Global versus phonemic similarity: Evidence in support of multi-level representation.

There is long-standing debate about the extent to which children cognitively represent words in terms of global properties or phonological segments, yet few studies have investigated how children's sensitivity to phonemic versus global similarity changes over time. The current study uses a mispronunciation-reconstruction task to measure both types of sensitivity within a cross-sectional (N = 90, aged 3;2 to 5;7) and longitudinal sample (N = 23, aged 3;2 to 5;1). The results show that children's sensitivity to phonemes increases over the first two years of school but does not reach adult levels. The findings indicate that global similarity relations remain important throughout development and support the idea of multi-level representation.

Story choice matters for caregiver extra-textual talk during shared reading with preschoolers.

This study aimed to examine the influence of the complexity of the story-book on caregiver extra-textual talk (i.e., interactions beyond text reading) during shared reading with preschool-age children. Fifty-three mother-child dyads (3;00-4;11) were video-recorded sharing two ostensibly similar picture-books: a simple story (containing no false belief) and a complex story (containing a false belief central to the plot, which provided content that was more challenging for preschoolers to understand). Book-reading interactions were transcribed and coded. Results showed that the complex stories facilitated more extra-textual talk from mothers, and a higher quality of extra-textual talk (as indexed by linguistic richness and level of abstraction). Although the type of story did not affect the number of questions mothers posed, more elaborative follow-ups on children's responses were provided by mothers when sharing complex stories. Complex stories may facilitate more and linguistically richer caregiver extra-textual talk, having implications for preschoolers' developing language abilities.

Memory and language in middle childhood in individuals with a history of specific language impairment.

This study reports on the sensitivity of sentence repetition as a marker of specific language impairment (SLI) in different subgroups of children in middle childhood and examines the role of memory and grammatical knowledge in the performance of children with and without language difficulties on this task. Eleven year old children, 197 with a history of SLI and 75 typically developing (TD) peers were administered sentence repetition, phonological short term memory (PSTM) and grammatical morphology tasks. Children with a history of SLI were divided into four subgroups: specific language impairment, non-specific language impairment, low cognition with resolved language and resolved. Performance on the sentence repetition task was significantly impaired in all four subgroups of children with a history of SLI when compared to their age peers. Regression analyses revealed grammatical knowledge was predictive of performance for TD children and children with a history of SLI. However, memory abilities were significantly predictive of sentence repetition task performance for children with a history of SLI only. Processes involved in sentence repetition are more taxing of PSTM for individuals with a history of SLI in middle childhood in a way that does not appear to be the case for TD children.

Effectiveness of enhanced communication therapy in the first four months after stroke for aphasia and dysarthria: a randomised controlled trial.

OBJECTIVE: To assess the effectiveness of enhanced communication therapy in the first four months after stroke compared with an attention control (unstructured social contact). DESIGN: Externally randomised, pragmatic, parallel, superiority trial with blinded outcome assessment. SETTING: Twelve UK hospital and community stroke services. PARTICIPANTS: 170 adults (mean age 70 years) randomised within two weeks of admission to hospital with stroke (December 2006 to January 2010) whom speech and language therapists deemed eligible, and 135 carers. INTERVENTIONS: Enhanced, agreed best practice, communication therapy specific to aphasia or dysarthria, offered by speech and language therapists according to participants' needs for up to four months, with continuity from hospital to community. Comparison was with similarly resourced social contact (without communication therapy) from employed visitors. OUTCOME MEASURES: Primary outcome was blinded, functional communicative ability at six months on the Therapy Outcome Measure (TOM) activity subscale. Secondary outcomes (unblinded, six months): participants' perceptions on the Communication Outcomes After Stroke scale (COAST); carers' perceptions of participants from part of the Carer COAST; carers' wellbeing on Carers of Older People in Europe Index and quality of life items from Carer COAST; and serious adverse events. RESULTS: Therapist and visitor contact both had good uptake from service users. An average 22 contacts (intervention or control) over 13 weeks were accepted by users. Impairment focused therapy was the approach most often used by the speech and language therapists. Visitors most often provided general conversation. In total, 81/85 of the intervention group and 72/85 of the control group completed the primary outcome measure. Both groups improved on the TOM activity subscale. The estimated six months group difference was not statistically significant, with 0.25 (95% CI -0.19 to 0.69) points in favour of therapy. Sensitivity analyses that adjusted for chance baseline imbalance further reduced this difference. Per protocol analyses rejected a possible dilution of treatment effect from controls declining their allocation and receiving usual care. There was no added benefit of therapy on secondary outcome measures, subgroup analyses (such as aphasia), or serious adverse events, although the latter were less common after intervention (odds ratio 0.42 (95% CI 0.16 to 1.1)). CONCLUSIONS: Communication therapy had no added benefit beyond that from everyday communication in the first four months after stroke. Future research should evaluate reorganised services that support functional communication practice early in the stroke pathway. This project was funded by the NIHR Health Technology Assessment programme (project No 02/11/04) and is published in full in Health Technology Assessment 2012;16(26):1-160. TRIAL REGISTRATION: ISRCTN78617680.

Developmental complexity of the stimuli included in mispronunciation detection tasks.

BACKGROUND: Phonological representations are important for speech and literacy development. Mispronunciation detection tasks have been proposed as an appropriate measure of phonological representations for children with speech disorder. There has been limited analysis, however, of the developmental complexity of task stimuli. Further, the tasks have not been used widely with typical populations. AIMS: The study aimed to examine the developmental progression of children's performance on a mispronunciation detection task, to evaluate the complexity of the task's stimuli, and to analyse the association between task performance and other skills important for literacy success. METHODS & PROCEDURES: A cross-sectional design was used to compare the mispronunciation detection performance of monolingual children within mainstream classrooms aged 4;0-4;5 (n = 26), 4;6-5;0 (n = 49), and 5;1-5;6 (n = 64). Comparison of the complexity of vowel mismatches, single consonant mismatches, consonant deletion mismatches, and consonant transposition mismatches was conducted. OUTCOMES & RESULTS: Children in the youngest age group were outperformed by the older age groups in the phonological representation task. Fine-grained mismatches were more difficult to detect than coarse-grained mismatches. There was a trend for vowel substitutions to be the most difficult mismatch to detect. Performance in the mispronunciation detection task was moderately correlated with the children's receptive vocabulary, speech, phonological awareness, and letter knowledge skills. CONCLUSIONS & IMPLICATIONS: Mismatch type must be taken into account when designing mispronunciation detection tasks. Access to segmental phonological representations is related to speech, language, and letter knowledge in children from mainstream classrooms.

Asking the right questions and getting meaningful responses: 12 tips on developing and administering a questionnaire survey for healthcare professionals.

Questionnaires provide a useful and versatile tool for new and occasional researchers, and can be applied to a wide range of topics. This paper provides simple guidance on some of the potential pitfalls in developing and running a questionnaire study, and how to avoid them. Each tip is illustrated with a real-life example from the development of a UK-wide questionnaire survey of trainee doctors and their educational supervisors.

Communication outcome after stroke: a new measure of the carer's perspective.

OBJECTIVE: To validate a measure of the carer's perspective of a stroke survivor's communication in everyday life. DESIGN: Cross-sectional, interview-based, psychometric study. SETTING: A community sample from the northwest of England, UK. SUBJECTS: Fifty-eight carers and 58 stroke survivors with communication problems (aphasia and/or dysarthria) following a stroke within the previous 4-12 months. INTERVENTIONS: Administration of the 20-item Carer Communication Outcome after Stroke (Carer COAST) scale, on two occasions, within a two-week period; the 15-item Carers of Older People in Europe (COPE) Index, the patient Communication Outcome after Stroke (COAST) Scale, and collection of demographic and other data relating to the stroke survivor's disability (Barthel Index), degree of aphasia (Frenchay Aphasia Screening Test) and hospital diagnosis of aphasia/dysarthria. MAIN MEASURES: Acceptability (missing values), reliability (internal consistency and test-retest reliability) and construct validity. RESULTS: Carer COAST showed good acceptability (no incomplete items, sample spread 24-100%), internal consistency and test-retest reliability for the scale (a = 0.94; intraclass correlation (ICC) = 0.91) and its subscales (a = 0.78-0.90; ICC = 0.75-0.87), and indicative evidence on construct validity (Carer COAST, COPE subscales and COAST). There were statistically significant correlations between the communication items of Carer COAST and the negative impact of caregiving (r(s) = -0.29) and the financial difficulties of caregiving (r(s) = -0.38). CONCLUSIONS: The Carer COAST scale has considerable potential as a reliable and valid measure of the carer's perspective on the communication effectiveness of stroke survivors. Intercorrelations with COPE provide specific evidence of the impact of caring for a person with communication difficulties following a stroke.

The effectiveness of portfolios for post-graduate assessment and education: BEME Guide No 12.

BACKGROUND: Portfolios in post-graduate healthcare education are used to support reflective practice, deliver summative assessment, aid knowledge management processes and are seen as a key connection between learning at organisational and individual levels. This systematic review draws together the evidence on the effectiveness of portfolios across postgraduate healthcare and examines the implications of portfolios migrating from paper to an electronic medium across all professional settings. METHODS: A literature search was conducted for articles describing the use of a portfolio for learning in a work or professional study environment. It was designed for high sensitivity and conducted across a wide range of published and unpublished sources relevant to professional education. No limits for study design or outcomes, country of origin or language were set. Blinded, paired quality rating was carried out, and detailed appraisal of and data extraction from included articles was managed using an online tool developed specifically for the review. Findings were discussed in-depth by the team, to identify and group pertinent themes when answering the research questions. RESULTS: Fifty six articles from 10 countries involving seven healthcare professions met our inclusion criteria and minimum quality threshold; mostly uncontrolled observational studies. Portfolios encouraged reflection in some groups, and facilitated engagement with learning. There was limited evidence of the influence of a number of factors on portfolio use, including ongoing support from mentors or peers, implementation method, user attitude and level of initial training. Confounding variables underlying these issues, however have not been fully investigated. A number of authors explored the reliability and validity of portfolios for summative assessment but reports of accuracy across the disparate evidence base varied. Links to competency and Quality Assurance frameworks have been demonstrated. There were conflicting reports about whether the different purposes of portfolios can be combined without compromising the meaningfulness of the contents. There was good evidence that the flexibility of the electronic format brought additional benefits to users, assessors and organisations, and encouraged more enthusiastic use. Security of data remained a high priority issue at all levels, and there was emerging evidence of successful transfer between electronic portfolio systems. CONCLUSION: The evidence base is extensive, but contains few high quality studies with generalisable messages about the effectiveness of portfolios. There is, however, good evidence that if well implemented, portfolios are effective and practical in a number of ways including increasing personal responsibility for learning and supporting professional development. Electronic versions are better at encouraging reflection and users voluntarily spend longer on them. Regular feedback from a mentor enhances this success, despite competing demands on users' time and occasional scepticism about the purpose of a portfolio. Reports of inter-rater reliability for summative assessments of portfolio data are varied and there is benefit to be gained from triangulating with other assessment methods. There was insufficient evidence to draw conclusions on how portfolios work in interdisciplinary settings.

Apraxia of speech: how reliable are speech and language therapists' diagnoses?

OBJECTIVE: To discover how reliably speech and language therapists could diagnose apraxia of speech using their clinical judgement, by measuring whether they were consistent (intra-rater reliability), and whether their diagnoses agreed (inter-rater reliability). DESIGN: Video clips of people with communication difficulties following stroke were rated by four speech and language therapists who were given no definition of apraxia of speech, no training, and no opportunity for conferring. SETTINGS: Videos were made of people following stroke in their homes. Ratings of the videos were carried out in the university lab under controlled conditions. SUBJECTS: Forty-two people with communication difficulties such as aphasia, apraxia of speech and dysarthria took part, and four specialist speech and language therapists acted as raters. MAIN MEASURE: Speech and language therapists' ratings of the presence and severity of apraxia of speech using videos. RESULTS: Intra-rater reliability was high for diagnosing (1) the presence of apraxia of speech (Cohen's kappas ranging from 0.90 to 1.00; 0.93 overall), and (2) the severity of apraxia of speech (kappa 0.84 to 0.92; 0.90 overall). The inter-rater reliability was also high for both the presence of apraxia of speech (kappa 0.86) and severity of apraxia of speech (0.74). CONCLUSION: Despite controversy over its nature and existence, specialist speech and language therapists show high levels of agreement on the diagnosis of apraxia of speech using their clinical judgement.

Teaching phoneme awareness to pre-literate children with speech disorder: a randomized controlled trial.

BACKGROUND: Awareness of individual phonemes in words is a late-acquired level of phonological awareness that usually develops in the early school years. It is generally agreed to have a close relationship with early literacy development, but its role in speech change is less well understood. Speech and language therapy for children with speech disorder involves tasks that appear, either implicitly or explicitly, to require a phonemic level of awareness. However, children typically attend for intervention at a pre-school, pre-literate stage, i.e. before they would be expected to have developed the relevant phoneme segmentation and manipulation skills. AIMS: To investigate whether it is possible to teach phoneme awareness skills to pre-literate children with speech disorder. METHODS & PROCEDURES: In a randomized controlled trial design 42 children with speech disorder, aged 4;0-4;6, were allocated to either a phonological awareness or a language stimulation programme. Children were assessed on four measures of phoneme awareness (alliteration awareness, phoneme isolation, word segmentation and phoneme addition/deletion) immediately before and after the programme and categorized as 'improved' or 'not improved' according to predetermined criteria. Fisher's Exact test was used to compare outcome in the two groups. OUTCOMES & RESULTS: Significantly more children improved in the phonological awareness group than in the language stimulation group for three out of the four measures (all except alliteration awareness). However, for the two most advanced tasks (segmentation and addition/deletion) only a small minority of children showed improvement. A marked improvement in Phoneme Isolation was made by the majority of children in the phonological awareness group. CONCLUSIONS: It is possible to teach some advanced phoneme awareness skills to some pre-literate children. Phoneme Isolation was the most easily learned and is a skill that appears very relevant to speech and language therapy. However, phoneme addition, deletion and word segmentation showed relatively limited improvement and only in a small number of cognitively able and older children. Whereas isolation of word initial consonants appears to be a skill that can be triggered at 4;0-4;6 by relevant activities, most children in the study were not cognitively ready for more advanced, abstract phoneme manipulation tasks. This raises questions about how speech and language therapists should tackle many common errors and the age at which we should aim to develop or draw on phoneme awareness to stimulate speech change.

The use of relative clauses by children with language impairment.

Recently, there has been increased attention to the development of complex syntax by children with language disorder. An example is the work of Schuele and Nicholls and Schuele and Tolbert who describe the acquisition of relative clauses by a group of children with SLI. The current paper presents data from 66 children with language impairment, aged 6 to 11 years. Their use of relative clauses is examined in two contexts, an elicitation and a narrative task. Data are presented on the omission of obligatory relative markers, postulated by Schuele and Tolbert as a recognizable stage in development by SLI but not typically developing children. Obligatory marker omission was rare in the current data. A more common pattern was use of the "reduced relative", described by Schuele and Tolbert as a developmental step prior to the production of full relative clauses. Possible reasons for the discrepancies are considered.

Using errorless learning to treat letter-by-letter reading: contrasting word versus letter-based therapy.

Some pure alexic readers have been shown to activate lexical and semantic knowledge under brief presentation conditions. This ability is not seen when letter-by-letter reading accuracy is high or the reading impairment is very severe. It is also unlikely to occur under normal untimed presentation because the pure alexic will make deliberate use of their letter-by-letter strategy. This paper presents data from a moderately severe letter-by-letter reader, FD, who had visual processing problems affecting reading. He also had other mild aphasic characteristics. FD showed implicit reading abilities under brief presentation conditions, being able to make lexical decisions and semantic categorisations well above chance. FD was given two therapy programmes, the first, whole word therapy to exploit this implicit ability and the second to improve letter-by-letter accuracy and speed. FD showed some improvement in reading ability after both therapy programmes, particularly for words of personal interest to him. His letter naming accuracy and reading of visually similar words were the most resistant to change. A striking effect of therapy was the cessation of FD's letter-by-letter reading and the emergence of some of the characteristics of deep dyslexia. Even when therapy concentrated on letter accuracy, FD did not revert back to his original letter-by-letter reading strategy. The results are discussed with reference to the two theories of pure alexia. Some conclusions are drawn about the need for therapists to examine and exploit all residual reading skills when devising therapeutic programmes.

PRHO views on the usefulness of a pilot ward simulation exercise.

There are concerns that pre-registration house officers (PRHOs) lack the expertise to initially manage acutely-ill patients. Simulation can support them in this role by providing a safe yet authentic setting. This paper shares PRHOs' views of a ward simulation exercise. The positive feedback has resulted in further development of the exercise to support PRHOs who have given cause for concern in their practice.

Pre-registration house officer training: a role for nurses in the new Foundation Programme?

PURPOSE: To explore senior nurses' views of pre-registration house officer (PRHO) training, including the scope for their contribution to the new Foundation Programme. DESIGN: Data reported here are drawn from a larger, national project, which aimed to identify a curriculum for the PRHO year. The project was based in the Education Development Unit, Scottish Council for Postgraduate Medical and Dental Education (SCPMDE), Dundee. As part of the project, 40 semistructured interviews, each lasting about 1 hour, were held with senior nurses. Interviews were fully transcribed and coded in the qualitative software NVivo for further analysis. Codes were studied for emergent themes and categories. PARTICIPANTS: Senior nurses (10 from each of the 4 postgraduate regions of Scotland), from diverse specialties. RESULTS: Data suggest considerable cross- regional/specialty consistency. Key emergent themes concerned the process of training as much as the educational outcomes. The nurses focused on the development of outcomes such as communication and teamworking in addition to clinical and practical skills. They guided the PRHOs informally, but were concerned that their own extended roles were detracting from this. DISCUSSION: Nurses are gaining increasingly advanced professional, clinical and practical skills. Traditionally, experienced nurses guide and support PRHOs, at least informally. Data collected suggested there may be scope for capitalising on their expertise, including formalising aspects of their contribution to the proposed PRHO Foundation Programme. However, this is a potentially sensitive area and more interprofessional dialogue is needed.

Grammatical performance of children with language disorder on structured elicitation and narrative tasks.

The primary objective was to compare the grammatical output of children with language disorders on different tasks. Sixty-five children with language disorders, aged six to eleven, completed the syntactic formulation (elicitation) and narrative subtests from the Assessment of Comprehension and Expression 6-11 (Adams et al. 2001). Grammatical variables were computed for the narrative data and their relationship with the syntactic formulation subtest score examined. The use of ten specific constructions was compared in the two contexts. The syntactic formulation score correlated highly with narrative grammatical variables. However, for seven of the ten constructions, the elicitation task was more likely than the narrative to yield specific target structures. Structured elicitation is an efficient normative measure of grammatical production capacity. For specific structures, elicitation and narrative may give a different picture of output. Elicitation is more facilitative and may more closely reflect grammatical knowledge. Target structures were less likely to be used in the narrative, which reflects grammatical performance in a cognitively and linguistically demanding task.

Linking appraisal of PRHO professional competence of junior doctors to their education.

In the UK, new medical graduates are known as Pre-registration House Officers (PRHOs). Postgraduate Deans are responsible for the PRHO year and for the final certification of PRHOs to allow them to be fully registered by the GMC as medical practitioners. However, as much as appraisal of professional growth is central to PRHO training, they are in need of a robust assessment mechanism to detect, at an early stage, individuals with significant clinical and professional deficiencies. Documented, reliable and valid ongoing information on PRHO performance will provide information for early intervention and will establish 'hard' observable evidence, for certification decisions. Thus, an approach that links appraisal/assessment of professionalism and clinical skills to education is the way forward. This paper describes a new approach to appraisal/assessment of PRHOs, which is currently being piloted in a number of regions in Scotland. The conceptual paradigm was developed during the last three years as a proposal for a Scottish national PRHO reform. 'Grounded' qualitative studies were employed to explore trainees' and trainers' perceptions of the expected competences (outcomes) of PRHO performance for appraisal/assessment purpose. The GMC recommendations are reviewed in light of the study results. An assessment model emerged that links appraisal to education. PRHOs' cumulative performance is documented over one year of training resulting in diagnostic profiles that provide guidance for evaluation and training of PRHOs. Poor performers are flagged in the early stages of training, thus allowing early intervention. The feasibility and acceptance of the model by educators, the health system and PRHOs has yet to be established.

Implicit recognition in pure alexia: The Saffran effect-a tale of two systems or two procedures?

Some patients with pure alexia or letter-by-letter reading demonstrate the Saffran effect: residual activation of higher order lexical-semantic representations despite poor word recognition. This study investigated the reading of patient FD, a letter-by-letter reader with a clear Saffran effect. Two alternative explanations for this effect were tested in a series of experiments and through the impact of whole-word and letter-based therapies on FD's reading. One theory assumes that the disparity between overt recognition and implicit activation of word meaning is underpinned by two separate reading systems. An alternative hypothesis argues for a single whole-word reading system supplemented by the deliberate, compensatory strategy of letter-by-letter reading. Under this hypothesis, the Saffran effect reflects partial activation of the single, whole-word system. FD's results strongly supported the latter hypothesis. FD's reading behaviour was characterised by partial activation of higher word representations, accuracy was graded by word variables known to influence the normal reading system, and most importantly, once the characteristics of the tasks were equated, there was no evidence for a dissociation between word categorisation and recognition. In addition, the whole-word therapy encouraged FD to abandon the letter-by-letter strategy. Without this compensatory technique, FD's emergent deep dyslexia was consistent with a partially activated, whole-word reading system that produces overt reading responses. Comparison of data from this and other studies suggests that the Saffran effect is most likely to be observed in patients with severe pure alexia.

Early literacy achievement of children with a history of speech problems.

BACKGROUND: There are conflicting reports in the research literature of the literacy outcome of children with speech disorder. The link between phonological awareness and literacy in typically developing and literacy delayed children is well established, but there is less research specifically into children with an isolated speech disorder (i.e. with age-appropriate language skills). There is a clinical need for clarification on their likely outcome as a group and for a means of predicting those individuals who might need support in literacy development. AIMS: To assess literacy and phonological awareness skills at age 6;6-7;6 years in children with a history of speech disorder, and to identify factors in their early profile that were predictive of later achievement. METHODS & PROCEDURES: Thirty-five children who had participated in an earlier therapy research study agreed to further assessment of their speech, language and literacy abilities. The children had originally been recruited between the ages of 3;6 and 5;0 years as having a moderate-to-severe speech disorder, and there were measures at that time of their non-verbal, language, phonological output and phonological awareness abilities. Follow-up assessments of phonological awareness, speech and early literacy were undertaken. OUTCOMES & RESULTS: As a group, the children had made good progress in speech and showed phonological awareness and literacy development at an age-appropriate level. However, a small number of children had phonological awareness and literacy delay. Phonological awareness at 3;6-5;0 years was the best predictor of literacy achievement. CONCLUSIONS: Speech and language therapists can be confident about the early literacy achievement of most children with isolated speech disorder, but should undertake assessment of phonological awareness to identify those children whose phonological awareness skills after speech intervention continue to be low.

Comparison of the effectiveness of the Hanen Parent Programme and traditional clinic therapy.

BACKGROUND: Both direct (clinician to child) and indirect (clinician to carer) approaches are currently used in the management of children with language delay, but there is as yet little evidence about their relative effects or resource implications. AIMS: This research project compared the Hanen Parent Programme (HPP) in terms of its effectiveness and consequent suitability for an inner-city UK population with clinic-based, direct intervention. METHODS & PROCEDURES: Thirty-seven children aged 2;06-3;06 years with a diagnosis of language impairment and their parents took part in the research project. The children were allocated on a geographical basis to receive therapy either as part of an HPP or in a clinic. Nineteen children and their families took part in one of the five Hanen groups that ran successively over 16 months; 18 children and their families received clinic-based intervention. The children's language was assessed using the PLS-3 (UK version) and from an analysis of audio-taped parent and child interaction at three assessment points, one pretherapy and two post-therapy over 12 months. Two parent language measures were also analysed. OUTCOMES & RESULTS: Significant gains in language scores were shown by 71% of the children over 12 months. There were no statistically significant differences in child language scores between the two therapy groups at any assessment point. However, the HPP was twice as intensive (in terms of therapist time) as clinic therapy based on average group size, which has resource implications. CONCLUSIONS. Results suggest that there are parent and child factors that need consideration when choosing an appropriate intervention programme for a child with language impairment. Parental expectations, existing interaction style and the level of child language may be important influencing factors.