No Voice (AAC) Challenge

On the week of the 6^th November 2017 Speech and Language Therapy students took part in a No Voice Challenge. For one day of the week they used a range of Alternative and Augmentative Communication aids instead of speaking with the aim of raising awareness of the importance of Speech and Language Therapy as part of the Giving Voice Campaign. The Regional Communication Aid Service kindly lent us high tech tablets with symbol programmes installed, e trans frames and communication charts. Other AAC approaches adopted included VOCA apps on our phones, symbol apps, signing, writing, alphabet boards and drawing.

Below are some comments from those who took part:

What AAC/ strategies did you use the most?

• Typing on a laptop/ phone was the easiest by far- hard to imagine how tough it must be for our clients who can’t type if they don’t have the language/literacy/ motor skills.
• Signing and gestures came naturally to me as I gesture a lot when I speak anyway. When gestures or signing failed, I tended to write. My hands were essential for my ‘voice’. I couldn’t reply anytime someone spoke to me when I had my hands full such as walking down a corridor.
• The E Trans frame was so difficult! It took such a long time to use. If it was my only means of communication I would say very little and be quite depressed.

 How did you feel?

• Really frustrated! I feel like that is a word we use a lot but it is TRUE!! Also felt rude when I couldn’t say excuse me/ thank you and people didn’t see me signing. Isolated from conversations.
• Makes you feel like not bothering because it is so much effort to get your message across.
• Sometimes I just gave up when communicating because it was so hard. I felt isolated, frustrated and self-conscious. By the end of the day I was emotionally and mentally drained. At 5pm I went home and accidentally fell asleep!
• When you have nothing and all your contributions are minutes after the original point was made in conversation- frustration builds.

How did others react to you?

• I got bad vibes from some people who I couldn’t say “excuse me” to. Speech therapy students were quite good at waiting for you to finish what you wanted to say but some non-SLTs really weren’t.
• I was appreciative of people adapting their communication for me e.g. being patient and waiting to respond via my VOCA app.
• I went to Subway with my order on a whiteboard and they thought I was crazy. They may my order though. It was so time pressured as there was a huge queue behind me.
• As there was nothing visible about not being able to speak people are surprised when they realise you’re not talking.

How did it impact your participation?

• Conversations often moved so quickly that by the time I had written what I wanted to say the conversation had already moved on. It was so hard trying to convey something complex in a limited time span. I couldn’t do it- I struggled.
• I couldn’t really contribute in class. A lecturer asked me for an answer and I couldn’t reply.
• People walked off when I was trying to communicate, I couldn’t get people’s attention without tapping them on the shoulder. It was very hard to participate in group conversations because the conversation would change before I could input. I didn’t realise how quickly people give up trying to have a conversation when you can’t talk back.
• Anything more than a basic yes/no or good/bad response required writing, gesturing, typing to using an app which takes much longer.
• People spoke to me less.
• I couldn’t sing in the shower and small things like that have a big impact!

How will this experience influence how you work with clients?

• When they say they’re tired I can understand why. Giving adequate time means more than you think. Communication difficulties would be a nightmare- lots of strategies were needed.
• I will give them loads of time to reply and not sit over them like I’m being inpatient. I understand why my non-verbal client didn’t want to use the iPad app- it was so frustrating.
• I will certainly make sure I am aware of my own body language, pitch etc.
• I think it’s help me grow in empathy and compassion towards them, experiencing in a really small way just something of how difficult it must be. I’ve grown in respect for how they keep going after understanding a little more of what a challenge having a communication difficulty must be.
• I can understand more deeply the importance of groups such as NETA where service users can meet others experiencing similar communication difficulties. For me, it really helped being around others who were taking part in the challenge and who could understand the difficulties.

We learnt a lot through the No Voice Challenge and would recommend it to anyone working with people with communication difficulties. It has helped us gain a small insight into what life is like for some of our service users. We’d like to thank everyone who sponsored us and helped us raise £532.13 (including Gift Aid at time of writing) for the Percy Hedley Foundation.

My name is Ana Matic and I am from Zagreb, Croatia. I have a Master’s in Speech and Language Pathology and I currently work in the Laboratory for Psycholinguistic Research at the Department of Speech and Language Pathology at the University of Zagreb. As my wonderful Professor Jelena Kuvac Kraljevic is passionately involved in this COST Action which includes over 30 countries across Europe and three international partner countries, she encouraged me to come and visit Professor James Law here at Newcastle University in order to share experiences and broaden my knowledge.

I must admit at first I was slightly worried about how I will represent our Laboratory and all the work we do. Words scientific and mission in the 4-word title of my visit did not help; you can probably imagine why. Nevertheless, my worries did not last long as I immediately fell in love with the University and all the academic staff which was more than welcoming and pleased to help in every way.

As this COST Action has an aim of enhancing the science in the field, improving the effectiveness of services for children with language impairment (LI) and developing a sustainable network of researchers, I was motivated to present the Croatian contribution on the matter. We all know that there are many services that are being delivered to children with LI out of which some do not meet the preferred criteria of being proven effective and cost-effective. Having that in mind, within the EU project Prerequisites for academic equality: early recognition of language disorders awarded to the Department of Speech and Language Pathology, University of Zagreb (head: Jelena Kuvac Kraljevic, PhD) we developed a Group and Indirect Language Therapy Programme aimed at fostering early literacy in preschool children with LI. It was a carefully designed programme based on the latest empirical findings in the area which involved two groups of four children and also their parents. The programme lasted for 30 sessions, each 45 minutes in duration and covered all the early literacy abilities that form a basis for later development of reading and writing. The programme was indirect in the sense that parents were also actively involved: they watched the group sessions through the one-way mirror, they were educated on the importance of early literacy and given advices on how to help fostering the targeted abilities in the home environment. The pre- and post- comparison of the children’s results achieved on tests measuring literacy and language, as well as the parental responses on the questionnaire given to them in order to gain insight on their thoughts on the therapy provided, led us to the assumption that this programme might indeed be effective. Of course, we should not rush and make final conclusions as there are some obvious disadvantages of the study (e.g., lack of the control group and a rather small cohort), but this is definitely something to be investigated further.

I have to say I am very thankful for being given the opportunity which does not happen that often – to present these findings to the lovely academic audience of Newcastle University. They all gave me stunning ideas and motivated me to explore this further. My one week experience here was informative and enlightening in every way and I will most certainly come back.

I want to seize this opportunity to thank my Professor Jelena Kuvac Kraljevic for always having brilliant and clear visions and pushing me forward, Professor James Law for welcoming me, giving me numerous useful advices and making me a part of the COST Action, and also Frances Hardcastle for so patiently answering all my questions and making this experience run incredibly smoothly.

Best to all,

Ana

I was recently doing some reading around to see how long people have been reporting on foreign accent syndrome (FAS) and related matters. I came across a case reported by Jonathan Osborne (1794-1864). He was a Dublin physician, professor of materia medica and surgical pioneer. He reported a case of speech after stroke in the Dublin Journal of Medical and Chemical Science, November 1833. The case was interesting from the point of view of my FAS searches, and wider studies in aphasia, but also had an added angle from the point of view of evidence based practice (EBP). We smugly sit here in 2016 thinking EBP is a recent ‘invention’, forgetting that we wouldn’t be where we are today if people in the past had not been practising it already. So, first a bit on Osborne’s case, then a little light on his therapy practices.

His description is of a 26 year old male, proficient in French, German, Italian, Latin and English and planning to take up medical training. A year prior to Osborne meeting him he had been staying up in the country. He was taking his breakfast after his usual morning swim in the local lake. During breakfast he suffered a stroke (the term then was apoplectic fit). A doctor was summoned. He was bled; and after being ‘subjected to the appropriate treatment’ became ‘restored to his intellects’ after about two weeks. Unfortunately he ‘had the mortification of finding himself deprived of the gift of speech’. He had no paralysis and spoke a variety of syllables fluently, with apparent ease. His speech though was incomprehensible.

To those unaware that he had suffered a stroke, it sounded as if he were talking in a foreign tongue. When he arrived back in Dublin his jargon caused him to be taken as a foreigner in the hotel where he signed in. When he went to Trinity College to visit his friend he was unable to convey whom he wanted to visit to the gatekeeper. He was only able to point to the flat where his friend had lived.

When he came under the care of Osborne he is reported to have been able to understand everything said to him. His written language comprehension was fine – he continued to read the newspaper daily and indicated correctly when tested on the content. His written output was fluent, ‘the words being orthographically correct, but sometimes not in their proper places’. He wrote correct answers to historical question and translated Latin sentences accurately and reported on medical tracts in French.

Arithmetic was accurate too and he could still play a good game of draughts. As Osborne had no knowledge of his pre-stroke musical abilities he was unable to test this in informed detail. The gent could nevertheless remember the tune of ‘God save the king’ (the whole of Ireland at the time was an English colony) and pointed to the ships on the river when played ‘Rule Britannia’.

Alas, despite all this, his spoken output was severely impaired, even though it appeared from efforts to self-correct that he knew his output was errorful. His repetition was confined to uttering certain monosyllables. A range of consonants in isolation were beyond him, even though on trying to utter one he would produce another he had not been able to speak a moment ago.

Osborne gave him some sentences to read aloud – not what today would be a standard aphasia passage – he used an excerpt from the Bylaws of the College of Physicians. Osborne transcribed what he heard — an early endeavour to phonetically transcribe disordered speech after stroke. His rendition of the sentence ‘It shall be in the power of the College to examine or not examine any Licentiate, previously to his admission to a Fellowship as they see fit’ was transcribed by Osborne as ‘And the be what in the tomother of the trothertodoo to majorum or that emidrate ein einkrastrai mestreit to ketra totombreidei to ra fromtreido asthat kekritest’. A repeat reading a few days afterwards elicited: ‘Be mather be in the kondreit of the compestret to samtreis amtreit entreido of deid daf drit des trest’.

Osborne speculated that a principal factor associated with the man’s jargon was his polyglot status – pointing out that several of the syllables here have a distinct German flavour. His speech output apparatus was unable to stably focus on one language, but ranged amongst them all.

This of course is a possible ingredient, but is unlikely to have been the prime factor. It is more likely that he presented either with what nowadays we might term apraxia of speech, conduction aphasia or phonological jargon. These do not require that someone speaks more than one language for them to arise. Certainly in the case in FAS the diagnostic marker is that the accent arises de novo and is not associated with another language which the person speaks, or has spoken. Osborne’s account of how this man was mistaken for a foreigner does, though, illustrate the power of the perceptual impression of the listener to read into a situation a dimension which is, in objective terms, not there.

C.S. Breathnach claimed in an article on the Irish Journal of Medical Science in 2011 that this was definitely conduction aphasia (principally focusing on the poor performance to repetition). Osborne does not offer sufficient detail to clinch a definitive diagnosis or differential diagnosis, so Breathnach’s conclusions are not that strongly supported.

The patient was given the interventions of the day for apoplectic seizures: repeated applications of leeches, a succession of blisters to the nape and occiput, mercurial purgatives and shower baths every morning. But to no avail. Based on his systematic, longitudinal investigation of what the man was, and was not able to accomplish by way of speech, Osborne was able to show that these interventions were unlikely to and did not affect the underlying speech problem.

Instead he prescribed actual speech therapy, basing it on revolutionary thinking for the time, that speech and language were separate processes, that the man did not have ‘loss of memories’ for words because he could not speak them (how could one speculate he had lost the memories of Latin words if he could correctly understand and translate them, Osborne argued). Accordingly therapy focused on actions and capability of ‘performing by means of his voluntary muscles’. He prescribed systematically built up drills (largely following the presumed order of acquisition in childhood) to re-establish basic movements for speech sounds, aiming to make them once more automatic, fluent, ‘with a rapidity almost equal to that of thought’. He also explained how his therapy focused on utterance initial recall and accuracy and what we might nowadays term using alternative routes to activation. He drew the analogy of a musician who cannot access a tune, but having been aided with the first notes his retained learning takes over. Thus his therapy aimed for the ‘faculty of setting the machinery of speech to the beginning of the sentence, trusting to the peculiar memory depending on associate objects for its continuance, and releasing him from the care of pronouncing the individual syllables of which it is composed’.

Given the later clearer transcriptions of the College regulation sentence in Osborne’s report, the therapy appeared to afford great strides forward. ‘It may be in the power of the College to evhavine or not, ariatin any Licentiate seviously to his amission to a spolowship, as they shall think fit’. No doubt cessation of the other treatments may have had a hand in progress too!

A fascinating case from many points of view – but made interesting by the level of detail Osborne was able to proffer on several levels. There is, for the age, a serious attempt to describe the strengths and weakness of the man’s impairments. There is the discussion of his therapeutic reasoning in why the purgatives and so forth would not affect language and a reasoned argument for his alternative methods (supported additionally with data from reports of cases from head injury in the battle of Waterloo). His advocacy of separation of speech and language, of circumscribed lesions associated with specific impairments anticipates by several decades the studies that today are celebrated as establishing these facts. It was a long time before writers reported data from their assessments and conducted longitudinal follow up. Finally, this may be a first report of systematic, explicit, theory based treatment for speech output problems after stroke.

Nick Miller

In winding up its endowment, the Northern Rock Foundation wanted to see a legacy of benefit to the North East. One of the objectives identified was improving literacy in primary and closing the attainment gap seen for disadvantaged children. For the North East, the big issue is the amount of disadvantage, with 39% of all children eligible for free school meals, much greater than the national average. So the attainment gap is depressing the life chances of a large swathe of the region’s children.

Asking the Education Endowment Foundation (EEF) to disburse £10M to improve literacy is a recognition of a shift in the landscape of education. A revolution is a misnomer for its connotations of turmoil when so many schools are enthusiastic, using their toolkit and participating in trials. The EEF synthesises and presents evidence about what works to improve education outcomes and also funds trials of new interventions which need testing to prove their effectiveness. They will be doing both in the North East, with the presentation of evidence being mediated by a network of “advocates” – people who help to introduce the best evidence based practice into schools.

On 9th February, one of two regional information events on the advocacy campaign was held at Newcastle University. Attending were representatives from Teaching School Alliances, universities, local charities such as Seven Stories, and national organisations such as Teach First and national literacy charities. Mr René Koglbauer, Acting Head of School of Education, Communication and Language Sciences was delighted that the school could host this information event as “it will bring new opportunities to the region. Through the EEF advocacy projects existing partnerships can be strengthened and new partnerships will be formed in order to maximise the impact of the funding available across the North East region!”

Advocacy for evidence of literacy interventions is not about telling individual schools and teachers what to do. Indeed the advocacy strand of this campaign is an acknowledgement that seeing evidence utilised in practice is more complex than producing it and advertising to the relevant people. There is not a list of magic bullets in education and what each school needs is responses which are effective for their children. And supporting decision making that is sensitive to context, empowering teachers rather than requiring compliance must be based on trust which is why the advocacy network is focused on existing collegial relations between schools and other partners in the region.

Of course, in funding advocacy for what works, the EEF has a mind to evaluating what works as advocacy, and they will be evaluating. They have already learned from another advocacy campaign in Yorkshire, promoting their guidance about the effective role of teaching assistants. Influence, passion and respect are prominent and a reflexive and developing understanding of the local context is implicit. But apart from appreciating the need to facilitate a cultural shift in engaging with evidence, it is not really clear how successful advocacy works.

The North East Campaign offers an opportunity to think more deeply and expansively about how advocacy works. Literacy is the core outcome at primary school, and the EEF have recognised this by planning guides to the evidence at three stages (early years, KS1 and KS2) rather than one overarching document: these guides or handbooks will be what will be used as the framework for the advocates. For older children writing will be much more significant but for younger children reading is the principal meaning of literacy. While phonics is established as instrumental in many interventions at KS1, the early years has more complex dependence on speech and language and even emotional development and executive function. Thus the three handbooks should offer an insight into the development of literacy skills in young children and a guide to how children fall behind and what practitioners can do about it.

The core outcome focus on educational attainment means that advocate will have to reach a greater diversity of actors within schools, at different levels of responsibility. The picture is complicated by early years provision (they mean ages 3-5) happening in various settings, only some of which are nurseries attached to schools. Individual teachers, literacy leads, governors, speech and language therapists and others will be involved, not just school leaders as may have been the case in the teaching assistants campaign. So there may be more opportunity to think creatively about reaching different groups at different levels and with different approaches to partnership and learning.

At the heart of this scheme is a challenge for the whole of the ‘what works’ agenda. Even when we know what works, it is not necessarily adopted, and we need to understand how this occurs. Teachers are professionals, and the context and progress of pupils can be hard to reconcile with evidence from trials in order to plan local intervention. However, even NICE has been criticised for preparing guidance which is too narrow and specialised for GPS to make use of it. Even getting research users from the same profession has not solved the problem of adoption, so perhaps advocacy offer a new hope.

Of course issues associated with evidence based practice are at the heart of the role of the speech and language therapist. Students study Research Methods in Practice, complete their dissertations in fourth year and go one to read about the best available evidence for an intervention before adopting it. We already have the What Works of Speech, Language and Communication Needs website with over 11,000 members world wide as well as other sources such as Speechbite in Australia and the ASHA website in the US. But in speech and language therapy decisions are usually made by individuals or by a relatively small number of people in a local service. It is true that SLTs may advocate for a specific approach but the EEF advocacy model is suggesting that not only schools but groups of schools perhaps in local authorities or in academy chains may adopt a specific intervention to promote reading and writing. What this means is that evidence and the way it should be interpreted should be at the forefront of discussions in schools across the region over the coming years and SLTs will be well placed to contribute to those discussions.

We don’t know what advocacy will look like in this campaign in the North East, partners have to apply currently, each committing to working with at least 50 schools. The idea being that all the region’s schools are reached in the five years of the campaign, with concentration on those in areas of high disadvantage. It may involve audit tools for school about their practice and engagement with evidence, and be deliberately reflective. The intention is that developing an evidence base will empower teachers rather than expecting them to comply with a ‘best practice’ model. It certainly is more about making the evidence fit the schools, rather than making the schools fit the evidence – a new kind of revolution. The premise of evidence of what works being used to enable better outcomes for things like literacy in primary is agreeable to all. But taking on the challenge of what works where: understanding the local context and the external validity of the evidence is going to another level. Watch this space – primary education in the North East has a great opportunity here.

More years ago than I like to think about, I was working as a fairly new lecturer at the University of Reading. Two visitors turned up one day at the department and asked to talk with us about our speech and language therapy courses; they both taught Logopedics at Lund University in Southern Sweden and were on an information-gathering trip with a view to changing and developing their course. I did not realise it at the time but that for me was the start to building a long-term network of academic- and practitioner colleagues across Europe. Not long after their visit there was an international conference on child language acquisition that took place in Lund, one spin-off from which was the formation of a small group of academics interested in specific language impairment: EUCLDIS (European Group for Child Language Disorder). This group met regularly every couple of years or so in a different European location, up until the mid 2000s.

A further personal spin off for me at the time was the opportunity to spend a term on sabbatical in the Logopedics department at Lund University. There I found students doing a four year undergraduate course who all appeared remarkably similar to the students I was teaching at Reading – mainly female and all very bright and highly motivated. I was able to watch clinical sessions and despite the language barrier was able to relate to the communication difficulties experienced by the children and the interventions that were being implemented. Therapists were faced with similar concerns and this continues to the present day. So ongoing issues for us all today include managing bi- and multi-lingual clients, problems around children beginning formal education without adequate language skills, and the need for practice to be based on a robust evidence-base. There are now far more opportunities to explore issues together. Fast forwarding from my time in Lund, we now have EU funding for networks that facilitate research collaborations, most importantly the COST Actions (see James Law’s January post about the most recent one: “Enhancing children’s oral language skills across Europe and beyond: a collaboration focusing on interventions for children with difficulties learning their first language. [IS1406]”).

Working together in this way is not without its challenges however. Training and service delivery varies widely across different countries. The therapists (or ‘logopeds’) I worked with in Sweden do not deliver therapy to children of formal school age (i.e. from seven years old in Sweden) and do not work within schools. A different professional group does this, made up of teachers who do a two-year additional training. So the clinical work I observed only involved children younger than seven. In Germany, SLT is delivered through private clinical practices, with the state funding clients to attend; once qualified, clinicians are either employed directly by a practice or save up to set up one of their own. Not all training across Europe is at degree level and in France for example, ‘orthophonistes’ do a diploma-level training (as was the case in the UK up until then end of the ‘70s; Newcastle was the first degree level programme and remained the only one for many years). One consequence of this is that therapists may have lower status and have limited autonomy to make their own diagnoses and decisions about intervention. Medical doctors, psychologists and/or clinical linguists will be the people doing this.

Terminology and definitions also pose major problems. It is not enough to share the same (English) term for something, you must also check that you share the same concepts and definitions for these terms. Think of the different definitions and terms used within the UK for child language difficulties for example (i.e. specific language impairment, language delay, primary language impairment, etc.) and then multiply by all the countries involved! English is invariably the language used at meetings, but this can sometimes lead to more confusion. For some years I was baffled by the word anamnesis, something that I have been repeatedly told is absolutely crucial for assessment of a client and moreover, is an English term. It seems to be something midway between a case history and a communication profile in ‘our’ terminology. Dealing with these confusions means first of all realising that they exist, and then carefully talking through what both parties mean.

To conclude, collaboration with colleagues from Europe and beyond is only likely to increase as time goes on, so do get involved. It is fascinating, can be frustrating at times, but most importantly it will broaden your professional horizons and constantly present you with new and different ways of doing things!

Carolyn Letts