Speech therapy provision in a social education centre: IS IT POSSIBLE TO TARGET INTERVENTION?

MENTAL HANDICAP VOL. 19 MARCH 1991

Speech therapy provision in a social education centre:

IS IT POSSIBLE TO TARGET INTERVENTION?

James Law Rochelle Lester

There is limited provision of speech therapy resources to social education centres throughout the UK. Thus the need to provide the best possible service is particularly pressing. This article describes a short initial measure for determining SEC students’ needs which will allow grouping for more thorough, ongoing assessment. Five different treatment groups are proposed.

The assessment measure comprises a simple questionnaire, for use with student and key worker together, which can be reliably used to group students. It is suggested that it can be used in the first instance without the speech therapist having prior knowledge of the student. The implications of the measure are discussed.

The Independent Development Council (1985) reported that as many as 46,000 people attend adult training centres (ATCs), social education centres (SECs) or special care units (SCUs) in England and Wales. McCartney, Kellett, and Warner (1984) indicated that 59 per cent of ATCs had weekly visits from speech therapists, while 21 per cent had visits monthly or “as required”. Ferris Taylor (1985) pointed out that this represents a gradual increase in speech therapy provision for adults with mental handicaps.

The proportion of adults with mental handicaps n e d n g speech therapy provision remains uncertain. Aarons (1981), for example, has suggested that the increase in resources is more a function of past neglect of the area, and consequent feelings of guilt, than any indication that treatment is effective. Farmer and Rohde (1981) maintain that there is “an almost open-ended need for speech therapy” in this population. In an informal survey (City and Hackney Speech Therapy Department, 1988), 77 per cent of pupils

in a school for children with severe learning difficulties within Hackney were thought to be in need of speech therapy. Stansfield (1989) found that the prevalence of speech problems was significantly higher in two groups of adults with mental handicaps - those attending ATCs and those living in hospital -than it was in the general population. In that study, 53 per cent of adults attending ATCs, and 57 per cent of those in hospital, had some sort of speech problem, most frequently stammering.

Enderby and Phillipp (1986) estimated a prevalence figure of 4.3 per cent for people experiencing speech or language problems in the population as a whole. The discrepancy between this figure and those estimated for adults with mental handicaps indicates that service provision for this group needs careful planning. This article presents one approach to organising such provision.

An issue of management City and Hackney Health Authority Speech

Therapy Department pursues an active policy towards adults with mental handicaps (Cameron, Lester, and Lacey, 1988). As in many other health districts, a speech therapist has been appointed who has special responsibility for them. Neverthe- less, referral for speech-therapy for this group of adults has been something of a random process. Therapists felt that a more global perspective was necessary if people in most need of speech therapy provision were to receive access to the resources available.

Three options presented themselves.

0 The first was to continue the existing approach, adults being selected for referral for speech therapy according to

JAMES LAW is a Lecturer in the Department of Clinical Communication Studies, City University, St. John Street, London EC1 and ROCHELLE LESTER is a Principal Speech Therapist at St. Leonard’s Hospital, Nuttall Street, London N1.

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the expectations of their key workers. This approach obviously reflects workers’ understanding of the role of the speech therapist. The second was for the speech therapist to formally assess all the adults within a given centre.

0 The third was to develop an accurate, but abbreviated, method of identifying appropriate adults.

0

Of these options, the first was rejected because only a comparatively small sample of adults would be covered. The second was rejected because, standardised tests available are either too specific, such as the British Picture Vocabulary Scales (Lloyd and Dunn, 19821, or they are too extensive as initial assessments, for example, the AAMD Adaptive Behavior Scale (Nihira et al, 19751, the Communicative Ground Scale (Leudar, 1988) and the Communication Assessment Profile for Adults with a Mental Handicap (van de Gaag, 1988). While these assessments could undoubtedly have been helpful, their use in the first instance would not have been an economical use of time.

The third option was, therefore, adopted. A study would be undertaken, concerned with the initial grouping of a number of SEC students, who could then be assessed on the basis of their communication skills.

The assessment measure A search was made for a key group of questions

which would allow speech therapists to allocate the students to a set of predetermined assessment groups. The questions were to permit therapists, who did not have extensive knowledge of the individual students to group them with others on a broadly similar level.

The short questionnaire that was developed was administered to students and their key workers, together, at one social education centre in an inner city health district.

The study had two pilot phases in which first four and then 30 students were given the questionnaire. Certain changes were made to the questionnaire as a result. In the main study, a further 50 students were given the questionnaire and the original 34 were re-examined in the light of the changes that had been made. This resulted in the grouping of a total of 84 students.

Study questions

questions. The study sought to answer the following

0 What proportion of SEC students need input from the speech therapy service?

0 Is it possible to identify students who do need speech therapy on the basis of a short questionnaire administered during individual interviews with students and their key workers? Is it possible to use this short questionnaire to allocate students to a set of predetermined assessment groups?

0

Speech therapy groups Initially, five assessment groups were devised

from the clinical experience of one of the authors (RL), as shown in Figure 1.

At this stage no specific reference was made to the type of activities on which each group would be working.

The pilot study The pilot study was divided into two sections.

Phase 1 Initially, four students were interviewed with

their key workers. Where possible they were encouraged to answer for themselves, so to begin with the questions used the second person pronoun, “YQU”. However, students often found it hard to answer, and so the opinion of their key worker was sought.

Four questions were used to group the students at this stage, as shown in Figure 2.

Two examples will serve to illustrate the procedure for allocation of students to the groups, according to the responses obtained.

1

2

3

4

5

~

7

Requirements of group members

a preverbal group, whose members were likely to be in need of basic work using different sensory environments; a group whose members had low levels of comprehension and expression, who were likely to need general language work and the possible introduction and maintenance of a signing system; a group whose members had comparatively high levels of comprehension and expression, whose primary need was for work on social skills; a group whose members had low levels of comprehension but high levels of expression, who often used highly stereotyped or echoed responses; and a group whose members were considered to need no further involvement.

FIGURE 1. The five groups identified prior to the study

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1. Which is the student’s most effective method of communication in the centre? Speech igesture i Makaton iother Can he/she respond verbally to open-ended questions? Yeslno

appropriate? Yeslno Can he/she make choices about what heishe wants?

2.

3. If heishe responds, are the responses

4.

FIGURE 2. Four questions used for grouping students during Phase 1 of the pilot study

Example 1 Mary is 34 years old. She copes reasonably well

with the routine of the mntre but finds it difficult to follow unfamiliar requests. Her abilities are sometimes difficult to assess because she frequently repeats what she has been asked to do without seeming to understand. In response to question 1 the answer was “speech”; to question 2 the answer was “yes”; to question 3 the answer was “no”; and to question 4 the answer was “yes”. From this Mary was allocated to Group 4. Example 2

Tom is 26 years of age. He does not generally participate in the activities of the centre, unless actively encouraged to do so by a member of the st&. To question 1 the answer was “other”; to question 2 the answer was “no”; to question 3 the answer was “no”; and to question 4 the answer was also “no”. Tom was allocated to Group 1.

The allocation to groups at this stage was made according to the criteria laid down in Table 1.

Question Group

KEY: sp=speech; g=gesture; m=makaton; o=other * indicates a likely sigdicant negative response

TABLE 1. Criteria for allocation to the five groups identified for Phase 1 of the pilot study

As a result of Phase 1 of the pilot study the following three sets of changes were introduced.

0 The possible responses to the questions were expanded slightly to allow for greater subtlety of interpretation. Thus, a gradation of response was possible, in question 2, for example: Always, Usually, Rarely, Never.

0 It was thought essential to have some information about each student’s medical and social background which might affect the issue of intervention. This resulted in questions 1 to 3 of Section One of the questionnaire illustrated in Figure 3. These questions relate to fadors which can make a student’s communication skills more difficult to assess. So, if a student had marked physical difficulties or was receiving medication which affected behaviour, for example, this could be noted at the outset as a possible confounding factor. Similarly , knowing that a student used a language at home which was different from the one used in the SEC meant that particular care could be taken in assessing that person’s individual needs.

It was recognised that the distinction between the group needing work on social skills and the group for whom no further involvement was necessary was difficult to make on the basis of the student and key worker responses to these questions. Another question was therefore added, asking how much help with communication skills was considered necessary. This was of greatest use when either a student or a key worker was adamant that no further intervention was needed. In effect, it enabled each student or key worker to seek or to opt out of potential speech therapy provision. This is different from the situation referred to earlier, in which only the most interested parties became involved with the speech therapy service.

0

Phase 2 The new questionnaire was administered to a

further 30 students. Seven were considered to have no need for speech therapy, one was placed in Group 1, one in Group 2, seven in Group 3, and five in Group 4. The other nine students could not be correctly placed in any of the five groups. This number was unacceptably high. Further examination showed that they could be correctly placed if the following two groups were added:



1. Does the student have any conditions

Student’s name: ............................................................. Address: ........................................................................

Date of birth: ................................................................. Date of screening: ...........................................................

Interviewer: ................................................................... Interviewee@): ............................................................... ........................................................................

I Don’t know Yes NO Specify such as: Hearing difficulties Visual difficulties Physical difficulties Epilepsy Other

2. 1s s I he on medication?

I ~

I Yes c3 No Don’tknow CI

If yes, can you specify the medication and reason for taking it? ..........................................................................................................................................................................

3. Does s h e have more than one language Yes NO Don’tknow 0 in herlhis background or environment? If yes, please specify languages: ......................................................................................................................

How much help do you think s/he needs with communication skills? (Communication skills refers to ability to understand and to use speech and language and to interact appropriately with others.)

4.

Daily c[ Frequently Sometimes [3 Aboutonce c] None 0 Don’tknow I7 each week each week each week each week

SECTION 2 5.

ti.

Which is herlhis most effective communicating with you in the

Speech

Gesture

Makaton

Body language e.g. turns away

v ocalisations (not speech)

Don’t know 0

way of centre?

I I

a) Can s/he respond to open-ended questions, e.g. “What have you been doing today?”, with speech or signs?

Are the responses appropriate (response relevant to the question/conversation)? Always Usually Rarely Never CI

Always r] Usually Rarely Never c] NotApplicable e7 b,

C) If sihe uses speech, how clear is it to strangers‘> Unintelligble CI Always Usually Usually difficult

clear El clear to understand

Doesn’t use speech Any other comments: ............................................................................................................................................. .................................................................................................................................................................................

FIGURE 3. Questionnaire used as a measure for screening communication difficulties



Group

Preverbal

Low expression /low comprehension

Social skills

Low comprehension /high expression

Intelligibility

Unplaced

No involvement

FIGURE 4. The seven groups identified after Phase 2 of the pilot study

a group whose members had reasonable comprehension but whom it was very difficult to understand;

a group whose members could not be reasonably placed at all.

The first of these additional groups was known as the “intelligibility group”. To identify members of this group the final questionnaire (Figure 3) contained an extra question, 6c.

The final seven groups identified are listed in Figure 4. Using the questionnaire, student profiles were predicted as shown in Table 2.

KEY: sp=speech; g=gesture; m=makaton; bl =body language; v=vocalisation

indicates likely significant response (ie shaded area on form)

TABLE 2. Criteria for allocation to the seven groups following Phase 2 of the pilot study

1

Phase 3 The final questionnaire was administered to a

further 50 students and their key workers. It was also reapplied to the students questioned in Phase 1 and Phase 2 of the pilot study. This gave a total of 84 students for whom results were available.

Students or their key workers were presented the questions as they are worded in Figure 3. Each question was considered to have a significant response which contributed to group allocation. These are represented by the shaded areas on the form.

Thus, in Section 1 question 1, the significant response is that there was a contributory condition which needed to be taken into consideration before any further allocation to groups was carried out. A tick in the shaded area here would result in the student being put in the “unplaced group” (Group 6) until a fuller assessment of needs had been carried out.

Where responses did not fall in the shaded areas these were not considered significant from the point of view of the assessment. Thus, in Section 1 question 1, the fact that there were no contributory handicaps only meant that Group 6 was ruled out as an option at this point. If it were then ruled out for questions 2 and 3 as well, it would not be a relevant option for the whole sample.

Results The number of students allocated to each group

is shown in Table 3, allocations being made according to responses to questions in shaded areas of the questionnaire, as shown in Figure 5.

There is a possible circularity in such a classification system. Therapists carrying out the questionnaire and knowing the students might be predisposed to group people on the basis of personal knowledge rather than on the information gleaned from the questionnaire.

To avoid this, in this study the other author (JL), who had no knowledge of the students or of how the first author had grouped them, also examined the questionnaire forms and, relying solely on the answers to the questions, made an independent judgement as to which group each student should be allocated. Using this method, the second author placed 12 students in different groups from those chosen by the first author. This resulted in a percentage agreement of 86 per cent (Sackett, 1978). The disagreements were subsequently resolved following discussion of each student’s placement by the two authors.

Reliability does not in itself presuppose validity. In other words, because two therapists can be shown to agree on the scoring of a particular measure it does not necessarily follow that the



2

3

4

5

measure actually does what it sets out to do. The problem comes in ascertaining a criterion. No standardised assessment procedure can be said to operate in the same fashion as the present measure. The Communication Assessment Profile (van de Gaag, 1988) comes some way towards this, but it does not try to group adults in a similar fashion, concentrating instead on establishing “priorities for change”. There is no way in which the scores or profiles derived from that assessment could be said to be comparable to those obtained using the present measure.

One means of evaluating this short measure is to look at the performance of the students questioned once they have been through the system of assessment groups operated. However, this is likely to be a rather unsatisfactory option because once they pass through the groups a variety of different treatment options become available to them. In other words the assessment groups are designed to operate in the short-term only, and as specific needs are identified these are met in a variety of different ways. In the final analysis, the short screening measure described, together with the assessment groups, effectively leads to programmes that are tailor-made. Individual students will be allocated to a variety of ongoing groups; some to more than one group, others being offered treatment on a one-to-one basis.

Low comprehensionilow expression

Social skills

Low comprehensionihigh expression

Intelligibility

Conclusion In answer to the questions raised at the

beginning of this article, 81 per cent of the students in the SEC studied were considered to be in need of help with their communication skills. Of the 84

I I

I 1 I Preverbal I I

KF-!--- No involvement

TOTAL

30.9

TABLE 3. Number of students allocated to each of the seven groups

Questionnaire

SECTION 1 Question:

SECTION 2 Question:

Question:

Allocated Group

1 .-> Group6

2 -> Group6

3 -> Group6

4 -> Group7

5 ‘speech’ .-> Group 1

‘gesture’ -) Group 2

‘makaton’ -) Group 2

‘body language’ 3 Group 1

‘vocalisations’ + Group 1

6 a) ~-) Group 3,4, or 5

b, -> Group 4

c) -> Group5 _ _ - FIGURE 5. Group allocation according to responses to

questions in shaded areas of questionnaire

students questioned, 16 were considered not to need any speech therapy involvement, seven were unplaced, and the remainder were placed in one of five treatment groups, purely by means of the short questionnaire. These five groups have, to date, proved appropriate from the perspective of key worker and speech therapist alike. The questionnaire has proved to be economical of limited speech therapy resources, taking no more than 10 minutes to administer.

Additional benefits were gained from the participation of key workers (care staff3 from the inception of the project. Clearly, as Peck and Hong (1988) have pointed out, treatment should revolve around care workers and carers rather than therapists. Informal reports have indicated a positive response to key workers’ involvement in the original questionnaire and in the subsequent assessment groups. It should be stressed that, although the questionnaire has been designed to stand on its own, it should not simply be seen as an assessment. Rather, it should be as a means of focusing on the communication skills of individual students, which should lead on to a discussion of the assessment findings and specific treatment objectives. Key workers are seen as an integral part of each stage of this process.

A further benefit has been increased awareness of the importance of communication by SEC staff. A number of authors (van de Gaag, 1988; Peck and Hong, 1988) have stressed the need for an optimum environment for communication. In the end it is the awareness of staff as to the issues involved which will improve this environment.



REFERENCES with the mentally

College of Speech Therapists, 1981; 349-1-2.

Cameron, L., Lester, R., Lacey, B. Developing interaction and initiation skills in a group of adults with learning difficulties. Bulletin of the Colle e of Speech Thempists, 1988; 438,3.

Peck, 8, Hong, C. S. Living Skills with Mentally Handicapped People. London: Chapman Hall, 1988.

City and Hackney District Health Authority S h Therapy Department. Review of Speech l%&ty Provision to Ickburgh School, Hackney, 1988. Available from the District Speech Therap office, St. Leonard's Hospital, Nuttall Street, %ndon, N1.

Enderby, P., Phili p, R. Speech and language handicap; tow args knowing the size of the problem. British Journal of Disomks of Com- munication, 1986; 21,151-165.

Farmer, R., Rohde, J. Interim Report on the Kensington, Chelsea and Westminster Mental Handicap Register. London: Westminster Hospital Medical School, 1981.

Ferris-Taylor, R. An Investgation of the Languuge Used by Staff to Severely Mentally Handicapped Adults in a Social Education Centre. Unpub- lished MSc Thesis. London: The City University, 1985.

Independent Development Council for People with Mental Handicap. Living Like Other People.

Next Steps in Day Services for People with Mental Handicap. London: IDC, 1985.

Leudar, I. Communication environments for individuals. In

hdicaP& en, G., Leudar, I. mentally Beveridge, M., Conti-

e, Communication and Mentally

1988. Llo d, M., Dunn, L. M. The British Picture

&eabulary Scales. Windsor: NFER Nelson, 1982.

McCartney, E., Kellett, B., Warner, J. Speech therapy provision for mentally handicapped

le - the results of a preliminary survey. K& tin of the College of Speech Thempists,

Nihira, K., Foster, R., Shellhaas, M., Leland, H. AAMD Adaptive Behuvior Scale. Washington: American Association on Mental Deficiency, 1975.

Sackett, C. P. Observing. Behavwr. Volume 2. Baltimore: University Park Press, 1978.

Stansfield, J. Stammering in adults with mental handicaps; a pilot study. Mental Handimp,

van de Gaag, A. The Communication Assessment Profile for Adults with a Mental Handicap. Glasgow: M and M Press, 1988.

(Eds-). Handicapped eople. London: C m m Helm,

April 1984; 1-3.

1989; 17:1,30-33.

Any correspondence _ . should be addressed to James Law 1

- J at the address gwen.

Staff issues involved in the resettlement of people with mental handicaps

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Speech therapy provision in a social education centre: IS IT POSSIBLE TO TARGET INTERVENTION?