Feeding difficulties in children with cerebral palsy: low-cost caregiver training in Dhaka, Bangladesh.

BACKGROUND: The majority of children with cerebral palsy have feeding difficulties, which, if not managed, result in stressful mealtimes, chronic malnutrition, respiratory disease, reduced quality of life for caregiver and child, and early death. In well-resourced countries, high- and low-cost medical interventions, ranging from gastrostomy tube feeding to caregiver training, are available. In resource-poor countries such as Bangladesh, the former is not viable and the latter is both scarce and its effectiveness not properly evaluated. The aim of this study was to evaluate the effectiveness of a low-cost, low-technology intervention to improve the feeding practices of carers of children with moderate-severe cerebral palsy and feeding difficulties in Bangladesh. METHODS: An opportunistic sample of 37 caregivers and their children aged 1-11 years were invited to a six-session training programme following an initial feeding assessment with brief advice. During home visits, pre- and post-measures of nutritional status, chest health and feeding-related stress were taken and feeding practices were observed. A control phase was evaluated for 20 of the participant pairs following initial assessment with advice, while awaiting full training. RESULTS: A minimum of four training sessions showed significant improvements in the children's respiratory health (P = 0.005), cooperation during mealtimes (P = 0.003) and overall mood (P < 0.001). Improvements in growth were inconsistent. Dramatic reductions were observed in caregiver stress (P < 0.001). A significant difference in the outcomes following advice only compared with advice plus training was also observed. CONCLUSIONS: In situations of poverty, compliance is restricted by lack of education, finances and time. Nonetheless, carers with minimal formal education, living in conditions of extreme poverty were able to change feeding practices after a short, low-cost training intervention, with highly positive consequences. The availability of affordable food supplementation for this population, however, requires urgent attention.

Children with phonological problems: a survey of clinical practice.

BACKGROUND: Children with phonological problems are a significant proportion of many therapists' caseloads. However, little is known about current clinical practice with these children or whether research on the effects of therapy have influenced this practice. AIMS: To investigate the methods of assessment and remediation used by therapists working in the UK. METHODS & PROCEDURES: A questionnaire was sent to therapists working with pre- and primary school-aged children. OUTCOMES & RESULTS: Ninety-eight clinicians of varying experience responded. Most used the South Tyneside Assessment of Phonology to assess children, were confident in choosing therapy, and were aware of evidence that therapy is beneficial. They used a variety of therapies. Auditory discrimination, minimal contrast therapy, and phonological awareness were popular and often used in combination. Most involved parents. In planning therapy, clinicians were more influenced by children's language and cognitive abilities and the motivation of parents than by the nature of the impairment. CONCLUSIONS: Constraints upon clinicians make it difficult for them to convert research findings to practice. In particular, assessments that allow more individualized and targeted interventions appear little used. Clinicians are aware of research but there is a danger that clinical practice and research are diverging.

Quality of life in multiple sclerosis: should clinicians trust proxy ratings?

PURPOSE: Measures of quality of life (QoL) are increasingly used to monitor psychological and social well being of clients with chronic illnesses. They are particularly useful in cases where an illness results in multiple disabilities. Where clients have difficulty completing the measure, others who know them may act as proxies. It is important, therefore to assess the accuracy of proxy scores. This study compared the QoL scores given by people with multiple sclerosis (PWMS) with proxy scores given by close relatives. METHOD: The Functional Assessment of Multiple Sclerosis (FAMS) quality of life instrument (Cella et al.) was used. Forty PWMS completed the measure in face-to-face interviews with a speech and language therapist. Close relatives were asked to independently complete the measure on behalf of these clients. RESULTS: The overall correlation between client and proxy scores was 0.62, which Sneeuw et al. suggest indicates good agreement. As in previous studies with other groups of clients, proxies underestimated the scores of PWMS. Despite these findings, the results showed substantial disagreements for individual clients and their proxies and a relationship was found which suggests that proxies underestimate the scores of clients with better QoL and overestimate those with poorer QoL scores. CONCLUSION: The level of agreement found between client and proxy scores and the tendency for proxies to underestimate clients' scores are consistent with research with other client groups. The overestimation by proxies of clients who rate their QoL as poor needs further investigation. If confirmed it may complicate the estimation of client scores from those of proxies. We conclude that while proxy scores may be useful as a means of estimating the QoL of groups of clients in research studies they should be used cautiously in the prediction of the QoL of individual clients at the clinical level.

Treating children with expressive phonological disorders: does phonological awareness therapy work in the clinic?

BACKGROUND: Recent research has shown that phonological awareness therapy can improve speech production in children with expressive phonological disorders. This approach may be appealing to clinicians as the therapy may also benefit the children's general phonological abilities and lead to gains in their literacy skills. AIMS: To examine the effectiveness of phonological awareness therapy under conditions more similar to those prevailing in many speech and language therapy clinics. Children were treated in small groups and less intensive therapy was offered than in previous studies. METHODS & PROCEDURES: Twenty children were randomly assigned to treated and untreated groups. A pre-/post-test design was used to monitor their progress in phonological awareness, literacy and speech production. Children were treated in groups of three. They received 12 hours of therapy. OUTCOMES & RESULTS: Comparisons of the groups showed that the treated group made significantly greater gains in phonological awareness. However, differences between the groups in the measures of literacy and speech production were smaller and non-significant. Considerable variation was detected in the response of individual children to the therapy. CONCLUSIONS: The results show the effectiveness of phonological awareness therapy in benefiting children's general phonological skills. However, the comparison of these and previous findings suggest that children may require more therapy than is often available if literacy and speech production are also to benefit. Further research is required to confirm the duration and intensity of therapy required. Until such information is available, clinicians might want to take a cautious approach and combine therapies that target phonological awareness with more traditional approaches, that target speech production more directly.

A lump in the throat: Should speech and language therapists treat globus pharyngeus?

PURPOSE: The causes of the feeling of a lump in the throat (globus pharyngeus) are disputed. The symptoms are persistent and may lead clients to change their diet and suffer a reduced quality of life. Coexisting swallowing difficulties are often reported but no neurological or structural abnormality can be found. Psychological factors are likely to play a part in the condition and an eclectic approach to therapy appears to be warranted. This paper reports on a treatment programme that includes education, reassurance and the use of exercises. METHOD: Fourteen clients participated. Their progress was assessed using the Glasgow and Edinburgh Throat Scale (GETS). A baseline period was used to assess the stability of their symptoms prior to therapy. This was followed by a group therapy session, use of the exercises and a further reassessment. Videofluoroscopy was conducted before and after therapy. RESULTS: Clients score on the GETS improved. However, change was seen both during the baseline and the treatment making it unclear which aspects of the treatment were effective. Improvement during the baseline suggests that clients benefit from attention and reassurance. It is unclear, therefore, whether the therapy session and the exercises provide a specific benefit or a general benefit due to continued attention. The clients' videofluoroscopies were unchanged after therapy. The presence of residue after the swallow in the valleculae and the pyriform sinuses may contribute to the symptoms of globus. CONCLUSION: The treatment is economical and appears to benefit clients. However, further research is needed to distinguish whether it has a specific effect or whether clients benefit from general attention and reassurance.

The cognitive competence of speakers with acquired dysarthria: judgements by doctors and speech and language therapists.

BACKGROUND: Studies have shown that listeners make negative attributions towards people with communication impairments. This appears to be the case for health care professionals as well as non-professional listeners. AIMS: This study extends this line of research to speakers with acquired dysarthria. These clients often complain that listeners treat them differently after the onset of their speech impairment. The study examines judgements of the cognitive status of speakers with acquired dysarthria made by health care professionals. METHODS AND PROCEDURES: Doctors, speech and language therapists and speech and language therapy students viewed videos of speakers with acquired dysarthria and of controls matched for age and gender who had acquired neurological deficits that did not affect their speech. Listeners judged whether speakers could carry out a number of everyday tasks. All the tasks were known to be within the speakers' competence. OUTCOMES AND RESULTS: Doctors were significantly less confident of the competence of speakers with dysarthria than of the controls. No difference was found for speech and language therapists or speech and language therapy students. CONCLUSIONS: Although caution is required in generalizing these results to other speakers, the results lend some support to the complaints of clients with acquired dysarthria that their speech leads others, in this case doctors, to misjudge their cognitive competence.

Teaching and learning speech and language therapy skills: the effectiveness of classroom as clinic in speech and language therapy student education.

BACKGROUND: Terms such as 'clinical intuition' have often been applied to the practice of speech and language therapy. Various authors have aimed to make the process of therapy practice more explicit, and it is argued that recently developed descriptive/analytic frameworks have the potential to engender the critical mindset necessary for student speech and language therapists to become good reflective practitioners, with the potential for enhancing clinical education. AIMS: To investigate whether and how aspects of clinical skills education could be usefully addressed in an academic, as opposed to a clinical, setting. The study aimed to address the question of whether use of an interaction analysis system, in conjunction with video observation, and 'practice simulation' in a teaching-learning programme could be shown to have a positive impact on: (1) students' perceptions of their own understanding and practice of therapy, and their perceptions of themselves as self-reflective practitioners; and whether (2) this was borne out by students' ability to observe and interpret therapeutic interaction, as measured by (i) an objective written assessment; (ii) an objective video observation assessment; and (iii) assessment of their abilities in clinical practice. METHODS & PROCEDURES: Thirty-six students from City University took part in an experimental, placebo-controlled study using a deferred intervention design. Assessments designed to reflect changes resulting from the teaching-learning curriculum were carried out pre- and post-intervention with experimental and control groups. Quantitative and qualitative results were obtained. OUTCOMES & RESULTS: The intervention programme was found to have had a significant impact on students' perceptions of their understanding of therapy, but not on their perceptions of their practice of therapy. The experimental group scored significantly better on a written assessment of 'interpretation of therapy interaction', but were no better than the control group on a 'Video observation' assessment. Owing to attrition and the poor quality of videos submitted for assessment, it was not possible to measure changes in actual clinical practice. Qualitative feedback from the teaching-learning programme suggests that students generally found the approach to be beneficial. CONCLUSIONS: While there were some encouraging results, it is still uncertain whether addressing the actual practice of therapy in an academic setting gives 'added value' to the work carried out on clinical placements. However, there is no doubt that bringing this type of programme under the umbrella of an academic institution would greatly increase the consistency of teaching and the range of experiences available to students.

When ottoman is easier than chair: an inverse frequency effect in jargon aphasia.

This paper presents evidence of an inverse frequency effect in jargon aphasia. The subject (JP) showed a pre-disposition for low frequency word production on a range of tasks, including picture naming, sentence completion and naming in categories. Her real word errors were also striking, in that these tended to be lower in frequency than the target. Reading data suggested that the inverse frequency effect was present only when production was semantically mediated. It was therefore hypothesised that the effect was at least partly due to the semantic characteristics of low frequency items. Some support for this was obtained from a comprehension task showing that JP's understanding of low frequency terms, which she often produced as errors, was superior to her understanding of high frequency terms. Possible explanations for these findings are considered.

Enhancing communication in jargon aphasia: a small group study of writing therapy.

People with jargon aphasia have severely disordered and incomprehensible speech that may be resistant to therapeutic intervention. In this study, we treated written output and examined whether it assisted communication for these clients. In stage one of the study, anagram sorting, delayed copying and lexical decision tasks were used to investigate the residual knowledge of written words in a group of ten people with jargon aphasia. Evidence of the presence of orthographic knowledge was taken as an indication that writing might be a useful focus for therapy. This hypothesis was explored in stage two with six clients. A personally useful vocabulary was selected for each, and copying, word completion and written picture-naming tasks were used in therapy to improve written production of these words. The clients made progress in written naming. However, they showed little change on a 'message' assessment that tested their ability to use the written words to convey messages. Stage three targeted communicative writing. Here, three of the clients received 'message therapy', which encouraged them to relate treated words to functional messages and to communicate them to a partner. The clients improved on the message assessment and observation of their communication and reports from relatives suggested that they made functional use of writing in a range of communication settings.

Pitch change in male-to-female transsexuals: has phonosurgery a role to play?

Male-to-female transsexuals, who have undergone gender reassignment surgery, may continue to have low pitched voices. Voice therapy may assist them to use their voice in a manner more likely to be perceived as female but, if this approach is unsuccessful, a laryngeal framework operation may be necessary to raise vocal pitch. This study assessed the effects of crico-thyroid approximation surgery in 14 transsexuals. Modal pitch was significantly increased by surgery but with substantial variation across speakers. Modal pitch was significantly correlated with judgements of gender by speech and language therapists who listened to tapes of the subjects. The results suggest that crico-thyroid approximation may be used to raise the pitch of voices of male-to-female transsexuals. Further research is needed to clarify the reasons for the variability in outcome, to monitor the longer-term changes in voice and the impact for clients of their modified voice in real life situations.

Verb retrieval and sentence production in aphasia.

This paper presents a subject with a selective verb retrieval deficit. Nouns were produced more successfully than verbs in spontaneous speech, picture naming and when naming to definition. The word class effect was not observed in comprehension tasks, reading aloud or writing. This indicated that it was due to a specific problem in accessing verbs' phonological representations from semantics. The second part of the paper explores the implications of the verb deficit for sentence production. Analyses of narrative speech revealed a typically agrammatic profile, with minimal verb argument structure and few function words and inflections. Two investigations suggested that the sentence deficit was at least partly contingent upon the verb deficit. In the first, the subject was asked to produce a sentence with the aid of a provided noun or verb. The noun cues were not effective in eliciting sentences, whereas verb cues were. The second investigation explored the effects of therapy aiming to improve verb retrieval. This therapy resulted in better verb retrieval and improved sentence production with those verbs. These findings suggest that an inability to access verbs' phonological representations can severely impair sentence formulation. Implications for models of sentence production are considered.

Why does monitoring fail in jargon aphasia? comprehension, judgment, and therapy evidence.

Many people with jargon aphasia seem unaware of their speech disorder. The first section of this paper reports data from four subjects which indicate that self-monitoring can fail even when subjects' input skills are apparently adequate to detect their errors. Explanations for this dissociation have attributed monitoring failure to a deficit in auditory feedback, or to a resource limitation which prevents concurrent speaking and monitoring. Section 2 reports a series of naming and judging experiments with one of the subjects which rule out these explanations. These show that the subject can detect his neologisms when he is repeating, but not when he is naming. These results suggest that his monitoring difficulties arise when he is accessing phonology from semantics. Section 3 presents a study which supports this inference, since it shows that semantically focused intervention yields improvements in self-monitoring. It is concluded (1) that monitoring failure can arise from deficits within the production process which preclude comparison of actual with intended output, and (2) that this deficit is best explained within a connectionist model in which monitoring is performed by feedback mechanisms in the word production process.

Phonological naming therapy in jargon aphasia: positive but paradoxical effects.

This article is a single-case investigation of phonological naming therapy. The individual involved had fluent jargon speech, with neologisms, verbal paraphasias, and paragrammatisms. The jargon was underpinned by a severe anomia. Content words were rarely accessed either in spontaneous speech or naming. Single word investigations highlighted some preserved skills. Auditory comprehension, at least for concrete words, was relatively intact and although nonwords could not be repeated, words could, and at a level which was far superior to naming. The patient also had some ability to respond to phonological cues. These results suggested that phonological representations were preserved and that there were some intact semantic abilities. It seemed that the naming disorder was primarily due to an inability to access phonology from semantics. Therapy took a phonological approach. The patient was encouraged to reflect upon the syllabic structure and first phoneme of pictured targets. Subsequently, she was required to use this partial phonological knowledge as a self-cue. It was hypothesized that this therapy might equip the subject with a self-cuing naming strategy. Posttherapy investigations of naming demonstrated dramatic improvements, which generalized to untreated items. However, there was little evidence that these were due to a self cuing strategy. Performance on phonological judgment and discrimination assessments, which required conscious phonological reflection, was unchanged, and there were no signs that the patient was self-cuing during naming. Reasons for these paradoxical results are discussed.

Written communication in undifferentiated jargon aphasia: a therapy study.

A subject, R.M.M., with a 2-year history of jargon aphasia is described. At the beginning of this study she had minimal meaningful spoken output and showed little awareness of her speech despite having relatively well-preserved auditory comprehension. Her spoken output had proved resistant to earlier periods of therapy. In contrast, R.M.M.'s written output showed some ability to access orthographic information and monitoring of this modality was shown by an acute awareness of her errors. A 3-stage therapy programme is described. This was designed to improve R.M.M.'s writing of single words and to encourage use of writing as an alternative means of communication. The initial stage of therapy aimed to increase R.M.M.'s access to written word forms by use of picture stimuli. She showed significant improvement in writing treated items in response to pictures both immediately after therapy and at re-assessment 6 weeks later. Despite the acquisition of these skills, R.M.M. failed to use them in communicative contexts. A second stage of therapy replicated the results of the first and sought to facilitate R.M.M.'s functional use of her written vocabulary by asking her to write words to spoken questions. She again showed improved written naming of the treated items and could now produce written names appropriately in a questionnaire-type assessment. Generalization of this ability extended to items that had not been trained in this way. Functional use of writing in everyday communication remained absent, however. The final stage of therapy made explicit the potential links between items which R.M.M. could now write and functional messages which they might convey. She again showed significant changes in the acquisition of new vocabulary and, encouragingly, progress was also seen in her use of the strategy in functional communication. R.M.M.'s speech is almost entirely incomprehensible. It has remained unchanged for 2 years and has not responded to therapy. Relatively well-preserved auditory comprehension and good monitoring of written output allowed therapy to effectively target a small written vocabulary. Despite significant progress in the acquisition of new items, transfer of this skill to functional communication was initially absent. Further therapy which specifically targeted the impairment causing this failure was needed before functional use was seen. The potential for treating written output in cases of jargon aphasia which have been resistant to therapy for spoken language is discussed.

When is it best to hear a verb? The effects of the timing and focus of verb models on children's learning of verbs.

This paper explores the effects of certain aspects of verb input on verb acquisition. It has been observed that the timing of a verb model affects children's learning of the verb (Tomasello & Kruger, 1992). It has also been observed that the focus of the event to which the verb refers affects the argument structure children assign to the verb (Pinker, 1989). This experiment investigated the interaction between the timing of verb models and the focus of the events to which they refer. Thirty children aged from 2;3 to 3;6 heard two novel verbs, one movement focused and the other result focused. Half heard the verbs before the event (impending condition) and half after it (completed condition). An interaction of verb timing and verb focus was found. The movement verb was learned better in the impending condition and the result verb in the completed condition. The contribution of this finding to our understanding of the processes involved in verb acquisition is considered.

Parent-child interaction therapy and dysfluency: a single-case study.

The hypothesis that the modification of parent-child interaction would reduce the dysfluency of a pre-school child was tested in an experimental single-case study. The subject, a four-year-old boy with a moderate to severe stutter, and his parents attended their local clinic for a total of 17 weeks. On each visit, 20-minute play periods with each parent were recorded and measures of fluency taken. No advice was offered in the first six weeks and these measures were used as a baseline for subsequent therapy. Therapy was given over the next six weeks. The parents were advised to make changes in their style of interaction and were asked to practise these at home each day. During the final five weeks, which served as consolidation, the parents continued to practise their skills at home but no new advice was offered. The analysis found no significant trend in the child's dysfluency during the baseline period, a significant improvement during therapy and stabilisation of the lower rate of dysfluencies during the maintenance period.

The difficulties of learning fingerspelling: an experimental investigation with hearing adult learners.

Fingerspelling is used to support sign languages, providing a means by which words without signs may be communicated. As with signing itself, it has often been reported that learners find greater difficulty reading fingerspelling than they do in encoding it. An experiment tested the skills of adult hearing learners of the two-handed fingerspelling system used in British Sign Language. Participants were asked to read video recordings of their own fingerspellings; thus each undertook the reading task at their own spelling speed. Participants were divided into fast and slow spellers. Each group made more errors in the reading than the spelling task and this continued to be the case when read items received a contextual cue to assist recognition. Words with regular and irregular spellings were used as a means to investigate the cognitive processes underlying fingerspelling. Regular words were spelled faster and read more accurately, suggesting that these processes place some reliance on phonological encoding. The implications of these results of the learning and practice of fingerspelling are discussed.

Speakers and listeners: some problems of generalising from a common speech pathology research design.

Experimental studies of speech and language behaviour often have difficulty measuring the phenomena that they seek to investigate. A common solution has been to collect data in the form of listeners' judgements of the speech of members of a clinical group of interest. If the speakers are taken to be a random sample of the clinical group and the listeners a random sample of those who they may communicate with, it is tempting to believe that results from such studies may be generalised to both other speakers and listeners, thus allowing a general statement about the communicative abilities of the clinical group to be made. Two related problems with this form of design are discussed. Both lead to the conclusion that greater caution is required in the interpretation of studies in which listeners' judgements of speakers are analysed. Potential solutions to the problem are offered.

No place for motor speech acts in the assessment of dysphagia? Intelligibility and swallowing difficulties in stroke and Parkinson's disease patients.

Speech and language therapists are increasingly being asked to treat dysphagic patients. Concern has been expressed and surveys have confirmed that radiological assessment procedures are rarely available. Consequently, patients must often be assessed and their treatment planned on the basis of bedside examinations. Despite evidence that swallowing disorders need not be related to problems of articulation, recommendations on the procedure of such examinations frequently include an evaluation of speech and non-speech articulatory movements. A study is reported of patients who exhibit both dysphagia and dysarthria as a result of either stroke or Parkinson's disease. Assessments of the intelligibility of their speech and of their swallowing problems were found to be unrelated. The implications of this finding for the assessment of dysphagia are discussed.

The effects of short courses in modifying the attitudes of adult and adolescent stutterers to communication.

Two studies examined attitude changes to communication by stutterers during short intensive courses. The Perceptions of Stuttering Inventory was used to monitor change. As the experimental hypothesis anticipated, change was most clearly seen in the avoidance items of the inventory. In both studies these showed significantly greater positive change than either the struggle or expectancy items. Moreover, positive changes were only found during the period of the course; no positive changes were found for any scales during the month prior to or after the course. The findings justified the use of short courses to change the attitudes of stutterers and suggested that they may be used in conjunction with other approaches which seek to influence fluency directly. An attempt to relate the changes in attitude to changes in speech over the short period of the course was unsuccessful.