
important market for Communicate. Might low
take-up stem from attitudes among those con
trolling resources within the independent residen
tial care sector towards investment in training?
Take-up of Communicate must be understood in
the context of the complete lack of any statutory
training requirements for carers of older people.
The difficulties in marketing Communicate have
led ADA to attempt to influence government pol
icy towards training of care workers.
The practical points listed in figure 2 have emerged
from our experience with the Communicate project
and should, we suggest, be considered by any ther
apists planning to offer training.
Lesley Jordan (Project Leader) is Principal Lecturer
in Social Policy and Linda Bell Senior Lecturer in
Research Methods, both at Middlesex University.
Karen Bryan and Jane Maxim are Senior Lecturers
and Catherine Newman a former Research Fellow
at University College London.
Resources
Action for Dysphasic Adults are at 1 Royal Street
London SE1 7LL, tel. 0171 261 9572, http://ada-uk.org
The second edition of the National Directory of
Language Opportunities for People wit h
Dysphasia is now available from ADA. It is divided
into eleven regions which can be purchased indi
vidually (15 print, 10 disk) or as a set (120
print, 90 disk). Details from ADA.
Acknowledgement
The authors wish to thank Niki Muir for her help
ful comments on an earlier draft of this paper.
References
Action for Dysphasic Adults (1995) Nat ional
Directory: National Register of Language
Opportunities for those with Dysphasia and
Families, ADA, London.
Bryan, K., Coles, R., Jordan, L., Kerr, J., Lester, ..
Maxim, J. & Rudd, T. (1996) Enabling care staff to
relate to elderly people with acquired commun'
cation disabilities, British Journal of Therapy and
Rehabilitation, 3 (7), 364-369.
Bryan, K. and Drew, S. (1989) A survey of co u
nication disability in an elderly population in r -.
dentia I ca re, International Journal
Rehabilitation Research, 12 (3), 330-333.
Bryan, K. and Maxim, J. (1996) Commu nicati
Disability and the Psychiatry of Old Age, Wh r .
London.
Jordan, L., Bell, L., Bryan, K., Maxim, J. all
Newman, C. (1998) Evaluating
Organisational issues and their relevance fo c - -,
cal evaluation, International Journal of Language
and Communication Disorders, 33, Suppl emen
Proceedings of the Royal College of Speech
Language Therapists 1998 Conference, Liverpoo
15-17 October, 60-65.
Jordan, L. and Kaiser, W. (1996) Aphasia - A Sod"
Approach, Stanley Thornes, Cheltenham.
Kagan, A. (1995) Revealing the compe enee
aphasic adults through conversation: a chalte e
to health professionals, Topics in S .>
Rehabilitation, 2 (1), 15-28.
Lester, R., Boddy, M., Evans, J. and T E
(1994) Care Staff Training, Volu ,
Communication Disability, Communk,, -- '"
Therapy, Community Health Sheffield.
Lester, R., Soord, G. and Trewhr
Towards a Better Understandi ng.
Communication Therapists I fa
Community Services Traning and
SPEECH & LANGUAGE THERAPY IN PRAOI CE SUM fR 1999 21
0

further r e a d l n ~
rthe r reading This regular feature aims to provide information about articles in other journals which may
be of Interest to readers.
~
The Editor has selected these summaries from a Speech & Language Database compiled by Biomedical Research Indexing. Every article in over
thirty journals is abstracted for this database, supplemented by a monthly scan of Medline to pick out relevant articles from others.
To subscribe to the Index to Recent Literature on Speech & Language contact Christopher Norris, Downe, Baldersby, Thirsk, North Yorkshire Y07
~
4PP, tel. 01765 640283, fax 01765 640556.
Annual rates are
Disks (for Windows 3.1, can run on Windows 95): Institution. 90 Individual 48
Pri nted version: Institution 60 Individual 36. Cheques are payabl e to Biomedical Researcl.1/ndexing.
REFERRAL
Keating, D., Syrmis, M., Hamilton, L. and McMahon, S. (1998) Paediatricians: referral rates and speech pathology
waiting lists. J Paediatr Child Health 34 (5) 451-5.
OBJECTIVE: This study aimed to examine paediatricians' training in and understanding of communication development and disabilities and
their attitudes to speech pathology waiting lists and management practices. The relationship between these factors and referral rates was
also investigated. METHODOLOGY: A total of 229 paediatricians registered with the Australian College of Paediatrics participated in the
study in November 1996. They answered 15 mUltiple-choice questions designed to collect demographic information and data pertaining to
their training and understanding of communication development and disabilities. The survey also obtained data on referral rates to public
and private speech pathology services and on paediatricians' perceptions of speech pathology waiting lists and possible management strate
gies. RESULTS: Referral rate to public and private speech pathology services was found to be associated with the quality of paediatricians'
trai ning in and knowledge of communication development and disabilities. Paediatricians who had regular contact with speech patholo
gists were also more likely to make more referrals. Waiting lists had a negative influence on referral rate.
Treatment rather than assessment waiting lists were preferred. Paediatricians believed the best solution
DEMENTIA
to speech pathology waiting lists was an increase in staffing levels particularly in community health cen
Wareing, L.A., Colemen, tres. Respondents reported that 1-4 months was an acceptable time to wait for speech pathology care
P.G., Baker, R. (1998) and indicated the order of importance of factors for prioritising children. CONCLUSIONS: The results have
Multisensory environ
important implications for developing best practice models for improving referral processes and access to
speech pathology services for children with communication disabilities.
ments and older people
with dementia. Br J Ther
Rehabil5(12) 624-9.
DYSPHAGIA
Caring for people with
Leder, S.B. (1998) Serial fiberoptic endoscopic swallowing evaluations in the
dementia is challenging
management of patients with dysphagia. Arch Phys Med Rehabil79 (10) 1264-9.
for professionals and rel
atives, with demand for OBJECTIVE: To determine whether serial ommendations for initial feeding status, when
care rising as longevity fiberoptic endoscopic evaluation of swallowing to resume oral feeding, and what bolus consis
(FEES) can be used successfully and efficiently in tencies to use for optimal swallowing success. increases. Current psy
deciding to change a patient's feeding status RESULTS: In all subjects, serial FEES detected
care rely on verbal com
chosocial approaches to
from nonoral (NPO) to oral (PO) with no pharyngeal phase dysphagia, aspiration, and
adverse health outcome. DESIGN: A prospec aspiration risk and enabled determination of
these are lost sensory
munication skills. When
tive, consecutive, cohort study. SETTING: initial feeding status (NPO or PO), when to
stimulation may be a Inpatient population of a tertiary-care universi resume successful oral feeding, and what bolus
ty teaching hospital. SUBJECTS: Thirty-two consistencies to use for optimal swallowing suc way of communicating
adults were recruited from a cohort of 400 con cess. Specifically, 15 of 32 (47%) subjects with and meeting the
secutive subjects who participated in a previous received FEES 3 to 5 times within only 6 to 22 needs of this vulnerable
dysphagia study. INTERVENTION: Serial FEES days. Timely serial FEES allowed 22 of 32 (69%) group of people. This
was performed 3 to 6 times in each subject to subjects to resume an oral diet as early and paper reports on a study
detect objectively pharyngeal phase dysphagia, safely as possible. CONCLUSIONS: No subject using a single case study
aspiration, and aspiration risk and to provide who resumed an oral diet based on results of design with four men in
information for recommendations regarding FEES developed an aspiration pneumonia. the later stages of
oral feeding status and therapeutic interven Serial FEES, therefore, enabled feeding status dementia. The benefits
tion. The number of FEES was based on the to be successful and efficiently changed from that resulted following
subject's medical status, evidence of dysphagia, NPO to PO with no adverse health outcome. treatment sessions were
and clinical judgement. MAIN OUTCOME MEA FEES was an efficient procedure with regard to reduction in apathy and
SURES: Identification of pharyngeal phase dys appointment scheduling, transportation, socially disturbed behav
phagia, aspiration, and aspiration risk, and rec- patient issues, and personnel requirements. iour with increased inter
est in the environment.
LANGUAGE DEVELOPMENT
Saxton, M., Kuicsar, B., Marshall, G. and Rupra, M. (1998) Longer-term effects of corrective input: an experimental
approach. J Child Lang 25(3) 701-21.
There is growing evidence that corrective input for grammatical errors is widely available to children (Farrar, 1992; Morgan,
Bonamo & Travis, 1995). However, controversy still exists concerning the extent to which children can identify and exploit avail
able negative input. In particular, very little is yet known about the longer-term effects of negative input. Performing a time
series analysis on observational data, Morgan et al (1995) conclude that corrective recasts are not related to future improvements
in grammaticality. It is argued here, though, that the data sets analysed in this study are inherently ill-suited to the demands of
ime series analyses. The present study adopts an experimental approach in order to compare the effects of negative evidence
versus positive input on the acquisition of irregular past tense verb forms. Twenty-six children (mean age 3;10) participated in a
wi t hin-subjects design over a period of five weeks. It was found that improvements in the grammaticality of child speech were
mnsiderably greater in cases where negative evidence had been provided. Moreover, children's intuitions concerning the status
of irregular and overregularised forms more closely approximated adult intuitions when corrective input was available.
BRAIN INJURY
Beardmore,S., Tate, R.
and Liddle, B. (1999) Does
information and feedback
improve children's knowl
edge and awareness of
deficits after traumatic
brain injury?
Neuropsychol RehabiI9(1)
45-62.
A frequent observation in
adults suffering severe trau
matic brain injury (TBI) is
that many minimise or
appear unaware of their
deficits. Few data exist for
children, but an initial study
by Jacobs (1993) found that
knowledge in children after
TBI was poor, and this raised
issues relating to awareness
of deficit. The present study
had two aims: (1) to investi
gate the extent of deficient
knowledge and awareness
in children and adolescents
after severe TBI; (2) to
develop an intervention
designed to improve knowl
edge of TBI and awareness
of deficit and evaluate its
efficacy. Initial evaluation
with 21 participants, aged
between 9 and 16 years,
found a very poor under
standing of TBI and some
were unaware of their
deficits. Subjects were ran
domly assigned to either an
injury-information or atten
tion-placebo session. The
results of two-way repeat
ed-measures analyses of
variance indicated that the
intervention session was not
successful in increasing the
children's knowledge or
awareness of deficit. These
findings are discussed in the
context of possible causes of
poor knowledge and
unawareness and implica
tions for rehabilitation prac
tice.
how I
At the time of writing, Sue
Foster was a speech and
language therapist with
South Lincolnshire
Healthcare Trust.
Dr Jane Mortley is a
research speech and
language therapist at
Frenchay Hospital in
Bristol.
Evelyn Abberton is based
in the Department of
Phonetics and Linguistics,
University College London
and Eva Carlson at St
Thomas' Hospital, London.
.. use
computers
in therapy
The potential value of
computers in therapy
has been touted for
many years but has not
found a great deal of
interest among speech and
language therapists. With
prices dropping, the home
computer market booming
and a marked increase in
the development of quality
software, this looks set to
change. Three therapists
share their views on the
best packages around for
paediatric, adult and
voice work, followed by
a report on B I I 99.
SPEECH & LANGUAGE THERAPY IN PRAGICE SUMMER lCJ99 23
h O ~
Screen
test
Sue Foster has
been searching
for useful
paediatric
software for two
years. She
demonstrates
the versatiUty of
her favourites
and makes a
plea for more
speech and
language
therapy input
to software
design.
F
inding your way through the maze of available
software can be difficult. Programs need to be
interesting, motivating, easy to use and relevant to
therapy. The Education Show at the NEC is an ideal
place to trial software before purchasing it. After I attended
last year, the Department purchased more software wh ich is
available for the multimedia computers in community clinics.
Motivating and rewarding
My First Incredible Amazing Dictionary'(Dorling Kindersley,
29.99) is an extremely motivating and rewarding program.
It takes the form of an animated dictionary and also includes
a number of games. The animated dictionary is the most
useful part and I have used it in several different areas of
therapy:
i. Phonology (Case example 1)
When a child is able to produce a target word initial sound at
single word level, the program can be used to practise short
phrase I sentence level production.
Case example 1
Daniel (6), moderate-severe phonological disorder,
target for therapy: lsI in word initial position at
sentence level.
Daniel had attended blocks of the.rapy for three years
which had been successful but he was no longer
motivated by a range of therapy reinforcers. The
computer was used as an alternative way of
facilitating speech practice:
1. Daniel selected NSN from the line of letters at the
. top of the screen.
2. A screen came up with pictures beginning with NSN.
He said the word he wanted to look at, for example
Nsea
N
and clicked on it.
3. A further screen came up including a written
description of the word and a larger picture of the
word. .
4. He made a sentence about the picture, for example,
"the boat is sailing on the sea".
5. If he said it correctly he clicked on the picture for
the animation. In this case, the boat sails across the
sea and the water comes out of the whale,
accompanied with a sound effect.
6. Sometimes he also read the description or played
the description of the word to help him to make more
sentences with the same word.
7. At the end of the session he selected the
Nbacktrack" option which played back some of the
. words practised, and he printed one or two pictures
for home practice.
Since Daniel enjoyed the program, he became
interested again in therapy. He successfully achieved
the therapy target by the end of the block and had
already started Work on another target.
One drawback with the program is that it can only be used
for word initial sounds. It is also important to consider that
the dictionary concentrates on letters not phonemes. For
example, under the pages for "s" you will find words
beginning with sh, sand s-blends. The way to get around this
is just to cover the words you do not want the child to
practise with a piece of card .
ii. Spontanteous speech and language
sample (Case example 2)
Usually by the end of a session a therapist is able to use their
skills and equipment to tempt even the most shy child to
speak. However, last year I received a referral for a child who
just would not talk.
Case example 2
Oliver (3;4 years) was referred by the health visitor
due to parental concern over both speech and
language. When he came to his initial assessment it
was evident that he was painfully shy and never
talked to strangers_ I tried all the toys I had to coax
him, all to no avail - he just hid his head in his
mother's coat. So I tried the computer.
As I played with the computer, he gradually left his
mother's knee and pulled her over to have a look. By
the end of the session, he started to exclaim and ask
questions about the animations. I made a further
appointment to see him and as he played with the
computer, I gained a lengthy speech and language
sample which truly was spontaneous.
This enabled me to make a diagnosis and when he
commenced therapy, the program was used to reinforce
phonological targets following listening work.
iii. Vocabulary development
A child can be given a category to brainstorm, for example,
'animals' or 'vehicles' and then cl ick on the category to see if
they can beat the computer!
I would use My First Incredible Amazing Dictionary with
ch ildren up to approximately nine years old. However Dorling
Kindersley also produce a Children'S Dictionary' (29.99) for
older children. The vocabulary in this program is much more
complex, for example some of the words under "I" are leopard,
liberate and luminous. It also includes other games which
include ' charades' (rather like the show 'Catchphrase'),
'spelling' and 'hangman' . Each activity is graded for difficulty.
Dorling Kindersley material is widely available in High Street
department stores, and can also be obtained directly. Many
schools and libraries have this software. Often parents can be
encouraged to practise with children on the library computer.
Special needs specialists
Inclusive Technology specialise in selling and producing
special needs software. Many of their programs can be used
with a touchscreen, switch or intellikeys instead of a mouse.
They also allow purchasers twelve weeks to return goods if
unsuitable. The most relevant packages I have found include:
1. Speaking for Myse/f*: Includes Makaton and Rebus symbols.
Makaton signs are shown on video clips. Encourages single word
naming and simple two to three word stories. Also includes
nursery rhymes, counting, matching, prepositions, colours and
auditory discrimination of everyday sounds. (Windows: (45)
2, On The Farm" : The task is to build up farmyard pictures.
This is useful for work on naming animals and giving and
receiving instructions (especially using prepositions) on
where to place the animals. Text can then be added to name
the animals. (Windows 5-user copy: (39)
3. Spider in the Kitchen* *: A suite of activities including work on
prepositions and sequencing. (Windows or Mac 5-user copy: (57)
Computer programs do have a role in paediatric therapy, but
should be used flexibly and as an additional tool to the therapist.
Many software companies, including Inclusive Technology, are
receptive to speech and language therapists' ideas for programs.
Such input would mean even more programs becoming available
which are directly relevant to our work.
'This is available only on a CD ROM, for use with multimedia
computers so would require a minimum of a Pentium processor.
"This is available only on floppy disk
Resources
The Education Show is an annual event held at the NEC in
March. Tickets are available from 01203 426549. Tickets to
the show are free (no students admitted) . See also
http://www.education-net .co .uk
Dorling Kindersley software catalogue, tel. 08700100350.
Inclusive Technology software catalogue, tel. 01457 819790,
http://www.inclusive.co.uk .00
h ow I
C
omputers have become more common and user
friendly in recent years, to the extent that t hey are
now as common in the home as a video recorder
was ten years ago. Even so, we are still at a very
early stage of development of computer therapy f or adults
with acquired disorders (Table 1). The slow progress of adop
tion of computer therapy has been partly due to the lack of
su itable software and partly due to not knowing how best to
integrate it withi n the therapy process.
These days computers playa crucial role in my approach to
aphasia t herapy. Specifically I use computers to facil itate more
intensive therapy wit hi n limited resources in order to develop
specific strategies or react ivate an impaired process. To ensure
that the computer tasks are appropriate for an individual, it is
essential that t he therapy exercises are based on sound theory.
Integral part
I use computers as an integral part of the impairment based
therapy process. Following a referral I conduct a detailed
assessment aimed at ga ining an understanding of the
impairment, from which I form a hypothesis of the deficit
based on psycholinguistic models.
I then plan a therapy progra mme aimed at the specific area
of breakdown. The therapy is based on a seri es of obj ectives
to target impaired processes or develop compensatory strate
gies based on intact residua l skills. Each objective is addressed
by a series of small incremental goals. I then consider whether
these goals could be ach ieved using a computer to facilitate
intensive, repetitive practice. This clearly depends on the type
and flexibility of software that is currently available.
I have successfully delivered a range of computer exercises
within INTACT, for example auditory discrimination,
grapheme-phoneme conversi on, picture word matching,
confrontat ion naming, spelling, and semantic categori sation
Table 1 - Software
To find out more I suggest that you send for a demo disc at the
address shown or download from the internet.
Software Description
INTACT
REACT
Developed
specifically for
dysphasic
individuals
Bungalow
software
PARROT
software
Software
Fun with
developed for
texts
foreign students
rearning English.
Clicker plus
Developed for
children with
learning
difficulties.
From
pi ctures
to words
Available from:
Aphasia Computer Team,
Speech therapy Research Unit.
Frenchay Hospital.
Bristol. BS16 1lE
Tel: 01179 186529
home.rednet.co.ukl
homepages/sltruadm
Propeller Multimedia,
28 Queen Margaret Close,
Edinburgh EH10 7EE
www.propeller.net/react
5390 NE Stanchion Ct,
Hillsborough OR 97124
www.bungalowsoftware.com
Parrot software,
P.O box 250755,
West Bloomfield M1 48325
www.parrotsoftware.com
Wida software.
2 Nicholas Gardens.
london W5 5HY
www.wida.co.uk
Crick Software.
1 The Avenue.
Spinney Hill.
Northampton NN3 6BA
www.cricksoft.com
Widgit software.
102 Radford Road.
leming10n Spa.
Warwickshire CV311LF
www.widgit.co.uk
tasks. I am greatly enco uraged that there is now more soft
ware developed specifically for this client group (t able 1).
I have also used software designed for foreign students learn
ing English such as "fun with texts" for higher level dysphasics,
and "from pictures to words" for children with learning diffi
culties. The clinician may need to be prepared to create their
own exercises to tailor it to the needs of their particular clients.
Functionally relevant
I always try to use some exercises authored specifically for a
client that include vocabulary of family, friends, pets and
places of interest. I realise it is time consuming and clinicians
do not always have time to create their own exercises. I
would argue however that it is time well spent. It is very
mot ivating for the client and, if the therapy is expected to
lead to item specific improvement, it makes sense that it is
based on the most functionally relevant vocabulary. This is
illustrated in figure 1 when an exercise was set up in INTACT
to practise repetition of family names for a client. The screen
shot shows the latest addition to the family! (The Aphasia
Computer Team is more than happy to scan in photographs
for clinicians to use in their exercises.)
Monitoring progress
If a client is using the computer independently it is essential
t hat the software being used automatically records progress
made. When a client has completed a set of exercises I
retrieve the results, analyse their pe rformance and then
decide the next set of exercises to assign to the patient. I
arrange face t o face sessions to work on specific areas of dif
ficulty as and when required.
Client decides
I find that using a computer in aphasia therapy can increase the
intensity of therapy considerab ly. The amount that a client uses
the computer depends on the individual but it can provide an
additional three
to four hours
therapy a week .
There are many
advantages
associated with
a client using a
computer inde
pendently, par
t icularly at
home. It enables
Sam
the client to
decide when to
Figure 1
try the exercises,
at what time of
day, for how long, and at t imes when they feel most able to
concentrate. The independent use of the computer provides
additional benefits, such as increasing self-esteem and confi
dence, as the client is in control of planning the length of the
therapy sessions.
Although the tasks can be very basic, their presentation on
a computer is acceptable to cl ients. Learni ng a new skill of
computing can enhance their perceived status, particularly
with the younger members of the fam ily.
An advantage of using a computer compared to traditional
homework type activities is that software specifically designed
for dysphasics usually provides feedback and intervention to make
the task easier if a client is struggling to answer a question. This means
that the client is able to perform the exercises independently
without having to rely on anyone else, for example, a spouse.
The feedback on the structured computer task is immediate
and consistent, which appears to help the learning process,
and enables the patient to concentrate specifically on the
process or strategy that is being developed. ~
Jane Mortley
describes how she
uses computers in
aphasia therapy.
and how it has
made her
impairment based
therapy for
aphasia more
effective as it
allows the patient
to move
incrementally
through tasks at
their own pace.
but under close
supervision.
Another important difference is in how often the task is per
formed. Paper tasks are usually performed only once, whereas
with the computer the exercise is repeated until the task
becomes easier, as shown in the typical graph illustrated. I find
aIso that clients often continue an exercise even when they have
improved to near ceiling level on a task. The "over-learning" sec
tion of the graph illustrates this and I feel this contributes sig
nificantly to the impairment based therapy approach.
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1 2 3 4 5 6 7 8 9 10 11 12 13 14

Around the corner
The use of computers in aphasia therapy is very exciting and
I fully intend to continue using them in my therapy.
Information Technology continues to expand rapidly, so there
are always new developments on the horizon. Computers can
now do things that I could only dream about four years ago . .
Today, we are able to use high quality photographs and digi
tised speech, with the use of video for sentence processing
tasks, speech recording and phoneme breakdown for repeti
tion just around the corner.
Computers have the potential to extend our current service
delivery. Research at the Aphasia Computer Team is investigating
service delivery via the internet. This has the potential to
offer extended therapy to long standing dysphasic individuals,
based on a "self-help" approach, and to clients living in
remote areas currently unable to access therapy. We are grate
ful for funding received for the Underwood Trust and the
Stroke Association enabling us to conduct this work .0
.....
how I

vOice
Evelyn Abberton
and Eva Carlson
use a
computerised
system with
cUents with a
voice problem to
assist
assessment and
measurement of
cthange over
time and to
provide objective
visual feedback
therapy.
T
he voice is a strong rival to the eye as a window on the
soul! However, even a human activity so clearly linked
to emotion and individuality as well as physical and
mental health can be illuminated by analysis and mea
surement. Indeed, in the current climate of evidence-based
practice, the therapist working with voice clients must give
serious consideration to providing outcome measures that
include quantified progress along certain acoustic parameters
to support clinician's and client's perceptual assessments.
Quantification of voice quality must be based on dimen
sions that relate to perceived attributes of a voice, and never
be measurement for measurement's sake, or simply a mea
surement that a certain piece of equipment is able to do.
However, it is a tall order for even fast, modern computers to
seek to match the human ear, and most software analysis
packages on the market don't come anywhere near this ideal.
The first problem is deciding which parameters of a voice are
most salient in sickness and health. The human ear clinician can choose which to use in a particular
is extremely sensitive to pitch and related aspects of case; and they can be used singly or in combination
temporal patterning in the acoustic speech signal. A for interactive visual feedback.
speaker with a voice problem will typically have dif
Auditorily relevant
ficulties with pitch control: the speaking fundamen
The modular PC-based package that we use is Lx
tal frequency range may be reduced (giving the
Speech Studio. It is an improved version of peLx, and
impression of monotony and maybe depression),
is explicitly designed to provide measurements, and
and average pitch may be too high or too low.
perceptually normalised visual displays, that are audi
Phonatory difficulties with vocal fold vibratory irreg
torily relevant. The laryngograph is used as well as
ularity may be present throughout the speaker's
the microphone signal so that measurement is highly
pitch range or appear at moments of
accurate, and analyses can be carried
figure 2 linguistically important pitch changes
out on several minutes of connected DFx1
evasub5a.spe
in intonation patterns. The conse
100-. _ .. - --- speech, as well as on sustained vowels.
figure 1
quent auditory impression of vocal
roughness may colour the listener's
impression of the whole utterance.
Perceived breathiness, related to the
relative durations of vocal fold clos
ing and opening phases, is also per
ceptually prominent and is often
associated with irregular vibration,
contributing to the overall perception
of hoarseness (Hirano, 1981).
Multi-dimensional
Measuring these salient perceptual
features is not easy: we are all familiar with the speaker who
can produce a beautifully clear voice on a sustained vowel at
"comfortable" pitch and loudness levels but whose voice dete
riorates drastically in ordinary connected speech. Software
packages based only on the analysis of sustained vowels (eg. Dr
If, in addition, vowel recordings
are made during stroboscopic
examination of the larynx using a
laryngograph-triggered strobo
scope (Lx Strobe) then vocal fold
vibration can be studied at particu
lar pre-determined moments in the
vibratory cycle. Figure 1 shows a
stroboscopic view of the voca I folds
in the middle of the open phase of
the vibratory cycle. The vertical line
on the laryngograph, Lx, waveform
below the photograph indicates the moment corresponding
to the view in the photograph. Controlled triggering of the
stroboscope enables any particular phase of the vibratory
cycle to be examined, providing a clearer indication of
pathology and the mucosal wave than is otherwise possible.
Speech) will give an unrepresentative picture of the voice in
question: measures of jitter (related to irregularity of vocal fold
vibration) will be spuriously low. Perceptions are multi-dimen
sional and attempts to produce simple, single figure values are
not realistic. The question of data acquisition and reduction is
a major one theoretically and practically: we need reliable mea
surements made on connected speech samples which are easy
to understand and which relate to what we can hear: pitch
range, average pitch, roughness and breathiness.
Although larynx activity - in terms of manner and rate of vocal
fold vibration - is typically the major diagnostic and therapeutic
focus in the clinic, loudness and vocal tract features of nasality
and frication also contribute to our perception and appraisal of
a voice; they too can be measured and their patterning pre
sented graphically. Different clinical problems need different
quantitative and therapeutic approaches, and we now outline
some perceptually based measures of voice production. The
how I
Figure 2 shows a fundamental frequency histogram based on
two minutes' reading for a female speaker with unilateral
paralysis. The 'pitch' range is excessively wide, with two clear
modal peaks, corresponding to the listener's auditory impression
of roughness. Within this display is a second order histogram
showing the very small parts of the two minute sample which
have some regularity. The visually much smaller pattern is an
indication of the gross irregularity of the voice since only larynx
periods that fall within the same statistical bin are used.
Values for the range, mean, mode, median, standard deviation
and regularity are all also available from the analysis program.
A case of unilateral paralysis with further figures and mea
surements is described in Carlson and Miller, 1998.
LX Speech Studio displays are useful for immediate visual
feedback - as, indeed, is Lx on a simple oscilloscope, to give
an interactive indication of vocal roughness. The Lx wave
form offers immediate feedback of changes in laryngeal
aerodynamics during voice exercises and as changes occur
with improvement in vocal control with voice therapy. Lx
reflects improvement in the extent, duration and stability of
vocal fold contact patterns. It a very useful adjunct in voice
therapy to illustrate achievement of the correct balance
between laryngeal resistance and airflow with better phona
tory support. It is particularly helpful in treatment of patients
with puberphonia (Carlson, 1995), muscle tension dysphonia
and vocal fold paralysis (Carlson and Miller, 1998). Visual
-eedback of funda mental frequency ("pitch") contours can
also be helpful for clients with laryngeal or hearing problems.
The whole range of Lx Speech Studio patterns and measure
ments is described in Abberton et ai, 1998.
References
Abberton, E., Hu, X. and Fourcin, A. (1998) Real-time speech
pattern displays for interactive therapy. International Journal
of Language and Communication Disorders 33,292-297.
Carlson, E.I. (1995) Electrolaryngography in the assessment
and treatment of incomplete mutation in adults. European
Journal of Disorders of Communication 30, 140-148.
Carlson, E. and Miller, D. (1998) Aspects of voice quality: dis
play, measurement and therapy. International Journal of
Language and Communication Disorders 33, 304-309.
Hirano, M. (1981) Clinical Examination of Voice. Springer.
Acknowledgment
We would like to thank Adrian Fourcin for help and advice.
Resources
o Lx Strobe (systems start from 15,000) and Lx Speech Studio
(including PC, 5500 - 6500; upgrades available for existing
users) from Laryngograph Ltd., 1 Foundry Mews, Tolmers Square,
London NWl 2PE. Tel : 01713877793. Fax: 01713832039,
e-mail: Ix@laryngograph.com, http://www.laryngograph.com.
o Information on Dr Speech from Tiger DRS inc, PO Box 75063,
Seattle, Washington WA98125, e-mail tiger-electronics@world
net.att.net, http://www.drspeech.comlts main package, Vocal
Assessment, is 565. There are also a range of products for
speech function, glottal inspection and nasality.
Practical points
1. Computer use should be based on sound theory and individual need.
2. software programmes must be motivating, rewarding, relevant and easy to use.
3. Computers should be seen as an additional therapy tool not a replacement for
the therapist.
4. Try before you buy - download from the internet or get demo disks, or visit a
technology exhibition.
S. Therapists should let manufacturers know what they need from software so
more appropriate programmes can be developed.
RESOURCES...RESOURCES...RESOURCES...RESOURCES...RESOURCES...RESOURCES...
RNIB
New guidance has been produced
for professionals involved with
newly diagnosed blind and partially
sighted children and their families.
Summary guidelines of good prac
tice Taking the Time: telling par
ents their child is blind or partially
sighted are available free and a
more detailed pack for 10.
Two children in every thousand in
the UK have aserious sight problem.
Royal National Institute for the Blind
Customer Services, tel. 0345 023153.
NVQ
A new workbook for NVQ Levell
has been designed specifically for
candidates ,with learning difficul
ties or some form of disability.
The City & Guilds initiative is
aimed at widening access to voca
tional education for those work
ing in Amenity Horticulture, of
whom around 20 per cent have
some form of disability and I or
learning difficulty.
Details: City &Guilds, tel. 0171 294 2468.
NAS
New leaflets from the National Autistic Society coincide with its 1999 cam
paign on diagnosis, 'Opening the Door' :
o Diagnosis: a brief guide for health professionals
o Important facts about autism and Asperger syndrome for GPs includes a
checklist to help GPs identify autism in toddlers at their 18 month screening.
o What next? Moving on from diagnosis is aimed at recently diagnosed adults.
It is estimated more than 520000 people in the UK are affected by autism.
Details: NAS, tel . 0207833 2299, http://www.oneworld.org/autism_uk!
SEN library
A London based special education library offers a loan and reference ser
vice by annual subscription.
The loan service is not available by post but a bi-monthly Current
Awareness Bulletin keeps local and long distance members up to date with
special needs developments.
Rates for individuals joining the Turner Library are Bulletin only, 14, Book
Loan 8, Both 17. The Bulletin is available to schools for 20 and libraries
for 28. The subscription year starts in September.
Details: The Turner Library, Whitefield Schools & Centre, Macdonald Road,
London E17 4AZ, tel. 0181 5318703, e-mail WHITEFIELD_edu@msn.com
Age Concern
Age Concern has published new resources to address the needs of the
growing number of elderly ethic minority people in Britain.
Age and race: double discrimination (5) and Developing services with and
for minority ethnic older people (2.50, both inc. p&p) by mail order from
Age Concern, tel. 0181 765 7203.
Symbols 1
SIGNA LONG has collaborated with
Widgit Software to provide symbol
matches for several of its resources
including the Phase 1 (Nouns) Picture
Resource and Very Important People.
Details: SIGNALONG, tel. 01634 819915.
Symbols 2
Picture Communication Symbols are
now available as an option on new
DynaVox and DynaMyte speech
devices. They can also be added to a
number of older units already in use.
Details: Sunrise Medical. tel. 01384
446789.
ADA
Action for Dysphasic Adults has pro
duced a resource pack for speech and
language therapy departments. A
full set of ADA booklets plus books,
factsheets, posters, lecture tr ansaipts
and cassette tapes are included i a
briefcase, with a 20 per cen saving
on the cost of the indi idual items.
ADA Library Pack, 52 inc. p&p from
ADA, 1 Royal Street, London SE1 7LL

_ , computers In therapy-*
Computers in therapy:
a BElTer Idea?
Avril Nicoll checks out some of the resources on show at the BETT '99 exhibition at Olympia.
BEn is an annual educa
tional technology show
where visitors can view
and try out computer
resources, including those
developed for pupils with
special needs.
Options for using comput
ers in speech and lan
guage therapy have
increased greatly over the
past couple of years.
Although our specific mar
ket is small, the increasing
flexibility of computer
software means it can
often be easily customised
for an individual . So,
material developed to aid
the dyslexic college stu
dent may well be appro
priate for an elderly per
son with dysphasia, soft
ware which can use pho
tographs rather than
drawings is acceptable to
all and what were origi
nally developed as com
munication aids can be
used as therapy tools.
As catalogues and 'demo'
CDs will give you more
idea about whether a pro
gramme will meet your
needs, and most compa
nies offer 30 day free tri
als, 'details are included:
let companies know you
are following up an article
in Speech & Language
Therapy in Practice.
Information on BEn is at
http://www.education
net.co.uk
Immediate feedback
The BEn 99 special needs award went to Crick software for
Clicker 3. For those of you who saw the potential of the pre
vious Clickers but struggled to master the set up, this latest
version appears very easy and speedy to customise. It is basi
cally a word processing tool, with the pupil able to choose
the words from a grid which can have written words and / or
pictures and / or symbols. Within the grid, which can contain
many words or as few as one, the size of the cells can be var
ied, as can the colour, so a speech and language therapist
could indicate groups of words such as prepositions for a
client by arranging them in small cells and / or colour coding
them. Groups of words could also be arranged in a certain
order - ego subject, verb, object - across the bottom of the
screen and used to work on a dysphasic adult's sentence con
struction. As Clicker 3 has sound and also a picture-as-you
type feature, clients can get immediate feedback about
whether they have written what they meant to write. Clicker
3 will be reviewed in a later issue.
Repetitive and consistent
The single user price is
Laureate (not to be confused with BT's
from 80.
Laureate) was exhibiting for the first
www.cricksoft.com
t ime in the UK. This Amer ican compa
Crick Software Ltd, 1
ny has been working on software
The Avenue, Spinney
development in special needs for 15
Hill, Northampton
years. The philosophy is one of training by repeated and
NN3 6BA, tel. 01604
graded exposure, and Laureate's Dr Mary Sweig Wilson, co
671691.
founder and speech-language pathologist, believes a com
Symbol literacy
Widgit's Writing with Symbols 2000 is a word processing and
symbol processing programme. Symbols support literacy
development and can act as an alternative ('symbol literacy')
when text would be unrealistic as a goal, but may also pro
vide a hook for our clients struggling with spoken language.
As with other software described, pictures, written words
and sound can all be selected. A range of symbol types is
included so a client can progress from a very particular image
to one that is more abstract. Inclusive Writer is based on
Writing with Symbols 2000 but geared more for a main
stream primary classroom . Both products have a pictorial
spell checker, useful for working on homophones.
http://www.widgit.com
Catalogue from Widgit Software Ltd, 102 Radford
Road, Leamington Spa, CV31 1LF, tel. 01926 885303.
Word games
Therapists who like to make word games appropriate to indi
vidual clients might find computer programmes make this much
easier. The AVP catalogue lists products such as Crosswords,
Word Games and Wordsquare for Windows (p.35-36).
AVP Primary (ages 3 - 11) catalogue and a guide to
software for special needs from AVP, School Hill
Centre, Chepstow, Monmouthshire, NP6 5PH, tel.
01291 625439. www.avp.co.uk
Social communication
Mayer-Johnson, producers of PCS symbols and Boardmaker,
were displaying Speaking Dynamically ProT", a communica
tion aid which again can also be used flexibly as a therapy
tool as it takes symbols, photographs, pictures, text and sound.
Word prediction and verb tensing options are included. TALK
Boards, made for use with Speaking Dynamically ProT" , are
designed "to employ text-users' pre-stored conversational
material to support effective, free-flowing social conversa
tion" . Perhaps they could also be used as a motivating thera
py tool for adolescents with poor social communication skills?
Catalog from Mayer-Johnson Company, PO Box 1579,
Solana Beach, CA 92075-1579, USA,
e-mail Mayerj@aol.com. UK supplier Cambridge
_t.66J\ Adaptive Communication, tel. 01223
'Mid.HiM
puter programme has the edge on a classroom assistant as
it does not give unintentional clues or inconsistent feedback.
The software is accompanied by a book - Sequential Software
for Language Intervention and Development - detailing the
theory behind its development, and programmes include
nouns, verbs, categories and verb tenses. Verbs can be depict
ed more accurately on a computer screen than in a picture, as
the movement can be shown. All Laureate material is pre
programmed by the therapist or teacher for the number of
tasks and the level of difficulty and results can be printed out.
Spoken praise for correct answers such as "way to go!" may
not always be meaningful to a UK audience so the company is
making moves to have its software available in UK English.
Time will tell if it will meet with acceptance here.
www.LaureateLearning.com
Demo CDs and previews are available from
Laureate Learning Systems, Inc., 100 East Spring
Street, Winooski, Vermont 05404-1898.
IT in the primary school
The organisation MAPE (Micros and Primary Education) is a
national organisation whose main object ive is to encourage
the effective use of information technology across the pri
mary curriculum. It has charitable status and is open to indi
viduals and institutions for an annual subscription of 20.
Details: Mrs Y. Peers, MAPE, Technology Centre,
Newman College, Genners Lane, Bartley Green,
Birmingham B32 3NT, www.mape.org.uk
IMPORTANT NOTICE
Subscribers should contact the
publisher if they have not
received their magazine(s) within
two weeks of the publication
date. Tel: 01569 740348
Speech & Language Therapy in Practice is
published on the last Monday of February
(Spring), May(Summer), August (Autumn) and
November (Winter).
EVENTS
International conference
Dyslexia and m Itilingualism
British Dyslex ia Association
17-19 June 1999
University of Manchester Institute of Science and
Technology
Details tel. 0161 2004100,
e-mail janet.adnams@umist.ac.uk
'Play 2000'
Association for Child Psychology and Psychiatry I
Disabil ity Challenge
Bi rmingham NEC, 13-14 June, 2000
Will look at the importance of play in the healthy
development of children and adolescents.
Sem inars, stands and a charity village will cater
for professionals and the public.
Details from ACPp, tel. 0171 403 7458 I Disability
Challenge, tel. 01483579390.
AFASIC in-service training 1999
Various dates and venues (London, Birmingham,
York)
Include functional language, collaborative work
ing, semantic pragmatic disorder, the reluctant
speaker, emotional and behavioural problems,
professional partnerships and the AFASIC parents'
conference in November.
Details from Carol Lingwood, tel. 01273381009,
e-mail carol.afasic@lingwoods.demon.co.uk
Contributions to
Speech & Language Therapy in
Practice:
Contad the Editor for more information and I
or to discuss your plans.
Please note.
articles must be of practical use to clinicians
use case examples and list useful resources
length is generally around 2500 words
supply copy on disk if possible
keep statistical information and references
to a minimum
photographs and illustrations will be
returned
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So, tell all your friends the advantages of a personal subscription to Speech & Language Therapy in
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be a NEW SUbscriber to the magazine.

a. .
________ __ IL-________________________
coro_ (Winslow, various prices).
use of the little gems known as
Colorcards is only as limited as the imagi
nation! I have a variety of sets - Emotions,
Everyday Objects, Prepositions, Verbs,
What's Wrong and Social Situations
(sequences) and plan to extend the collec
tion. Although I steer away from the more
child-orientated ones, ' I find Colorcards
have innumerable uses: comprehension
and information carrying word work, nam
ing and descriptive tasks, categorisation. I
also 'mix and match' between sets for
semantic work or sentence building, for
example. They provide me with a versatile
means of, in particular, making language
work concrete and accessible for both high
and low \:eve I clients.
o 0'0 (Winslow, 39.95).
At the risk of soundjng cliched, I find a tape
. ecorder invaluable for baseline and moni
toring work, and thus as a tool for
i ng a client's -awareness....As much of my
work involves the treatment of soc ial skills
I frequently tape pro('edural and descrip
tive narrative and, m0st importantly, dis
course. For those clients with less expres
sive output and / or dysarthria it has all the
usual, obvious uses. Tighter joint working
with the other therapies is resulting in a
more regular use of video on admission
and discharge, but I find that audio record
ings remain a notable resource for devel
oping cl ients' insight.
n e - '4
Back in the dark ages of my first post, a stu
dent on placement with me drew a simpl i
fied mid-sagittal view of the head and
neck . Specifi cally, it labels the main articu
lators, the nasal and oral cavity and shows
the epiglottis and position of the larynx
and cricopharyngeus. It is therefore useful
for explanations of speech production and
swallowing. I use : opies galore in training
and information for new staff. A laminat
ed version is pinned to a cupboard in my
room with blu-tac, easily accessible for
explanations at any time.
Po-'
Sadly I have reached the age at which,
unless I write something down, it leaves my
brain, likely never to return. Post-it notes
are perfectly formed for this but I employ
them in a "traffic light" priority system!
Yes, red (well, orange or pink) are red-alert
jobs that must be done today or this week .
Yellow tasks have a bit more leeway wh i le
green ones represent more long-term pro
jects. Th is arrangement works well for me;
I have the-luxury of a room to myself and
these colourful reminders are strewn deco
ratively all over my noticeboard.
,.. arne (LOA, discontinued).
This consists of 42 picture cards and 38
word cards numbered 1 to 6 (to link with a
dice) on the reverse side according to what
they represent (feelings, situations, people,
objects, actions and animals) . . The cl ient
throws the dice and mimes "t he item. This
game can be modified toslJit seveial appli
cations and is reaJly us'eful for both group
and individualwQrk. Cognitive-communi
cation problems such as-initiation and turn
taking Can be addressed, as can gesture
and facial expression as well as verbal out
put. .The principles of this game can clearly
be 'applied to cards tailored much more to
individual clients, and it provides an informal
W<Jy of assessing and treating.
o r.
Severa l 'bibles' adorn the shelves. A solid
dictionary and a Gray's Anatomy constitute
the bread and butter tomes. Other publi
cations notable by their well-thumbed
appearances are:
Practical Approach to Saliva Control,
Johnson and Scott, (Psychological
Corporation, 1993, 29) - simplified infor
mation in an easy-to-read format .
Neurology for the Speech-Language
Pathologist, Love and Webb,
(Butterworths, 1986) there may well be an
updated version, but th is comprehensive
volume is very practical for extracting fid
dly bits of neurology.
Cognitive-communication Disorders fol
lowing Traumatic Brain Injury. Freund et ai,
(Communication Skill Builders, 1994,
40.50) - accessible on a number of levels
and packed with ideas .:md information.
The Wordsworth Dictionary of Idioms,
Wordsworth Reference, (Wand R
Chambers Ltd., 1982) - an implement extra
ordina ire or f igurative language work.
Phrases are listed by key word and the full
derivation of the rhrase is usually included.
Talkworks, British Teleom, (1997) - explains
and exemplifies everyday, commonsensical
communication skills.
Communicating 2 (Royal College of
Speech & Language Therapists, 1996) - need
I say more?
.. ).r c es
I return time and time aga in to:
'Reanimati ng the face and mouth' from
Starting Again, Patri cia Davies, (1994,
Springer-Verlag)
'The neglected face' from Steps to follow,
Patricia Davies, (1985, Springer-Verlag)
Uust badger the nearest neuro-physiother
apist for these two) .
An A4 booklet entitled 'Rehabilitation of
the Face and Oral Trc:ct' from the Facial
Oral Tract Therapy course run by Kay
Coombes (1995) also provides pra ctical
information for oro-facia l and swallowing
work from the 80bath school of thought,
useful in therapy and training sessions.
1:1. Speec or,u 0"9 age therapy "UP >0 t
As the only speech and language therapist
here, working on my own can be difficult
and I have to ensure I 'keep up'. I attend
the London / South East Head Injury Special
Interest Group two or three times a year
and make regular visits to colleagues at
nearby brain i njury centres. I am regularly
in touch with the Royal College's informa
tion department and when new clients
start or I have a query, a phone cal l to their
previous therapist is a must. Reading jour
nals and books is vital, although this most
ly occurs out of work time. These links
might sound minimal but I know many
therapists are in a similar position even
when they have more obvious networks.
'i Ii , "e cnglJng S s en
I use a variety of assessments but particu
larly the Measure of Cognitive-Linguistic
Abil ities (Winslow, 87.50) and the Mount
Wilja High Level Language Screening
Assessment (supplier unknown) . The MCLA
is a new acquisition and is user-friendly; it
examines receptive and expressive lan
guage, reading, writing and pragmatics
and includes an oral motor screen and a
carer questionnaire. I particularly like its
bias towards functional reading and spo
ken and written narrative. Although the
checklists are quite subjective, other results
can be compared with normative data.
Mount Wilja is like an old friend - it covers
in deta i l naming, verbal explanation, plan
ning, auditory memory and comprehen
sion, reading, writing and numeracy - and
thus provides specific direction for therapy.
o FUI c "In (bits store
Woebetide me if I don't have a stock of
functional read i ng materials availab le.
There are newspapers, magazines, a tele
phone directory, social signs, recipes,
instructions - used for written comprehen
sion / information find ing, memory work,
sequencing and description and as a pre
cursor to experience in commun ity and
'real life' settings. This then links up w ith
work by other departments such as
Independent Living Skills, Recreation,
Psychology and with educational and voca
tional tasks. I also try to keep a wide selec
tion of photos up to date, relating to he
cl ients and to Banstead Place (staff, areas
of the bu il ding, loca l haunts) . This bank of
' goodies' also facilitates clients' awareness
of how speech and language t herapy -
communication therapy - relates to ' he real
world.

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Speech &amp; Language Therapy in Practice, Summer 1999

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ISSN (online) 2045-6174 www.speechmag.

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Speech & Language Therapy in Practice, Summer 1999

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