Working with Children's Voice Disorders
By Jenny Hunt and Alyson Slater
(Bicester: Speechmark, 2003)
[Pp. 153.] ISBN 0‐86388‐279‐X. £34.95
Working with Children's Voice Disorders has been written by two speech and language therapists who clearly have considerable experience in this area of practice. It is well written, highly accessible and designed for clinicians who do not have extensive experience working with voice disorders, but whose caseloads include occasional children with vocal dysfunction. Although the emphasis is on practical strategies and procedures for assessment and treatment of children with voice problems, the authors have included some discussion of the theoretical bases and rationales for their recommended clinical procedures, and there are some references to current research findings. Clinicians would, however, need to consult more comprehensive texts (e.g. Andrews Citation1986, Citation1995, Colton and Casper Citation1996, Harris et al.Citation1998, Stemple et al.Citation2000, Mathieson Citation2001, Rammage et al.Citation2001) and journal papers to understand and evaluate fully the authors' recommended approaches to voice evaluation and intervention.
The first four chapters provide the general foundations for working with children's voice disorders. These chapters cover normal development and anatomy of voice, the aetiologies and contributing factors of common vocal pathologies, voice evaluation strategies, and the principles of intervention and management. These foundation chapters are supported with case examples of children with frequently encountered voice problems and children who have other communication and behavioural disorders that often coexist with voice problems. Particular strengths of these chapters are that voice is placed in the context of children's general communicative and psychosocial development, that key differences between the management of children and adults with voice disorders are outlined, and that the case examples provide details of the outcomes of assessment and intervention in addition to comprehensive information on the management approaches. There are, however, several limitations in the foundation chapters of the book. There are some errors of fact in the section on vocal anatomy; there is insufficient detail in the section on normative data; and there is a lack of supporting evidence for some of the authors' claims about the aetiologies and management recommendations for specific vocal disorders. The chapter on assessment, for example, does not cover instrumental assessment methods in sufficient detail and recommends an auditory perceptual and vocal functioning evaluation format that would be suitable only for screening purposes. The chapter on therapy strongly promotes the use of group therapy, but little convincing evidence for the effectiveness of this approach is provided. This chapter is also somewhat at odds with the authors' earlier caution against attributing all voice problems in children to vocal abuse and misuse; much of the chapter on general principles of therapy focuses on the use of a traditional vocal hygiene and vocal abuse reduction approach. In addition, the case examples include reference to a child with a ‘unilateral nodule’ without making the crucial point that nodules are not unilateral pathologies and that unilateral conditions such as a cyst or polyp require different management approaches than nodules.
The remaining five chapters provide clinicians with practical strategies and procedures for promoting vocal hygiene in children, reducing hyperfunctional vocal behaviours, improving body alignment, muscle tension and respiratory patterns for efficient voice production, enhancing vocal technique at both the laryngeal and resonance levels, measuring intervention outcomes, and implementing a group therapy approach. The intervention procedures covered are generally those recommended in the most recent voice literature (e.g. techniques to reduce vocal fold resistance to airflow, voice rest, promoting forward resonance, improving respiratory support for voicing). Some techniques, however, are not outlined in sufficient detail for the reader to apply in practice (e.g. ‘calling’ and holistic techniques such as the Accent Method and Vocal Function Exercise). The section on resonance therapy is confusing because it outlines exercises to encourage nasal resonance without making it clear that the focus is on improving projection rather than promoting hypernasality.
Working with Children's Voice Disorders also includes a series of appendices with useful case history and voice evaluation formats, information sheets for parents, anatomical diagrams, appealing pictures to use with children in therapy, and report formats. Although most of the appendices are clear and practical, some are too brief and simplistic to be of great value (e.g. the referral acknowledgement letters and voice group record form). A reasonably extensive reference list is also provided, although most of the references are texts rather than recent journal papers.
The book certainly provides clinicians and students with a practical guide to the management of children with common voice disorders. It is a valuable addition to the very limited literature on paediatric voice and occupies that important ground between the voice manual type of publication (e.g. Flynn et al.Citation1990) and the more comprehensive voice text (e.g. Andrews Citation1986).
Jenni Oates
School of Human Communication Sciences
La Trobe University
Victoria, Australia
e‐mail: [email protected]
Diagnostic Evaluation of Articulation and Phonology (DEAP)
By Barbara Dodd, Sharon Crosbie, Alison Holm, and Anne Ozanne
(London: Psychological Corporation, 2002)
ISBN 0‐7491‐1480‐0. £219.90
The DEAP is a new generation, comprehensive, standardized assessment of children's ‘speech’. It is a welcome move from the single channel view of speech difficulties that first considered articulatory factors only and, then, from the 1980s switched focus to phonological aspects largely ignoring any articulatory deficits. The DEAP acknowledges the contribution of both aspects in the development of speech and provides the means of making a differential diagnosis between articulatory and phonological delays and disorders.
The DEAP Test comprises a battery of five assessments:
Diagnostic Screen, which takes 5 minutes: the ten target words include most consonants and a range of clusters and vowels; the words are elicited twice and production of error sounds in isolation is checked. The outcome directs the therapist to the appropriate in depth assessment.
Articulation Assessment: 30 items are used to check the child's ability to produce all the English phonemes in words and the stimulability of error/problem sounds both at CV level and in isolation.
Oro‐motor Assessment: checks the diadochokinetic rate (DDK) and ability to perform gross isolated and sequenced movements.
Phonological Assessment: 50 object pictures are presented to elicit single words and identify error/simplification patterns; three additional pictures elicit 14 of these target words at connected speech level.
Inconsistency Assessment: the consistency of a child's production of 25 words on three separate trials is used to measure the stability of the child's phonological system.
Much thought has gone into ensuring that the test is examiner and child friendly. The pictures are bright, cheerful and very appropriate to the full age range (3:0–6:11 years), and are all presented in one flip‐over, stand‐up volume. The sections required for each assessment are colour coded for easy identification. The forms are designed for speedy recording and analysing (e.g. circling phoneme, ticking simplification process). The information on the test forms is comprehensive and once a therapist is familiar with the administrative procedure, they would only need to refer to the manual for norms.
It is helpful to have access to norms — some quantitative (e.g. percentage consonants/vowels/phonemes correct, DDK, inconsistency rating), others qualitative (phonetic consonant inventory, error/simplification patterns); all are easy to use. The standard scores are based on a mean of 10 and standard deviation of 3, a familiar system.
The UK normative sample for the standardization seems robust — over 85 children were included in the sample for each age band, with the exception of the youngest group (51), and how refreshing to have standardized data based on a true normal distribution rather than one truncated by the exclusion of those children who present with difficulties. The sensitivity of the diagnostic screen has been proven through two studies of children who completed the screen and the entire DEAP.
Target words are easily elicited with individual tests quick to deliver. The connected speech sample allows the same words to be checked at single‐word and connected speech level. This provides valuable points for comparison. The articulation assessment is helpfully laid out to record speech sound stimulability. Multi‐syllabic words are included in the Phonology Assessment, but sounds/words are not systematically ordered. The absence of any developmental progression in the Phonological Assessment makes it less useful when reviewing selected speech sounds/processes (e.g. clusters).
The Diagnostic Screen is more suitable for the older children; a simpler version would be helpful for the under fours. The sequenced movements subtest of Oro‐motor Assessment was difficult to follow for both client and clinician. The test is housed in a soft black bag. Therapists may very well prefer a small sturdy transparent zip case. These are minor issues though and do not detract from the overall clinical worth of this battery.
The DEAP seems an extremely useful training tool for students and less experienced therapists to develop professional competence in assessing and identifying speech difficulties. Following the comprehensive analytical procedures should help therapists to become more aware of the impact of different aspects of speech disorder and the value of making a differential diagnosis. The norms will help ensure that therapy is directed where it is most pertinent.
The experienced therapist is likely to use the assessment selectively and to transpose from one assessment to another (e.g. taking account of error patterns while administering the articulation assessment). An average phonological assessment or review is likely to involve no more than transcription and brief qualitative summary, rarely will there be the time or need for the full battery of analyses.
The main, and very real, concern is that the cost of the DEAP will be seen as prohibitive for many authorities. For a service to adopt the DEAP as its standard speech assessment will mean purchasing a test for each point of service delivery with an ongoing commitment to purchase test forms.
Newly qualified therapists who have used this test in training should as a result feel confident in their abilities to diagnose and differentiate phonological and articulatory disorders. They may however need to be weaned off the assessment and encouraged to consider other quicker means of assessment to accommodate the time and financial restrictions of clinical practice in the real world.
Angela Abell
Speech & Language Therapy Service
Epping Forest Primary Care Trust
St Margaret's Hospital
Epping, UK
e‐mail: [email protected]
Expression, Reception and Recall of Narrative Instrument (ERRNI)
By Dorothy Bishop
(London: Harcourt Assessment/Psychological Corporation, 2004)
[Manual, pp. 147; picture book, two sets of record forms.]
ISBN 0‐7491‐2606‐X. £106.79
Dorothy Bishop has consistently championed narrative assessment and the rich information about language that it can give clinicians and researchers. The Expression, Reception and Recall of Narrative Instrument (ERRNI) is the long anticipated translation of that interest into a practical tool for speech and language therapists and psychologists. Examining the oral narratives produced by an individual can give us insight and information concerning their syntactic, semantic and pragmatic language skills. It can also help us make certain predictions about their prognosis both for spoken language and literacy (Bishop and Edmundson Citation1987, Klecan‐Aker and Caraway Citation1997).
The ERRNI ‘tests a person's ability to relate a story, comprehend it, and remember it after a delay’ (ERRNI Manual, p. 10). The full test set comprises the manual, the picture book and record forms for the two different stories. The test has two versions: The Fish Story and The Beach. This allows for retesting within a shorter time scale than single‐version assessments, giving greater scope for the evaluation of episodes of intervention. It is recommended for use with children with language impairments or learning disabilities aged from about 6 years and for adults with aphasia. It is standardized on a representative UK sample of 892 people and although standardized on children as young as 4 years, sensitivity at this age is reported to be poor. The ERRNI is not recommended as a test to detect language impairment, except as part of a battery of assessments, although it would undoubtedly provide a good insight into the nature of the individual's language and areas for further detailed assessment. The sensitivity for adolescents and adults is reported to be good.
The manual is clear and easy to follow, with helpful sections on transcription, scoring, and quantitative and qualitative interpretation. The verbal directions during the assessment do not appear stilted and the verbal prompts are adequate and appropriate. There is an introductory picture to help the testee ‘warm up’ to the task, and 15 pictures in each story. The pictures are detailed and coloured and have proved, in my experience, as appropriate for a 14 year old with ADHD as for a 6 year old with SLI. Ten to 30 minutes after the initial story telling, the testee is asked to retell the story without the pictures. This yields a ‘forgetting score’ related to long‐term auditory memory. The comprehension assessment taps into inferential and factual understanding and includes some questions about false belief and emotion. I have used this assessment with approximately 50 young people now and have been consistently impressed with the quality and usefulness of the outcome. The scoring tables are easy to use and it is possible to use the content of the narrative to do a more detailed linguistic analysis if the individual's difficulties warrant it. The transcription of the narratives has proved to be less onerous than I first thought it would be.
The elicitation method of the ERRNI differs from The Bus Story (Renfrew Citation1997) and Peter and the Cat (Allen et al.Citation1994) in that the story is not initially told by the examiner. Instead, the child is shown the pictures and asked to tell the story with little or no verbal prompting. Each story contains a crucial detail that the child needs to understand in order to tell the story. This is indicated by pointing, but no verbal comments are made. In The Fish Story, this occurs when a little girl swaps the contents of two bags, out of sight of their owners. Even when the individual has had this incident pointed out to them they do not always interpret the pictures correctly and the subsequent story gives information as to how they deal with incongruity: do they ignore it or formulate some explanation for the doll rather than the fish being in the bag? Some children in my experience have told the story missing out a description of the incident, but still produced a narrative with an outcome congruent with its presence. Then in the recall, without the pictures as prompts, have indicated their pragmatic understanding by including additional information about the incident. This type of knowledge about aspects of narrative other than information and linguistic content is easy to obtain from the ERRNI due to its structure, despite not being part of its stated outcome.
The ERRNI fills a gap in the range of standardized assessments available to us and I have no hesitation in recommending it to all speech and language therapy departments.
Helen Stringer
Newcastle upon Tyne Hospitals NHS Trust/School of Education, Communication and Language Sciences
University of Newcastle upon Tyne
Newcastle upon Tyne, UK
e‐mail: [email protected]