Under the heading of psychology, the following range of subjects would be relevant:
Several other fields of study would make their appearance, including:
welfare services, relevant aspects of the law)
In addition to these contributory subjects, there are the core topics of communicative pathology, providing coverage of the full range of disability. The difficult task for the trainee clinician is to apply to language pathology the theory, methodology and empirical findings of the various contributory disciplines. Thus, alongside linguistics, in its various branches, there is the clinical application of these ideas to the various pathological areas – such as the use of grammatical and phonological models in carrying out assessments, or motivating remedial programmes. Alongside psychology, there are the various applications of that subject – for example, taking theories from developmental psychology of how and why children learn, and using them in clinical teaching situations.
The multidisciplinary nature of the education of language clinicians reflects the multifaceted nature of communicative disability. Patients may have complex conditions which require an understanding and description of their communicative basis, of the physical limitations of the patient’s anatomy and physiology, and of the possible cognitive, social-emotional, educational or occupational consequences of the disability. It is often the case, therefore, that the language pathologist is working as part of a multidisciplinary team. The size of the team is variable, but the range of other professionals who might be involved from time to time would include:
All of these professionals have an area of expertise which, although overlapping with that of the language pathologist, is distinct. If the members of the multidisciplinary team work effectively – recognizing the limits of their own expertise, knowing when to refer to the relevant profession difficulties which are beyond their area of knowledge, and communicating their findings to others in the team, a complete picture of a patient’s difficulties can be built up, which in turn allows for effective management.
The language pathologist, then, may work as part of a multidisciplinary team and, like all other members, has a distinct area of expertise within that team. What are the roles that language clinicians should fulfil as part of their professional responsibilities? The most obvious roles are the assessment and treatment of communication disorders, and as these are central we shall consider them in some detail below. But other areas of responsibility can also be identified. First, the language pathologist has a role in preventing communication disorders. This is perhaps a surprising claim, because many of the disorders we have reviewed in Chapter 5 have causes which are beyond the language pathologist’s area of control. Hence programmes to improve maternal health in pregnancy (e.g. through reducing smoking and improving diet) might have an influence on the incidence of damage to the foetus, and health programmes to control hypertension in the adult population (through control of diet, stress and smoking, and the regular monitoring of blood pressure) might reduce the incidence of stroke, but it is difficult to see a specific role for the language clinician in these activities. They are clearly the remit of those involved in health education – medical and nursing staff in particular.
However, there are areas of preventive intervention which are clearly within the remit of the language clinician. One such example might be with infants who are identified as being ‘at risk’ of a subsequent developmental handicap.2 If a child is born with a severe physical or intellectual disability, it is essential that the child is placed in an environment which provides maximal opportunities for subsequent language learning. The environment should be carefully structured so that the input is in tune with the child’s current level of function. Opportunities can be provided for the child to practise and develop new skills, and attempts at new learning should be reinforced and encouraged. This might appear to be stating what is obvious, but the disabled child may not be in an environment which will maximize opportunities to learn. It is not difficult to imagine the effect that the birth of a child with a disability has on both parents and other members of the family. Parents who are shocked and distressed may not interact with the disabled child in an entirely normal way. An understandable response to the knowledge that a child has a profound hearing impairment is to assume that talking to this child is a futile exercise. Few individuals with hearing impairments are, however, completely deaf – there may be some degree of residual hearing (p. 210). The task for the carers of hearing-impaired children is to try to ensure that they receive maximal auditory input, that the amount of distracting ambient noise in the environment is controlled, and that they are able to see the speaker, in order that incomplete auditory information is supplemented by visual information from lip-reading. Similarly, children with a profound intellectual handicap require that the task of language learning is simplified for them. A situation where different adults refer to a single object by different names (e.g. a teddy bear as ‘teddy’, ‘cuddly’ or ‘Fred’ (p. 161)), will not simplify the task of the disabled child in learning language. In both these examples it is the behaviour of carers, as opposed to that of patients, which is modified. This is an important model of intervention in language pathology, and very different from therapeutic approaches adopted in medical science, where treatment is solely directed at the patient.
A preventive approach is not just restricted to early intervention with developmental disorders; it also has applications for some acquired disorders of communication. An important adult population to target for preventive intervention is the so-called ‘voice professionals’ – individuals who use their voices extensively as part of their occupation. Teachers, actors and singers are in a high-risk group for voice disorders, partly because of their heavy use of voice, but also because they use their voices in far from ideal conditions. A teacher, for example, may have to be heard over a large space and in competition with high ambient noise. Preventive work with trainee voice professionals can suggest ways in which problems can be avoided, and if voice difficulties do begin to develop, action can be taken at an early stage to prevent a voice disorder becoming established.
A second general role for the language pathologist is to act as an information provider on the subject of communicative pathology. We have already emphasized that language pathology is a coherent field of intellectual enquiry which requires that its practitioners draw upon a body of knowledge from both behavioural and medical sciences. The language pathologist needs to integrate these approaches and then to put them into practice. This means that the language pathologist has a unique set of knowledge and skills and is equipped to act as a source of information on communicative disability to society generally, to other professionals (e.g. medical practitioners and teachers), and most importantly, to patients and their families. Society, represented by its various institutions, needs information on the nature, incidence and needs of those with communicative disability in order to plan and cater for these needs. Other professionals require the language pathologist to provide accurate information on an individual’s communicative difficulties in order to inform their own assessment and treatment decisions, and also to contribute to their professional development by expanding their knowledge of communicative disability. The importance of patients and their families understanding the nature of a communicative difficulty cannot be over-emphasized. Knowledge and insight into a disorder reduces fear and anxiety of the unknown. Patients and their carers can make predictions as to which situations are likely to cause particular communicative difficulties, and so make plans to control and ameliorate the effects of these situations.
The third general role of language pathologists is in research and development. Because clinicians have a unique blend of theoretical knowledge and the ability to put this knowledge into practice, it is important that they take responsibility for identifying areas where knowledge is short, or where techniques of assessment or intervention are in need of development. It is essential for the development of language pathology as a coherent academic field that it develops a flourishing research base. It would be quite possible for language pathologists to surrender the research role to psychologists, linguists and neurologists, and to become consumers, as opposed to generators, of research. But the consequences of this would be profound in terms of the health of the profession. In failing to ask questions, and to seek to supply answers to questions, a profession can lose its intellectual integrity. Language pathologists are often busy practitioners, but working in collaboration with colleagues and other behavioural and medical scientists time can be created for research. This is particularly true now that single-case study research is widely reported in academic journals. The single-case study is a detailed report of an individual patient – often relating the findings from the study of the patient to theories of language processing. It represents an alternative to the research methodology which has been pre-eminent in both medical and behavioural science – the large-scale group study. The latter research design, which involves large numbers of research subjects, and often relatively superficial assessments and measures of behaviour, is difficult for the practitioner to effect. One could argue, as we have done throughout much of this book, that in order to expand our knowledge of language pathology, only detailed descriptions of disordered communicative behaviour will suffice.3
These are some of the less obvious roles of the language pathologist. The central roles are those of the assessment and treatment of communication disorders, and it is to the more detailed consideration of these responsibilities that we now turn. When patients (and, to a degree, their carers and usual interlocutors) are referred to a language pathologist, they enter a process which has the following steps: initial or screening assessment, full assessment, treatment, reassessment and re-evaluation of treatment. The initial assessment is a quick and relatively superficial evaluation, the purpose of which is to decide whether or not a person does indeed show any evidence of linguistic disability. If the initial assessment indicates no obvious disability, or perhaps a very minor difficulty, the language pathologist will inform the patient and the referring agent of this finding. If the difficulty is minor, and the clinician predicts that it will resolve without professional intervention, the patient may be asked to return to the clinic after an interval, at which point progress will be reassessed. If, however, the screening assessment detects the presence of disability, the patient’s communicative skills will undergo detailed assessment, which incorporates methods from both the medical and behavioural sciences. Thus the child with unintelligible speech will receive an evaluation of the speech organs, and potentially also be referred to an audiologist for a hearing assessment, and at the same time the child’s speech will be recorded and a detailed phonetic-phonological analysis undertaken. The in-depth assessment should reveal behavioural and medical parameters of the disorder. This information, together with a detailed case history (taken from the child’s parents) should suggest possible causes of the deficit and possible behavioural interventions to improve the situation. Any causative factors can be eliminated, or at least diminished; for example, any hearing loss would be treated by appropriate audiological intervention. At the same time, the language pathologist can identify the behavioural parameters of the disability; for example, determining whether the child is using a large number of substitutions, or whether certain sounds are being used with little consistency (p. 202). Once the behavioural deficits are identified, the clinician is then in a position to initiate treatment.
Treatment can be viewed as a process of hypothesis testing. From the assessment, the language pathologist develops one (or more) hypotheses which might account for the patient’s problems. Treatment then tests out these hypotheses. If the working hypothesis is that the child’s unintelligible speech is due to a deficit in tactile feedback from the oral cavity, and a therapy programme has been targeted at this deficit, then if the hypothesis is correct the child’s speech should improve. If it does not, the hypothesis may be wrong or the intervention poorly planned or implemented. Alternatively, the reason for the absence of behavioural change may be because of a factor which is not so easily within the clinician’s control, such as a lack of motivation in the patient or the carers. Whatever the cause of the failure, it is clear that the clinician must re-evaluate the treatment plan and the hypotheses which underlie it. The reasons for failure must be identified and appropriate alterations made: the initial hypothesis might be rejected or modified, the intervention procedures changed, or the limited motivation of the patient and carers addressed. The process of continual re-evaluation of the working hypothesis and the intervention means that assessment and treatment are closely linked. The patient’s behaviour is regularly reassessed, and performance after treatment is compared to behaviour prior to treatment. Pre-treatment performance is usually described as ‘baseline’ behaviour, and the evaluation of the effectiveness of intervention involves a series of baseline to post-treatment comparisons.4 This process is not simply one of trial-and-error; the patient and the clinician’s employers do not have an endless supply of time and patience until the clinician happens upon the correct hypothesis and the appropriate intervention! But as more is known about the characteristics of language disorders, their causes, and the types of intervention that prove effective, clinicians will be able to act quickly and efficiently to tackle disabilities.
The assessment and treatment of disorders of communication are the core responsibilities of the language clinician and in the following sections we will consider some of the issues involved in these activities. Before we do this, we will address some general factors which are fundamental to the holistic management of communicative problems and which are relevant to both assessment and intervention. The first of these is that language involves interaction, and there is a minimum of two participants in a communicative exchange. Linguistic procedures such as conversational analysis (p. 49) have illustrated that the interaction of participants is patterned and that linguistic behaviour of one participant determines what is likely to occur in the turns of another participant. If one participant asks a question, it is likely that a second participant will provide an answer or some other linked response to the question. Language pathology traditionally has focused both in assessment and treatment on the patient, which is part of the inheritance from a medical approach to disease. But given that the communicative behaviours of other participants have a significant effect on the patient’s behaviour, more contemporary behaviourally motivated approaches to management advocate assessment of the behaviours of both patients and their usual interlocutors.
The type of questions that an assessment of interlocutor behaviour might address would be: does the communicative partner produce utterances which the linguistically-impaired listener will be able to process and understand? Do non-impaired participants give the patient sufficient time to formulate and produce a response? If the patient gets into difficulties, does the non-impaired participant produce helpful behaviours which allow the interaction to be continued or does the conversation break down irretrievably? The issue here is not only of assessment and description of the communicative environment of the patient, but also potentially one of treatment. The language clinician might choose to intervene to modify the behaviour of carers: for example, if carers are quite unconsciously using interactional behaviours which are facilitatory to the communication of the patient, these behaviours might be highlighted by the therapist, and their use encouraged yet further. Alternatively, if an analysis of the interaction between the patient and the usual interlocutors reveals the presence of behaviours which are not assisting communicative exchange – for example, the use of irony and complex metaphors is unlikely to assist the comprehension of a patient with Alzheimer’s disease – such behaviours can be identified and reduced. This type of intervention is particularly important in disorders which are chronic (or long-lasting) and which represent serious disruptions of cognition or language; the ability to learn new information or new ways of behaving is likely to be slow for an individual with serious brain damage or an intellectual impairment. In this situation, intervention which is directed at carers who suffer from no such limitations in their ability to modify and change their behaviour may be a more viable management strategy than treatment directed solely at the communicatively-impaired individual.
The issue of management of chronic disorders of communication leads to the second general issue which spans concerns in both assessment and treatment. In this book we have been using the terms impairment, disability and handicap interchangeably, but they have come to have specific and different meanings in discussion of the management of chronic conditions. The distinctions between the three terms were originally made by the World Health Organisation (WHO) in 1980, but they took a considerable time to permeate the vocabulary of language pathology.5 These terms attempt to isolate different components of a disorder and suggest that the total or holistic management of a condition should address all three issues. An impairment is the underlying anatomical, physiological or neurological deficit. This can be defined in medical terms, such as a lesion to the temporal regions of the left hemisphere, or in behavioural terms, as in a psycholinguistic deficit such as a failure of the lexical retrieval system. The disability is the consequence of the underlying impairment for surface behaviours and, continuing with the example of lexical retrieval failure, this might result in conversational breakdown as the speaker is unable to convey his or her intended meaning. Handicap addresses the consequences of the impairment and disability for the activities and roles an individual can undertake in society. For example, a communication disorder might limit an individual’s ability to form social relationships and to take up certain forms of employment, such as teaching, or a job involving extensive use of the telephone. The restriction in activities might be due to the intrinsic limitations of an individual’s abilities caused by the impairment, but it might be caused by the attitudes that societies have towards individuals who have disabilities.
The content of this book has been directed largely at the impairment and disability components of communicative problems. First let us show that the distinction between the two terms is a clinically useful one, in that we can identify situations where level of disability is not entirely predictable from the impairment. An example of this nature can be seen in the transcript of the fluent aphasic given in Chapter 5 (p. 169). This individual has very marked lexical retrieval difficulties, and we might hypothesize that his underlying impairment represents a failure of the mental mechanisms involved in accessing and retrieving items of vocabulary. A word-finding test might reveal a fairly pronounced degree of impairment, but when we examine this albeit short transcript, we perhaps form the impression that the patient, with the assistance of a helpful interlocutor, is really rather successful in communicating his intended meaning. In this example, the level of linguistic impairment does not translate in a direct way to the degree of communicative disability. The interlocutor’s willingness to collaborate in locating the intended meaning is one reason for this, but there are also the behaviours that the patient has developed, such as circumlocutions, gestures and the cueing of the listener, which contribute to the success of the interaction. Given that the aim of clinicians is to improve their patients’ competence in everyday communicative situations – the playground, the classroom, work, conversation with family and friends, and so on – it is clearly important to extend the scope of assessment and treatment to address issues both of disability and impairment.
Assessment is of central importance in any endeavour in language pathology. In research, it is the key to identifying the behavioural characteristics of disorders, whereas in clinical intervention treatment can begin only after assessment has revealed the behavioural strengths and weaknesses of the patient (and interlocutors). The purpose of assessment is, first, to allow the language pathologist to answer a series of questions which are posed by the referral of a patient. These questions are: does the patient have a communication problem? What is the exact nature of the problem (the diagnosis)? and how should the difficulties be managed? A second, related, purpose is to quantify behaviour. This permits comparisons of behaviour to be made: the patient’s behaviour can be compared to establish normative behaviour (see p. 153), or, alternatively, across two points in time (e.g. prior to treatment and post-treatment), or across two communicative contexts (e.g. degree of non-fluency when talking in a high-stress versus a low-stress situation).
In answering the first of the questions posed by the referral of a patient (does he or she have a communication disorder?), the clinician will first collect preliminary case-history information. The content of the case-history will vary depending upon the type of condition which is being considered. In a developmental disorder, the clinician will focus on aspects such as early medical history and progress towards a range of developmental milestones – for example, the age at which a child took his or her first steps. The aim here is to establish whether there might be any pre-natal or post-natal factors which might affect development (e.g. evidence of birth trauma) and to establish an overall perspective on the child’s development (e.g. is the case displaying a delay in development affecting language alone, or a broad pattern of delay of which a language deficit is just one component?). If the disorder under consideration is one of voice, the content of the case-history will obviously be different. The clinician will again be interested in any medical factors that might affect the functioning of the speech organs (e.g. information from the laryngologist regarding laryngeal structure and function), but will also seek information on the patient’s patterns of voice use. The clinician here will be looking for any evidence of misuse of the voice, such as excessive shouting, or evidence of abnormal tension in laryngeal muscles. In addition to collecting broad background information from the patient and perhaps from other professionals involved (such as doctors and teachers), it is important to establish the patient’s perspective on the disorder. Clearly, if the patient and the family feel that they have little or no handicap, their willingness to attend the speech and language clinic, and to comply with any treatment, will be limited.
Once preliminary case-history information has been collected, the language pathologist will then move to an initial or screening assessment of the patient’s behaviour. This should provide an answer to the question ‘is there a disability here and is it deserving of further assessment?’ If this question is answered in the affirmative, the clinician will move on to a detailed assessment of the patient’s behaviour. The initial assessments are usually informal and unpublished procedures often devised by clinicians themselves. These have the advantage of being quick, but the disadvantage of not being familiar to other clinicians, so that the findings of an informal assessment procedure cannot be easily communicated to others. This is one of the major reasons for switching to published assessment procedures in the next stage of the analysis of the disorder.
The use of screening in this context deserves some discussion. When we hear of ‘screening’ programmes, we generally think of assessments which are applied to a very wide population in order to identify medical or behavioural abnormalities. Most developed countries run infant-screening programmes – blood samples are taken from neonates to check for diseases such as phenylketonuria (see p. 160). As part of child-health programmes, professionals keep a check on the general development of the child so that any difficulties can be identified early and intervention can begin before difficulties become compounded. Similarly, groups within the adult population who are identified as being ‘at risk’ of certain disorders – for example, middle-aged woman identified as being at risk of breast cancer – can receive regular screening checks. When we talk of screening assessments in language pathology we are discussing screening on a more modest scale. Rather than scrutinizing a total population for possible communication disorders, a very small sample – often preselected by other professionals (such as doctors or teachers) – is subjected to the screening process.
Once a screening assessment has indicated that the patient is displaying some degree of communicative disorder, the process of full assessment begins. The first step in this is informal observation of the patient in a relatively natural communicative context – for the child this might be play, and for the adult it is usually conversation. In this context the clinician can form a rapid impression of the extent of the patient’s disability, which is an important perspective to establish before various psycholinguistic impairments are examined. In selecting subsequent tools for use in assessment, language clinicians have a number of options open to them. One option is a checklist. This type of assessment lists a series of behaviours, and the clinician records the presence or absence of any of the pr-selected behaviours. A checklist of grammatical development might list behaviours such as the presence of Subject-Verb-Object or Subject-Verb-Object-Adverbial structures in the patient’s speech. Clinicians base their judgements of whether certain structures are present either by directly observing the child’s speech or by asking parents to report on the type of structures their child uses. The former approach is more likely to be an accurate record of the child’s speech in one particular sampling situation – for example, playing with toys in the language clinic. The use of parent-reports is likely to result in less accurate data; parents may not be so clear as to what the behaviours are, and their recall of the child’s competencies may not always be correct, particularly if there are a number of young children present in the home. However, although parent-report data may be less accurate, they do have the advantage of being more comprehensive. Parents have the opportunity to record their child’s behaviour across a variety of communicative contexts and thus have access to a much broader database than does the clinician. This factor is of importance when assessing skills for which performance across a variety of contexts is essential. Hence checklists are particularly suited for the assessment of vocabulary production or of pragmatic ability. Checklist assessments are quick measures, and also have the advantage that, if carer-reports are used, the clinician can gain insights into the patient’s behaviour in contexts outside that of the clinic. The speed at which an assessment can be completed, however, often has costs. The quicker a procedure is, the more likely it is to prove a rather superficial analysis of complex communicative behaviours. The major difficulty with checklist assessments is that they preselect behaviours for analysis. Although they may prove efficient in identifying the presence or absence of those behaviours, what happens if the patient is demonstrating other behaviours which are also potentially significant in understanding the nature of a disorder and planning its remediation? Speed of assessment is therefore bought at the expense of comprehensiveness.
A second option in assessment is the use of a speech or language test. This is a popular and widely used technique of assessment. Tests can be directed at various components of linguistic performance – some at very broad aspects of behaviour (e.g. ‘receptive language’ or ‘expressive language’); others at more specific components of language competence (e.g. the understanding of grammatical structures). In addition to tests directed at language, clinicians are also likely to use tests of other cognitive skills linked to language, such as symbolic ability, attention or memory skills. Tests are particularly useful when a therapist wishes to evaluate a specific hypothesis such as the patient has difficulty in finding words which occur infrequently in a language versus those which are frequent’; or ‘the child has difficulty producing a particular sound when it occurs at the end of a word, but not in a word-initial position’. Often tests are described as ‘standardized’ assessment procedures. These are tests in which there is strict control of the materials and the administrative procedure. Because these tests often include normative data (i.e. information on the scores that non-disordered subjects achieve on the test) and also the typical pattern of scores obtained by groups of disordered subjects, it is essential that the patient who is being compared to the norms is administered the test in an identical manner to the subjects from whom the normative data are drawn.
Standardized tests are a widely used method of assessing language behaviour. Their popularity is due to the fact that they are relatively quick procedures – particularly when compared to an alternative such as producing a detailed linguistic profile of behaviour (see p. 240). The administration and scoring of tests is also relatively straightforward, and this simplicity is also an advantage to the busy clinician. Often the scorer has to decide only whether the patient selected the correct picture, or manipulated objects in a way consistent with a command. Alternatively, in language production tests, the decision may be based simply on whether the description of an object or picture is acceptable, and often the test provides a criterion by which correct responses can be identified. A further reason for the popularity of tests is that, very often, they provide normative data. The patient’s test performance can be compared against that expected of a normal 4-year-old, or a normal adult, and where there are significant discrepancies between the patient’s behaviour and normative patterns there is strong evidence for some form of unusual language behaviour. Such data help the clinician to answer the question ‘does the patient have a communication problem?’ The standardized test may also assist the process of exact diagnosis of particular linguistic pathologies if it gives details of the typical profiles of different groups of language-disordered patients. Thus, if a profile of a typical agrammatic aphasic patient is given, or a child with a typical semantic-pragmatic language difficulty, the test performance of a particular patient can be compared to these typical patterns, and areas of similarity or difference can be highlighted. A further advantage of the language test is a consequence of its popularity among clinicians. Procedures which are popular are also likely to be familiar to a large number of professionals. Additionally, the standardized test, with its carefully controlled materials and procedures, should produce the same score whether the test is administered by clinician A or by clinician B. As a consequence, standardized tests are valuable in assisting communication between different professionals. If a patient moves from one clinic to another – perhaps from a general clinic to a specialist one, or from one part of the country to another – a second clinician can review the patient’s test results, derive an impression of areas of strength and deficit, and so will not need to begin the assessment process from the very beginning.6
Language tests have very clear advantages, but there are also significant problems which need consideration so that a balanced evaluation of their role can be obtained. Tests suffer from the same disadvantage as checklist assessments in that they are selective in what they measure. Only a small set of predetermined linguistic structures is probed, and these may not address the significant components of a patient’s difficulty. Major difficulties also concern the question of the ecological validity of the test performance (p. 33), or whether the results of a test can be used to predict communicative performance in less artificial situations. Tests do not always yield valid measures of behaviour, perhaps because the person being tested is bored, or made anxious, or is simply confused by the artificiality of the situation. (One test of aphasia includes comprehension questions such as Are you a man?’ (to women) and Are you a woman?’ (to men).) Most tests are designed to examine isolated components of language (e.g. comprehension of different grammatical structures, retrieval of vocabulary), and to give detailed accounts of impairments within component systems. It is left to the clinician to put the component systems together and to combine descriptions of various impairments with an acknowledgement of the various compensatory mechanisms that the patient may be using to great effect. A word retrieval test may suggest that a patient has very great difficulty in locating and producing the target words, but requires the clinician to note that all non-retrieved target items were successfully communicated via gesture, circumlocutions or drawings.
In the face of these difficulties with tests, a further option in assessment is to base an analysis on a sample of behaviour obtained in a naturalistic context – for the child, this would be play, and for the adult, conversation. The patient’s communicative behaviours are then analysed, with the clinician usually targeting particular aspects of behaviour for detailed analysis – for example, grammatical ability. The results of these analyses are often displayed on a profile chart, so this method of assessment has come to be known as profiling.7 Profiles are often based around levels of linguistic organization – grammar, semantics and phonology – but can also be targeted at other facets of communication, such as patterns of eye contact. As the sample upon which the profile is based is usually collected in a natural communicative context, it is more likely to be typical of the patient’s performance outside the clinical context. As such it is more likely to give the clinician a clearer sense of the communication difficulties experienced by the patients and their families. Because tests generally use controlled materials (such as a set of pictures or objects), the patient is communicating already known information to the clinician. In deciding on a patient’s intelligibility, if the clinician or any other listener knows what the intended target of an utterance is, it is possible to over-estimate the ability to produce it accurately. Using natural conversation as the basis for a communicative assessment places the clinician in the same – often frustrating – position as the carers of the communicatively disordered individual, and allows a real estimation of the patient’s communicative difficulties.
The behavioural profile therefore has advantages over speech and language tests in that it avoids the sometimes bizarre and unnatural interactions of the test context. It has other advantages too. Whereas both tests and behavioural checklists measure only a predetermined set of behaviours – for example, a particular set of grammatical structures or vocabulary – the data yielded by a profile are more comprehensive. Because the situation is not constrained by the test materials, or by the checklist items, patients may display a much wider range of their behavioural repertoire. The difficulties of patients who show interactions between various components of their linguistic performance are also more likely to be revealed by analysing a full behavioural sample. One school-aged child was referred to the speech clinic because his teachers reported that his speech was unintelligible. The speech pathologist administered a test of phonetic and phonological abilities, which consisted of asking the child to label pictures (the targets being known to the clinician and requiring single-word responses from the child). The analysis of the results revealed few difficulties, and this information was relayed back to the class teacher. The teacher was perplexed by this result, and asked for a reassessment. The equally perplexed therapist complied with the request, but this time recorded a sample of the child’s speech while he played with toys in the clinic. The interaction and the subsequent analysis revealed that the child was indeed very difficult to understand – but only in connected or conversational speech. His difficulties were described as those of cluttering (see p. 194), where the rhythmic structure of speech was disturbed. In the course of an utterance, his rate of speech gradually speeded up, to the point where the time-frame for each articulatory movement was so short that movements were not fully executed. As a consequence, each articulatory movement influenced its neighbours in abnormal ways, resulting in a large number of assimilations between sounds. Only by basing the assessment on a full behavioural sample was this deficit revealed, and, in particular, the problematic interaction between articulatory accuracy and the utterance length. The example also illustrates the need for clinicians to place themselves in the same situation as the patient’s usual interlocutors (i.e. communicating unknown information), because only then are they really able to appreciate the difficulties likely to be experienced in communication.
The profile based on natural conversation therefore has significant advantages over testing as a method of assessment. But, as always, in addition to benefits, there are costs associated with profiling. The two most significant costs are time and clinical skill. At a number of points already in this book we have indicated the need for detailed assessment procedures in order to extend the theoretical basis of language pathology. The reason such analyses are not performed routinely in speech and language clinics is that they are extremely time-consuming. Basing an assessment on a sample of natural communication requires that the patient – clinician interaction is recorded. In terms of time this is a relatively insignificant procedure; the time expenditure comes when the audio- or video-recording of the interaction is transcribed (p. 35). A 30-minute interaction might take several hours to transcribe in any detail. Then the transcription must be further analysed, for example a grammatical analysis completed, and the results of this analysis evaluated for significant features. Clearly, the behavioural profile can be a time-consuming procedure, which perhaps only automatic (computational) procedures can significantly alleviate.
The second cost is the degree of clinical skills required to elicit and analyse data. The collection of samples of interactions from patients with communication disorders is not a simple or obvious procedure. Many young children are reluctant to talk to strangers. Adults with communication difficulties may be unwilling to talk and reveal those difficulties. Interactions can consist of clinicians asking lengthy questions and patients responding with monosyllabic yes or no answers. An analysis of a data sample consisting of 300 instances of yes or no is clearly going to reveal little of the patient’s expressive linguistic difficulties! The clinician needs considerable skill in eliciting communicative behaviours from individuals who, for one reason or another, are unwilling to talk.
We have reviewed a number of alternative assessment procedures. All of them have a place in the language pathology clinic as, to a great extent, the advantages of one method offset the disadvantages of others. Thus checklists allow access to behaviours which occur outside the clinic, whereas tests do not. Tests are completed by the clinician, and avoid inaccuracies that may stem from reliance on a carer-report of behaviours. Tests are quick, but at times fail to produce results which generalize to natural communicative situations; profiles are time-consuming, but yield detailed and comprehensive behavioural data. It is important for the clinician to perform a cost-benefits analysis on each type of assessment procedure, and then to decide what is most appropriate for each client. At the end of the process of detailed assessment, the clinician should have answered the questions ‘What is the nature of the disorder?’ and ‘How can the disorder be treated?’ A good assessment procedure should, at its conclusion, give the clinician strong indications of which routes might be productive to follow in treatment.
In the treatment of language pathology, the clinician works with the patients and their carers to maximize the effectiveness of communication. The techniques used in treatment are immensely varied as clinicians may focus on different components of a condition: addressing issues linked to social handicap may result in the use of counselling and psychotherapeutic techniques, which aim to help patients to understand the nature of their disorder, and to deal with the anxiety, frustration and depression that communication difficulties might engender; at the other extreme, the use of computers can help to remediate impairments in speech production. As a consequence of this breadth we can do no more than give an overview of broad approaches which can be used in intervention, and focus only on treatment approaches targeted at speech, language and communicative functioning rather than those dealing with the psychological and social elements of a handicap.8 But even within this narrowed area, there is a huge diversity of approach. There are very few formalized treatment programmes for linguistic disorders. Treatment programmes are tailored to fit the individual client, and are created from the careful evaluation of assessment results. Moreover, the treatment process is informed by both medical and behavioural approaches, and both need to be taken carefully into account.
A scientific approach, whether motivated by medical or behavioural sciences, suggests that a key component in intervention is to remove the causes of a pathology (p. 24). Thus, if a child’s slow acquisition of language is viewed as a consequence of living in an environment where there is little or inappropriate stimulation, the language pathologist will act to modify this environment. If a patient’s voice difficulties are thought to be a consequence of vocal misuse, intervention will attempt to reduce or eliminate harmful behaviour. Elimination of the causes responsible for the genesis of a disorder is likely to have a profound effect on certain disorders – potentially eliminating the pathology without any further therapeutic intervention. An additional example is the reduction of parental anxiety when a child is normally non-fluent during the course of language acquisition; this would prevent the behaviour being perceived as ‘stuttering’ and the child developing anxieties about speech (see the ‘diagnosogenic’ theory of stuttering, p. 193).
Other disorders, however, have no clear causes. A child may fail to learn language at a normal rate despite being raised in a perfectly adequate environment, and in the absence of physical or intellectual deficits. Other disorders – for example, aphasia as a result of a stroke, or the intellectual and communicative deficits of Down’s syndrome – may have a clear cause, but this cause cannot be directly remedied. In these instances, behavioural approaches come into prominence, suggesting that the clinician should identify the patient’s current stage of communicative ability, define where there are significant discrepancies between this and normal performance, and then seek to move the patient’s behaviour as near to the norm as possible in a series of steps. As well as providing the motivating principle behind treatment, branches of the behavioural sciences provide valuable components of the treatment process. The methods of linguistic science enable the clinician to produce a detailed evaluation of language behaviour at the various levels of language structure.
Linguistics and developmental psychology together suggest the first structures that should be introduced to the patient as part of a treatment programme. Clinicians will usually follow the sequence in which behaviours normally develop. In the area of phonological intervention, for example, early acquired sound contrasts, such as contrasts between oral and nasal sounds, will be introduced before those later acquired, such as contrasts between stop and fricative sounds. Procedures of this kind are standard practice when working with children; interestingly, they are also often employed when working with adults. But can the use of developmental hierarchies be justified with acquired disorders such as aphasia and apraxia, or are there other ways in which linguistic structures can be graded for complexity which might prove more appropriate to adult language? Both the method of recognizing the relative difficulty of structures and the actual content of any hierarchy are subject to much debate – and very little consensus – within psycholinguistics. In the absence of other agreed ways of defining linguistic difficulty, accordingly, the use of developmental hierarchies in planning a sequence of stages in treatment is widely practised. Linguistically, aphasics have to stand before they can walk, and walk before they can run, and a developmental model suggests one practicable direction in which they can move.
Intervention in language pathology may target any of three components of a communicative interaction. Communication involves a minimum of two participants and the exchange of messages in a context in which the interaction takes place. In a situation where communication has failed, it may be possible to facilitate a more successful interaction through intervention directed at any one of these variables. Treatment may be focused at the patient’s ability to send and/or receive messages efficiently – a patient-centred model of intervention. Here, intervention may endeavour to increase the patient’s linguistic knowledge, or to use this knowledge effectively. A second option is to direct therapy at the patient’s usual interlocutors – a carer-centred model – encouraging them to behave in ways which facilitate the patient’s understanding, or their understanding of the patient. Third, the environment in which communication takes place can be modified in ways which enhance communication – a context-centred model of intervention.
The first of these models is the most familiar; it is, after all, the system of treatment that we receive when we go for a medical consultation. Patients report the symptoms they are experiencing; the medical practitioner examines the patient for signs of illness, and treatment is directed at the amelioration or control of the condition. In the language pathology context, a patient-centred model of intervention entails working with patients to maximize their communicative abilities. Usually this occurs in a one-to-one situation, with patients receiving individual consultation, assessment and treatment sessions, although group therapy is also possible. Within these situations, the content of the therapy may be very different. It may be directed at reducing the degree of impairment (in the WHO sense of this term, p. 234) of linguistic or related cognitive skills – for example, developing their phonological knowledge, improving their grammatical ability, or facilitating their memory or ability to pay selective attention. Alternatively, treatment may try to minimize the level of communicative disability by enabling the patient to develop compensatory behaviours which circumvent the underlying impairments. For example, a patient with a disorder of comprehension might ask speakers to repeat a misunderstood message, or to slow down their speech rate, or to chunk the message into more easily understood components. Included within disability-type approaches are the many systems of augmentative communication or communication aids. For a very large number of children and adults, the normal use of spoken language is out of the question, because of the gross nature of their physical or intellectual disability. Signing and other forms of supplementary communication have long been in use (p. 215), as have simple mechanical devices used for pointing at letters, words, or symbols on a chart. But this is only the tip of a vast iceberg of innovation involving new technology, which affects the lives of many speech-handicapped people, such as those suffering from cerebral palsy, other types of dysarthria, and learning disabilities. The growth in computer technology has led to the production of portable and increasingly affordable systems, such as speech synthesizers for use in supplementing the communicative ability of patients.9 The final component of treatment might address issues linked to a handicap (again, in the narrow sense of the WHO definition). Instead of treatment focused directly on language, management might be of the counselling or psychotherapeutic type, to help patients cope with the anxiety and frustration of their communicative disability, and also with the attitudes of able-bodied society towards them.
Within patient-centred approaches, therefore, there are a number of fundamentally different modes of treatment, but the type of intervention which is most common in the language pathology clinic is that aimed at improving the patient’s impaired linguistic or language-related cognitive skills. Let us take an example of how this type of therapy might work. The first stage in any treatment process is to evaluate assessment results and identify therapeutic targets and possible routes which it would be fruitful to follow. To illustrate this process, let us take the example of a 3-year-old boy whose assessment of spoken language indicates that he appears to have difficulties in grammatical development. His utterances usually consist of single-element structures, when we would expect to hear two- and three-element structures at least at this age. More detailed analysis of grammar and vocabulary indicates that his utterances consist predominantly of nouns (e.g. dog, socks, cup), adjectives (e.g. dirty, broken) and a small number of adverbs and prepositions (e.g. up, now), but very few verbs. The clinician adopts two strategies: the first is to encourage the child to link together two items from his existing vocabulary (e.g. dirty socks, cup broken); the second is to develop his verb vocabulary, with a hypothesis that once he has access to a larger number of verbs, it will be possible to develop a wider range of sentence structures (e.g. Subject-Verb, Verb-Object, Verb-Adverbial). In pursuit of the first goal, the clinician reviews the vocabulary already available to the patient, and sets up contexts in which the existing vocabulary can be used in two-element combinations, for example playing at dressing dolls with dirty and clean sets of clothes. This gives the child’s interlocutor the opportunity to present him with examples of two-element combinations (e.g. dirty vest, clean dress), such examples being referred to as models, and the interlocutor’s behaviour as modelling utterances to the child. The importance of this procedure cannot be over-estimated in intervention with developmental disorders. It is based on the notion that children are active in learning language; for them, language is a puzzle which they are endeavouring to solve. In order to solve the puzzle, children need language input or data from which they can attempt to recognize units and structures. Initial guesses about the way language works are compared with new material (i.e. the child verifies hypotheses against further data) and are tested through their use in the child’s own language repertoire. Providing children with clear and unambiguous models ensures that the data they use in cracking the language code will be of good quality and will facilitate correct hypothesis formation. In the present case, after initial modelling, the patient is gradually encouraged and given the opportunity to produce the two-element utterances himself; for example, a situation might be engineered in which he sorts articles of clothing into two piles for the laundry, and reports on his activities to an adult. The patient’s attempts at the two-element utterances are encouraged, and supported by further models from the clinician or parent.
The second therapeutic goal – that of developing the patient’s verb vocabulary – could be tackled in a variety of ways. One method might be to use picture-books or cards depicting various actions. The therapist would label them or model the relevant verb to the patient, and then ask him to repeat the verbs back, encouraging and reinforcing successful attempts. A second strategy might be to play games involving a large number of actions, for example playing with pots and pans, using such actions as cook, stir, pour, wash and dry. The situation provides the opportunity for the patient to hear a large number of verb examples, with the meaning of each verb being demonstrated by the clinician, and the child performing the corresponding action with the pots and pans. Ultimately roles are switched and, instead of the clinician providing a commentary to the play, the child is encouraged to direct and recount activities. These two therapeutic strategies are rather different: the first is more familiar as a formal teaching situation; the second is embedded within play. For this reason, the second strategy might be the preferred one to adopt, particularly if the patient is a young child or an individual with learning disabilities. Because the second talk is placed within a context which is familiar in the world outside the clinic, behaviours which are taught in this setting are more likely to generalize to other situations.
The patient-centred model of treatment represents the popular conception of how language pathologists work with patients – that is, working in a one-to-one situation, developing new linguistic and communicative behaviours. But it is an expensive mode of service delivery. One-to-one teaching means that the clinician is unable to see very many patients in a working day, and that patients are treated for only a short time. This is a serious difficulty. Communicative behaviour is immensely complex, and disorders of communication require detailed and thus time-consuming assessment in order to identify deficits and plan a remedial course. Some patients have severe linguistic and intellectual deficits which entail that learning will not take place easily or quickly. Such individuals need intervention programmes which develop and stimulate new behaviours on a round-the-clock basis, rather than for an isolated hour or so once in the week. In such situations, other models of service delivery, such as carer- and context-centred treatment, are needed to supplement a patient-centred model. It should be emphasized that the latter two models do not exclude or neglect the patient, even though they are not ‘patient-centred’. In all three models, patients and their communicative strengths and weaknesses are at the core, and all three aim to improve communicative functioning. They differ in the immediate target of the intervention, but the ultimate target is always the communicatively-disordered patient.
Carer-centred (or interlocutor-centred) and context-centred treatment are similar in many ways, as both highlight the role of the patient’s usual interlocutors. Contexts or environments are inanimate, and can be modified only through the actions of families or other carers. As the intervention is directed at the patient’s usual carers and their everyday environment, it is less likely to meet the problems of poor generalization of behaviours taught in a clinical context. Both models are particularly relevant to clinical intervention with patients who have profound linguistic and cognitive disabilities, and also to clinical situations where a therapist is faced with too many patients and too little time. Carer and environmental intervention may also be essential in cases of developmental language disorders where the pathology has been partly attributed to environmental factors. The first therapeutic strategy may well be to modify the environment and the language of the carers so that the patient receives appropriate language input – that is, input which is in tune with the patient’s language processing abilities and which is neither too complex nor too simple.
In situations where the patient suffers from a profound linguistic or cognitive disability, for example dementia, learning difficulties or severe aphasia, carer-centred intervention aims to develop new communicative behaviours in the individuals with whom the patient usually interacts, in order to facilitate the exchange of messages between them. These may be behaviours which will facilitate patients’ understanding of the carers’ language, or patients’ ability to convey their needs to the carers. Patients with a language comprehension disorder may begin to understand better if certain parameters of the message are modified. Patients with difficulties in attending to messages may have fewer problems if the message is accompanied by ‘alerting signals’, which indicate to patients that they must try to attend selectively to the linguistic message which is about to be sent to them. Examples of alerting signals are simple verbal commands such as ‘listen’, or non-verbal signals such as taking patients’ hands or encouraging them to look at the speaker whilst they are spoken to. The message itself may be modified in a number of ways; for example, ‘topic-fronting’ can be used, particularly with patients with short attention or memory spans. Topic-fronting puts salient information right at the beginning of the utterance, so that if the patient manages only to receive and decode the first fragment of the message, that fragment will be highly informative. Thus, what are you doing this weekend? might be modified to this weekend, what are you doing?
Other elements of utterance form might also be altered; for example, interlocutors might avoid sentence structures which the patient has been shown to have difficulties understanding. Sentences in the passive voice and sentences containing subordinate clauses within the main clause are structures which many linguistically-disordered patients have difficulties in understanding. Various phonological variables can be modified: words which convey important information can be heavily stressed, or the tempo of speech can be altered. Many patients with comprehension disorders understand more when they are given more time to process an utterance; thus, simply by slowing the rate of speech there may be a positive effect on performance. In addition to manipulating linguistic variables, non-verbal information can be altered. Use of touch whilst talking may assist the patient with a severe input disorder to keep attention on the message. Pointing to the referent of part of a message may establish what the communication concerns – for example, holding a cup while asking patients if they would like a drink. All these examples show ways in which the interlocutor can behave in order to give language-disordered patients inputs that they are more likely to process successfully. Interlocutors can also alter their behaviour in order to assist patients’ ability to express their needs. Instead of asking what are known as open questions (i.e. questions which can be answered by a wide range of responses), the patient can be presented with alternatives (e.g. do you want tea or coffee?), or a single choice, to which they can respond yes or no.
The third model of service delivery – context-centred intervention – involves a careful assessment of the patient’s communicative environment, and the identification of factors which facilitate and (in the case of developmental language disorders) encourage language learning or those which are inhibitory. The types of intervention that may occur include the control of potentially distracting noise, the reduction of which permits patients to concentrate on, and listen to, speech. This is a particularly significant factor for the hearing-impaired and those with attention disorders. Also, environments have to be created in which there is something to communicate about. This is true particularly of institutional settings which are dominated by a high degree of routine. In such contexts, the linguistically-disabled patient may be relieved of the need to communicate because wants and desires are routinely met by the staff of the institution. This may seem to be a positive thing, but the needs which are met are identified by the institution and not by the patient. Therapists working in institutional settings sometimes ‘sabotage’ routines in order to create a context for communication. One clinician working in a school for children with learning disabilities reported the remarkable effect on her patients’ communication when a student clinician inadvertently served up cheesecake upside-down during lunch-time!
Whichever model of intervention is used – and often they are used in combination – there are common features. Intervention is based upon the careful assessment of the nature of a problem, and upon the observation of how carers and context operate to encourage or discourage effective communication. Just as a teaching programme is based upon a detailed assessment of a patient’s linguistic and cognitive competencies, so also programmes aimed at modifying carer behaviour and contexts are based upon an analysis of which variables, when modified, will effect communication. Therefore, before suggesting that carers do modify aspects of their behaviour – for example, the type of vocabulary and sentence structures, or the rate of speaking – the clinician needs to ascertain that these modifications are likely to be effective and to have a positive effect on the patient’s communication. A second common factor between all types of intervention also links to assessment. Throughout the intervention process, the clinician is re-assessing the patient’s linguistic performance, and judging whether significant changes are occurring. Where changes in a positive direction are identified, it can be assumed that the hypothesis which motivated treatment was correct and that an appropriate therapeutic strategy has been identified and followed. Where change does not occur, the clinician is forced to re-assess both the original hypothesis and the therapeutic approach.
We began this book with a discussion of the effects of linguistic disability on all aspects of the life of an individual – personal, social, educational and occupational. In subsequent chapters, we have tried to show that language pathology is a coherent field of intellectual enquiry, and tracked the medical and behavioural science influences upon it. In a review of the range of linguistic disability that may occur, we have stressed the still urgent need for research into many disabilities. In this, our final chapter, we have moved to the more practical concerns of the assessment and treatment of disability, and the need for further research has again emerged. We do not apologize for this concluding emphasis. Only from such research will come greater knowledge of language pathologies and new and better ways of dealing with them, so that ultimately all patients will benefit.