AusTOMs - Amazon S3 · AusTOMs speech pathology scales. There are also AusTOMs scales available for occupational therapists and physiotherapists. As all three sets of scales are based

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AusTOMs for Speech PathologyCite this work as: Perry, A. & Skeat, J. (2013). AusTOMs for Speech Pathology (2nd Edition) Melbourne, Victoria: La Trobe University.

AusTOMs Investigators 2004Professor Alison Perry, School of Human Communication Sciences

Professor Meg Morris, School of Physiotherapy

Associate Professor Carolyn Unsworth, School of Occupational Therapy, and

Professor Stephen Duckett, School of Public Health

Faculty of Health Sciences, La Trobe University, Victoria, Australia.

Research Associates 2004Ms Jemma Skeat, School of Human Communication Sciences

Dr Nicholas Taylor, School of Physiotherapy

Dr Karen Dodd, School of Physiotherapy

Ms Dianne Duncombe, School of Occupational Therapy

La Trobe University, Victoria, Australia.

Associate InvestigatorsProfessor Pam Enderby and Dr Alex John, University of Sheffield, Community Sciences Centre, Sheffield, United Kingdom.

AcknowledgementThe Australian Therapy Outcome Measures (AusTOMs) project was funded by the Commonwealth Department of Health and Ageing. The AusTOMs were developed in Australia from the Therapy Outcome Measure, originated by Professor Pam Enderby, Dr Alex John, University of Sheffield, and Dr Brian Petheram, Frenchay Hospital, Bristol (United Kingdom) and the ICF (WHO).

Professor Pam Enderby assisted the research team at La Trobe University in the application to the Commonwealth to support this project. Both Professor Enderby and Dr Alexandra John from Sheffield University, United Kingdom, were associate researchers to this project, providing the Research Team with advice, discussion and support in this development of the AusTOMs.

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Measuring outcomes using the AusTOMsIncreasingly, speech pathologists, as well as other health care practitioners, are required to demonstrate that their services are achieving outcomes for patients (Skeat and Perry, 2008). Outcome measurement involves evaluating client status at the beginning and at the end of intervention, in order to ascertain whether or not there has been a change in this status. In routine clinical practice, outcome measures are an important part of quality assurance and service improvement, because they evaluate the most important measure of the quality of health care - the outcome of that care for patients.

Outcome data can identify areas that need improvement, as well as those of particular strength within a service. The AusTOMs may be used to compare client progress within and across client groups to enable decisions to be made regarding resource allocation, intervention type/amount, timing of intervention and more. For example, Brunner, Skeat and Morris (2008) used the AusTOMs to explore whether or not patients with the same diagnosis had different outcomes depending on the place that they received their rehabilitation (inpatient program versus home-based program). Additionally, when used in the context of controlled clinical research, outcome measures may be used to demonstrate the effectiveness of speech pathology interventions in improving patient function.

The AusTOMs are not an assessment tool; a client does not have to perform a particular task in order for you to make a rating. We have designed the AusTOMs to provide a snapshot rating; that is, a rating that broadly reflects a client’s status across four domains of health and functioning.

The AusTOMs are rated by you, the speech pathologist, based on your clinical judgement, using your knowledge of the client and how they are functioning. The initial rating is made on the basis of all the information that you have at the start of intervention- including your assessments and the case history details, explored with the client and/or carer. An outcome rating is made at the end of a block or period of intervention, and again is based on your knowledge of client functioning during intervention, and/or on the basis of re-assessment/ review results.

This manual provides you with training and information so that you can apply the AusTOMs speech pathology scales. There are also AusTOMs scales available for occupational therapists and physiotherapists. As all three sets of scales are based on

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Introduction and Background to the AusTOMs

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Table of contents Acknowledgement ..................................................................................................... IAusTOMs for Speech Pathology ......................................................................................... I

AusTOMs Investigators ........................................................................................................ I

AusTOMs Associates ............................................................................................................ I

AusTOMs Investigators ........................................................................................................ I

Chapter 1: Introduction and Background to the AusTOMs ................................. 1 Measuring outcomes using the AusTOMs ............................................................................. 1 The AusTOMs project ................................................................................................................ 2 Development of the scales ......................................................................................................... 2 Changes in the second edition of AusTOMs for Speech Pathology ......................................... 3

Chapter 2: User’s Guide .............................................................................................4Overview of AusTOMs ....................................................................................................... 4 The AusTOMs domains ............................................................................................................. 5 Making a rating using the AusTOMs ............................................................................... 6

Chapter 3: Frequently Asked Questions ............................................................... 9

Chapter 4: Using AusTOMs in Practice: Clinical Case Examples .......................15Case 1: Leonard ........................................................................................................................ 15 Case 2: Sara ................................................................................................................................ 18

Chapter 5: Cases for Practice ................................................................................. 21Adult clients .............................................................................................................................. 22 Paediatric clients ....................................................................................................................... 28

Chapter 6: Answers and Discussion Points ...........................................................34Adult clients .............................................................................................................................. 34 Paediatric clients ....................................................................................................................... 38

Chapter 7: AusTOMs Scale Properties .................................................................. 42Reliability ................................................................................................................................... 42Validity ....................................................................................................................................... 43Sensitivity .................................................................................................................................. 44 Use of the AusTOMs for Speech Pathology .......................................................................... 44

Chapter 8: Collecting AusTOMs Data .................................................................... 45 Example data collection form ................................................................................................. 46Example disorder and aetiology codes .................................................................................. 47

References ................................................................................................................. 48Used in this manual ................................................................................................................. 48AusTOMs development ........................................................................................................... 49 Use of AusTOMs for Speech Pathology scales in clinical research .................................... 50

Appendix A: AusTOMs Core Scale ..........................................................................51

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the same core scale, the AusTOMs are broadly comparable across all three professions, meaning that it is possible to get a comprehensive picture of client progress across multiple functional areas. For example, a patient who has had a stroke could have their Language and Swallowing outcomes (speech pathologist) evaluated as well as their Balance and Postural Control and Musculoskeletal Movement Related Functions (physiotherapist) and their Functional Walking and Mobility and Carrying out Daily Life Tasks and Routines (occupational therapist). This would give a very comprehensive ‘snapshot’ of a person’s strengths and deficits at a particular time point.

The AusTOMs projectThe AusTOMs are based on the Therapy Outcome Measures (TOM), published in the UK by Professor Pam Enderby and Dr Alex John (Enderby & John, 1997; Enderby, John, & Petherham, 1998) and use the concepts of health outlined by the World Health Organisation (WHO) in the International Classification of Functioning, Disability and Health (ICF; WHO, 2001).

The ICF is a taxonomy of the consequences of disease, providing a useful organising framework for clinicians to identify where to focus their intervention. In this system, clinicians can think about their client’s problems and the kinds of intervention needed in relation to body function and structure (impairment), ability to undertake activities (activity limitation), and their participation (for example, socially, in education or in employment).

Development of the scalesThe development of the AusTOMs scales within the context of a two-year Australian research project is described more fully in Perry et al (2004).

To begin, the team at La Trobe University reviewed the TOM scales and, in discussion with expert Australian clinicians, decided to establish the three sets of AusTOMs scales for the Australian context. We developed an AusTOMs core scale on which to base the speech pathology, occupational therapy and physiotherapy scales (see Appendix A). We then held focus groups with clinical speech pathologists, occupational therapists and physiotherapists in Victoria to develop the scales for each profession. We derived the scale areas from the International Classification of Functioning, Disability and Health (WHO, 2001), in consultation with clinicians in each dicipline.

The draft scales were sent to expert clinicians across Australia for review and feedback. We revised the scales for each profession the basis of the above review, and then sent them back to clinicians for further feedback. The final scales were evaluated over a six month data collection phase where data were collected on over 1000 patients in order to examine their reliability, validity, sensitivity and clinical usefulness (see Chapter 7).

There are several published articles on the development and use of the AusTOMs scales which may be useful for further information. A full reference list can be found at the end of this manual.

AusTOMs for Speech Pathology scales

SpeechLanguageVoiceFluencySwallowingCognitive-communication

AusTOMs for Occupational Therapy scales

Scale 1. Learning and Applying KnowledgeScale 2. Functional Walking and MobilityScale 3. Upper Limb UseScale 4. Carrying Out Daily Life Tasks and RoutinesScale 5. TransfersScale 6. Using TransportScale 7. Self CareScale 8. Domestic Life—HomeScale 9. Domestic Life—Managing ResourcesScale 10. Interpersonal Interactions and RelationshipsScale 11. Work, Employment and EducationScale 12. Community Life, Recreation, Leisure and Play

AusTOMs for Physiotherapy scales

Scale 1. Balance and Postural ControlScale 2. Cardiovascular System Related FunctionsScale 3. Musculoskeletal Movement Related FunctionsScale 4. Neurological Movement Related FunctionsScale 5. PainScale 6. Respiratory System FunctionsScale 7. Sensory FunctionsScale 8. Skin FunctionsScale 9. Urinary and Bowel Continence

Changes in the second edition of AusTOMs for Speech PathologyChanges have been made to this manual to provide further information regarding the use of the AusTOMs for Speech Pathology scales and more detail about how the validity, reliability and sensitivity of the scales has been assessed. We have included two case examples of the use of AusTOMs in clinical practice to further support clinicians who wish to use these scales.

In the second edition, the AusTOMs for Speech Pathology scales remain unchanged. Clinicians using the first edition of the AusTOMs will be able to continue to use these scales.

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nn Compare across service types for the same patient group – for example, rehabilitation at home versus inpatient rehabilitation – to examine any differences in outcomes;

nn Evaluate the results of quality improvement initiatives, for example, to assess children’s language outcomes before and after provision of information about language development strategies to parents attending the service.

The AusTOMs domainsWe have based the AusTOMs scales on one common core scale (Appendix A). The core scale provided a uniform basis for developing each of the profession-specific scales, allowing comparison across scales since they all follow the same framework.

The core scale includes four domains: Impairment; Activity Limitation; Participation Restriction; and Distress/Wellbeing. We based the first three of these domains on the International Classification of Functioning, Disability and Health (ICF; WHO, 2001). The fourth domain (Distress/Wellbeing) is embedded within the ICF but is not a distinct domain. Enderby and John (1997) drew out this concept as a distinct domain, as therapeutic intervention is often directed at alleviating distress and promoting wellbeing in both clients and their carers. As clinicians in Australia felt that this area was relevant to their clinical practice, the AusTOMs scales include the domain of Distress/Wellbeing.

Each of the six speech pathology scales (Speech, Language, Voice, Fluency, Cognitive-Communication and Swallowing) include these four domains. The domains are related, but also distinct. For example, a speech sound disorder (Impairment) impacts on communication (Activity Limitation), may reduce a child’s ability to join in with peers in the playground (Participation Restriction), and the child and/or parent may be quite concerned about it, or distressed about lack of friendships or teasing (Distress/Wellbeing). On the other hand, two clients may have similar levels of impairment (for example, percentage of syllables stuttered) but different levels of participation (perhaps one is extremely reluctant to speak and does not participate in verbal activities at school, while the other is happy to join in, despite their stutter). This is why the AusTOMs scales consider these four domains independently; each is rated in relation to client performance in that area, and change (the outcome) is also considered independently for each domain.

Additionally, all of the AusTOMs domains are considered in relation to the age of the client: for example, a lack of autonomy would not be an indication of Participation Restriction for a young child.

What is covered in each domain?

The Impairment domain describes structural (anatomical) or functional (physiological

or psychological) difficulties that a client may have. For example, a client may have an

abnormality of the oral structures, such as cleft palate (structural) and/or difficulty

in producing speech sounds (functional). Speech pathology assessment tools are

commonly used to evaluate an impairment, and provide a good source of information

for determining how a client should be rated on this domain.

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Overview of AusTOMsThe AusTOMs are functional outcome measurement scales, designed to provide a structured means of describing patient outcomes across four areas that are important to patients and to speech pathologists: Impairment; Activity Limitation; Participation Restriction and Distress/Wellbeing.

The AusTOMs are not assessment tools and do not provide information to inform diagnosis. The scales are designed to summarise assessment information (i.e., describing client status) across four functional domains, so that clinicians can later re-evaluate client performance in these domains to examine progress.

As a clinician, the information that you get from AusTOMs may be useful;

nn As a framework to understand client needs and intervention goals from a broader view point than traditional assessment, which is usually restricted to the Impairment domain;

nn To assist you to make decisions about ongoing intervention versus discharge, for example, based on whether there is a plateau in the outcome scores over a specified time (no further change has been made);

nn To support clinical goal setting- for example, targeting intervention goals towards outcome domains that are the most severely restricted, or where progress may enhance change in other domains;

nn When discussing goals, intervention targets and outcomes with clients and families.

If you are collecting AusTOMs within your service (across many clients), you will be

able to do additional things with the data, such as:

nn Compare outcomes within and across patient groups to answer clinically-relevant questions, such as do older and younger clients with stroke experience have similar or different outcomes in relation to swallowing?

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The Activity Limitation domain describes a client’s level of ability and difficulty in

performing tasks and activities that relate to their impairment. For example,

a client with a swallowing impairment may have difficulty with the activity of eating/

drinking; and a client with speech impairment may have difficulty with the activity

of communication.

The Participation Restriction domain is used to examine the overall social limitation

that a client may experience in their daily life. Social limitations include roles within

employment, educational, social and familial contexts. For example, a teacher who

loses her voice may not be able to work for a few weeks while her voice recovers. This

is a restriction to her vocational role. The domain considers participation in relation

to fulfilling roles (e.g., at work), social integration, involvement in decision-making,

control over environment and reaching potential (with or without assistance).

The Distress/Wellbeing domain describes the client and/or carer level of concern,

which may be evidenced by anger, frustration, apathy or depression. Carer distress/

wellbeing should be rated if you anticipate that this will be an area of intervention in

the client’s episode of care. For example, you may rate the distress/wellbeing of the carer

of a young child or consider this domain when you plan to spend time counselling

and advising carers.

Making a rating using the AusTOMsSelecting clients to score

The purpose of using the AusTOMs is to measure client progress over a period of

intervention. Intervention does not always mean traditional therapy sessions between

you and the client - it may be that you have provided a home program, or given

feedback and recommendations to a parent. It could be that you are working through

a third party, such as a carer at a day service, for whom you have provided training

relating to specific communication strategies, or a therapy assistant who will implement

an intervention program that you have designed.

Regardless of the intervention that you implement, you can collect AusTOMs data on

all clients for whom you expect an outcome (a change in any of the four domains), and

for whom you are able to make at least two ratings across all four domains - once at the

beginning and once at the end of intervention.

Selecting scales

For each client, there may be a number of areas that you are going to target in your

intervention with a client. For example, a client with a stroke may have speech,

language and swallowing difficulties that you will be working on, or a child may

present with both language and cognitive-communication difficulties. AusTOMs scales

should be chosen to represent the areas in which your client is experiencing difficulties,

and which you will target during intervention. It is in these areas that you might expect

to see an outcome.

You may select up to three AusTOMs scales on the basis of your assessment findings

and your goals for intervention.

Each AusTOMs scale includes a description of the types of disorders that may be

rated using that scale. Further examples can be found in Chapter 3.

When to make a rating

Make an initial rating at the beginning of an episode of care, before you begin any

intervention. This initial rating is a baseline against which you will evaluate the

outcome of care. You should base the initial rating on the information that you have

at hand prior to commencing your intervention - this includes formal and informal

assessment information and case history/other client information.

You may make an interim rating if you wish. This may be suitable for clients whom

you are seeing over a long period of time, when you will be regularly re-assessing and

likely setting new goals. We recommend that staff members specify and standardise the

time at which an interim rating is made; for example, every six months, particularly if

outcomes data are being used to compare across patients.

You make a final (outcome) rating at the end of an episode of care. This could be when

the client is to be discharged, transferred to another service, or when you significantly

change the goals of intervention so that you are focussing on a new ‘outcome’ entirely.

At the least, an initial and a final rating on all four domains of the AusTOMs for speech

pathology are needed because it is the change between these two ratings that reflects the

outcome.

How to make a rating

You will need to rate the Impairment and Activity Limitation domains for each of the

scales that you select. These domains are disorder-specific, and we have developed

descriptions of a range of behaviours for each scale to describe the levels

of difficulty that clients experience. For example, the Impairment domain of the

Speech scale describes a range of behaviours that typify a client who has ‘the most

severe’ presentation through to a client who has ‘no problem’ in relation to the use

of speech sounds.

The Participation Restriction and Wellbeing/Distress domains are considered to be

global, so are rated only once per client, even if several AusTOMs scales are used. It is

often difficult to discriminate whether a client’s participation or distress is in relation

to their speech disorder or in relation to their language disorder, for example. Therefore,

clinicians should think about a client’s overall functioning in these areas and then make

a rating.

Each domain is rated independently of the others; a severe level of impairment does

not necessarily indicate that all of the other domains will be at a severe level for the

client. For example, a client may have a severe language impairment, but if they use an

augmentative or alternative communication (AAC) system effectively to communicate

with most of the people around them, then their Activity Limitation score might be

rated as better than their Impairment score.

The AusTOMs include the option to rate the Distress/Wellbeing domain for carers, in

addition to clients. We recommend that you make use of this option if you anticipate

the distress or wellbeing of a carer will be part of your intervention, perhaps by use of

specific strategies.

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How to choose scale points

Each domain of the AusTOMs scales has six levels (0-5) where 0 represents ‘complete

difficulty’ (the most severe presentation) and 5 represents ‘no difficulty’ (see Figure 1,

below). You should choose where your client is in each domain by reflecting on the

client’s abilities and difficulties in relation to that domain.

Figure 1: Continuum of scale points for the AusTOMs scales

Choose scale points according to the ‘best fit’ with the scale descriptors, relating this to

your knowledge about the client. The descriptions at each point (0-5) are designed to

reflect that level; they are not absolute descriptions of a client that ‘fit perfectly.’ There

may be elements of the description that are not relevant to your client - for example, the

Impairment descriptors for speech cover both children and adults. Match the client to

the description that is the best fit, despite them not having all of the behaviours listed or

having some behaviours that are not listed.

Although points from 0-5 are described, you may also use half points. That is, if the

impact of a disorder on a client is more severe than a rating of 2, but not quite as severe

as a rating of 1, you may rate this as 1.5.

Figure 2: Summary flow chart: Rating the AusTOMs for Speech Pathology

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This chapter provides answers to some of the most commonly asked questions about the AusTOMs for Speech Pathology. It should be read in conjunction with the previous chapter (User’s Guide) to get a full picture of the use of the AusTOMs scales in practice.

1. Which austOMs scales should I choose?

Scale Examples (not exhaustive lists)Speech Motor speech disorder (dysarthria, dyspraxia)

Articulation delay/disorderPhonological delay/disorderChildhood apraxia of speechCleft palate with speech consequencesHearing impairment with speech consequences

Language Expressive language delay/disorderReceptive language delay/disorderProgressive language disorderAphasia/dysphasiaLearning disabilityReading/writing difficultySocial communication disorderHearing Impairment with language consequences

Voice Hyperfunctional voice disorderNeurogenic voice disorderOrganic voice disorder (nodules, polyps etc)LaryngectomyHyper/hyponasalityTracheostomy management related to voice

Fluency StutteringOther disorders of rate, effort, continuity (e.g, resulting from Parkinson’s Disease, dyspraxia, dysarthria)

Cognitive Communication Learning disabilityCognitive impairmentTraumatic brain injury

Swallowing DysphagiaFeeding disorderTracheostomy management

Frequently Asked Questions

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F R E Q U E N T L Y A S K E D Q U E S T I O N S

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An initial and a final rating, using the same scales, are necessary to measure a client’s outcome

Initial (admission) ratings On the basis of your assessment, select AusTOMs for Speech Pathology scales that reflect the client’s main areas of difficulty (choose areas that you will target in therapy).

Interim ratings At re-assessment and/or change of goals, use the same scales you selected for your admission rating. You can

make as many interim ratings as necessary.

Final (discharge) ratings At discharge from your intervention: use the same scales selected for your admission rating(s).

Impairment and Activity Limitation—rate each scale chosenParticipation and Distress/Wellbeing—rate once per client at each time pointCarer Distress/Wellbeing (optional)—rate once per client at each time point

Profound Severe Severe to Moderate Moderate Mild No

difficulty

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2. Are the AusTOMs scales suitable for use with both adults and children?The AusTOMs can be used to rate outcome for both adults and children. Each scale includes descriptions that are relevant to clients across the lifespan.

When rating each domain, consider your client’s age. For example, under Participation Restriction, it is not relevant to consider work roles for children.

For babies or very young children, consider rating Participation Restriction and Distress/Wellbeing in relation to their carer, in addition to (or instead of) the client. For example, the parent of an infant with a feeding difficulty who is frequently at the hospital with them potentially has Participation Restrictions in relation to their own work, family and social roles. Addressing the Impairment and Activity Limitation domains for the infant may reduce the need for hospital visits, and thus produce a positive outcome for the parent that would be identified by change to your rating of their participation.

3. Is it appropriate to use the AusTOMs for clients who have deteriorating conditions?Yes, it is appropriate to measure outcomes for clients who have conditions that mean that their speech, language, voice, fluency, cognitive-communication and/or swallowing is expected to deteriorate over time.

For these clients, you may expect initial ratings to be better than subsequent ratings. However, as the AusTOMs provides a broad view of client outcomes, you may find that some domains are positively impacted on by your intervention, although others may deteriorate. For example, for a client with a progressive condition that impacts on their swallowing, you may introduce strategies to facilitate safe swallowing, so that although the client’s Impairment score is likely to decrease (as their condition deteriorates), their Activity Limitation score may stay the same - or even improve. This is an important and positive outcome to record.

Outcome scores should always be recorded alongside client data including their condition/aetiology, so that negative changes over time can be seen in context. See Chapter 8 for an example data collection sheet which shows the type of client information that should be collected alongside ratings from the AusTOMs.

4. How do I rate clients with laryngectomy?Use the Voice scale to rate clients who have had a laryngectomy. If the client has TEP or oesophageal voice, or any other form of voice that uses his/her own structures as an alternative vibrator (instead of the vocal folds), rate the client’s use of these using the Impairment domain. You do not need to compare this client’s voice to a ‘normal’ voice. Simply make a rating of the client’s voice in relation to their consistency of phonation, control, and quality of voice.

Then, rate their communication (e.g., whether they are able to get their message across) under Activity Limitation. Additionally, if the client uses a communication aid, for example a Servox, to produce voice, rate the use of this device to increase the client’s functional communication in the Activity Limitation domain.

For example, Josef has had a total laryngectomy. At admission, he has no voice (Impairment), and uses a Servox to communicate (Activity Limitation). At discharge, he has oesophageal speech (Impairment), and uses both this speech and the Servox to communicate, depending on the situation (Activity Limitation).

5. How do I rate tracheostomy management using the AusTOMs?The presence of a tracheostomy may impair both voice and swallowing, so choose one (or both) of these scales, depending on your assessment of the client and your goals. The Impairment domain rating may not change while the tracheostomy is in situ. Intervention may be directed at improving activity - of voice (for example, increasing communication by the client, using a speaking valve or finger occlusion over the tracheostomy tube); and/or of swallowing (for example, by teaching the client, nursing staff, and carer strategies for safe(r) swallowing). You may also anticipate changes to their Participation and Distress/Wellbeing domains.

6. How do I rate expressive and receptive language using the AusTOMs? There is a single Language scale to the AusTOMs, which includes descriptions of both expressive and receptive language. Expressive and receptive language functions may, however, present at differing levels of severity. For example, a client may have mild receptive language difficulties, but a moderate to severe expressive language impairment.

If you are setting goals for both expressive and receptive language, you can make two ratings in both the Impairment and Activity Limitation domains—one rating for the client’s expressive language, and one rating for the client’s receptive language. In this way, you can show the outcome for each area of language independently. As usual, you only need to rate Participation Restriction and Distress/Wellbeing domains once per client at each point when you rate the AusTOMs (e.g., initial, interim, final).

7. What if a client uses augmentative or alternative communication (AAC)The client’s functional ability to use gesture, symbols, written words or other methods (including speech) to communicate is rated under the Activity Limitation domain of the AusTOMs scales.

Which scale you choose to rate depends on your goals for the client. For example, if you are seeing a client who has complex communication needs for whom you aim to extend their use of communication using an AAC device in various settings, you might use the Language scale to rate their understanding and use of symbols to communicate - whether words (spoken or written), picture symbols, or gestures under the Impairment domain, and rate their communication (using all systems available to them) under Activity Limitation.

For clients who have a specific primary impairment of speech, language, voice, fluency or cognitive-communication, and who use formal or informal AAC to support communication, you can choose a scale that relates to their primary impairment, and rate their communication under the Activity Limitation domain, taking into account any of the communication methods that they use.

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11. What happens if another speech pathologist implements intervention after I have assessed the client?As long as both speech pathologists are familiar with the AusTOMs and have enough information about a client to make their ratings, it should not matter whether the same or different clinicians make the initial and final ratings. We recommend that teams do joint training, using the case examples in this manual, in order to get the same understanding of the AusTOMs and how it works. Ratings of client status should be made by therapists who are able to accurately reflect on the client’s abilities and difficulties- in most cases the initial rating will be made by the clinician who undertook the assessment, and the final rating by the clinician who has been involved in intervention and/or reviewed the client.

12. When would I include a rating of carer distress/wellbeing?Rating the Distress/Wellbeing domain in relation to carers is optional. We recommend that you use this rating if you have set goals regarding the distress/wellbeing of carers. For example, if you are working to educate a carer about the management of dysphagia in order to reduce their anxiety, or working with a parent to reduce their frustration in communicating with their child who has a fluency disorder, by providing them with strategies to support smooth speech. Additionally, see Question 2 regarding rating distress/wellbeing for clients who are babies or very young children.

13. Are the AusTOMs only for use in Australia?The AusTOMs were developed within the Australian context, by Australian clinicians and were validated in that country. Since the initial publication of these scales in 2004, they have been used by clinicians across several countries, including New Zealand, Canada and the USA. There has been research conducted using the AusTOMs for Occupational Therapy in several countries, and that tool has been translated into Swedish.

We recommend that clinicians from other countries consider whether the AusTOMs, or another outcome measurement tool (e.g., the UK TOMs) best suits the context for use- including the clinical setting and patient groups seen.

14. Is it possible to use the AusTOMs to determine if intervention has caused the improvement in my client?The AusTOMs is designed to show a change in client status across four domains. Under usual clinical conditions, it is not possible to be confirm that these changes are the result of your intervention versus other factors, including recovery or maturation/development. The information provided through AusTOMs is designed to inform your clinical decision-making about individual clients, and can also be used to demonstrate similarities and differences in outcomes within and across client groups, in order to answer important questions about service provision and resources.

Under controlled research conditions, it is possible to show that an intervention is responsible for the outcome measured using AusTOMs. We recommend the use of AusTOMs in research situations as a supplement to detailed assessment/reassessment protocols, as it provides a broader understanding of change in client status as a result of intervention than traditional standardised assessments. For example, in

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8. How do I rate clients who are only seen for screening or assessment?AusTOMs is designed to measure intervention outcomes, therefore intervention of some type is needed, as well as at least two ratings (one prior to and one at the end of intervention).

Intervention can be anything that aims to have an impact on the client’s impairment, activities, participation and/or wellbeing- for example, it may include direct therapeutic approaches as well as broader strategies, such as giving advice/strategies to reduce swallowing risk or providing training to a parent to enable them to set up an AAC device for their child.

We recommend that you make an initial rating for all clients for whom you will be providing some form of intervention, and where you anticipate that there will be an opportunity for one follow up session (for example, a review). At least one point of follow up is required in order to make a final rating using AusTOMs. See also below regarding ‘one off ’ intervention sessions.

If you are not providing any intervention for a client, then you do not need to make a rating using AusTOMs.

9. What about ‘one off’ intervention sessions?You need to make a rating using the AusTOMs at least twice - once at the beginning and once at the end of intervention. Usually this means that you will see the client over a period of time; however, it is possible to score a client that you see only once, providing an admission and a discharge rating can be made for that same session.

For example, a speech pathologist may visit a client for a feeding assessment and implement changes to positioning, timing and texture of food as a single session, evaluating the effectiveness of these changes in situ. In this example, the client can be scored based on their status at the beginning of the session (using the assessment information), and then a second rating made of their status at the end of the session (based on the evaluation of client function once the changes have been implemented).

10. What if a client is discharged or leaves therapy before a final rating is made?As with any outcome measure, the AusTOMs require at least two ratings (initial and final). Therefore, when the client is discharged, you need to rate each domain of each scale that you selected for the initial rating.

If the client has left your service unexpectedly, make the rating by reflecting on the client’s status at the last time point that you saw them.

If a client has left before optimal discharge, you may want to note this using a discharge code. Chapter 8 provides discharge codes that you could use. These allow you to be able to identify those clients who completed the recommended course of intervention versus those who did not (and therefore potentially did not achieve the full outcome that they could have), which may be useful if you are evaluating client outcomes across a service.

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Introduction and background to the AusTOMs

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examining the impact of a language-focussed treatment for preschool-aged children using a Randomised Controlled Trial, the use of the AusTOMs in addition to detailed standardised assessments of language abilities (e.g., the Clinical Evaluation of Language Fundamentals), would allow researchers to be able to comment on the impact of the intervention across multiple areas- impairment, activity, participation and distress, which may be important to understanding the real value of the intervention.

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U S I N G A U S T O M S I N P R A C T I C E : C L I N I C A L C A S E E X A M P L E S

Using AusTOMs in Practice: Clinical Case Examples

Jacqui Frowen1 (Case 1), Melinda A. Schambre2, Lisa M. Furlong2, Katrina B. Smeets2 Tristan M. Nickless2, 3 (Case 2)

1. Speech Pathology Department, Peter McCallum Cancer Centre

2. Word By Mouth Pty Ltd

3. Department of Audiology & Speech Pathology, University of Melbourne

This chapter provides two case examples demonstrating how the AusTOMs for Speech

Pathology tools were applied with real clients. These examples illustrate the way that

AusTOMs fits within clinical practice, and can be used to inform decisions about

client care.

Leonard is a 58 year old man from regional NSW. He was referred to the Long River

Cancer Centre with a three month history of pain on swallowing. He was diagnosed

with a large squamous cell carcinoma (cancer) of the left base of tongue. It was

recommended that he undergo extensive surgery following by radiotherapy and

chemotherapy.

Leonard underwent a near-total glossectomy (removal of the tongue), a neck dissection

(removal of his neck lymph nodes) and a tracheostomy insertion, plus reconstruction.

A percutaneous endoscopic ga strostomy (PEG) feeding tube was inserted.

Assessment and initial AusTOMs ratingLeonard was seen by a speech pathologist regularly while he was an inpatient.

Despite initial difficulties with managing his own secretions, he progressed well

with tracheostomy cuff deflation and then the tracheostomy was safely removed two

weeks after his surgery. At this point, an assessment of his speech and swallowing was

conducted. The initial AusTOMs rating was made when Leonard was considered to

be stable and a comprehensive assessment of his speech and swallowing had been

conducted, which was about three weeks post-surgery.

Case 1: Leonard

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Speech scale – Impairment and Activity Limitation

Due to the degree of tongue resected, and marked intra-oral swelling from surgery,

Leonard had significant difficulties with articulation. Following the removal of his

tracheostomy, he was reluctant to talk due to his poor speech intelligibility, even with

familiar listeners such as his sister, nursing staff and the speech pathologist. He was

rated as 20% intelligible with short phrases only. Writing was his preferred method

of communication.

Swallowing scale – Impairment and Activity Limitation

Oral trials of various food and fluid consistencies were commenced the day after his

tracheostomy was removed. Leonard demonstrated significant difficulties with oral

control and transit of the bolus. Head extension was required to assist with the oral

stage of swallowing. However, due to premature spillage of food into the pharynx

and his impaired airway protection, this technique frequently resulted in coughing,

indicating airway penetration/aspiration. It was recommended that Leonard commence

small amounts of mildly-thick fluids, using a head extension posture to assist oral

transit, then quickly transferring to a chin tuck posture to swallow. All his nutritional

requirements were met via PEG feeding. He managed these recommendations safely

over a few days in hospital and was advised to continue this protocol on discharge

home, which occurred three weeks post-surgery.

Participation Restriction and Distress/Wellbeing

At this time, Leonard’s participation was markedly reduced, due to both his hospital

admission and his communication and swallowing difficulties. Leonard had very little

control over what happened to him at this point, and limited possibility for social

interaction even when discharged due to his reduced communication. Leonard was

upset about the impact his difficulties would have on his life, and together with his

speech pathologist chose a rating of 2 on the AusTOMs to describe his distress.

Initial rating

Scale Impairment Activity Participation Distress

Speech 2 11 2

Swallowing 1 1

Interim AusTOMs ratingLeonard started his post-operative chemo-radiotherapy(CRT) treatment. Due to the

acute side effects of treatment including oral pain, nausea and fatigue, he ceased any

oral intake, did not communicate verbally and was unable to participate in active speech

pathology sessions for approximately six weeks. Making an AusTOMs rating during this

time was not suitable, as his speech and swallowing functions were significantly affected

by the acute side effects of CRT. Once these improved, Leonard re-commenced active

speech therapy at about three months post-surgery. An interim AusTOMs rating was

made at around four months post-surgery to evaluate Leonard’s progress and to assist

with setting goals for ongoing intervention.


At this point, Leonard’s speech was approximately 50% intelligible at a conversational

level with familiar listeners. He continued to experience communication breakdown

with unfamiliar listeners, and often had to resort to writing.


Leonard persevered with his oral intake, despite the effort required due to his poor

oral control and moderate pharyngeal difficulties. He was assessed as able to safely

manage one cup of mildly-thick fluid and small serves of runny smooth food (such as

custard, thick soup, pureed fruit, pureed vegetables with gravy) at each mealtime.

He was also able to commence occasional small sips of thin fluids, with very strict

strategies to reduce the risk of aspiration. He continued to require PEG feeds for

supplementary feeding.

Participation Restriction and Distress/Wellbeing

Leonard was now living alone in his home on a small property. Prior to surgery, he had

enjoyed catching up with a few close friends once a week at the pub for a drink and

meal. He also regularly saw his sister who lives nearby.

Due to his improvements in speech and his ability to swallow small amounts of food,

Leonard attempted to resume his weekly pub outings with friends. However he found

these outings challenging as he was often misunderstood, particularly in the noisy

environment, and he needed to bring special foods/drinks from home. Leonard’s

main goal from therapy was to be able to resume attending his pub outings. Although

Leonard was feeling more positive than a few months ago, he still found the challenges

he faced distressing and required encouragement from his sister to remain positive.

Interim rating


Speech 3 23 3

Swallowing 2 2

Discharge and final ratingLeonard was seen regularly over the following few months, and worked hard to achieve

improvements in his speech and swallowing. At eight months post-surgery, another

AusTOMs rating was made. At this time, the speech pathologist felt that Leonard had

reached a plateau and a discussion was needed to determine what, if any, ongoing

speech pathology intervention he needed.


Leonard was now 80% intelligible in conversation with familiar listeners and

had resumed his weekly pub evenings with friends. He continued to experience

communication breakdown with unfamiliar listeners, but he rarely interacted with

people he didn’t know well. He had learned to use a TTY (teletypewriter) phone so he

could type messages during phone calls, instead of talking.


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Leonard progressed extremely well with oral intake, despite ongoing severe oral and

moderate pharyngeal dysphagia. He continued to require mildly-thick fluids and runny

pureed foods, but was able to manage larger amounts and eventually to have his PEG

tube removed. The cook at his local pub was now aware of the types of foods Leonard

could manage and provided a texture-modified meal when he came in. Leonard

persisted with swallowing thin fluids and was eventually able to manage a full glass of

beer with friends. Nevertheless, he continued to use his swallowing strategies to reduce

the risk of aspiration of thin fluids.

Participation and Distress/Wellbeing

Leonard was pleased to have been able to achieve his goal of returning to his social life

with his friends, although this was still effortful. He also required some assistance from

his sister and her family to maintain his property and he was not able to return to paid

employment after his surgery. Overall, Leonard reported being satisfied with his speech

and swallowing function, and felt that he had adjusted to the changes that his speech

and swallowing difficulties had made to his life. He reported being content to spend

most of his days quietly on his property, reading and fishing, with his animals

for company.

Final rating


Speech 3 33 5

Swallowing 2 3

The AusTOMs ratings were used to discuss Leonard’s progress with him, showing his

steady improvement, but also that there was a plateau evident, particularly in relation

to his impairment. Given the extent of the surgery, Leonard and his speech pathologist

were aware that there was minimal scope for further improvement, and they agreed to

cease speech therapy at this point.

Sara is a 13 year old girl transitioning from primary school to secondary school. She

has an extensive history of speech pathology intervention since she was around 3 years

of age, including one to one, group, and classroom based support provided through her

primary school. Her support needs were recently reviewed by an Education Department

speech pathologist, revealing a significant language impairment across both receptive

and expressive language domains, as well as a severe impairment in her working

memory. Her parents approached a local private practice for specific language and

literacy intervention as the school speech pathologist was unable to provide one to one

intervention.

Initial AusTOMs ratingAs Sara had been very recently assessed by a speech pathologist through the Education

Department, the results of that assessment, together with observations from diagnostic

therapy and discussions with Sara and her mother, were used to make the initial

AusTOMs rating. The AusTOMs Language scale was chosen as this described Sara’s

predominant difficulties.

Language scale – Impairment and Activity Limitation

The Impairment rating for both expressive and receptive language was based on

Sara’s performance on standardised tests carried out by the Department of Education

speech pathologist on the Clinical Evaluation of Language Fundamentals 4th Edition,

Australian Language Adaptation (CELF 4; Semel, Wiig and Secord, 2006), Sara obtained

a Receptive Language Standard Score of 67 (Percentile Rank 1) and an Expressive

Language Standard Score of 65 (Percentile Rank 1). She also presented with a literacy

impairment based on standardised testing, with her single word spelling and reading

of words (real and nonsense) more than one standard deviation below the mean. These

scores indicated a significant level of difficulty, relative to Sara’s age.

Sara could follow simple directions and communicate using simple sentences

containing concrete ideas. Her impaired knowledge of language limited her ability

to participate in classroom discussion, draw inferences, explain and retell stories/

narratives, demonstrate her knowledge through written tasks, follow written

worksheets, understand humour, sarcasm, double meanings, slang and jargon used by

her peers.

Matching Sara’s performance against the AusTOMs descriptors, her Impairment score

for both expressive and receptive language was 2, and the rating given for Activity

Limitation for both expressive and receptive language was 3.


Sara’s mother reported her difficulties participating socially both at school and in

social situations outside of school. Sara found it hard to make and keep friends, and

her participation both within the classroom and in extracurricular activities was

restricted, limiting her social connectedness with peers both at and outside of school.

An initial rating of 2 on the AusTOMs reflected these difficulties. Sara demonstrated

low confidence, and required a lot of encouragement to attempt tasks during her earlier

sessions. Parent report indicated that she was unlikely to contribute to classroom

discussions or draw attention to herself by asking questions. Sara was reluctant to

attempt challenging written tasks and at home was moody and defiant when required

to complete homework tasks. Sara and her mother contributed to rating the AusTOMs

Distress/Wellbeing scale, with a score of 3 chosen.

Initial rating


Language – expressive 2 32 3

Language – receptive 2 3

Intervention and final ratingOver a period of 12 months of weekly intervention, Sara attended speech pathology

focusing on: expressive and receptive language, written expression, reading

comprehension and core literacy skills including sight vocabulary reading and spelling,

4 4


Case 2: Sara

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phoneme grapheme correspondence, phonological decoding, and spelling rules.

Following this, her language skills were reviewed.

Language scale – Impairment and Activity Limitation

A reassessment of Sara’s expressive and receptive language skills was undertaken using

the CELF 4. The results revealed mildly impaired to low average skills in both expressive

and receptive domain. Additional testing of her reading and writing showed that Sara

had the ability to form and understand written language with some assistance.

Sara’s language gains were also reflected in the area of activity limitation. At review,

she was able to follow complex directions most of the time, understand ideas and use

strategies spontaneously to overcome any difficulties, and to express herself orally and

in writing.

An AusTOMs rating of 4 reflected Sara’s performance on the Impairment and on the

Activity Limitation domains at this point, for both expressive and receptive language.


Sara and her mum reported a number of strategies Sara was now able to apply in

order to help her compensate for her remaining mild language and literacy difficulties.

The confidence with which she shares and collaborates at school was improved,

and her ability to ask for assistance and seek clarification no longer restricted her

learning. Additionally, Sara was participating in drama groups and talent shows, and

was connecting well with peers in these contexts. Sara and her mother reported that

while she occasionally still required emotional support or encouragement, she was

generally self-sufficient and independent in the classroom, at home and within social

settings, and was able to manage her emotions in most situations. An AusTOMs rating

of 5 (Participation) and 4 (Distress/Wellbeing) reflected Sara’s performance in these

domains following intervention.

Final rating


Language – expressive 4 45 4

Language – receptive 4 4

The gains made on the AusTOMs scales reflected Sara’s progress, and supported a

decision to discharge her from therapy at this point.

We have designed some practice cases to help you become familiar with the AusTOMs

for Speech Pathology scales. There are adult and paediatric cases for each of the six

scales.

The first two adult and paediatric cases are divided into information relevant for each

AusTOMs domain, and we have indicated the scale that would be chosen for that case.

Further cases provide less structure and rely on you determining which scales should be

used and which parts of the case information is relevant to score under each domain.

We recommend that you work through these practice cases before you start to use the

AusTOMs in daily clinical practice. If you are working within a team who will be using

AusTOMs, we strongly suggest that you make ratings independently, and then discuss

your ratings, attempting to come to a consensus about the rating that you would choose

for each domain for each case.

Chapter 6 provides suggested answers and discussion points for you to compare against

your ratings.

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Practice cases: Adult clients

Relevant History: Jim is a 60 year old widower. He recently had a stroke and was

admitted to hospital for ten days, after which he was judged fit enough to return home,

despite a mild residual left hemiplegia.

Impairment: Jim has a noticeable delay in triggering his swallow reflex, with audible

aspiration (coughing) when he sips liquids. He has very poor oral bolus control and

experiences drooling and labial spillage when trying to manage a liquid bolus.

Activity Limitation: Jim has alternative feeding (PEG) for his daily nutritional needs.

A VFSS shows no aspiration when swallowing small amounts of thickened fluids.

Participation Restriction: Jim is restricted in many areas. He is unable to handle his

own paperwork or finances and has handed power of attorney to his son. Jim cannot

do things such as shopping without assistance, and his food shopping choices are

necessarily restricted by his limited oral diet. He has a reduced social life, as he cannot

eat socially, nor can he drive himself places to visit his friends. He relies heavily on his

son, when he is available, to take him to places.

Distress/Wellbeing: Jim is constantly worried about his son, who has to drive a round

trip of two hours several times a week to assist him. Jim is very upset that he had the

stroke and says that he is more sensitive to things; for example he cries very easily and

becomes disorientated and very agitated at minor changes in routine.

Scale used: Swallowing

Impairment(circle one)

Activity(circle one)

Participation(circle one)

Distress(circle one)

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See p 34 for suggested answers and discussion.

Relevant History: Lee, aged 68, had a brainstem CVA, followed by an infarct about

12 months later. A speech pathologist assessed him in relation to his cognitive-

communication skills.

Impairment: Lee’s psychosocial and cognitive skills are affected. He is always orientated

to his surroundings and, although he responds consistently, his responses are slow.

It is difficult for Lee to stay on task for more than a short period of time, as he is easily

distracted, and he displays very poor insight into his problems.

Activity Limitation: Lee spontaneously attempts to make his needs and wants known;

he can request simple items like food or drink by name. His responses are slow, and

sometimes a bit off topic. If the language used when instructing him is simple, he

completes concrete, routine tasks independently.

Participation Restriction: Lee is dependent on his wife and immediate family for a

social life. His son and wife live at home with Lee and his wife. He does not go out into

the community, as family members do not take him out and he cannot go alone. Lee

makes limited choices within this safe environment and with family assistance.

Distress/Wellbeing: Lee is an easy-going man who is content and happy within his own

environment. He does, however, get upset occasionally, when reminded of his previous

activities and at these times, he requires support and reassurance from his family.

Scale used: Cognitive-Communication





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Adult case 2: Lee

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Voula is a 55 year old widow. She lives at home with her 28 year old daughter, while

her son lives interstate with his family. Voula recently had a stroke and was admitted

to hospital for 12 days, before being discharged home. She receives speech pathology,

occupational therapy and physiotherapy rehabilitation services in her home. Since

her stroke, communication with Voula is difficult. Successful communication requires

listener support through provision of visual cues and keeping her on track, and slowing

and simplifying questions. Voula finds it very hard to process even simple information

and requires a lot of extra time to do so. She sometimes understands everyday questions

in context, particularly with extra cues, and sometimes understands simple sentences.

She finds it almost impossible to understand questions or conversations that do not

relate to concrete, present, things. She is able to verbalise simple, concrete sentences,

although her son reports that he sometimes does not understand what she is talking

about because she ‘mixes up words’ (e.g., asking for a cup when she means a spoon).

Voula has found it difficult to get out of the house. She can no longer drive or walk

long distances, and she is unable to do everyday activities such as the shopping because

of her difficulty processing information and communicating her needs. She has some

friends who visit her, but she cannot go out to socialise any more. She mostly stays

at home with her daughter. Voula is extremely upset about her loss of independence,

particularly as she feels she is no longer in charge of planning her day-to-day life.

Voula reports that she becomes distressed very easily, finding it difficult to control her

emotions, particularly when she is frustrated by not being able to do things that she

used to.

Note: Although in real life Voula is likely to have primary impairments across several speech pathology relevant areas (e.g., speech, swallowing, language), for practice purposes consider her performance on the Language scale. For this scale, there is the opportunity to consider both expressive and receptive language with separate ratings of Impairment and Activity Limitation for each.

Scale used: Language

ImpairmentExpressive language(circle one)

ActivityExpressive language(circle one)

ImpairmentReceptive language(circle one)

ActivityReceptive language(circle one)



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Ian is 42 years old. He is a managing director of an international electronics company

and has a diagnosis of motor neuron disease, made three months ago when he returned

from a family holiday in the south of France. A factor that led to his diagnosis was

reduced clarity of his speech.

Since the diagnosis, Ian has limited his work-related speech activities. He no longer

chairs meetings, and reports that he joins in with his ideas or opinions far less than

previously, particularly when there is noise and interruptions, because he does not

like feeling that others may be straining to understand him. In general, he feels that he

requires more time to get a sentence out because of motor sequencing difficulties.

He is able to communicate effectively in 1-1 situations, but has reduced intelligibility

over the phone and doesn’t like using it anymore. Ian is using his secretary to make

telephone calls to colleagues whom he does not regularly deal with.

Although outwardly stoical, Ian reports being frustrated with his speech, especially

when people ask for repetition of a word or phrase. He also reports regularly feeling

distressed, particularly when he considers that his speech problems are likely to get

worse, and will continue to impact on his job role. Ian’s wife feels that he is overplaying

his current problems, and comments that the only time she realises his difficulties

with speech are when starts to ‘sound drunk’ when speaking at length, and this

becomes worse when he is tired. She also feels that other people do not notice and

tries to reassure him that it is normal for people to sometimes ask for repetitions. Ian

still attends social functions, and enjoys visiting friends and travelling interstate to

conferences.

Your answers

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Alex attends an evening group speech pathology class for people who stutter. He is a 38

year old man who has had a stutter since early childhood. Alex is shy of strangers and

does not like new social situations; he requires maximum encouragement and support

to join in social activities, and even then he gives up easily. Alex lives at home with his

mother, who usually makes any necessary phone calls for him and generally assists him

in dealing with the world. She reports that Alex has been passed over several times for

promotion because of his dysfluency, and is overqualified for the job that he holds.

Alex has obvious dysfluencies, with more than 13% syllables stuttered. There are

secondary behaviours evident most of the time when Alex speaks, including frequent

loss of eye contact and occasional grimacing and tooth grinding. He is able to read

aloud quite successfully, but has pronounced dysfluency in his conversational speech.

He often cannot control his dysfluency. Alex occasionally becomes a little depressed

about his lack of social life and having no girlfriend. In most situations, Alex shows

a happy face to the world, and only shows this depression at home. He says that he

sometimes feels his stutter has reduced his opportunities in life and has held him back

in terms of work and social opportunities.

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Christine is a 42 year old secondary school teacher, happily married, and with two sons

aged 16 and 8, both of whom live at home. She was, until recently, a moderate smoker

and social drinker.

Christine lost her voice after a heavy cold six months ago. Although her voice has now

returned, since that time she has been extremely frustrated by an ongoing extremely

hoarse sounding and weak voice. She now finds it difficult to project her voice to the

back of the class. She has poor control over her voice and finds that her voice fades at

the end of the day, recovers somewhat with rest, and then becomes hoarse again. Her

throat feels painful when she uses her voice excessively. Christine has had to change

her teaching style to use her voice less, and she has stopped smoking. She has a problem

using her voice against noise, so the family has ceased eating out and socialising, as

Christine feels she cannot cope when competing with loud background music or talk.

She feels depressed about her voice problem, as she finds it impacts on so much of her

life, and she feels it is not getting better. She has visited her GP regularly to try and get

some answers and reassurance regarding whether her voice would get better. Her GP

recently referred Christine to an ENT specialist, where direct laryngoscopy examination

showed reddened, dry edges to the vocal folds, with bilateral Reinke’s oedema.

Your answers

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Adult case 6: ChristineAdult case 5: alex


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5 5


Practice cases: Paediatric clients

Relevant History: Malia is a 7 year old girl who attends primary school. She came in for

a speech pathology assessment with her mother who is concerned about her stuttering.

Impairment: A speech pathology assessment reveals that Malia speaks with 3% syllables

stuttered. She does not have any secondary behaviours (such as grimacing) evident

when speaking.

Activity Limitation: Malia is able to get her message across to all listeners, although

she may take slightly longer to do so than her peers. Her speech does not look or sound

effortful. Malia’s teacher stated that she hardly notices her stuttering any more, although

she was concerned at the beginning of the school year.

Participation Restriction: Malia is a confident girl who is happy to join in with

anything her classmates are doing, including speaking in front of the class. At home,

she plays with her brothers and with children in the neighbourhood, and is a leader in

deciding on activities and games.

Distress/Wellbeing: Malia is happy and confident. She does not seem aware of her

fluency difficulty. Her parents say that they have been careful not to point it out to her

for fear of making it worse. She has a close group of friends at school who have known

her since preschool and does not get teased by the other children, although her parents

fear that this may happen in the future.

Your answers

Scale used: Fluency





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Relevant History: Mark is a 10 year old boy whose mother reports that he has constant

colds, usually leading to a period of aphonia. His mother describes his voice, in-between

these periods, as ‘husky’. Mark’s mother states that he needs to shout or speak loudly

to compete for attention with his two noisy older brothers. He also regularly goes to

football matches with his father and always returns from the matches with no voice.

Impairment: At the time of assessment, Mark is recovering from a cold, and only able

to talk in a whisper.

Activity Limitation: Mark can communicate in quiet situations. His teacher enforces

strict quiet during work periods at school, so Mark is able to ask and answer questions

in this environment. At home he usually cannot get his message across due to the noisy

environment. Once he is able to gain his mother’s attention, he can communicate his

wants and needs.

Participation Restriction: At school, other students tease Mark because of his

voice problem. He dislikes having to talk in front of the other children (e.g., for

presentations), and avoids this. If he has lost his voice, he does not even attempt to

ask or answer questions. His teacher is encouraging him to partner up with another

child for show and tell presentations when he is aphonic. So far, this has been a good

alternative.

Distress/Wellbeing: Mark is very distressed about his voice problem. He feels

embarrassed when his voice is not working properly, and is unwilling to go to school at

these times because he will get teased. He has started to lash out physically against boys

in his class when they tease him.

Your answers

Scale used: Voice





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Paediatric case 2: Mark

Paediatric case 1: Malia


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Claire is a girl aged 3 years 10 months. She lives at home with her mother, father

and younger sister. Claire’s preschool teacher referred her for a speech and language

assessment. Claire participated in a speech sound assessment, which revealed that

she fronts (e.g., k"t), stops (e.g., s"t), reduces clusters (e.g., sk"t) and uses a /b/

sound in place of /f/ (e.g., “bish” instead of “fish”). For all of these sound errors,

Claire is using the sound correctly in some words, but not in others. For example she

correctly articulates her sister’s name (Fiona). A chart of typical development shows the

following age norms:

Fronting /k/—usually resolved by 3;6

Cluster reduction—usually resolved by 4;0

Stopping /s/, /f/—usually resolved by 3;0

Claire is able to copy her mother’s productions of /k/ and /s/ at home but refused to

do so in the clinic. Her mother reports that Claire is a happy, chatty child at home

who speaks in five to six word sentences, which are sometimes difficult to understand.

Her mother reports that people who are used to Claire’s speech can understand her

approximately 80% of the time. If Claire’s message is not understood, she shows

frustration, however her mother reports that this rarely happens, as most people in

Claire’s immediate environment are familiar with her speech and can understand her.

Unfamiliar people occasionally comment that she is difficult to understand unless they

know the context of the utterance.

Claire’s teacher reports that she usually plays with a select few children at preschool,

and joins in readily with the other children. Claire follows teacher instructions

independently. She is very independent at home, for example choosing what she will

wear and what she will eat. She plays happily with her baby sister, and with friends who

come to visit.

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Danny is a 3 year old boy, who lives with his mother and younger sister. Danny has been

diagnosed with a significant developmental delay. He has mild to moderate difficulties

with gross and fine motor skills, as well as a language delay.

Danny babbles a lot to himself and uses repetitive phrases, for example, “good boy”,

which he says to himself while he is involved in an activity. Other than these limited

phrases, Danny has little verbal communication, using only two words consistently

to request—“cup” and “bear”. He is very rarely able to communicate his needs and

wants; however, his mother anticipates these for him when he is at home. Danny also

shows compromised comprehension skills, with consistent identification of simple

objects (e.g., spoon, ball). He is able to follow simple, routine or concrete directions

consistently (such as “get your shoes”) when he is given cues such as pointing. Danny

never shows frustration, either at home or kindergarten. He is happy to play in his own

little world. When presented with a situation that he does not like or understand, Danny

moves away from the activity or person.

Danny receives one to one help at kindergarten; yet, even with this assistance he does

not interact with the other children, and will run away from them if they attempt to

join in what he is doing. He requires encouragement and hands on support from adults

in attempting new and unfamiliar activities. At the prompting of his aide, he will sit on

the mat for story time, but does not join in with any of the actions to the songs, even

though these have been the same for several months.

Note: For this case, there is the opportunity to consider both expressive and receptive language with separate ratings of Impairment and Activity Limitation for each.

Scale used: Language

ImpairmentExpressive language(circle one)

ActivityExpressive language(circle one)

ImpairmentReceptive language(circle one)

ActivityReceptive language(circle one)



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Paediatric case 4: ClairePaediatric case 3: Danny


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William is a 15 year old boy who was admitted to hospital following a car accident in

which he was a passenger and not wearing a seatbelt. He has a traumatic brain injury,

although the full extent of his injury is not yet clear. He was in a coma for three days.

Prior to his accident, William was attending a local high school and was involved in

many after school sports such as football and cricket, and played the drums in the

school band.

At your assessment, William responds to some stimuli, such as blinking his eyes when

the lights are turned on, although his responses are usually delayed. He does not seem

aware of people around him. William is not attempting to communicate, and does not

show any response to communication from others.

Your answers

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Suzy is an eight week old baby girl, who was born with a cleft lip and palate to Jane who

recently split from her partner. She has had a lip repair but not a palate repair as yet.

Suzy has been readmitted into hospital several times due to feeding/nutritional issues.

Suzy experiences feeding difficulties related to her cleft palate. She has a very weak

suck and milk often comes out of her nose when she is feeding. She cannot feed for

more than a few minutes at a time because her sucking gets progressively weaker over

time, and it takes several attempts before she can finish a bottle. At this stage, Suzy is

sometimes able to feed using a modified teat, however her feeding difficulties mean that

she requires mainly alternative nutrition (from a nasogastric tube).

Suzy’s mother Jane is having difficulty coping with the fact that her first baby has a cleft

lip and palate. Jane does not like trying to bottle feed Suzy, as Suzy gets fussy and this

upsets her. She has had to readjust her lifestyle to fit in numerous trips to her GP and

the hospital, and feels that this is a burden. This has impacted on Jane’s part-time job as

an administrative assistant for a small local business, where she has been asked to take

recreation leave until a routine for the care of Suzy has been established. Her job

is Jane’s only source of income at the moment, besides government support.

Jane is finding it hard to cope emotionally with Suzy’s care, and has needed many

counselling sessions with the social worker at the hospital, as well as emotional

support from friends.

Your answers

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Paediatric case 6: WilliamPaediatric case 5: Suzy


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In this section we will take you through the answers to each of the case studies.

Remember that scoring cases like these is actually more difficult than scoring real

clients, since you usually know more about your real clients and therefore have more

information on which to make your AusTOMs ratings.

It is acceptable to have ratings within 0.5 point of our suggested ratings. For example,

with a suggested rating of 2, ratings of 1.5 or 2.5 are also acceptable. The discussion

points should help you to understand our reasoning in choosing each of the scale points

that we have.

Adult case answers

Scale: Swallowing

Impairment Activity Participation Distress

2 1 1 0

Impairment: We suggest a rating of 2 because: Jim’s delay in swallowing reflex is

described as noticeable, rather than very delayed and his control of bolus is described as

poor, rather than absent.

Activity Limitation: Important points to note are that he can safely swallow small

amounts of modified fluids, but requires PEG feeding to meet nutritional needs—a

rating of 1 fits this description best.

Participation Restriction: Jim is restricted in many areas—specifically in making

decisions about finances, paperwork, food, and his social life. He has handed decision-

making of important areas, such as his finances, to his son. The overall description puts

him at the severe end of the scale, and a rating of 1 has the best overall fit.

34

Distress/Wellbeing: The terms used in the description, such as “constantly worried”,

“very upset”, “cries very easily”, and “very agitated” place the rating at the severe end

of the scale. A rating of 0 best fits this description.

Scale: Cognitive-Communication

Although in real life Lee would probably have other areas of difficulty, to simplify this

training case we are asking you to rate just his cognitive-communication.


2.5 3 1.5 4

Impairment: The main points of information about Lee’s impairment are that he is

oriented to his surroundings (consistently); he is responsive (consistent but delayed); he

is easily distracted but can stay on task for short periods; and he has very poor insight.

Most of this description is consistent with a rating of 3 (moderate impairment), with

the exception of his poor insight, which does not fit. A rating of 2.5 reflects that Lee’s

impairment is not as severe as a rating of 2, but is more severe in some areas than a

rating of 3.

Activity Limitation: The main points given about Lee’s activity limitation are that he

is able to make needs and wants known (spontaneously); his responses can off topic/

inappropriate; and he completes concrete, routine tasks independently if instructed

using simple language. Lee’s activity limitation description fits with a rating of 3.

Participation Restriction: Lee is described as participating in a limited environment

(family only, no involvement in the community), and able to make simple choices (with

assistance) in this environment. A rating of 1.5 fits this description; some of the features

match a rating of 1, and some match a rating of 2.

Distress/Wellbeing: The description of Lee’s distress shows that he is only occasionally

upset and that he requires support at these times (from family). This description

matches a rating of mild concern (4).

Scale: Language


Expressive 3 21 1

Receptive 3 1

Discussion points: In this case, you need to take into consideration both Voula’s expressive and receptive language. Expressive and receptive language function independently, so you are able to make a rating of Impairment and Activity Limitation

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A N S W E R S A N D D I S C U S S I O N P O I N T S

6 C h a p t e r S I X

Answers and Discussion Points

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Adult case 2: Lee

Adult case 1: Jim

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Adult case 3: Voula


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Scale: Fluency


2 2 1.5 4

Impairment: Alex has quite a severe stutter (13% syllables stuttered), with secondary behaviours usually evident—a rating of 2.

Activity Limitation: Alex scores 2 on the Activity Limitation domain: although he is able to read aloud fluently, his stutter is evident in conversational speech, and he cannot always control this.

Participation Restriction: Alex’s participation restriction is also severe. He requires maximum support to join in social activities, and is not reaching his potential at work—being passed over for promotion, despite being qualified for jobs above his current position. A rating of 1.5 reflects this.

Distress/Wellbeing: From the description of Alex’s quite severe difficulties, and his poor social and work prospects, you might expect his level of distress to be more severe than a rating of 4. However, based on the information about Alex’s feelings (he becomes depressed occasionally; he is able to control his emotions), this rating is appropriate.

Scale: Voice


2 2.5 3.5 2.5

Impairment: Christine’s voice impairment is moderate/severe—a rating of 2, because of the poor quality of her voice, including poor control, hoarseness, lack of power, and losing her voice when she uses it excessively.

Activity Limitation: When she teaches, Christine’s voice use is limited, but she can communicate effectively in other situations, as long as there is not a lot of competing noise—an Activity Limitation rating of 2.5.

Participation Restriction: Christine’s participation in her family, social, and work life is restricted. However, she has been able to modify her teaching style so she can continue teaching—a rating of 3.5 is appropriate.

Distress/Wellbeing: Christine is reportedly very frustrated and also depressed by her voice problem, and has been seeking reassurance from her GP regarding recovery. However, she is able to control her emotions enough to continue in her job. A rating of 2.5 reflects Christine’s level of concern.

for both of these areas of language. As usual, make just one overall rating of Participation Restriction and Distress/Wellbeing.

Impairment: Voula scores 3 for expressive language impairment, as she is able to form simple sentences; and 3 for receptive language impairment because she understands concrete questions and directions, although she requires extra time and/or cues to do so.

Activity Limitation: In relation to expressive language, Voula scores 2, because she can make her needs and wants known through simple sentences. In relation to receptive language she is rated as 1, because she requires extra time, visual cues, and simplification of sentences to allow her to understand simple, concrete questions or directions.

Participation Restriction: Voula’s participation is extremely limited; she is unable to participate in tasks such as shopping without help, she cannot visit friends independently, and she has little control over her daily life—this shows a severe restriction (rating of 1).

Distress/Wellbeing: Voula is very upset, becomes distressed easily, and finds it hard to control her emotions—a rating of 1 for Distress/Wellbeing.

Scale: Speech


4 3.5 4.5 4

Impairment: Information rating to Ian’s speech impairment indicates that he has

difficulty sequencing motor movement, and that he may slur his words (‘sounds

drunk’) when speaking for a period of time or when he is tired. As the problem is

not noticeable to most others, Ian’s difficulty sits at the mild end, and a rating of

4 captures this.

Activity Limitation: Ian is limited in communicating with unfamiliar people, and there are specific situations where communication is more difficult for him (for example, in meetings where there is noise or interruptions). The fact that his communicative attempts are usually successful, with the exception of certain environments, puts this description at a rating of 3.5.

Participation Restriction: Ian has been restricted in some aspects of his work role, but is able to join in social events, such as functions and visiting friends. The description is slightly better than a rating of 4; Ian does not require assistance for social activities and shows control over his environment (e.g., he is able to request assistance with phone calls).

Distress/Wellbeing: The points of interest when rating Distress/Wellbeing are that Ian gets frustrated occasionally when others do not understand him, and sometimes feels frustrated by his slowed speech. Ian has made moves to counteract his difficulties, such as using his secretary, showing that he understands his limitations. This represents a mild problem— a rating of 4.


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Adult case 6: Christine

Adult case 5: alex

Adult case 4: Ian


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situation (that is, situations with no competing noise, and situations where he has the communication partner’s complete attention).

Participation Restriction: The description shows that Mark is restricted in his participation at school, and we know that he is restricted from participating at home because of the noisy environment. With support and assistance, Mark is able to participate in presentations at school. A rating of 2 reflects Mark’s level of restriction.

Distress/Wellbeing: Mark is described as being very distressed and embarrassed, avoiding school because of teasing, and responding to other children negatively. A rating of 1 shows the severe concern that Mark has about his voice problem.

Scale: Language


Expressive 1.5 10.5 4

Receptive 2.5 2

Discussion points: In this case study you need two ratings of the Impairment and

Activity Limitation domains: one for receptive language, and one for expressive

language.

Impairment: Danny’s expressive language is severely impaired—he uses only two

words meaningfully, babbles and uses repetitive phrases. A rating of 1.5 reflects Danny’s

limited use of meaningful words; he does not use meaningful verbalisation frequently

or consistently.

Danny’s receptive language is also impaired. A rating of 2.5 is appropriate because

Danny is able to comprehend simple language (a rating of 3), but requires cues such as

pointing to do so (a rating of 2).

Activity Limitation: Danny attempts to communicate, and uses a few words

meaningfully (to request), but is not able to make his needs and wants known—rating

of 1 for expressive language. Danny can follow simple directions if he is given extra

cues—a rating of 2 for receptive language.

Participation Restriction: Danny receives maximum assistance to participate at

kindergarten, and even with this help has very limited participation. He has limited

control over his environment at home, and does not make choices or decisions. A rating

of 0.5 is appropriate.

Distress/Wellbeing: Danny shows no concern or frustration. However, he is described

as needing encouragement and support in confusing or alarming situations, e.g., when

he is faced with an unfamiliar activity. A rating of 4 is appropriate.

Paediatric case answer

Scale: Fluency


4 4 5 5

Impairment: The main points about Malia’s impairment are that she has 3% syllables stuttered, with no secondary behaviours. This description is consistent with the mild end of the Impairment domain, and a rating of 4 is appropriate.

Activity Limitation: Malia communicates successfully with all communication partners, and these communication attempts are only slightly slowed by her dysfluency. She is described as speaking without obvious effort, and her dysfluencies are not noticeable to familiar people. Malia’s Activity Limitation rating fits with a rating of 4 (mild).

Participation Restriction: Malia has no participation restrictions—she joins in at school and at home with no difficulties. Malia’s description fits with a rating of 5, as she appears to have no difficulties in this area.

Distress/Wellbeing: Malia seems to be unaware of her dysfluencies—she is not upset by them, and she does not get teased. However, her parents are worried that she may get worse if she notices her problem, and are concerned about her future. In this case study, the parental concerns are a red herring—these are not taken into consideration when rating client Distress/Wellbeing, regarding Malia’s concerns. However, if you were setting goals in intervention to address her parents’ worries, you could make an additional rating of carer Distress/Wellbeing. That is, you would use the Distress/Wellbeing domain twice—once to rate Malia’s level of distress (in this case, a rating of 5, no difficulty), and once to rate her parents’ level of distress.

Scale: Voice


0 2 2 1

Impairment: Mark’s voice is not always aphonic, but at the time of the assessment, it is. Ratings using the AusTOMs are based on a ‘snapshot’ of how the client is functioning at that time; thus, Mark’s impairment is scored as 0 (no voice). An interim rating— when Mark’s voice has recovered from his acute aphonia, would be appropriate.

Activity Limitation: Mark is restricted in using his voice in situations with competing noise. While he is able to use his voice at school during quiet periods, he needs to get his mother’s complete attention to communicate his message at home. A rating of 2 has been chosen to reflect that Mark can communicate in more than one type of

Paediatric case 1: Malia

Paediatric case 2: Mark

Paediatric case 3: Danny


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Distress/Wellbeing: Jane is also having difficulty coping emotionally, and requires

counselling from a social worker—a rating of 2 shows Jane’s need for frequent

encouragement and support.

Scale: Cognitive-Communication


1 0.5 0 n/a

(rate later)

Discussion points:

Impairment: William blinks in response to environmental stimuli, but even this limited

response is delayed. A rating of 1 shows his severe impairment.

Activity Limitation: A rating of 0.5 shows that William’s activity is slightly more severe

than a rating of 1, as he is not responding to communication at all, but slightly less

severe than a rating of 0, as he does show a response to some stimuli.

Participation Restriction: You have to extrapolate the information needed here.

William is currently in hospital, and his ability to interact with his environment is

currently extremely limited—rating of 0.

Distress/Wellbeing: William’s cognitive status negates the possibility of rating his

distress/wellbeing. You would make an interim rating of William’s distress/wellbeing

once he is awake and aware enough to indicate his status. At this point, however, it

would be appropriate to rate the distress/wellbeing of William’s parents/carers if you

have goals relating to their level of distress.

Scale: Speech


4 4 5 4.5

Impairment: The age norms given show that Claire’s speech impairment is limited to

a few sound errors, which are not unusual but are usually resolved by her age: stopping

of /s/ and /f/, and fronting of /k/. She is able to use these sounds in some words, but not

in others, and is also able to copy her mother’s examples of some of these sounds. This

indicates a mild speech impairment, and a rating of 4.

Activity Limitation: Claire is rarely restricted in communicating her message, as most

of her communication partners are familiar and understand her nearly all of the time.

People unfamiliar with Claire’s speech can usually understand her when they know the

context. A rating of 4 reflects Claire’s mild activity limitation.

Participation Restriction: Claire is not restricted in her participation—she plays with

children at preschool and joins in with group activities. She is independent at home

and makes her own choices. A rating of 5 reflects that Claire has no difficulties with

participation.

Distress/Wellbeing: Claire is a happy child, and shows only occasional frustration when

people do not understand her,—a rating of 4.5.

Scale: Swallowing


1 1 2.5 (of mother) 2 (of mother)

Discussion points: Suzy is only eight weeks old, so it is more appropriate to make

a rating of her mother’s levels of participation and distress/wellbeing. You are more

likely to target change in Jane, rather than Suzy, in these areas. See Chapter 3 for more

information on rating Participation Restriction and Distress/Wellbeing when the client

is a baby or very young child.

Impairment: Suzy has severe feeding difficulties, characterised by a weak suck, fatigue,

and milk coming out of her nose because of her unrepaired palate. A rating of 1 is

appropriate.

Activity Limitation: Suzy is bottle-feeding using a modified teat, however she needs

nasogastric feeding to meet her nutritional needs, and a rating of 1 reflects this.

Participation Restriction: Suzy’s mother Jane is restricted in her work and social life

because of the level of care that Suzy needs, including frequent visits to doctors. The fact

that she has been asked to take time off work means that this is not a mild problem—a

rating of 2.5.

Paediatric case 4: Claire

Paediatric case 5: Suzy

Paediatric case 6: William


6 6


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AusTOMs demonstrates overall good reliability, and can be used by differing clinicians

to make comparable ratings of client outcomes.

Re-test reliability

Across all of the AusTOMs scales, we found re-test reliability to be generally satisfactory,

with high levels of agreement across most domains on most scales, approaching

80–100%.

The Language scale showed lower levels of agreement, but there were also lower returns

of follow up cases, limiting the analysis of this scale (Morris et al, 2005).

Further evidence of re-test reliability using the AusTOMs scales has been demonstrated

in Occupational Therapy by a detailed examination of the Self Care scale, where Intra-

class Correlation Coefficients (ICCs) of 0.74-0.94 were achieved (Scott, Unsworth,

Fricke and Taylor, 2004).

ValidityThroughout the development of the AusTOMs tools, we closely involved those who

will use the tool. Speech pathology, physiotherapy, and occupational therapy clinicians

across Australia made a large contribution to the development of the tool, in particular

to the written descriptors used for each level of each domain. Consumers (clients with

disabilities, along with client advocates) reviewed the scales and suggested changes to

the wording of the Participation Restriction and Distress/Wellbeing domains. Such

involvement enhances the AusTOMs’ face validity.

We further used clinicians’ ratings over a six-month period to examine the validity of

the scales. The results showed that the scales were able to discriminate change in client

status over time (from admission to discharge). For detailed information on scale

development and face validity, refer to Perry et al, 2004.

The validity of the AusTOMs Swallowing scale was further examined in an in-depth

look at the data collected on this scale during the AusTOMs study (Skeat and Perry,

2005). We examined profiles of change over time to determine whether the tool

was able to demonstrate the differences that we would expect to see across patient

groups. The results showed that the AusTOMs Swallowing scale demonstrated

expected differences in the profile of change over time for clients seen in acute versus

subacute settings, with patients in acute settings tending to demonstrate change in the

Impairment and Activity Limitation domains, versus subacute settings where more

positive changes in Activity Limitation and Distress/Wellbeing domains were seen, with

fewer patients demonstrating Impairment level changes. Further, the tool demonstrated

discriminant profiles for people with acquired neurological conditions and those with

progressive neurological conditions. Specifically, while those with acquired conditions

showed positive changes over time across all four domains, people with progressive

neurologic conditions tended to have static ratings from assessment to discharge across

all four domains, which is in line with expected functional performance for these

patient groups across a 6 month period.

A construct (concurrent) validity study was undertaken by comparing client data

collected by the three professions on the AusTOMs with data collected on the EQ-5D,

a short form generic measure of health status rated by patients (Unsworth et al, 2004).

This chapter of the manual provides you with an overview of the reliability, validity and

sensitivity of the AusTOMs scales.

Reliability refers to the reproducibility of measurement, whereas validity refers to the

extent to which a measure captures the required information, is accurate, discriminates

different levels of performance and relates to a strong theoretical construct. Sensitivity

relates to the tool’s ability to indicate change. Outcome measurement tools such

as AusTOMs need to demonstrate all of these variables, in order to accurately and

consistently evaluate client outcomes in clinical practice.

ReliabilityInter-rater reliability

We have examined the inter-observer agreement between clinicians’ ratings for all

scales (Morris et al, 2005). To do this, we trained 150 speech pathology, occupational

therapy and physiotherapy clinicians using practice case vignettes, prepared by panels

of experts and similar to those provided in this manual. Clinicians were encouraged

to first discuss and compare ratings, and then were asked to make ratings of case

vignettes without discussion. From this we obtained percentage agreement scores across

clinicians for each domain.

We then determined retest-reliability of scores four weeks after the initial training, by

measuring the agreement between ratings made at training sessions, and ratings made

at follow-up sessions by each therapist.

All speech pathology scales showed high levels of inter-rater agreement, although some

domains had less than 80% agreement, and this varied for child versus adult cases

(Morris et al, 2005). Participation Restriction and Distress/Wellbeing tended to be

more difficult to rate reliably, meaning that these domains were interpreted in different

ways by different professionals. We believe this reflects that the main focus for allied

health professionals is on impairment and activity limitations rather than societal

participation and/or wellbeing, and the fact that there are more standardized measures

to support ratings in the former domains than the latter. However, we feel that the

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We asked 205 clients to score themselves on EQ-5D, and the same clients were scored

by approximately 115 therapists, using the AusTOMs at admission and discharge.

Moderate to strong statistically significant correlations between the AusTOMs and

EQ-5D were found, providing evidence that the AusTOMs and EQ-5D were both

measuring global health outcomes (Unsworth et al, 2004).

The validity of a tool is never fully confirmed. Many studies are required over time to

demonstrate that a tool is operating in the manner that developers intended. In future

validity studies to investigate the ability of AusTOMs to predict client discharge data

from admission status, and to discriminate between clients with differing impairment

severity levels and activity limitations, could be designed.

SensitivityThe sensitivity of the AusTOMs tool was investigated through a large, multi-site study

in which therapists across SP, OT and PT collected outcomes data on over 1000 adult

and paediatric clients who accessed acute and rehabilitation services across Victoria.

The tool demonstrated sensitivity to change over time for a broad range of client

diagnoses.

Skeat and Perry (2005) then investigated the sensitivity of the Swallowing scale of the

AusTOMs in depth. They found that, on average, clients made a clinically significant

(one point) change from admission to discharge on the Impairment and Activity

Limitation domains, and a 0.5 point change on the Participation Restriction and

Distress/Wellbeing domains.

Use of AusTOMs for Speech PathologyThe original AusTOMs study gave us some insights into the clinical usefulness of the

tool, discussed in Skeat and Perry (2004). We found that clinicians reported that it the

AusTOMs took less time to use than they had originally thought, but that they found it

difficult to remember to use the tool, since they were not used to doing so.

Given the research context for the AusTOMs study, it was not possible to truly evaluate

the clinical utility of the tool to support clinicians and managers to evaluate (and

ultimately to improve) patient outcomes. However, since the development of the tool,

we have been able to observe its usefulness in describing outcomes in a number of

clinical studies. These studies demonstrate some of the ways in which clinicians use

outcome measures to formally investigate clinical questions about patients or groups

of patients. A list of relevant research publications where the AusTOMs for Speech

Pathology has been used is included in at the end of this manual, see page 50.

8Collecting AusTOMs Data

C h a p t e r e I G h t

To be able to use AusTOMs data for purposes such as monitoring or comparing service

quality, you need to collect AusTOMs ratings alongside other data. This may include:

client codes (e.g., UR number), aetiology/disorder codes, number of sessions (or

amount of contact/resources), type of treatment, therapist level (e.g., grade 1; senior)

and other variables. The data you collect alongside the AusTOMs will depend on the

reason for which you are using the tool. For example,

nn If you wish to examine/compare outcome in relation to treatment types, you need to collect a code (or name) for the type of treatment. You may wish to indicate whether the treatment was group or individual, or what particular intervention type you used, depending on your question;

nn If you wish to look at service efficiency, you will need to collect outcome data alongside an indicator of resource use, such as the amount of time that a clinician spends with each client;

nn If you wish to make comparisons across centres (benchmarking), each centre needs to collect the same variables, and use comparable codes (e.g., for aetiology/disorder, treatment type, and sessions/resources).

In each case, it is important that every clinician using codes (e.g., for treatment

type) understands how they are to be used, and uses them reliably. The above is not

an exhaustive list of suggestions, and you will need to determine for yourself which

variables are likely to be of interest for you to collect alongside AusTOMs data. You

may already collect many of these variables (such as aetiology codes and number of

contacts) within a statistics system at your workplace. In this case, the AusTOMs data

could perhaps be added to this system, so that data are not collected twice.

The following pages show an example AusTOMs for Speech Pathology data collection

form, and a list of aetiology/disorder codes.

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8 Collecting contextual data along with AusTOMs dataTo be able to use AusTOMs data for purposes such as monitoring or comparing service quality, you need to collect AusTOMs ratings alongside other data. This may include: client codes (e.g., UR number), ICD-10 codes to describe the disorder, number of sessions (or amount of contact/resources), type of treatment, therapist level (e.g., grade 1; senior) and many other variables. The variables (data) you collect alongside the AusTOMs will depend on the reason you are using the tool. For example:

nn If you wish to examine/compare outcomes in relation to treatment types, you need to collect a code (or name) for the type of treatment. You may wish to indicate whether the treatment was group or individual, or what particular therapy type you used, depending on your question;

nn If you wish to look at service efficiency, you will need to collect outcome data alongside an indicator of resource use, such as the amount of time that a clinician spends with each client;

nn If you wish to make comparisons across centres (benchmarking), each centre needs to collect the same variables, and use comparable codes (e.g., ICD-10 codes, treatment type, and sessions/resources).

In each case, it is important that every clinician using codes (e.g., for treatment type) understands how they are to be used, and uses them reliably. This is not an exhaustive list of suggestions, and you will need to determine for yourself which variables are likely to be of interest to you to collect alongside AusTOMs data. You may already collect many of these variables (such as aetiology codes and number of contacts) within a statistics system in your workplace. In this case, it is ideal if the AusTOMs data can be added to this system, so that data are not collected twice.

Example completed data collection forma

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Example disorder and aetiology codesWe suggest that you use disorder and/or aetiology codes alongside AusTOMs ratings

so that you can usefully group patients when examining outcomes. The level of coding

needs to be tailored to your specific question. For example, if you wish to examine client

outcomes for different groups of clients with progressive neurological diseases, you may

want to code each type of disease (e.g., M.S., Parkinson’s disease) separately.

The following list is one example of aetiology and disorder codes, developed from the

list contained in the UK Therapy Outcome Measures manual (Enderby & John, 1997)

and clinician feedback during the development of the AusTOMs. It is also possible to

use existing coding systems, such as ICD-10 Disorder Codes, which can be found online

at http://www.who.int/classifications/apps/icd/icd10online/.

Disorder Aetiology1. Disorder of fluency

2. Disorder of voice

3. Acquired language disorder (aphasia/

dysphasia)

4. Dyslexia

5. Dysarthria

6. Dyspraxia (acquired)

7. Dysphagia/ Feeding disorder

8. Autistic communication disorder

9. Semantic-pragmatic disorder

10. Developmental language impairment

11. Developmental articulation

impairment

12. Developmental phonological

impairment

13. Deaf speech/language

14. Hyper/hyponasality

15. Cleft palate speech

16. General learning disability

17. Behavioural

18. Sensory/perceptual impairment

19. Cognitive impairment

20. Trache management

21. Childhood apraxia of speech

(Developmental verbal dyspraxia)

1. Mental illness

2. Cardiovascular

3. Acquired neurological

4. Neurosurgical

5. Craniofacial (e.g., cleft palate)

6. Oncology

7. Progressive neurological disease

(e.g. Parkinsons disease, Multiple

Sclerosis)

8. Voice pathology (e.g., nodules)

9. Burns/plastic

10. Cerebral palsy

11. Autistic/Asperger’s syndrome

12. Multifactorial (elderly)

13. Visual problems/blind

14. Epilepsy

15. Respiratory (e.g., COAD)

16. Transplant

17. Metabolic

18. Nothing abnormal detected

19. Not yet diagnosed

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R E F E R E N C E S

References Used in this manualBrunner, M., Skeat, J., & Morris, M. E. (2008). Outcomes of speech-language pathology

following stroke: Investigation of inpatient rehabilitation and rehabilitation in the home

programs. International journal of speech-language pathology, 10(5), 305-313.

Enderby, P., & John, A. (1997). Therapy outcome measures for speech and language

pathology. San Diego, CA: Singular.

Enderby, P., John, A., & Petherham, B. (1998). Therapy outcome measures manual:

physiotherapy, occupational therapy, rehabilitation nursing. San Diego, CA: Singular.

Enderby, P., John, A., & Petheram, B. (2006). Therapy Outcome Measures for

Rehabilitation Professionals: Speech and Language Therapy, Physiotherapy,

Occupational Therapy (2nd Edition). UK: Wiley

Morris, M., Perry, A., Unsworth, C., Skeat, J., Taylor, N., Dodd, K., Duncombe., D.,

& Duckett, S. (2005). Reliability of the Australian Therapy Outcome Measures for

quantifying disability and health. International Journal of Therapy and Rehabilitation,

12(8), 340-346

Perry, A., Morris, M., Unsworth, C., Duckett, S., Skeat, J., Dodd, K., Taylor, N., & Reilly,

K. (2004). Therapy outcome measures for allied health practitioners in Australia: The

AusTOMs. International Journal for Quality in Health Care, 16(4), 1-7.

Scott, F., Unsworth, C.A., Fricke, J., Taylor, N. (2006). Reliability of the Australian

Therapy Outcome Measures for Occupational Therapy (AusTOMs – OT) Self-care

scale. Australian Occupational Therapy Journal, 53, 265- 276.

Semel, E., Wiig, E., Secord, W. (2006). Clinical Evaluation of Language Fundamentals,

Fourth Edition, Australian Standardised Edition (CELF-4 Australian). Pearson Clinical.

Skeat, J., & Perry, A. (2004). Outcomes in practice: Lessons from AusTOMs. ACQuiring

Knowledge in Speech, Language and Hearing, 6, 123-126.

Skeat, J., & Perry, A. (2005). Outcome Measurement in Dysphagia: Not So Hard to

Swallow. Dysphagia, 20(2), 113-122.

Skeat, J., & Perry, A. (2008). Exploring the implementation and use of outcome

measurement in practice: a qualitative study. International Journal of Language &

Communication Disorders, 43(2), 110-125.

Unsworth, C., Duckett, S., Duncombe, D., Perry, A., Skeat, J., Taylor., N. (2004).

Validity of the AusTOM Scales: A comparison of the AusTOMs and EuroQol-5D.

Health and Quality of Life Outcomes,2, 1- 12.

World Health Organization. (2001). International classification of functioning,

disability and health (ICF). Geneva, Switzerland: WHO.

AusTOMs developmentAbu-Awad, Y., Unsworth, C.A., Coulson, M., & Sarigiannis, M. (2013 accepted). Using

the Australian Therapy Outcome Measures for Occupational Therapy (AusTOMs-OT)

to measure client participation outcomes. British Journal of Occupational Therapy.

Fristedt, S., Elgmark, E. & Unsworth, C.A. (2013). Reliability of the Swedish translation

of the Australian Therapy Outcome Measures for occupational therapy. Scandinavian

Journal of Occupational Therapy, 20, 182- 189.

Morris, M., Perry, A., Unsworth, C., Skeat, J., Taylor, N., Dodd, K., Duncombe., D.,

& Duckett, S. (2005). Reliability of the Australian Therapy Outcome Measures for

quantifying disability and health. International Journal of Therapy and Rehabilitation,

12(8), 340-346.

Perry, A., Morris, M., Unsworth, C., Duckett, S., Skeat, J., Dodd, K., Taylor, N. & Riley,

K. (2004). Therapy Outcome Measures for Allied Health Practitioners in Australia: The

AusTOMs. International Journal for quality in Health Care, 16 (4), 285- 291.

Scott, F., Unsworth, C.A., Fricke, J., Taylor, N. (2006). Reliability of the Australian

Therapy Outcome Measures for Occupational Therapy (AusTOMs – OT) Self-care

scale. Australian Occupational Therapy Journal,, 53, 265- 276.

Skeat, J., & Perry, A. (2004).Outcomes in practice: Lessons from AusTOMs. ACQuiring

knowledge in Speech, language and Hearing, 6 (3), 123- 126.

Skeat, J., & Perry, A. (2005). Outcome measurement in dysphagia: Not so hard to

swallow. Dysphagia, 20 (2), 390-399.

Skeat, J., Perry, A., Morris, M., Unsworth, C., Duckett, S., Dodd, K., Taylor, N. (2003).

The use of the ICF framework in an allied health outcome measure: Australian Therapy

Outcome Measures (AusTOMs). In Australian Institute of Health and Welfare, ICF

Australian user guide. Version 1.0. (pp. 77- 81). Canberra: Australian Institute of Health

and Welfare.

Unsworth, C.A.(2005). Measuring outcomes using the Australian Therapy Outcome

Measures for Occupational Therapy (AusTOMs - OT): Data description and tool

sensitivity. British Journal of Occupational Therapy,68(8), 354- 36

Unsworth, C.A., & Duncombe, D. (2005). A comparison of client outcomes from

two acute care neurological services using self care data from the Australian Therapy

Outcome Measures for Occupational Therapy (AusTOMs - OT). British Journal of

Occupational Therapy, 68(10), 477- 482.

Unsworth, C., Duckett, S., Duncombe, D., Perry, A., Skeat, J., Taylor., N. (2004).

Validity of the AusTOM Scales: A comparison of the AusTOMs and EuroQol-5D.

Health and Quality of Life Outcomes,2, 1- 12.


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Use of AusTOMs for Speech Pathology scales in clinical researchBrunner, M., Skeat, J., & Morris, M. E. (2008). Outcomes of speech-language pathology

following stroke: Investigation of inpatient rehabilitation and rehabilitation in the home

programs. International journal of speech-language pathology, 10(5), 305-313.

Cheung, W., Clayton, N., Tan, J., Milliss, D., Thanakrishnan, G., Maitz, P. (2013). The

effect of endotracheal tube size on voice and swallowing function in patients with

thermal burn injury: An evaluation using the Australian Therapy Outcome Measures

(AusTOMS). International Journal of Speech-Language Pathology, 15, 216-220.

Frowen, J., Cotton, S., Corry, J., & Perry, A. (2010). Impact of demographics, tumor

characteristics, and treatment factors on swallowing after (chemo) radiotherapy for

head and neck cancer. Head & neck, 32(4), 513-528.

Frowen, J., Hornby, C., Collins, M., Senthi, S., Cassumbhoy, R., and Corry, J. (2013)

Reducing posttreatment dysphagia: Support for the relationship between radiation dose

to the pharyngeal constrictors and swallowing outcomes. Practical Radiation Oncology

[online before print publication] http://dx.doi.org/10.1016/j.prro.2012.11.009

Maclean, J., Szczesniak, M., Cotton, S., Cook, I., & Perry, A. (2011). Impact of a

laryngectomy and surgical closure technique on swallow biomechanics and dysphagia

severity. Otolaryngology--Head and Neck Surgery, 144(1), 21-28.

McLeod, S., Harrison, L. J., McAllister, L., & McCormack, J. (2013). Speech sound

disorders in a community study of preschool children. American Journal of Speech-

Language Pathology, 22(3), 503.

Stocks, R., Dacakis, G., Phyland, D., & Rose, M. (2009). The effect of smooth speech

on the speech production of an individual with ataxic dysarthria. Brain Injury, 23(10),

820-829.

Taylor, O. D., Ware, R. S., & Weir, K. A. (2012). Speech Pathology Services to Children

With Cancer and Nonmalignant Hematological Disorders. Journal of Pediatric

Oncology Nursing, 29(2), 98-108.

Ward, E., Crombie, J., Trickey, M., Hill, A., Theodoros, D., & Russell, T. (2009).

Assessment of communication and swallowing post-laryngectomy: a telerehabilitation

trial. Journal of Telemedicine and Telecare, 15(5), 232-237.

Wenke, R. J., Theodoros, D., & Cornwell, P. (2008). The short-and long-term

effectiveness of the LSVT® for dysarthria following TBI and stroke. Brain Injury, 22(4),

339-352.

Appendix A: AustTOMs core scaleThe core scale is the common basis for the disorder-specific AusTOMs scales. Each of the AusTOMs scales follows this format. When rating clients, use the disorder-specific scales that come with this manual.

IMPAIRMENT OF EITHER STRUCTURE OR FUNCTION (AS APPROPRIATE TO AGE): Impairments are problems in body structure (anatomical) or function (physiological) as a deviation or loss.0 The most severe presentation of impairment 1 Severe presentation of this impairment2 Moderate/severe presentation3 Moderate presentation4 Mild presentation5 No impairment of structure or function

ACTIVITY LIMITATION (AS APPROPRIATE TO AGE): Activity limitation results from the difficulty in the performance of an activity. Activity is the execution of a task by the individual. 0 Complete difficulty1 Severe difficulty 2 Moderate/severe difficulty3 Moderate difficulty4 Mild difficulty5 No difficulty

PARTICIPATION RESTRICTION (AS APPROPRIATE TO AGE): Participation restrictions are difficulties the individual may have in the manner or extent of involvement in their life situation. Clinicians should ask themselves: “given their problem, is this individual experiencing disadvantage?” 0 Unable to fulfill social, work, educational or family roles. No social integration. No involvement in decision-making. No control over environment. Unable to reach potential in any situation. 1 Severe difficulties in fulfilling social, work, educational or family roles. Very limited social integration. Very limited involvement in decision-making. Very little control over environment. Can only rarely reach potential with maximum assistance.2 Moderately severe difficulties in fulfilling social, work, educational or family roles. Limited social integration. Limited involvement in decision-making. Control over environment in one setting only. Usually reaches potential with maximum assistance.3 Moderate difficulties in fulfilling social, work, educational or family roles. Relies on moderate assistance for social integration. Limited involvement in decision-making. Control over environment in more than one setting. Always reaches potential with maximum assistance and sometimes reaches potential without assistance.4 Mild difficulties in fulfilling social, work, educational or family roles. Needs little assistance for social integration and decision-making. Control over environment in more than one setting. Reaches potential with little assistance.5 No difficulties in fulfilling social, work, educational or family roles. No assistance required for social integration or decision-making. Control over environment in all settings. Reaches potential with no assistance.

DISTRESS/WELLBEING (AS APPROPRIATE TO AGE): The level of concern experienced by the individual. Concern may be evidenced by anger, frustration, apathy, depression etc.0 High and consistent levels of distress or concern.1 Severe concern, becomes distressed or concerned easily. Requires constant reassurance. Loses emotional control easily.2 Moderately severe concern. Frequent emotional encouragement and reassurance required.3 Moderate concern. May be able to manage emotions at times, although may require some encouragement.4 Mild concern. Able to manage emotions in most situations. Occasional emotional support or encouragement needed.

5 Able to cope with most situations. Accepts and understands own limitations.


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Documents

AusTOMs - Amazon S3 · AusTOMs speech pathology scales. There are also AusTOMs scales available for occupational therapists and physiotherapists. As all three sets of scales are based