Digital technology and aphasia: From teaching machines to Eva Park and beyond

I don’t think Audrey Holland, a most eminent aphasiologist, who published the first report (Holland & Matthews, 1970) of a computerized application for speech and language therapy, knew what a viral spread digital technology would become. A ‘teaching machine’ is what we now call a ‘computer programme’ or even an ‘app’! Back then, the words ‘Google’, ‘internet’, ‘digital technology’, ‘blog’ were either alien or didn’t exist. Now, they’re part of everyday conversations. More importantly, what they represent, is not just aspects of digital technology but everyday communication environments and communication media. The digital revolution is happening, evolving and challenging aphasia therapists, their clients and services to embrace it, almost willy-nilly.

Speech & Language Sciences were privileged to host this year’s Research Update Meeting of the British Aphasiology Society. This is an annual forum where research projects at any development stage (from ideas to finished or near-finished projects) are presented. This year’s theme was ‘Digital technology and aphasia’ and attracted an audience and researchers who were aphasia therapists and software engineers of human-computer interaction (HCI). The event took place in April and included 12 cutting-edge projects.

The morning session started off with Fiona Menger’s (PhD student in Speech & Language Sciences) presentation of the IDEA project (Inclusion in the Digital Economy for Aphasia). Laorag Hunter (NHS Tayside) described the inter-disciplinary work carried out in Dundee aiming to facilitate computer use in people with aphasia. This was followed by Abi Roper’s PhD project (City University) on computer-assisted gesture therapy for severe aphasia and Gennaro Imperatore’s (Strathclyde University) word-prediction work for a mobile AAC application.

In the afternoon session, Faustina Hwang (University of Reading) discussed the challenges of assessing computer skills in people with aphasia, while Rachel McCrindle (University of Reading) described several cutting edge applications that could be used to mitigate communication difficulties for people with aphasia. Laura McCain (Speech & Language Sciences) described Memo, a new software application used to assess and treat short-term memory difficulties for spoken language. And the firework of the day or big splash, at least for me, was Jane Marshall’s (City University) virtual communication game of Eva Park, a fictitious island, which enables people with aphasia to use language in a virtual environment, and, even have a splash in the ocean!

And, last but not least, the poster presentations. Zula Haigh (City University) explored the challenges of remote aphasia therapy. Lexi Johnson (dissertation student in Speech & Language Sciences) presented the results from a UK-wide survey of speech and language therapists about the technological challenges they face in their clinical practice. Becky Moss (City University) described a treatment study for reading and writing deficits for aphasia. Monika Winkler with Victoria Bedford (City University) talked about the potential power of blogs person-carer relation in aphasia.

This was the most inter-disciplinary array of projects I’ve ever come across in one forum. It highlighted the close collaboration between speech and language therapists, HCI specialists, people with aphasia and their carers. The projects also highlighted the new, and quickly evolving challenges that we have to embrace to make digital technology work for people with aphasia.

Christos Salis

Lecturer in Speech & Language Sciences

Speech & Language Therapist

 

Reference

 Holland, A. L. & Matthews, J. (1970). Application of teaching machine concepts to speech pathology and audiology. Language, Speech, and Hearing Services in Schools, 1, 2, p14

Listening, not testing, will improve children’s vocabulary

Every few months a story appears about the declining speech and language skills of children arriving in primary school. The epithet “the daily grunt” was invented by one newspaper to capture the lack of communication between parent and child, implying it caused poor communication skills and a lack of “school readiness”.

Now a new report by the UK school regulator Ofsted – its first on the early years – has called for children to start school at two years old, in part to help those from lower-income backgrounds who arrive at primary school with poor reading and speech.

While we may actively teach our children to read, oral language skills (the ability to learn words, form sentences and to communicate abstract ideas) is a defining human characteristic and, of these, it is vocabulary which is the pivotal skill. Children grow up acquiring these skills driven by, in Canadian telly-don Stephen Pinker’s words an “instinct” for language.

Recent evidence from twin studies suggests that language skills become increasingly heritable as the child moves through middle school, stressing the import role that the environment plays in the early years.

Yet there has been an abiding concern that some children are simply not speaking enough to access the national curriculum, the inference being that they are not being talked to enough. But how would we really know there was a problem?

When vocabulary develops

To start addressing this question we have to look at the whole population rather than focusing on the most extreme cases. Fortunately the UK’s Millennium Cohort Study allows us to do just this. The graph below compares the vocabulary skills of thousands of five year olds, across five different social groups, measured by what is known as the index of multiple deprivation.

 

The vocabulary of five-year-old children in England. Save the Children
Click to enlarge

The graph tells us two things. First, vocabulary skills do differ markedly from one social group to another. Children from more disadvantaged groups recognise and name fewer pictures than those from higher groups. Second, and perhaps more importantly, there are lots of children in each group who have difficulties learning vocabulary. Unfortunately, we can’t say whether this pattern has changed over the decades without repeating the same assessment on different cohorts of children across time.

But how important is vocabulary at school entry? Parents often say that if they ask their GP whether they should be worried about how much their child is talking they are told that he or she will “grow out of it”.

In another study we followed 18,000 children born in 1970 until they were in their early thirties. Rather to our surprise we found that children with restricted vocabulary at five years old were more likely to be poor readers as adults, have more mental health problems and have lower employment rates.

This does not mean that everyone who had poor vocabulary aged five had difficulties later on, just that their risk was higher. There were all sorts of variables that contributed to this prediction but social factors were always in the mix. What is more, there is plenty of data to suggest that the difference between children from higher and lower social groups widens over time.

Creating the right environment

It is tempting to jump to conclusions and say poor speech in young children is simply a matter of parents not talking to their children in a way that encourages language. This is the position taken in the often-quoted 1995 book by Hart and Risley in which they studied 42 children. Their solution is essentially paternalistic – intensive daycare from very early on for the most disadvantaged groups.

A more positive approach is to support both children and parents through awareness, careful observation and the fostering of these early language skills – both in terms of expression and comprehension – from birth. This creates the right environment for language learning rather than simply providing instruction.

Sure Start and Children’s Centres in the UK have played a critical role in doing this. And there will be more opportunities for schools as the pupil premium in the UK – extra money schools get for disadvantaged children – starts to be paid in early years settings. It is important that this type of work should begin long before children reach compulsory schooling.

Clearly children who do not communicate well are vulnerable for all sorts of reasons. There are risks associated with relatively weak early oral language skills but children are immensely resilient and there are many things that can be done to promote these early skills.

But we need to be careful that our expectations are not driven by the pressure to formalise the child’s educational experience. We know that early years settings and primary schools are immensely variable as to how well they support communication. The solution is less about structure than following relatively simple guidance and improving the interaction in class.

It is certainly not about doing more testing – something the government is determined to introduce for younger children. If we demand conformity from young children, immaturities can be seen as “problems” – as with behaviour so as with oral language.

Oral language skills are important in their own right but also because they are critical precursors to inclusion in school and elsewhere. We know that children are active learners. This is not just about the instruction they receive but the environment they are in at home and in school. This means encouraging oral language skills in young children is everyone’s job.

James Law

Why do we test children on sentences they almost never hear?

If I were to design a comprehension test for children containing sentences such as “Which firewall did the hacker infiltrate?” or “which entrecote did the sous-chef drizzle?” you would probably think I was crazy. The problem with these sentences is that they use rare terminology (from computing and cooking) which young children are unlikely to have heard. It’s obviously crazy to use sentences like this. It’s a good thing that standardised tests contain nice normal garden-variety sentences.

Think again.

Assessments such as the Test of Reception of Grammar (TROG) contain sentences such as “The sheep that the girl looks at is running.” This describes a fairly common situation using simple vocabulary, so what’s wrong with it? The problem is that this sentence is probably just as rare as “Which firewall did the hacker infiltrate?” The issue is the Noun Phrase (the girl). This comes inside a relative clause (that the girl looks at). Relative clauses almost always contain pronouns (e.g. she) because one of their basic functions is to refer back to previously stated information. If you don’t believe me, just read Fox and Thompson (1990).

There is evidence to suggest that the input frequency of particular types of sentences greatly affects children’s ability to process them. For example, Kidd et al. (2007) found that just by changing “the girl” to “she”, a pattern far more frequent in the input, sentences like the above become a lot easier to understand. Another good example of this is questions. Novogrodsky and Friedmann (2011) report that children with Specific Language Impairment find questions such as “which cat was the dog chasing?” particularly difficult to understand. They attribute this finding to a grammatical principle called Relativised Minimality. However, an alternative explanation is that this type of question is extremely rare in the input. In fact, according to my count, only 0.4% of object questions contain both a question phrase such as “which cat”, and a full Noun Phrase such as “the dog.” The exact reason for this low frequency is open to debate, but it does appear that there is a very strong connection between input frequency and how well we understand a sentence.

Is this a problem? Perhaps not. And I would never question the reliability of an assessment such as the TROG which has been carefully designed and rigorously standardised. But if we’re presenting sentences which children almost never hear, then it does beg the question “what exactly are we testing?” Answers on a postcard please.

Fox, B. A., & Thompson, S. A. (1990). A discourse explanation of the grammar of relative clauses in English conversation. Language, 297–316.

Friedmann, N., & Novogrodsky, R. (2011). Which questions are most difficult to understand?: The comprehension of Wh questions in three subtypes of SLI. Lingua, 121, 367 – 382.

Kidd, E., Brandt, S., Lieven, E., & Tomasello, M. (2007). Object relatives made easy: A cross-linguistic comparison of the constraints influencing young children’s processing of relative clauses. Language and Cognitive Processes, 22(6), 860 – 897.

Nick Riches

The biggest shake-up in special needs provision for a generation

As the Children and Families Bill winds its way through parliament its time to take stock and think about what it might mean for children and young people with Special Educational Needs and those that work with them. The changes are likely to be as important as those that follow the Warnock report and introduced the Statement of Special Education need thirty years ago.  I have been talking with Mark Hope Policy Officer from the Royal College of Speech and Language Therapists who has been fighting to make sure that the necessary amendments are being put in place.

First the good news..

As usual there is good news and bad news. Its  good news for children who will get an education, health and care (EHC) plans (which will replace statements of special educational needs in the new system) and who require speech and language therapy. The bad news is for those who will not have EHC plans but for whom schools need to be able to obtain speech and language therapy and other external support services.

Speech and language therapy as special educational provision

After much lobbying a government amendment, heavily influenced by the  legal advice of RCSLT and other organisation has been agreed by the House of Lords has been included in the bill to maintain the current approach to classifying speech and language therapy as special educational provision. The main concern here was that such provision could be reclassified as health provision. This would mean that the health service could simply refuse to fund it on grounds of cost and, worse, parents would not have the right to go to tribunal to contest what their child was being offered. The test for whether speech and language therapy is to be treated as special educational provision rather than health care provision will be simply whether it “educates or trains” the child or young person. Crucially, RCSLT obtained a statement from the government spokesperson which could potentially be referred to in court to help ensure that the new wording is construed to mean a continuation of the current approach: “In our view, a local authority and, where relevant, a tribunal, in considering whether healthcare provision or social care provision was to be treated as special educational provision, would ask themselves whether it was educational, taking the approach set out in the current SEN code of practice in respect of speech and language therapy.”

But no EHC..?

Now for the bad news. RCSLT did not manage to strengthen the new duty of local authorities and their health partners to make joint commissioning arrangements. This is particularly bad news for the children and young people with SEN who will not have EHC plans. This includes many children who currently would have a statement of educational need but more worryingly includes all those on school action and school action plus categories will disappear.  There is a danger that schools could increasingly be left on their own to secure the speech and language therapy and other external support services that are needed by many of these children and young people.

And a bit more bad news ..joint commissioning

For years educational and health services have wrestled over who should fund provision for children with SLCN leading to what sometimes led to “border disputes” to some frankly ludicrous arrangements. In the new act the duty requires local authorities and their health partners to make arrangements for agreeing what provision is “reasonably required” but, crucially, does not require them to make arrangements for actually securing it (though there is a duty to make arrangements for securing the provision in EHC plans). The proposed RCSLT amendments strengthening the joint commissioning duty were not ultimately successful but were debated in the Lords and were supported by the opposition front bench. If you are interested have a look at RCSLT legal advice on the Children and Families Bill: http://tinyurl.com/qbou8va . They were also supported by a very wide range of other organisations including the National Association of Headteachers, the Royal College of Paediatrics and Child Health, the British Association for Community Child Health, Nasen and the Royal College of Nursing.

So where does this leave us?

The need for local authorities and their health partners to be required to make arrangements for securing provision for children and young people without EHC plans will not go away. Parents will not stand by if they think that they are not being dealt with fairly and head teachers will have to act according but it would be helpful to have clearer guidance to avoid the nightmares that many parents have had to go through to date fighting for the needs of their child. A freedom of information request in a few months’ time could well reveal a postcode lottery in terms of joint commissioning arrangements at local level. RCSLT remains ideally placed to lead on this issue, given that many of their members are health service employees delivering educational provision, and the support college and other organisations have obtained from parliamentarians and from other organisations provides an excellent basis for continued lobbying in the run-up to the general election.

James Law

Oral language: a matter of social justice?

A recent call to be a witness on an enquiry being carried out by the  Centre for Social Justice [CSJ] (13.11.13) on the significance of early oral language development led me to reflect on what exactly social justice had to do with communication.

But first a few words on social justice itself. The term ‘social justice’ implies fairness and mutual obligation in society: that we are responsible for one another, and that we should ensure that all have equal chances to succeed in life. In societies where life chances are not distributed equally (such as the UK), this implies redistribution of opportunities, although the shape that such redistribution should take remains contested http://www.thersa.org/action-research-centre/

In view of this it is slightly strange that the CSJ was set up by MP Ian Duncan Smith (IDS) erstwhile leader of the Conservative party. The CSJ appears to have its roots in IDS’ reflections about poverty and society after a visit to Easterhouse, a large Glasgow housing estate but the CSJ became a right leaning think tank trying to think creatively about how to address society’s social ills. A number of reports followed, often written in collaboration with labour MP Graham Allen. One of the features of their analyses was a focus on the relationship between poverty and it’s effect not only on the family but more specifically on child development, interestingly at a time when similar conclusions were being drawn by Labour’s Frank Field and health inequalities guru David Marmot. IDS’ conclusions led him to question the perverse incentives of the current benefit system and to propose the universal benefit which is being piloted in various areas in England and has been the topic of much debate in recent months. Explicit in the CSJ reports was that the implications of poverty in a family, hard enough for those concerned, was grossly unfair to the child. The child was being made to pay for the sins of the parent, as it were. While others have been content to describe the cycle of disadvantage, IDS and the CSJ sought change and framed the argument as a matter of justice rather than blaming indigent, work shy parents or teenage mothers ..etc. etc. common enough narratives in current modern political discourse. The CSJ carries out enquiries (CSJ 2013,2014) and has become very interested in child development in general, and child language in particular, as a marker of inequality – hence my reason for giving evidence to the enquiry.

Language development and the way that we regard it is one of those phenomena that tells us something about the way we see children and perhaps less directly how we see society and human as a species. Its importance has been accentuated over the last century or so during which employment (one index of social attainment) has changed substantially in post industrial societies (Ruben 2000). This, in turn, raises questions about why we identify children with language difficulties. It is true that parents or teachers may raise concerns but there are lots of things that we could identify but we don’t ask society to pay for.  The important issue is whether these difficulties are likely to have long term consequences and whether these can be ameliorated. It is fairly clear that the odds of long term negative outcomes are certainly raised, even if this does not always play out at an individual level. Data suggest that school entry language delays, in conjunction with a variety of social factors, can have effects on literacy, mental health and employment, well into adulthood. As a result, oral language development has moved into the foreground to become not just an advantage but a prerequisite for success and, as such, has become a marker of social justice.

These are some suggestions to enhance social justice for this group of children.

1. Better understanding

  • We know lots about what we should recommend to support child development in the early years but this needs to be better disseminated;
  • Oral language difficulties may exist, on their own, but they rarely come without baggage. Behaviour and mental health difficulties often co-occur, exacerbating social inequalities because of the effect they have on adjustment in school and home. Again the mechanisms for this are not well understood;
  • We need to know more about the long term implications of poor early oral language, for example in terms of social mobility. Are there jobs that people with low language skills cannot do or even within white collar jobs are there jobs where there is a communication ceiling..beyond which promotion is impossible?

2. Better provision

  • Speech and language therapy is an important part of the mix and we need to ensure that services are not adversely affected under current economic stringencies. But speech and language therapists cannot “own” early language difficulties. There are simply too many children involved. It is critical that understanding of oral language is central to the training of teachers who all too often confuse oral language with literacy;
  • We need to be careful in assuming that early is always better WITHOUT good data to show this. It should not be a simple trade off – more early intervention means less support later on;
  • We need to consider the implications of oral language across the life course. There has been lots of emphasis on the early years but provision and support in secondary and further education and beyond is nugatory.

The CSJ will be bringing out another report in the middle of 2014, hopefully discussing the importance of early language and what can be done about it. The intention is that this will then feed into the development of the 2015 party manifestoes. Keep an eye out for oral language in the manifestoes as they start to emerge. And, for those at Newcastle University, don’t forget that the Newcastle Institute for Social Renewal has a competition going at the moment for ideas for the party manifestoes. Try lobbying your MP and let’s see if we can get oral language further up the policy agenda.

James Law

Centre for Social Justice (2013) REQUIRES IMPROVEMENT: The causes of educational failure London: Centre for Social Justice http://www.centreforsocialjustice.org.uk/UserStorage/pdf/Pdf%20reports/requires.pdf

Ruben, R. J. (2000), Redefining the Survival of the Fittest: Communication Disorders in the 21st Century. The Laryngoscope, 110: 241. doi: 10.1097/00005537-200002010-00010.

PhD? It could be you..

Most readers of this blog will have come across me as someone primarily involved in teaching on the pre-reg speech/language therapy courses. However in September 2013, I took on a new role – that of Director of Postgraduate Research (or PGR) for our whole School. This in essence involves looking after the PhD students in the School of ECLS and includes anything from selecting at the admission stage, welcoming new students, making sure that students are progressing satisfactorily, to negotiating with the University Estates service about workspace for students.

To say that this has been a steep learning curve is probably an under-estimate. Every day seems to bring some new issue or fact about PGR that I was not aware of before. ECLS is a very diverse school; in handbooks and at induction we do mention to everyone that there are two other sections besides SLS, i.e. Education and Applied Linguistics, but I am sure this is quickly forgotten as you start to think about linguistics and anatomy and clinics… For me this diversity has meant that not only have I been meeting international students from a whole range of countries, but I have also been trying to get my head around research that ranges from international education to second language teaching to conversational analysis and back to speech and language pathology again, with a few other things I’ve now forgotten about. Two things have stood out though. Firstly, there is a strong support system for PhD students within the university: this means that students get regular meetings with supervisors, that their progress is monitored and help in place when needed, and that their concerns are being listened to and addressed. As regards the latter, the introduction of a ‘Postgrad Research Experience Survey’, similar to the NSS is very recent, but is clearly having an effect. In the past students were very dependent on the resources and time their supervisors could provide and in many instances it was ‘sink or swim’. In my own case, I had an excellent but very eminent supervisor who early on I found frankly scary, so I relied a lot on fellow PhD students for advice in the first year or so. Things would be easier if I was starting out now!

The second thing I have realised is that we do not have many PhD students in Speech and Language Sciences and those we do have are fairly well on with their projects. At the same time we have a clear need for research to develop the SLT evidence base, and also there are funding opportunities out there for those who want to do a PhD. So, anyone who is currently enjoying their dissertation work, or is looking forward to doing it, and who likes exploring complex ideas, this may be for you.

So what is this PhD thing and why would you want to devote a minimum of 3-4 years of your life to doing one? It involves working on a project which you design and carry out yourself; you would have two supervisors, minimally one who is an expert in the area you choose, and one who has a good amount of experience in supervision. While you would need to heed advice from your supervisor, working on a PhD means you have an amazing amount of autonomy to work on something that interests you. You would be provided with research training by the Graduate School and have opportunities to get to know a wide variety of other research students and to discuss your work with them. Many lifelong friendships are forged while doing a PhD! At the same time though, you have to be prepared to work alone at your project and motivate yourself when you hit a tough patch. Why would you do it? Well, if you have a PhD this serves as an immediate indication that you are able to design and conduct research in your chosen area. The way is open to working on further projects, possibly within the NHS, and/or for embarking on an academic career.

You may well be wondering by now why I’m suggesting embarking on more study when most readers of this will be committed to (or seriously thinking about) a clinical career as an SLT. There is a lot to be said for combining the two though. You can do a PhD part-time while working clinically, or you can choose to apply for funding for a PhD after you have been qualified and working for some time – sometimes a good way to do it because after a few years working you are likely to have some burning research questions. Alternatively, if you embark on full-time PhD work immediately post degree, we will ensure you have opportunities to gain further clinical experience in house and get those competencies signed off.

So if you think you might be tempted by this, get in touch with me. You will need to have a good first degree (i.e. 2.i or above), or if you’ve done an MSc, at least Merit standard. Don’t worry if you think that this sounds interesting but you haven’t got the faintest idea for a project; once you have indicated the broad areas you might be interested in, we can get you in touch with a potential supervisor who can help you develop a proposal. Also don’t worry if you are some way off from finishing your degree: the earlier you start thinking about this the better.

Meanwhile I am actively exploring sources of funding that speech & language sciences students can tap in to. Watch this space..

Carolyn Letts

 

 

There’s an app for that?

I have recently come back from the madness that is the 2013 ASHA (American Speech-Hearing Association) Convention which was held in Chicago this year. Those of you who have attended previous ASHA meetings may not be so surprised by the following account, but for the uninitiated like me there was so much to take in, and some interesting snippets to share. The most remarkable aspect is the size of the meeting, which is massive! 12000 delegates, an average of 40 parallel sessions, and a convention centre the size of a small town. Going through the programme of talks and activities was in itself a big job, made easier by a conference app – the first I’ve come across in my conferencing experience – which your life depended on throughout the conference. If you’d done your homework and gone through the programme to tick sessions of interest, the app then pulled together a personalised programme for you which had a diary of what you were attending each day, with each chosen presentation showing easy links to the abstract, venue (with a map) and everything else you needed to get to it (or at least try to) on time. If, on the other hand, you had chosen two consecutive talks taking place at opposite ends of the huge building then you only had yourself to blame.

The exhibition hall had over 150 exhibitors and, in keeping with the theme of apps, between them they had apps for everything. Literally. Whether it’s assessment, diagnosis, or treatment, there was an app for it. Phonological disorders? They’ve got it covered; Literacy? Just ask. Aphasia therapy? You’ve come to the right place. I have honestly never come across such a vast market of SLT-related apps and I can only hope that some are really as useful as the companies selling them claim they are. And given that the exhibition hall is also meant to provide a bit of respite from the barrage of talks which were taking place from 8am till 8pm each day for 4 days, quite a few of the stalls offered the opportunity to try many of the Wii-style apps with funky music on, dancing, and a right big party all in the name of demonstrating physical exercises for most types of mobility treatment.

Behind the party though, and in stark contrast with the ‘sell sell sell’ drive of the exhibitors, the talks had very stringent rules, including a disclosure statement that all presenters had to make to declare whether they got any financial or non-financial benefit from any products they were about to mention in their talk (this not only included therapy products, but also publications, grants and anything else that the presenter was promoting). This is probably the organisers’ way of separating the science, which they know needs to remain clean and honest, from the ‘fringe’ aspect of the meeting, which provides them with the much needed funding for a conference of this size. And why shouldn’t they, when SLP in the US receives hardly any funding at all; they need to pull out all the stops to keep the profession alive, even if it means an opening ceremony delivered by Ben Cohen and Jerry Greenfield (founders of Ben & Jerry’s ice cream).

And that does seem to keep the science alive. The range of clinical and research presentations on offer included some excellent stuff, and there were two main highlights for me: The first was a special session on navigating the Twitter terrain for SLPs by Bronwyn Hemsley, Caroline Bowen, and Patricia McCabe, which dealt with social media and its potential benefit (as well as pitfalls) for SLT trainees and professionals (our own social media guru, Helen Stringer, would be proud…); the second was a series of talks and special sessions on working with children from diverse cultures, headed mostly by Sharynne Mcleod. These included anything from new knowledge on assessments in various languages to tips on empowering monolingual SLPs to work with multilingual children. The sheer number of sessions on this topic, including a session I was invited to present at on linguistic and cultural considerations for working with children of Arab, Persian, and Turkish descent, shows that this topic is high on the agenda for SLPs everywhere right now and should hopefully lead to more efforts in addressing the gap in multilingual and multicultural assessments.

The awards for this year included a fellowship to Ben Munson, who was our visiting research fellow in 2011 and to Stephanie Stokes, a former member of staff in SLS at Newcastle, for their services to the profession.

Ghada Khattab

A ‘classic revival’ of bilingualism and suspected speech and language disorders

In 1984 I published a book ‘Bilingualism and Language Disability’. This book has recently been reissued by Psychology Press in their Classic Revivals series http://www.guilfordpress.co.uk/books/details/9781848722408/. It’s strange to think of oneself as a classic revival, I might be expected to get up on stage and start singing Flanagan and Allen’s ‘Underneath the arches’ or Gertie Gitana’s smash hit ‘Old mill by the steam’! The Classic Revivals series consists of works from ‘some of the most influential scholars of the last 120 years’, of works which made a great impact at the time. It sounds flattering, but in today’s world a cynic might condense such statements down to that some publisher has noticed they have a stack of old manuscripts on their shelves and they’re not making any money there, what selling point could we find to persuade people to buy them again. Anyway, whatever you might think about the publishing industry, I thought it might be worth a few lines of reflection on how the book came about in the first place, and some other random thoughts vaguely in the same direction.

It all started when I was a student on placement with a rather overwhelming, loud clinician. The epithet of ancient tree-felling war weapon springs to mind (think Hyacinth Bucket, Keeping up Appearances, and then some). The therapist had arranged for me a morning of children with what were called speech problems (I don’t think phonology had been invented then, or not when she had trained anyway). The plan was that I would observe for the first child; by that time I would have learned all there is about how to treat speech disorders and so would be able to take the rest of the morning (checking notes beforehand to look at assessments and what previous therapy had been conducted? Preparation? Session plans? Totally unjustifiable and unnecessary – we’re talking here of the sink or swim approach to student training prevalent at the time).

In the opening session I was treated to a demonstration of a therapy method I hadn’t encountered previously, but which I suspected was not part of established speech/ phonology intervention, when she took the poor wee mite over her knee to give her a good hit on the bottom for not trying hard enough (see below for more on that…). I was allowed to show my skills (or not, given the stage in my training, and again, the fact that phonology had not been invented) with the next child, who was barely intelligible. After the session I remarked on how severely she was affected and that I hadn’t met anyone like that before. ‘Just you wait till you hear the next one!’ was the reply I received as she waltzed out into the waiting room, promptly reappearing with a rather reluctant, anxious looking wee child in tow.

We sat down at the table and Jan started to speak with liberal doses of retroflex affricates, palatal and velar fricatives, word initial sound combinations like /dv, /ʃr/, ʃtʃ/, various nasal vowels, a stress pattern rule which emphasized penultimate syllables in multisyllable words, and that just for starters. Mrs X nodded knowingly across the room at me, expressing a definite ‘see what did I tell you, could you ever get worse than that’ look. An expression not as priceless, though, as the one that crossed her scandalised face, when I too started babbling in this bizarre jargon, the one she had been trying to eradicate by foul means or fair for the last however many months. For Jan was speaking nothing more bizarre than perfectly well-formed, appropriate, fluent Polish.

I’ll omit the transcript of the post session discussion; you can imagine what it might have sounded like. The ancient tree-felling war weapon’s defence was that she had noticed on the referral that Jan had a foreign name but she had had been assured by the mum (who spoke barley any English) that they only ever spoke English at home and ipso facto this must most certainly be a developmental speech disorder. Observing the interaction between my supervisor and mum paralleled exactly the type of conversation that was had with the poor wee girl in the first session. She hadn’t taken the mum across her knee and commanded her to speak only English, but she battered her in every other way. Of course there is a further,  unnamed culprit in this chain of events, the person who referred Jan in the first place with an alleged speech problem.

When I got back to college I reported everything to the placement organiser, thinking that this would be the prelude to getting advice/assistance on taking up the matter with the therapist’s superior, if not going straight to the disciplinary board at the College of Speech Therapists. Not so. My concern about the bottom hitting incident was dismissed with the suggestion that I was creating a fuss over nothing, ‘a lot of people do that, I’m sure, it’s common’, ‘so long as she didn’t hurt the child’, ‘she’s a first rate therapist, you’re lucky to have a placement there’. The kerfuffle over Jan was brushed aside with the retort of ‘well, what should she have done, you can’t expect her to know every language can you? And she had checked with the mother that he was talking English’.

I was absolutely incensed at this. I let the staff member know what a bunch of irresponsible and ignorant iijits (I might have been a smidgen more diplomatic) I thought she and the rest of the staff were. This wasn’t such a shock for her. They were already used to me giving off in this manner (they provided plenty of opportunity for it) and so the dismissive end of the conversation was ‘well if you think it’s so important you can give us a lecture on it’. So, even though that’s not what the illocutionary force of the offer had been, that’s what I did.

I didn’t know a great deal on bottom smacking, but I reckoned I could assemble some facts and figures on bilingualism. And feeling this should not be just for the class of ‘77 I decided to write it up and submit to the British Journal of Disorders of Communication (the grandparent of the Int J Lang and Comm Dis) http://informahealthcare.com/doi/abs/10.3109/13682827809011322

After I graduated the incensedness persisted. I channelled it into getting the Health Authority I worked for to set up a policy on management of bilingual or non-English speaking clients, probably the first speech therapy service in the country to have one. I set up a special interest group (they weren’t called that then) for speech therapy and educational psychology clinicians working with bilingual clients. I gave various talks around the place emphasizing the message. Somehow word of all this must have spread because a while later I got an invitation from a publisher, Croom Helm in GB, who were paired up with College Hill in USA, to write a book about bilingualism and speech therapy. Which I accepted, and that’s how the book came about in the first place, thanks to Jan and a clinical ill-advisor.

By the time the invitation for the book arrived I was long since moved back to Ireland. The impetus for all the work where I was employed in England had been around the large influx of people from south Asia and east Africa at the time, from numerous countries and with numerous languages.  Bilingualism was a big issue in Ireland then too, but on a completely different stage. So my activity in bilingual directions was of a quite different nature for many years (though in work I was ostracised by a section of my colleagues for a while for having in the acknowledgements preface of the book signed off as having written it in Béal Feirste rather than Belfast, which gives a minor indication some of the attitudes to even indigenous languages that people wishing to use Irish were up against).

The book received rave reviews, so it must have been fulfilling some need; and it went to further printings, so folk must have been finding it useful. Certainly in the 1980s concern over management of bilingual clients in SLT took off as a topic of training and research. I can’t claim that the book was solely responsible for that. It was more likely the needs of the time pressuring SLTs into realising something had to be done, but then the book did provide the background and templates and methods and hypotheses to test out to advance the field from the point of view of practice and research. It was a long time before other works overtook it, and even some of today’s publications don’t move much beyond it in many aspects (I did spot the 1978 article mentioned in the 2007 RCSLT document of good practice for working with clients from linguistic minorities). The big area of advance compared to 1984 has been in our knowledge of bilingual language acquisition and usage, the development of some well validated testing materials and techniques and methods for working with bilingual children – and of course the awareness that all this is a vital part of the knowledge and practice base for SLTs.

In the late 1990s the RCSLT together with the SIG Bilingualism had prepared a document of good practice around training in bilingual issues in SLT. The model adopted was one where there weren’t specific courses on bilingualism. The aim was to have bilingualism integrated into, permeating the whole curriculum. So, when language or sound acquisition was tackled bilingual acquisition would be part of this. When models of word production were discussed this would cover the lexicon and output of bi- and multilingual speakers. Aphasia recovery would encompass patterns of recovery not just in monolingual speakers.

The SLT course in Newcastle was actually held up as a model example at the time that had these characteristics (and coincidentally did have dedicated specialist courses on bilingualism too). There were big (300-400 delegate) conferences on bilingualism organised from the department (the profits paid for a new photocopier on one occasion!). Myself and a great bilingual colleague at the time, Li Wei, launched the International Journal of Bilingualism http://ijb.sagepub.com/ which is still going strong.

How fragile things are though. Countless reorganisations and curriculum development ‘advances’ later and it is doubtful the same course would be held up as a beacon example. There certainly are pockets of excellent input on bilingualism and some top class dissertations have emerged around the topic.

The big hole that still seems to persist, at least in student training at Newcastle and many other SLT institutions in GB, concerns management of people with acquired communication disorders who are bilingual. The same applies to RCSLT guidelines which are heavily weighted to child cases. There are some services with model practice out there; there is ample research in the field to support practice; there are assessment materials – most notably the Bilingual Aphasia Test, which for all its imperfections has been a great stimulator to work and progress – take a look, you’ll find assessments in most languages you are likely to want to use: http://www.mcgill.ca/linguistics/research/bat/.

Communicating Quality 3 and other guidelines make it clear: ‘’With regard to assessment and differential diagnosis, bilinguals are vulnerable to misdiagnosis if linguistically and/or culturally inappropriate tools are used…An incomplete picture of their skills will emerge if only one language is assessed’ (p270). Still too often, despite this one can observe clients who have been assessed on only half or less of their languages, in English only, or the clinician has felt that asking the family about whether the person sounds disordered in their other language(s) and what is difficult or not for them suffices for an assessment. Too close to ancient tree-felling war weapon and Jan for my liking!

So, if you’re out there and that’s what you see – time to get incensed again!

Nicholas Miller

Statistics never lie

It’s good to count stuff. We can count how frequently someone makes a grammatical error. Or how many speech sounds they find difficult. Or how many times they point to the wrong picture in a comprehension test. Once we’ve done our sums we can get out or look-up table and find out if someone is language-typical or language-impaired. We can find out if an intervention programme is working. We can demonstrate that speech and language therapy works. There’s no need for messy subjective judgments. We can let the data do the speaking. We might even run a few statistical tests which will enable us to quantify our degree of certainty. And we can even count that certainty (using p-values).

There’s no escaping that Speech and Language Therapy needs to embrace quantitative methods. Yet at the same time we risk making the wrong conclusions if we cannot think “beyond” the numbers. One particular pitfall is understanding the difference between causation and correlation. People who live in large houses are more likely to vote Conservative, but this doesn’t mean that the size of one’s house actually determines one’s voting habits. Fortunately, SLT students with their advanced statistical training are able to spot such dodgy claims a mile off. And tear them apart with savage gusto.

But let’s not be too smug. There are plenty of research areas where vigorous debates thrive on the causation versus correlation dilemma. One example is the field of Verbal Working Memory (VWM). VWM tasks involve retaining and recalling linguistic items while simultaneously doing some kind of additional processing task. A classic example is “listening span” where you have to say if sentences are true (the processing task), and then recall the final words from the last few sentences (the recall task). Because performance on VWM is strongly associated with language skill (e.g. comprehension of complex sentences), many have argued that VWM determines language skill. But as every SLT student will know, correlation does not equal causation. An alternative, and I think, far more convincing explanation, is that performance on both language and VWM tasks are influenced by the same underlying factor, which is… err… language. Viewed from this perspective, the idea that VWM determines language skill simply vanishes in a puff of smoke.

To be fair, proponents of VWM accounts have countered these criticisms with some rather sophisticated methods (e.g. structural equation models). No one has yet struck a killer blow and the debate rages on. But stepping back one or two paces, there is a larger lesson to be learned. Running stats is just the starting point. The crucial thing is how we interpret the stats. At the end of the day, though we do lots of complex stuff with numbers, it’s all about the fine art of crafting a convincing and persuasive argument. And in that sense, perhaps we have more in common with the humanities than we’d like to think…

Nick Riches